Clinical

Problem

Solving

John

Z. Sadler,

biopsychosocial

Engel’s

systems

theory,

model,

is oflimited

M.D.,

while

utility

and the Biopsychosocial and

unifying

in organizing

Yosaf

F. Hulgus,

the sciences bedside

relevant clinical

Model

Ph.D.

to medicine

problem

solving.

under

general

The

authors

consider this issue in light ofthe structure and goals ofthe clinical encounter. The biopsychosocia! model is a model for organizing the sciences relevant to medicine; however, medical/psychiatric practice poses problems both within and outside the scientific realm. Since the biopsychosocial model cannot account for clinical problems to which the methods ofscience do not apply, the authors seek to facilitate biopsychosocial problem solving by proposing a clinical decisionmaking model that complements the biopsychosocial modeL Their model directs the clinician’s attention

to three

pragmatics.

The

core

aspects

authors

of the

reconsider

clinical

Engel’s

encounter: case

of Mr.

emphasis of the model. Other clinical examples are used from mistaking one kind of aspect of medicine for another. are respected (Am

equally,

J Psychiatry

a biopsychosocial 1992;

149:1315-1

practice

he biopsychosocial model of medicine and psychiatry (1, 2) is an influential paradigm in psychiatry (3), family practice (4), and research (particularly psychiatric research) (5). It provides models for treatment by emphasizing the multidimensional nature of medical problems and demonstrating the functional interdependence of these multiple dimensions. Yet, to what degree does the biopsychosocial model actually shape clinical decisions? Concerns are frequently voiced about its lack of utility in everyday clinical decision making (6-9), its inability to differentiate important from unimportant clinical data (7, 8), and the tendency for it to be used in understanding clinical situations retrospectively rather than prospectively (7, 8). One empirical study (10) demonstrated that medical students prefer to use biomedical rather than biopsychosocial conceptions of illness, and another study ( I I) verified this trend among clinicians treating mood disorders. Psychiatrists are no exception to this tendency to have difficulty in using the biopsychosocial model. Paul Fink, in his response to an APA presidential address (6), noted that the everyday applicability of the model is a critical problem for psychiatry. Indeed, Fink raised the possibility of “biopsychosocial” being but an empty catchword with little methodological bite.

Received July 10, 1991; revision received Nov. 27, 1991; accepted Dec. 1 2, 1 991 . From the Department of Psychiatry, The University of Texas, Southwestern Medical Center at Dallas. Address reprint requests to Dr. Sadler, Department of Psychiatry, The University of Texas, Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd., Dallas, TX 75235-9070. Copyright © 1992 American Psychiatric Association.

Psychiatry

149:10,

October

1992

Glover

of knowledge,

to demonstrate

to demonstrate When these

ethics,

and

the anticipatory

the difficulties arising three aspects of medicine

is unavoidable.

323)

T

Am]

problems

The biopsychosocial model was intended to preserve scientific rigor while attending to the whole person. The model is based on general systems theory, in which the sciences are organized around a systems hierarchy (2, 12). The systems hierarchy is organized around levels of organization, the lowest of which is subatomic partides, and there is a progression up through higher 1evels such as the molecule, cell, organ, person, couple, community, and biosphere. Each system level is interdependent with the others, and none has functional priority over the others, at least in theory. This model was and is much needed, given the reductionism of the biomedical model that characterizes much practice and research (1, 13). The systems hierarchy provides a means for conceptualizing the often-observed dependence among biological, psychological, and social levels of organization. Why has the biopsychosocial model had limited success in changing physicians’ behavior in actual clinical problem solving? That is, why are physicians not practicing biopsychosocial medicine? There is surely a multiplicity of reasons: physicians vary in their time constraints, in their interest in nontechnical (or nonprocedural) aspects of patient care, and in their sources of professional satisfaction. Many of these preferences may be incompatible with practicing truly biopsychosocial medicine. There are also conceptual reasons for the biopsychosocial model’s limited assistance in clinical problem solving. This article focuses on those reasons. Two key conceptual problems shape the difficulties in using the biopsychosocial model (i.e., practicing biopsychosocial decision making). The first has to do with the systems hierarchy itself. The systems hierarchy is

