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Beyond the Biopsychosocial Model New Approaches to Doctor-Patient Interactions
METHODS: Interactions between Dr M and 9 Native Americans with type 2 diabetes were audio-recorded following preliminary interviews. Interpretations of the interactions were elicited from Dr M through interpersonal process recall and interpretive dialogue sessions. The author analyzed this data using techniques from interpretive anthropology and narrative discourse analysis.
RESULTS: In a preliminary interview, Dr M described a sophisticated biopsychosocial approach to practice. However, she viewed her actual interactions with these patients as imbued with misunderstanding, mistrust, and disconnection. This occurred in spite of her experience and commitment to providing culturally sensitive primary care.
CONCLUSIONS: Biopsychosocial models of disease may conflict with patient-centered approaches to communication. To overcome difficulties in her practice environment, Dr M adopted a strategy that combined an instrumental biopsychosocial approach with a utilitarian mode of knowing and interacting with patients. The misunderstandings, mistrust, and constrained interactions point to deeper problems with the way knowledge is formed in clinical practice. We need further understanding of the interrelationships between physicians’ clinical environments, knowledge of patients, and theories of disease. These elements are interwoven in the physicians’ patient-specific narratives that influence their interactions in primary care settings.
For 2 decades the biopsychosocial model has been important for the practice of family medicine.1,2 Physicians using this model integrate biological, psychological, social, and cultural domains in solving clinical problems and developing therapeutic strategies.3,4 Most writing on the biopsychosocial model has focused on theory development and educational transmission.5,6 Little attention has been paid to whether community-based family physicians apply biopsychosocial strategies in their interactions with patients.7 This qualitative case study addresses the following question: How does a community-based family physician trained in the biopsychosocial model apply this understanding to interactions with patients with type 2 diabetes from different cultural backgrounds?
Methods
Framing the Problem
This study was conducted in a Native American health center located in a multiethnic low-income urban neighborhood. The research focused on 3 interrelated contexts present in all physician-patient interactions: disease, patient, and physician. The significance of disease is often ignored in studies of physician-patient communication. Type 2 diabetes was selected to represent an important problem in family practice from within both biomedical and biopsychosocial paradigms.8 Native Americans were selected because type 2 diabetes is a serious concern in their communities, and use of the biopsychosocial model should be particularly important where significant sociocultural differences exist between patients and physicians.9 A diverse group of patients was recruited on the basis of duration of disease, tribal background, sex, and prescribed medical regimen Table 1. Dr M—a white, board-certified family physician with 6 years’ experience at this health center—was selected because of her sophisticated understanding of biopsychosocial theory and strong commitment to the health care of urban Native Americans.
Procedure
The overall design for this case study was interpretive.10-12 This approach to data collection and analysis assumes that meaning is constructed out of subjects’ everyday interactions with others and is situated in the particular contexts of their sociocultural activities.13,14 The researcher actively interacts with the subjects to describe and interpret their actions, the context of their actions, and the meaning they ascribe to their actions.15 Within this general design, specific methods were employed for gathering and interpreting data. Interviews with patients explored their understanding of type 2 diabetes, self-care practices, social backgrounds, and relevant life histories.16 Interviews with Dr M explored her understanding and treatment of type 2 diabetes, concerns specific to diabetes in Native Americans, and views about the context of practice and its relationship with diabetes care. Patient visits for diabetes care with Dr M were audio-recorded and replayed to elicit her interpretation of the interaction using a modification of interpersonal process recall (IPR).17-20 The transcribed interviews, interactions, and IPR sessions were then interpreted using methods adapted from narrative and discourse analysis,21-23 interactive ethnography,24 and grounded interpretive research.25 Themes that emerged from the review of the interviews, interactions, and IPR sessions were analyzed with Dr M in interpretive dialogue (ID) sessions. In the ID sessions, the interpretations of specific interactions and IPR sessions were discussed with Dr M to elicit her views about the broader context of the interactions. General interpretations were developed and reviewed in further sessions with Dr M. The process was closed when it appeared that more sessions would add little to the general interpretations of the study.
Results
Preliminary Interview
In the initial interview, Dr M held that type 2 diabetes in Native Americans had complex biological, psychological, and social causes Table 2. She emphasized that “as a family practitioner, my outlook is that of a generalist, so I like to look at as many levels as I can, because I think that is what being a generalist is about.” She viewed quality communication as central to multilevel care and saw herself as introducing metaphors into the way patients thought about their bodies to “get them to understand [diabetes] the way” she understood the disease. This approach involved translating her biopsychosocial model of type 2 diabetes into the patient’s language to explain how diet, exercise, medication, and glucose monitoring were key self-care behaviors. She considered her strategy successful if her patients “said they would do these things, and they actually did them.”
