THE SCIENTIFIC VALIDATION OF
THE BIOPSYCHOSOCIAL MODEL
The Evidence-based Patientcentered Interview
ICCH Symposium
September 30, 2014
Francesca Dwamena, Arnstein Finset,
Auguste Fortin VI, (Richard Frankel,)
Richard Street, Robert Smith
SYMPOSIUM OVERVIEW
For its next advance, the field needs to adopt an
evidence-based patient-centered interviewing
method
See recent PEC paper
Panel present pro/con and related theoretical
and research issues  audience
MOST AGREE ON NEED FOR PTC
• Patients – see TV, newspapers, and magazines
• IOM; AAMC/MCAT; Healthy People 2020; etc.
• Professional organizations/societies; e.g., ACP,
ABIM
• Mission statements all educational programs
• Everyone: more personhood of the patient
CHANGE SLOW TO COME – WHY?
Means changing highly successful present
approach
– Biomedical Model; Disease Model; Biotechnical
Model
– DISEASE FOCUS ONLY
– Produced all major medical/surgical advances
– Ingrained in medical education – late 1800s
(Osler)
IF WE ARE TO CHANGE,
WE NEED:
Strong theoretical basis
• Adds personhood of patient
• Not jeopardize present disease benefits
• Our focus: General System Theory (GST) & the
bio-psycho-social model – to replace the
current biomedical (disease only) model
Natural Systems & BPS Model
Culture
Community
Family
Patient/person
SOCIAL
(environment
interaction)
PSYCHO
(individual)
Body Systems
Tissues
Cells
Organelles
BIO
(parts)
BPS MODEL FILLS THE BILL
The BPS model
1. Includes now overlooked personhood of patient,
the psychological and social aspects
2. Maintains the benefits of the BM (disease)
model
Just what we’re looking for
GEORGE L. ENGEL
WHY SO SLOW TO ACCEPT?
BPS MODEL NOT SCIENTIFIC
• NOT TESTABLE – can’t make predictions;
rationale for mind-body connection
• TOO GENERAL – requires all BPS data;
inefficient; doesn’t apply to individual patient
• NO METHOD – prescribes BPS content but
does not tell how (process) to obtain it
FUNDAMENTAL FLAW OF BPS MODEL
MUST ANSWER: Exactly “how” do doctors
efficiently identify essential BPS data in the
individual patient?
Need: repeatable method that consistently
identifies only relevant BPS information at each
patient visit
PATIENT-CENTERED INTERVIEW
• New – Rogers; Kleinman; Balints  Univ.
Western Ontario (Levenstein, McWhinney)
• Patient leads – use open-ended questions;
don’t interrupt
• Much highly productive research
(observational)
• Widely espoused – IOM domain of quality –
mission statements most medical schools
PATIENT-CENTERED INTERVIEW 2
Problems for teaching and research
• Directions variable – no specific definition
• Not repeatable; often contradictory teaching
• Problem: no research testing; difficult to teach
• Field plateaus: variable teaching;
observational research
Standing on the shoulders of these giants and
Engel  our MSU work since 1985 = next step
AN EVIDENCE-BASED
BEHAVIORALLY-DEFINED METHOD
• 1991 & 1996 -- first behaviorally-defined
patient-centered model = repeatable,
sequenced, prioritized, multiple steps = model
• 1998 – RCT: easily and effectively learned
• 2006 & 2009 -- model associated with positive
medical and psychological outcomes in RCTs
• Frankel: Very similar model shown effectively
learned in a 2011 RCT
APPLY TO INDIVIDUAL PATIENT AND
JUST THEIR UNIQUE PROBLEMS?
• Ask same questions of everyone? Like a Social
History or Family History?
• Specifies steps/signposts > questions
• Research on patients:
– Unique stories = relevant & not rote questioning
– Extraordinarily high satisfaction; e.g., “finally,
someone listened;” “she really understood me
and what I needed”
KEY QUESTION: TESTABLE?
Ann Intern Med RCT – learnable
JGIM RCTs – positive patient outcomes
PEC pilot RCTs – linguistic and fMRI intermediate
outcomes
Evidence-based
Satisfaction Mean
Estimate
Total Satisfaction
100
92.1
92.5
90
Treatment
Control
79.7
80
80.4
80.5
6 Months
12 Months
77.5
70
0 Months
Time in Months
EXAMPLE OF TESTABLE HYPOTHESIS
Hypothesis: an antihypertensive given via the
patient-centered method will have better biopsycho-social outcomes than giving the
antihypertensive via an isolated doctor-centered
method (usual care).
POINT: can now test patient-centered method =
test the BPS model
NEXT-STEP RESEARCH DIRECTIONS
(Not previously possible)
1. Hypothesis-testing study – predict improved
outcome
2. Between patient and outcome; e.g., fMRI,
linguistic
3. Mechanism(s) of method: mediators; e.g.,
satisfaction – moderators; e.g., gender
4. Pathways to improved outcomes; e.g., access
to care, social support, agency
DISCUSSION
Propose: evidence-based patient-centered
method as the next-step to advance the field:
• All teach same method = define BPS model for
each patient
• Experimental research  definable patientcentered method as predictor = test BPS
model scientifically
IMPLEMENTING
• ONLY behaviorally-defined, evidence-based
method (+ very similar recent one -- Frankel)
• Method meets 6 criteria of “operationalism:”
1.
2.
3.
4.
5.
6.
Logically consistent
Behaviorally specific
Empirically based
Technically feasible
Repeatable
Greater predictability
PATIENT-CENTERED METHOD MAKES
BPS MODEL SCIENTIFIC
• Defines BPS model ~ telescope shows cosmos
• Heisenberg: “…what we observe is not nature
in itself but nature exposed to our method of
questioning.”
• Better methods will develop ( better BPS
model) = research task
• FIRST, SMALL STEP  scientific BPS model:
testable, efficient, relevant, and know “how”
FLIP SIDE OF SAME COIN
BPS
MODEL
INTEGRATED
INTERVIEWING
http://bpsmedicine.msu.edu/
Auguste – details of methods/models
Arny – theoretical perspectives
Rick – research perspectives
Francesca -- Discussion