1315

CLINICAL

PROBLEMS

AND

THE

BIOPSYCHOSOCIAL

MODEL

not hierarchical: it provides no functional priority of one level over another (14), at least as far as clinical problem solving goes. The clinician-user has no guided priorities to structure clinical decisions. Thus, the clinician has no method for determining which system level is most critical to the problem at hand. The second conceptual problem has to do with the way the biopsychosocial model is conceived as a medical model. We will show that it methodologically limits the scope of medical inquiry in ways that are antithetical to Engel’s (and biopsychosocial practitioners’) intent. First, however, let us review Engel’s conception of the biopsychosocial model. According to Engel, the model is a scientific one: “In any consideration of a scientific model for medicine that would qualify as a successor to the biomedical model, be it the biopsychosocial or any other, the fundamental issue is whether physicians can in their study and care of patients be scientists and work scientifically in the human domain” (15, p. 1 13). The admirable thrust of Engel’s lifework has been to open up all areas of medical life to scientific inquiry. Engel endorses this definition of science from Charles Odegaard: “Science represents man’s most persistent effort to extend and organize knowledge by reasoned efforts that ultimately depend on evidence that can be consensually validated” (IS, p. 1 15). For Engel, then, a medical model should be scientific, and for it to be scientific, its knowledge claims must be supported by reasons and evidence that are open to consensual validation. However, is scientific inquiry relevant to all problems that arise in the clinical encounter? The answer is no, if one considers ethical and practical problems a part of medical/psychiatric practice. Indeed, the methods of science, we will show, are very well-suited to establishing knowledge about areas relevant to medicine but are methodologically ill-suited to other problems in clinical practice. As the examples below illustrate, many significant clinical problems in medicine defy resolution with the methods of science alone. In his later work, Engel himself increasingly views the biopsychosocial model as a model for the scientific aspects of medicine, rather than a general medical model (15). The bulk of this article demonstrates the importance of ethical and practical problems to biopsychosocial decision making and proposes a simple complement to the biopsychosocial model that provides a biopsychosocial problem-solving method.

THE

STRUCTURE

OF THE

CLINICAL

ENCOUNTER

Before going further, we need to define some fundamental concepts that are relevant to the tasks of any medical model. First, what is the context or situation in which the goals of medicine are realized? Fundamentally, these goals are realized in the clinical encounterthe clinical relationship between the physician and the patient. Medical research, public health, and so forth play supportive roles when the practice of medicine is considered.

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The various sorts of events that transpire in a doctor-patient relationship are what we call the clinical content. Because the clinical encounter is conducted over time, the clinical content changes over time. Examples of clinical content could include taking a psychiatnic history, performing a physical examination, performing a gastric lavage, discussing a treatment compliance problem with a cocaine addict, or making a psychotherapeutic interpretation. In the course of the clinical encounter, the clinician attends to some things and ignores others. The clinician’s attention is selective, and the object of attention is thematic for that moment. The theme of the encounter is the clinical content that the physician selects at a particular point. A particular kind of clinical theme is the clinical problem (16). Clinical problems are nodal themes in the clinical encounter, since they often provoke changes in the clinician’s inquiries or prompt the clinician to take therapeutic action. Examples of clinical problems could include determining the diagnosis of schizophrenia, evaluating the role of cholecystokinin in cholelithiasis, managing blood loss in a gunshot victim, improving a patient’s compliance with an antihypertensive medication regimen, or deciding whether to fund treatment for the homeless mentally ill rather than prenatal care for the medically indigent. Clinical problems reflect the broad diversity of difficulties in rendering health care. The clinical problem is the fundamental unit of decision making in the clinical encounter (16). Indeed, a focus on clinical problems (instead of disease entities) has already established itself in psychiatric record keeping ( I 7-20). The idea that clinical problems are the fundamental unit of medical decision making is quite different from the usual idea that a diagnosis, disease, or illness is the fundamental unit. However, considering the actual decisions a clinician makes in everyday work will make this point obvious. Consider this fictionalized example of a clinician’s activities today. Perhaps he came into the office at 8:00 a.m. and found a statement from an insurance company that is supposed to be paying for his treatment of an adolescent with borderline personality disorder. The company says his treatment was unnecessary and it will not pay. Perhaps he had a 9:00 a.m. patient that he could not see until 9:40. Now the patient is very angry. He might wonder how to deal with the patient’s anger. Or perhaps he consulted with the family of a patient in the intensive care unit whose intracranial hemorrhage has left her in a coma for I 1 days. He might wonder when to begin discussing discontinuation of treatment with her family. The point in these examples is that the clinician’s decision-making process is not limited to diagnostic/treatment considerations at all; instead, it focuses on the everyday problems that clinical work presents. Moreover, clinical problems are not limited to explaining biological factors, understanding behaviors or meanings, or integrating these data. Nevertheless, these activities encompass the task of scientific medicine as

Am]

Psychiatry

149:10,

October

1992

JOHN

Engel conceives it. Our examples here and later illustrate that scientific understanding is only a part of the larger task of taking clinical action. A medical model that embraces only scientific understandings will not address important clinical problems. How can we conceptualize a clinical method that will answer the complete range of clinical tasks? On the basis of Pellegrino’s analysis of the clinical encounter (2123), we propose three types of clinical content and, derivatively, three types of clinical problems. These three “faces” of medicine embrace a biopsychosocial approach and provide the means for addressing the special categories of clinical problems we have mentioned. The three faces or aspects are the epistemic aspect, the ethical aspect, and the pragmatic aspect. The