Initial Interpretive Sessions
During the IPR and ID sessions, Dr M discussed an array of problems with misunderstanding and distrust in her patient interactions. Although the interactions were problematic for all of the study patients, what varied between patients was the intensity and significance of the misunderstanding or mistrust Table 3.* Dr M talked about feeling manipulated, disbelieving statements, distrusting information, despairing over differences, and even detaching from any expectation of helping a patient she could never trust. She considered her approach constrained by basic value differences with her patients, believing that for many health was not a high priority. This value difference, combined with her perception of fatalism in her patients, caused her to believe it unlikely that she could convince them of the value of her approach. This created a central conflict, because she thought her approach would not work unless her patients accepted its value. Thus, Dr M concluded that she needed to change her patients’ values about their health. However, she did not know how to change their values, and she did not know if value change was possible. In one of our final interviews she concluded, “They [the 9 patients in this study] are over there. I’m over here. I feel this absence, this nothingness between us that I don’t know how to bridge.”
Reframing the Research Problem
Although it is not surprising that a white physician and Native American patients would have difficulties communicating with each other, what was unexpected was that misunderstanding and mistrust would be problematic between this physician and these patients. Characteristics of both the patients and the physician selected for this study made it much more likely that gaps in communication could be bridged. The patients were all bicultural and fluent in English. The study was situated in an urban environment, decreasing the likelihood of a more unified cultural understanding that might be present in an isolated rural Native American community.26 Dr M was aware of potential problems in communication with patients from different cultural and class backgrounds. She spoke of carefully translating medical information into the language of the patient and was knowledgeable about historical and political aspects of relations between Native Americans and whites and their relevance to the care of patients in her practice. The problems of mistrust and misunderstanding that emerged in this setting required further interpretation of the way Dr M’s knowledge of person, disease, and clinical context were interrelated and in the background during her patient interactions.
Knowledge of Patients
Dr M perceived that knowing patients well was “the single greatest thing” in her interactions with them. “I really have a lot of trust that my patients will red-flag those problems that are serious. I don’t have that with all my patients, but if I know a patient well, then I’ll trust that he won’t let it go if it’s important.” “Knowing a person” and “trusting a person” was not a conscious aspect of her decision-making process but an awareness that framed her stance toward each interaction. Dr M interpreted a patient’s story out of her own constructed story about the patient. Her interaction with Patient C is presented in this paper, but she had a story to tell about every patient involved in this study Table 4.
Knowledge of Disease
Dr M’s multilevel understanding of diabetes produced tensions in her clinical practice. These are exemplified in her views of the relationship between stress and diabetes care Table 4. In any given interaction, she needed to make decisions about what aspects of the disease required focus. Dr M developed an approach for determining what was important in particular situations. By “knowing a patient well from a medical perspective” she felt that she could very quickly assess what needed attention. This often meant directing the patient away from problems like stress and toward issues like exercise, diet, and medications, which were “the cornerstones of diabetic care” for Dr M. In this manner, she focused on the aspects of the disease she thought she could affect.
Knowledge of Clinical Context
Dr M described a web of problems in her clinical context that constrained her interactions with patients. Every day she contended with numerous barriers to patient care created by a medical care system that ignored the health concerns of the poor. Chronic staffing and resource problems within the health center created situations where she spent a large proportion of her time away from direct patient care. Within this context, she developed an approach to make the most efficient use of her time with patients.
Dr M and Patient C: A Cycle of Hopelessness
Although interactions with all of the patients were used in developing these interpretations, the findings from a crucial discussion with Patient C show the way detachment emerged in practice for Dr M. In the fourth recorded interaction between Patient C and Dr M Table 5, Patient C first told Dr M that she was not taking her prescribed medicine. Dr M interpreted this revelation as shown in Table 4. Although Patient C’s truth telling could have opened up the relationship, instead it confirmed Dr M’s previous beliefs about Patient C. Within Dr M’s practice constraints, Patient C was viewed as a chaotic, noncompliant alcoholic, and thus Dr M’s time could be more effectively spent by detaching from Patient C and attending to other patients she might change. In contrast to Dr M’s constructed reasons explaining Patient C’s elevated blood sugars, Patient C tells a different story about her personal struggles with alcohol and diabetes while living in poverty. Patient C’s interview was conducted a few months after she moved from the streets to a low-income apartment and 3 months before the fourth recorded interaction Table 6.
Patient C distrusted the “white man’s medicine” and was preparing to tell Dr M about her reluctance to take the medicine. Patient C’s belief that some physicians “care” suggests that she valued attributes of a physician separately from their approach to illness. Although Patient C’s honesty may have opened up the possibility for dialogue about differing interpretations of diabetes illness experience and self-care, Dr M’s stance blocked her ability to enter into the very dialogue needed to potentially reconstruct the relationship with this patient.
Patient-Specific Narratives: Stories about People, Disease, and Clinical Context
Dr M implicitly used patient-specific narratives as powerful instruments to identify aspects of patients’ illness experiences that she considered clinically important and potentially manageable. To construct her story about a patient, Dr M combined narratives gathered from her cumulative interactions with a patient in the health center, her interactions with people in the community, and her discussions with others working at the health center. In addition, the stories were broadened by Dr M’s patient-specific application of disease theory and the particular pressures of her practice environment.
Discussion
Important theoretical models for primary care physician-patient relationships include sustained partnership, patient-centered care, and enhanced autonomy.27-29 Although they advance somewhat different theoretical claims, each of these models emphasizes knowing the “whole person,” fostering empathy and trust, and engaging in shared decision making. With a focus on “the patient” or “the relationship” in these models, “disease” is often marginalized or considered only as an important outcome variable for measuring the impact of physician-patient interactions.30 In contrast to patient- or relationship-centered models, the biopsychosocial model is frequently assumed to combine a holistic understanding of disease-illness processes with attention to the primary care relationship. This study demonstrates that biopsychosocial models of disease may actually conflict with patient-centered approaches to communication.
Biopsychosocial models are integrated theories of disease, not models for physician-patient interactions in family practice. There are at least 2 distinct strategies for working with biopsychosocial understandings of disease. In an instrumental approach, the family physician strives to change the patient’s perspective to adapt to the physician’s biopsychosocial understanding of disease and illness care. In a dialogical approach, the family physician interacts with the patient to understand the biopsychosocial disease and co-construct the approach to illness care over time. Both strategies can claim to be directly applying biopsychosocial models, and both might be successful in various clinical contexts. In this study, Dr M took the first approach and found herself left with an unbridgeable gap in communication.
The misunderstandings, mistrust, and constrained interactions found in this study point to deeper problems with the way knowledge is formed in clinical practice. Physicians construct their understanding of disease in individual patients through patient-specific narratives that combine knowledge of disease, patients, and clinical context. These narratives may gain richness, depth, and complexity over time, but they may also become static forms of representation. Knowledge of the illness experience of patients with chronic diseases like type 2 diabetes is expanding; however, our understanding of the practice experience of primary care physicians is limited.31-33
Recent use of direct observation of family physicians has provided a more thorough knowledge of “the black box” of community-based practice.34,35 This paper seeks to add to that literature by offering an in-depth multimethod qualitative approach for studying physician-patient interactions. Techniques using pre- and postencounter rating instruments cannot grasp what actually happens in interactions. Quantitative content or process analysis of physician-patient interactions cannot fully address the relationship between context and meaning in these interactions.36-39 However, the depth of meaning and context provided by qualitative studies in general and discourse analysis in particular are frequently dismissed because of concerns about generalizability.40,41
Critics might argue that the findings from this study derive from the practice of an uncaring physician and should not be generalized to the theoretical and practice issues drawn in the analysis. The evidence points in the opposite direction in regard to the integrity of Dr M. Although mistrust and misunderstanding were important issues to explore in Dr M’s interactions with patients, this was not immediately apparent from the content of the interactions themselves. This study required Dr M’s honesty and willingness to engage in the difficult process of disclosure and self-reflection over a busy 1-year period of clinical practice.
Limitations
Sampling strategies were used to address the generic critique of generalizing from a single case. The practice site was chosen to be exemplary of a community health center in a challenging low-income, urban, cross-cultural setting. The physician was selected to be an exemplary representative of a community-based clinician, and the patients were recruited to provide a sample of Native American adults with diabetes with varying degrees of social and cultural differences from the physician. If problems of distrust and misunderstanding exist in this setting, then similar patterns are likely to exist in other low-income cross-cultural contexts. Finally, this form of qualitative research allows the reader to judge the relevance of the findings to their own context.42 Are the problems Dr M described in her interactions with these patients understandable? Physicians may ask themselves: Am I getting through to this patient? Is this patient manipulating me? Is this patient telling the truth about their adherence to the regimen I have recommended? Do I have anything to offer this patient? Is there an unbridgeable gap in communication, or has the approach taken toward care of this patient been narrowed by an instrumental understanding of the person, the disease, and the context of care?