Three

Faces

of Medicine

Epistemic aspect. This aspect of medicine concerns much of the scientific or empirical basis of the clinical encounter. The epistemic aspect has to do with clinical knowing. When considering the contribution of basic and clinical science to clinical decision making, one is probably considering the epistemic aspect of medicine. For example, the epistemic aspects of medicine could include conceptualizing and testing a diagnostic classification system for psychiatric disorders, making a clinical diagnosis, choosing a treatment based on studies of clinical efficacy, or choosing the best approach in counseling a stubborn patient. The epistemic aspects pertain to understanding or explaining clinical events. Ethical aspect. This aspect includes factors in the clinical encounter related to choosing preferable (in the evaluative sense) courses of action. Ethical aspects of medicine could include decisions about risk/benefit ratios for treatments, the justification for withholding important treatment information from a patient, or decisions about distributing scarce treatment resources, such as intensive care beds. The ethical aspects of medicine deal with values, and ethical problems have to do with I ) value conflicts between doctor, patient, and relevant others, such as nurses, families, and society, and 2) threats to valued things or values themselves, such as a diabetic patient’s loss of a leg and subsequent loss of independence. The ethical aspect forces clinical decisions based not on science alone but on values as well (24). This is one reason why the biopsychosocial model, as currently formulated, is of limited assistance in dealing with this category of clinical problem: the biopsychosocial model is a narrowly defined medical model with science as its core method. How can a method for the attainment of knowledge resolve problems involving a clash of values? Pragmatic aspect. This aspect pertains to translating clinical knowledge and ethical choice into effective therapeutic action. Pragmatics pertain to what is done or what action is taken. Pragmatics are necessarily intersubjective-relevant to actual dealings with people. The pragmatic aspects will often emphasize predicting clinical events. Examples could include modifying a

Am]

Psychiatry

149:10,

October

1992

Z. SADLER

AND

YOSAF

F. HULGUS

drug regimen according to anticipated drug interactions, anticipating potential problems with treatment compliance in a patient of a different ethnic background, modifying office management procedures, or meeting Medicare payment guidelines. A pragmatic problem could be not knowing what to do or how to do some relevant task. A pragmatic problem may involve not having sufficient supplies, materials, or assistance, i.e., not having drugs or equipment available. Pragmatic problems prevent effective therapeutic action. The science and art of prognosis is a clinical area in which pragmatics is made concrete. Pragmatic aspects of medicine require actions based on commonsense (or other utilitarian) criteria. Thus, medical scientific knowledge, or the pursuit of it, is only a requirement of, but not the same as, pragmatic doing. Three aspects of one medicine. The three aspects of medicine can be considered explicitly or implicitly in any clinical situation. That is, a clinician can apply each of these aspects to a clinical theme in greater or lesser degrees. Significant overlap from epistemic to ethical to pragmatic aspects occurs. Consider this example from consultation-liaison psychiatry. The clinician is admitting reluctant and delirious patient to the coronary care unit. The obvious pragmatic problem is considering what to do next if the patient refuses admission. Epistemic considerations could include choosing an interviewing approach that will enhance the patient’s consent to admission. At the same time, an ethical consideration could be the status of the patient’s competence to choose admission, with the attendant conflict of protecting or restricting the patient’s freedom. Note that these three aspects are simultaneously present in the clinical encounter, yet they are distinguishable from one another. Each aspect illuminates the clinical goals by providing a relevant context for those goals. It may be tempting to (mis)construe our intent as merely renaming the psychosocial aspects of medicine as the ethical and pragmatic aspects of medicine. This would miss a major point of this article. The psychosocial aspects of medicine as described by Engel have to do with the scientific conceptions of the nonbiological aspects of human life: those aspects of life that are studied by scientific disciplines such as psychology, sociology, and anthropology. The ethical and pragmatic aspects reflect a much broader context of study, one that may include these sciences but also include disciplines that are not scientific at all and are perhaps more properly considered humanities. For example, solving an ethical problem may require moral philosophy, while solving a pragmatic problem may require a business management technique. Most important, ethical problems in medicine require their own method for problem solving, that of resolving competing values. Pragmatic problems require their own method for problem solving, too; that is, common sense. (Ironically, systems theory has much to offer common sense!) Both ethics and pragmatics are readily distinguishable from the knowledge-acquiring methods of science.

1317

CLINICAL

Advantages

PROBLEMS

AND

of Considering

THE

BIOPSYCHOSOCIAL

the

Three

MODEL

Faces

Precisely because both biomedicine and biopsychosocial medicine are properly scientific models for the scientific part of medicine, these models fall short in accounting for the complete clinical encounter by excluding pragmatic and ethical meaning and the taking of clinical action based on those meanings. Clinical problems in these models formally focus on epistemic problems exclusively: What is the diagnosis? What is the most effective treatment? What does this symptom mean? If students and residents are trained to make inquinies about only scientific facts concerning a patient (10, 25-29), then they will ignore the ethical and practical problems that so stubbornly impede the realization of therapeutic goals. The patient is dehumanized-is functionally an object for scientific study. These students mature into practitioners who resent and avoid the ethical and practical aspects that have always been part of medical practice. When only fact gathering is emphasized to students, ethical and pragmatic problems are made a troublesome, intrusive irritant in the practice of scientific medicine. However, by formally considering the three aspects of medicine, the clinician cannot avoid practicing biopsychosocial medicine as it was ideally intended. When the clinician seriously considers and acts upon ethical and pragmatic clinical problems (as well as epistemic ones), the biopsychosocial approach cannot be avoided or ignored. How can one solve ethical problems without considering the values, wishes, ambivalences, and personal histories of the people involved? How can a clash of values be understood without making an empathic connection? How can one solve practical problems without considering the social systems that influence the patient or without considering the psychological and social sciences? Once the epistemic, pragmatic, and ethical dimensions of the clinical encounter are considered equally, the biopsychosocial perspective is unavoidable. In considering these three faces of medicine, the biopsychosocial approach is utilized by focusing reasoning and inquiry, without reviewing every science relevant to medicine. Indeed, what drives clinical decisions is not a structural hierarchy but the moral goals of the clinical encounter (8). What do we mean by considering the three faces? We mean simply that every clinical pnoblem has a theme that is reflected by the three faces, as in the example of the reluctant delirious patient. One or more themes may be explicit, others implicit. In our example, admitting a reluctant patient to the hospital is a pragmatic theme. However, when we ask ourselves how to solve this problem, the overlap with the epistemic and ethical themes can emerge. How should the patient be approached? Is the patient competent? In order to realize therapeutic goals, the clinician’s decision making must provide a way of planning for, or anticipating, future clinical problems. The biomedical model anticipates future clinical (epistemic) problems through its discipline of pathology, which predicts the

1318

longitudinal course of diseases. The biopsychosocial model of Engel recommends a diversity-of-sciences approach but provides no guidelines for selecting the science that applies to a particular patient at a particular time (7). Moreover, the biopsychosocial model provides no formal method of anticipating the idiosyncratic problems that every individual patient presents; only the interdependence of the various system levels is emphasized. The three-aspect method proposed here acknowledges the importance of scientific explanation and prediction while also accounting for the individual, unique person.

RECONSIDERATION

OF THE

CASE

OF

MR.

GLOVER

In Engel’s classic article “The Clinical Application of the Biopsychosocial Model” (2), the case of Mr. Glover provides an example for the application of the biopsychosocial model. We will recast this familiar case to illustrate the three faces decision-making model as well as highlight the differences between the biomedical model, the biopsychosocial model, and the supplemented biopsychosocial model we propose. In the original case, Mr. Glover, a driven, overly responsible man, suffers his second myocardial infarction at work. Denying to himself the seriousness of his illness, he continues working until his boss notices his visible discomfort and convinces him to go the hospital. There he relaxes until an inept intern repeatedly fails to obtain an arterial blood sample. Unnerved and in pain, Mr. Glover begins to doubt the competence of the hospital staff, and his chest pain increases again as his anxiety mounts. He loses consciousness as ventricular fibrillation ensues. The hospital staff jump to the conclusion that he was lucky to be in the hospital when this happened, or else he would be dead. The doctors fail to realize that events that occurred in the hospital may have contributed to Mr. Glover’s cardiac arrest (8). How does the biomedical clinician interpret this case? How does the biomedical clinician decide what data are clinically meaningful or important? The biomedical model would emphasize the importance of the empirical signs and symptoms of myocardial infarction and would bring to bear action that would address the acute course of this disease, including the increased risk of fatal cardiac arrhythmias. The biological aspects of the case would be seen as therapeutically and etiologically most important, with the psychosocial aspects relegated to the background if they are considered at all. In contrast, the biopsychosocial clinician would emphasize the interdependency of biological and psychosocial contributions to Mr. Glover’s illness. In retrospect, the anxiogenic effects of the failed attempts at obtaining an arterial blood sample would be considered important to the development of arrhythmias. This is an example of how the interpersonal system level would have a direct impact on the organ and cellular levels, and vice versa. Note that precisely how a particular case interpretation is developed is not clear with either model.

Am]

Psychiatry

149:10,

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1992

JOHN

In the case of the biopsychosocial model, the clinician is left without guidance toward anticipating and effectively intervening at the appropriate system level. Moreover, as we will describe, certain aspects of clinical reality are deemphasized by both models. For the recasting of Mr. Glover’s case, let us put ourselves in the place of the clinician in the emergency room, where the actual first meeting with Mr. Glover would occur. The physician would have no information about Mr. Glover other than what he or she could obtam firsthand. This scenario will illustrate the application of the three faces of medicine under conditions that are more reflective of a real clinical encounter. This is important, because the test of a problem-solving model is its utility in the face of uncertainty. Let’s say that Dr. Smith is now meeting Mr. Glover to examine him in the emergency room. Smith: Hello, I’m Dr. Smith. Glover: Aw, I’ve been having

What seems to be the trouble? some chest pain. I don’t think

it’s a big deal, but my boss insisted that I come Smith: You’ve had this sort of thing before?

in.

Glover: Yeah, I had a heart attack 6 months ago. Smith: You’ve broken out into a sweat and look pretty pale. Let me get you to lie down while I have the nurse hook up an ECG. Tell me more about your heart disease. Glover: I had a heart attack 6 months ago; since then I’ve only needed to take nitroglycerin occasionally. You don’t think

this

is another

heart

attack,

do you?

Smith: That remains to be seen, but in the meantime, we ought to keep you comfortable. How much pain are you hay-

Smith:

Any

Glover:

I

Smith:

Smith:

(points like

Pretty (examining

quite

a bit at work,

but it’s a little

symptoms?

does

Here Just

Glover: Smith

other

had nausea

Where

Glover: (left) arm.

hurting

your

at work

and

felt weak.

it hurt?

to substernal heart

attack

region)

and

down

this

before?

Glover:

Glover’s

chest):

I think

there’s

a good

chance you’re having another heart attack, so I want you to take it easy for now. There will be an intern coming in to draw some blood and finish your exam, and the nurse will give you some pain medication and some Valium. The initial clinical priority in any first-time clinical encounter is making sense of the patient’s clinical complaints. This is obvious and an example of an epistemic problem, namely, understanding Mr. Glover’s medical problem. Dr. Smith accepts Mr. Glover’s complaint of chest pain at face value and tries to characterize it as one of the many types of chest pain he has encountered in his training and experience. In this way, he may statistically specify and predict potential events of clinical significance. Thus, this aspect of his clinical inquiry resembles a natural scientific inquiry, explanation, and prediction (30, 31). As Dr. Smith conducts his inquiry into the chest pain, he anticipates potential new clinical problems. This anticipation of future problems is the initial priority of the pragmatic face of medicine. The tentative diagnosis of

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Psychiatry

149:10,

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1992

Smith:

YOSAF

F. HULGUS

Valium? To help

What you

for?

relax

so your

heart

won’t

have

to work

so hard. Glover: It’s not going to knock me out is it? I want to know what’s going on. Smith: Let’s see how you do with the pain medicine alone, but

it’s important

that

you

relax.

and nurse Brown attends to Mr. Glover (to nurse): You know, in here

much.

AND

myocardial infarction foretells a range of dangerous clinical possibilities. Dr. Smith notes the incongruity between Mr. Glover’s casual dismissal of his complaint as “some chest pain” and his observable diaphoresis and pallor. Dr. Smith wonders whether Mr. Glover is denying to himself the severity of his illness. Dr. Smith sees this as an important potential pragmatic problem; if Mr. Glover is seriously ill and denies it, he may refuse lifesaving treatments. Dr. Smith keeps in mind this hypothesis of Mr. Glover’s denial for later interactions with Mr. Glover. The ethical aspects of this encounter are more implicit. The ethical priority is to ask the question, What values are at stake when I take any clinical action? Dr. Smith works in a setting-the emergency room-where the ethics are significantly different from those of other outpatient or inpatient settings. For example, Dr. Smith feels less bound to provide careful disclosure for informed consent, because such disclosures interfere with undertaking effective and potentially lifesaving therapeutic action in the limited time available. Thus, Dr. Smith has in effect decided to override the ethical demand for complete disclosure at this time. However, if Mr. Glover contests this relative lack of disclosure, the ethical aspects of the case could emerge as an ethical problem that would demand attention from Dr. Smith. Dr. Smith, then, as a biopsychosocial clinician, should attend to Mr. Glover’s wishes for more information.

ing?

Glover: It was better now.

Z. SADLER

because

of my

work,

but

(Dr.

Smith

leaves

Glover.) I really didn’t now

I do

the

want feel

a lot

room,

to come better.

What is this pain medicine anyway? Brown (smiling): Morphine; it should help you feel even better. Glover: Seems like pretty strong stuff for chest pain. Brown: We don’t want people with heart attacks to hurt. (Nurse

Brown

attends

leaves

as intern

enters.)

to

various

technical

procedures

and

Dr.

Smith’s sensitivity to a potential ethical problem out by Mr. Glover’s behavioral response to the offering of analgesics and anxiolytics. Mr. Glover’s concern about avoiding excessive sedation and maintaming control of himself suggests to Dr. Smith the potential for power struggles with the patient. Recognizing Mr. Glover’s compulsive personality style, Dr. Smith compromises a pragmatic goal, control of anxiety, in order to obviate an ethical conflict, that is, handling Mr. Glover’s implicit refusal of diazepam. At the same time, Dr. Smith brings to bear a rudimentary knowledge (epistemic aspect) of the compulsive personality in shaping his choice to forgo the diazepam. Dr. Smith, as a preceptor to his intern, now turns his attention to the encounter with Dr. Young and Mr. is borne

1319

CLINICAL

PROBLEMS

AND

THE

BIOPSYCHOSOCIAU

MODEL

Glover. Ever vigilant, he pragmatically considers what potential problems could emerge from this interaction as he moves to the next patient in the next room. He wonders whether Dr. Young’s own anxiety about doctoning will somehow compound Mr. Glover’s anxiety and makes a mental note to check in on them shortly. Young: Hi, Mr. Glover. I’m Dr. Young, the intern working with Dr. Smith. I need to go over some of the information again that you discussed with Dr. Smith and do a more complete physical. Glover (sighing): Okay. (Dr. Young takes the history and examines Mr. Glover.) Young: Mr. Glover, I need to take an arterial blood sample from you to determine if your blood has enough oxygen. You can expect the stick to hurt some. Glover (tensing up): Can I look? Young: If you want. (Dr. Young attempts to draw the arterial blood but has difficulties. After Dr. Young has made several unsuccessful attempts, Dr. Smith returns, as he had planned.) Smith:

How’s

it going?

Young (nervously): Fine. Glover (anxious and in pain): Can’t this guy just get the blood? Smith (diplomatically, to Dr. Young): Let’s get Ms. Brown to hold his wrist while we go over another case. Mr Glover, I don’t think the arterial blood sample is essential at this time. Let’s hold off on it until you’re more comfortable. How’s your chest pain? Glover (relieved): Better, thanks. Smith (looking at the ECG monitor): You got pretty excited with that stick, but you’re already settling down. Glover: You’ll be back soon? Smith:

Sure.

(Mr. Glover plications.)

In the

is taken

meantime,

Ms.

to the coronary

Brown

care

will

unit

be with

without

you.

com-

When Dr. Smith reenters the room, witnessing Mr. Glover’s clenched teeth and grimace, he immediately concludes that things are not going well at all, despite Dr. Young’s reassurances. Effective action is needed, and Dr. Smith has a number of important pragmatic factors to consider before acting. Is Mr. Glover dyspneic enough to warrant the arterial blood gas procedune? Is the need for the procedure more important than keeping Mn. Gloven calm and collected? Is it ethical to allow Dr. Young, a trainee, to continue his painful attempts to draw arterial blood when these very attempts may present some degree of risk to Mr. Glover (i.e., precipitate a cardiac arrhythmia through increased sympathetic tone)? In his deliberation, Dr. Smith keeps in mind his goal of getting Mr. Glover safely to the intensive care unit. Dr. Smith’s pragmatic consideration of these ethical and epistemic factors prompts his decision to withhold further attempts at the arterial blood gas procedure, and indeed he successfully transfers Mr. Glover to the intensive care unit. Note that in this example, the three faces (epistemic, ethical, pragmatic) are interdependent. Dr. Smith’s choice to withhold diazepam (a pragmatic move) is dependent on his knowledge (epistemic aspect) of the pathophysiology of myocardial infarction, the relation-

1320

ship of anxiety to arrhythmia, and so on. Dr. Smith’s withholding of diazepam is also dependent on his view of the ethics of paternalism, that is, how he views the conflict between a patient’s refusal of treatment and the need for urgent and beneficent action. Dr. Smith’s prionities are tripartite: 1 ) (epistemic aspect) what is the problem? 2) (pragmatic aspect) what actions need to be taken and what will be their consequences? 3) (ethical aspect) what value implications do my actions have? Precisely because he moves comfortably from clinical knowledge to clinical ethics to clinical pragmatics and back again, Dr. Smith is a truly biopsychosocial clinician. Working through the three faces provided him a problem-solving map for the uncertainties of on-yourfeet practice.

THE

PROBLEM

OF CROSSED-ASPECT

DECISION

MAKING

Earlier in this article we discussed briefly the training of medical students-a process dominated by the lesson that medical science is the primary discipline relevant to the practice of medicine. These students may develop into practitioners whose expectation is that all clinical problems can be solved with the well-honed tools of the natural scientific inquiry. Indeed, the overwhelming majority of material in medical school curricula is basic and clinical science. For these students (and many practitioners), there is only one face of medicine: the epistemic aspect. The most obvious difficulty with singleaspect decision making is the one that inspired Engel’s “biopsychosocial” response: attending to a narrowly defined science in medicine dismisses the broad range of human experience and dehumanizes patients. We now illustrate why the single-aspect approach to clinical decision making may often be fruitless in dealing with ethical and pragmatic problems and, in some cases, may be even dangerous to patients. We use the term “crossed-aspect” decision making to describe the situation in which a clinical problem in one face of medicine is confused with another. The confusion or misidentification can lead to great difficulty in solving a clinical problem. This confusion can be avoided simply by reconsidering the clinical problem in light of all three faces or aspects. Examples

of Crossed-Aspect

Decision

Making

Applying an epistemic solution to an ethi cal problem. A colleague discussed with one of us an ethical problem that occurred in the context of the psychiatric emergency room. He had a patient, brought in by police, who was refusing to be meaningfully interviewed. The patient had a history of violent psychotic illness, so an evaluation would be essential if there was to be any possibility of his release into the community. Our colleague’s problem was whether it was ethical to tell the patient, “You should talk to me, because if you don’t, I have no choice but to commit you to the hospital.”

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Intrigued, we pursued his thinking about this problem. His solution was to survey the emergency room psychiatrists, asking them how they handled this situation. Our colleague was quite reluctant to consider what values were at stake. Instead, he thought that if the majority of the emergency room psychiatrists did it one way, that must be the right way. In effect, our colleague was applying an epistemic solution to a correctly identified ethical problem. What is disturbing, even dangerous, is his thinking that scientific data gathering, which mdicated consensual agreement only, would be sufficient to suggest right (ethical) action. Of course, in some cases it could dictate a right action or, more likely, reveal some way of avoiding or circumventing the ethical problem. Nevertheless, what was needed to answer the ethical problem was a qualitative inquiry into the cornpeting values at stake (32). The idea that consensual agreement about practices is adequate for making ethical choices can be dangerous. In the extreme it can result, as in Nazi Germany, in consensually agreed-upon atrocities (33). Inquiries that give equal respect to the three faces moderate the extremes of any single mode of decision making. Mistaking a pragmatic problem for an ethical one. An internist, Dr. A, consulted one of us for an “ethical” problem he had with a critically ill, elderly patient. The patient, Mr. Z, had experienced cardiac arrest, had an anoxic cerebral injury, and was diagnosed as being in a persistent vegetative state. He had a living will and had told his internist and family members that if he became a “vegetable,” he would not want to be kept alive artificially. The internist had planned to withdraw life-sustaming treatments, but he had been threatened with a lawsuit by Mr. A’s estranged daughter. The daughter wished “everything be done” to keep Mr. Z alive, despite her knowledge that her father preferred otherwise. Dr. A was now hesitant to discontinue treatment. Upon further questioning, Dr. A outlined his rationale for the ethical discontinuation of Mr. Z’s treatment. It became clear to him, and to us, that his best ethical judgmentto discontinue treatment-was reasonable; thus, prob1cm-solving efforts should be focused instead on the practical (pragmatic) problem posed by the daughter: litigation. The case was resolved by bringing in the hospital attorney to discuss the case with the daughter. Treatment was discontinued, Mr. Z died peacefully, and no litigation ensued. Seeking more “facts to solve ethical or pragmatic problems. This kind of crossed-aspect error demonstrates persistence in thinking about clinical problems as exclusively epistemic-aspect scientific problems. In the context of an ethics conference, a case was presented in which a psychiatrist (Dr. B) had to choose whether or not to inform the fianc#{233}e(Ms. X) of the patient (Mr. Y) of his HIV-positive clinical status. To complicate matters, Ms. X was also a patient of Dr. B. The identified problem was the ethics of breaching confidence about Mr. Y’s HIV status in order to provide possibly lifesaving information to his fianc#{233}e.The questions raised by several residents betrayed discomfort “

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about grappling with the ethics or values in conflict. They asked questions about the clinical status of Mr. Y and details of the couple’s engagement: What signs or symptoms of AIDS or AIDS-related complex did Mr. Y have? How long had Mr. Y been under the physician’s care? What was the patient’s psychiatric diagnosis? How long had the patient been engaged to Ms. X? Did Mr. Y otherwise have an honest and open relationship with Ms. X? Under what circumstances did Dr. B discover Mr. Y’s HIV status? After this information had been disclosed, the residents came to realize that the new information shed very little light on the problem at hand. A discussion of the conflicting duties, including ethical obligations as well as legal (pragmatic) ones, resulted in a near-consensus on the decision that Dr. B should try first to persuade Mr. Y to tell his fianc#{233}ehimself, and failing that, Dr. B should inform Ms. X. This example shows that scientifically driven fact gathering can detour decision making that is more efficiently handled within the ethical or pragmatic mode of reasoning. This is not to dismiss the value of scientific inquiry or the acquisition of relevant facts regarding ethical problems. Rather, this example suggests that adding the ethical and pragmatic modes of thinking can be fruitful and efficient. Indeed, crossed-aspect decision making emphasizes the interdependent nature of the three aspects; for example, an inquiry into the values at stake can help in determining the relevant facts, and the relevant facts of the case can shed light on the values at stake. There are many other possible examples of crossedaspect failures in clinical decision making. It would be misleading, however, to suggest that a problem in a single face or aspect requires a solution in that aspectfor example, that an ethical problem requires a valuebased solution. Frequently, a clinical problem in one aspect can be resolved within another aspect. Reconsider the case of Mr. Y. If Dr. B had been able to persuade Mr. Y to tell his fianc#{233}eof his HIV status, Dr. B would have used a pragmatic solution to obviate a more ethically profound decision: to breach or not to breach confidentiality.

DISCUSSION The biopsychosocial model reflects a particular theory as well as an intended ideal. It is the ideal or spirit that has influenced us the most. The biopsychosocial model, for us, symbolizes humane, empathic, yet rigorous medical care. It is in this spirit that we make the distinction between the importance of the biopsychosocial model and having a concrete method for making humane, empathic, and rigorous clinical decisions. The clinical method introduced here is intended to render the biopsychosocial model more useful in clinical decision making. As we have argued, however, clinical decision making requires a disciplinary scope much broader than science alone can offer. The three faces or aspects can provide a conceptual shorthand for system-

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CLINICAL

PROBLEMS

AND

THE

BIOPSYCHOSOCIAL

MODEL

FIGURE 1. Disciplines Relevant to the Biopsychosocial Model Alone and to the Biopsychosocial MOdel and the Three Faces Model Considered Together

BIOPSYCHOSOCIAL MODEL

General

systems

BIOPSYCHOSOCIAU THREE FACES

theory

General

systems

Biology

Biology

Psychology

Psychology

Sociology

Sociology

Anthropology

Anthropology

Other natural/social sciences

Other natural/social sciences Health

PLUS MODEL

theory

law

Ethics

Other

philosophy

Informatics Communications Business Other

theory

management disciplines

atically examining the breadth of clinical decision making. Figure 1 shows the conceptual scope of the biopsychosocial model and that of the three faces decisionmaking model described here. It underscores the fact that the complementanity of the three faces model is not simply a matter of semantics. Making biopsychosocial decisions involves ways of reasoning besides scientific thinking. Figure 1 may lead the reader to think that we are adding to the complexity of the biopsychosocial model. In a sense we are, and in a sense we are not. Complexity is suggested by the set of extra formal disciplines that are relevant to biopsychosocial medicine. However, in another way we are not adding complexity. We are not advocating a review of every science in figure 1 before one makes a clinical decision. Indeed, this would counter the demands of the pragmatic face of medicine. With the systems hierarchy, the sciences relevant to psychiatry and medicine are a long list indeed. Should we review each of them before making a clinical decision? With the three aspects described here, clinical problems and decisions can be framed in three interrelated areas without going over each relevant science. Engel himself recognized the limitation of the biopsychosocial model in problem solving and reconceptualized it in his later work (15) as a model for the science of medicine. To use our language, it is a model for the epistemic aspect of medicine. As such it is an attempt to integrate the pluralism of sciences within medicine. We consider the systems hierarchy essential to research in

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psychiatry and medicine, as a theoretical structure for intenlevel research problems. However, the diversity ofsciences that embrace the epistemic aspect of medicine may not be the place to look for integration of patient care. It may be through pragmatic and ethical considerations that the wholeness and integrity ofthe patient can be preserved (34). After all, it is the patient’s complaint or need that shapes the inquiries and actions in medicine. Science cannot address patients’ needs directly; rather, pragmatic and ethical considerations are required in order to render treatment whole. Patients’ practical and moral imperatives direct every therapeutic inquiry and action. The basic clinical method offered here emphasizes the equivalent importance of epistemic, pragmatic, and ethical considerations in everyday clinical decision making. Further work is needed to describe how the clinician recognizes or distinguishes epistemic, pragmatic, and ethical problems in the clinical encounter. Furthermore, once a problem in a given aspect is recognized, a method is needed for selecting relevant information that contributes to solving the clinical problem (31, 34). Clinical decision analysis has directed research attention toward clinical decision making and problem solving at least partly to enhance the teaching of clinical skills. However, the majority of work in decision analysis has focused on the problems of diagnosis and treatment (35) (i.e., epistemic aspects), while the incorporation of ethical (36) and practical concerns into these analytic procedures is rare. It seems unlikely that decision analysis will model human clinical decision making accurately without attending to clinical problems per se as well as the ethical and pragmatic aspects of medicine. Research in education has demonstrated the disparity between so-called cognitive knowledge and clinical knowledge (37-40). This disparity is reflected in the three faces of medicine. Cognitive knowledge has to do with what we call the epistemic aspect of medicine, while clinical knowledge would reflect equally the epistemic, ethical, and pragmatic aspects of medicine. Even when we try to define away all but the epistemic aspects of medicine, ethics (36) and pragmatics stubbornly sneak into the problems that confront us. Forrow et al. (41 ) described the improvement of clinical care that clinical ethics has fostered and the new questions for research that clinical ethics has posed. What new questions does clinical pragmatics pose? Clinical pragmatics raises questions having to do with taking effective therapeutic action. Some examples could include the following: How do we fund health care for the indigent? What kind of office management facilitates efficient delivery of care? How does a clinician effectively manage the medically ill patient with a personality disorder? What is the best triage system for an emergency room? How do we improve compliance with complicated drug regimens? The disciplines that would deal with these questions would be diverse indeed-biology, psychology, sociology, systems theory, economics, informatics, philosophy, business manage-

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ment, and so on. Many of them are not science at all, at least in the formal sense. Many clinicians would claim that these questions have little to do with medicine (42) and certainly not with medical education. Can we afford to not study and teach about the ethical and practical aspects of medicine? Can we practice effective medicine without these considerations?

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