The organization of practice and the underlying structure of knowledge construction and use can create conflicts between the intentions of physicians and their actions in clinical practice.43-45 To understand and meet this challenge, we need further research of community-based physician-patient interactions that brings together theoretical and empirical forms of inquiry. Theoretical models, derived from ethics and the philosophy of medicine, seldom incorporate practice-based empirical study, while empirical work on physician-patient interactions frequently demonstrates a very limited attention to important theoretical concerns.46-49 Study of patient-specific narratives can bring together literature on biopsychosocial models, physician-patient interactions, patient illness narratives, physician self-awareness, and the organization of primary care practice. Further qualitative research should examine the way patient-specific narratives are developed by physicians practicing in different clinical environments and explore the interrelationships between patient-specific narratives and the content and quality of physician-patient interactions.
Conclusions
To apply biopsychosocial disease models in practice, physicians construct stories about patients as persons. These patient-specific narratives may be opened up or constrained by clinical context, and they both frame and are framed by physicians’ approaches to disease in particular interactions. To advance our use of integrated disease models, we need further study of the way patient-specific narratives are constructed in clinical practice. Application of integrated models of disease and construction of stories about patients may involve problems of misunderstanding and mistrust by either the patient or physician. The presence of these factors does not necessarily close off the possibility of meaningful and effective physician-patient interactions. The challenge is to strive to recognize misunderstanding and mistrust and to develop new strategies for reconstructing problematic interactions in community-based family practice.
Acknowledgments
The fieldwork for this study was conducted while Dr Bartz was a fellow in the Clinical Scholars program at Stanford University, with funding from the Robert Wood Johnson Foundation.
Dr Bartz gratefully acknowledges Richard Addison, PhD, Benjamin Crabtree, PhD, and Halsted Holman, MD, for advice on the initial design and implementation of this research; and Suzanne Fleischman, PhD; William Miller, MD, MA; Jessica Muller, PhD; and Guenter Risse, MD, PhD, for their thoughtful feedback and comments on earlier drafts of this paper.
1. Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977;196:129-36.
2. Campbell TL. Medical interviewing and the biopsychosocial model. J Fam Pract 1998;47:339-40.
3. Engel GL. The clinical application of the biopsychosocial model. Am J Psych 1980;137:535-44.
4. Burkett G. Culture, illness, and the biopsychosocial model. Fam Med 1991;23:287-91.
5. Medalie JH. Angina pectoris: a validation of the biopsychosocial model. J Fam Pract 1990;30:273-80.
6. Brody H. The validation of the biopsychosocial model. J Fam Pract 1990;30:271-2.
7. Marvel MK, Doherty WJ, Weiner E. Medical interviewing by exemplary family physicians. J Fam Pract 1998;47:343-8.
8. Greenfield S, Kaplan S, Ware J, Martin Y, Frank H. Patients’ participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med 1988;3:448-57.
9. Hagey R. The native diabetes program: rhetorical process and praxis. Med Anth 1989;12:7-33.
10. Stake RE. Case studies. In: Denzin N, Lincoln YS, eds. Handbook of qualitative research. Thousand Oaks, Calif: Sage Publications; 1994;236-47.
11. Yin RK. Applications of case study research. Newbury Park, Calif: Sage Publications; 1993.
12. Geertz C. Thick description: toward an interpretive theory of culture. In: Geertz C. The interpretation of cultures. New York, NY: Basic Books; 1973;3-30.
13. Rabinow P, Sullivan WM. The interpretive turn: emergence of an approach. In: Rabinow P, Sullivan WM, eds. Interpretive social science: a reader. Berkeley, Calif: University of California Press; 1979;1-21.
14. Taylor C. Interpretation and the sciences of man. In: Taylor C, ed. Philosophy and the human sciences: philosophical papers 2. Cambridge, Mass: Cambridge University Press, 1985;15-57.
15. Addison R. Grounded interpretive research: an investigation of physician socialization. In: Packer M, Addison R, eds. Entering the circle: hermeneutic investigation in psychology. Albany, NY: State University New York Press; 1989;39-57.
16. Crabtree B, Miller W. A qualitative approach to primary care research: the long interview. Fam Med 1991;23:145-51.
17. Kagan N. Interpersonal process recall: a method of influencing human interaction. Mason, Mich: Mason Media; 1975.
18. Arborelius E, Timpka T. General practitioners’ comments on video-recorded consultations as an aid to understanding the physician-patient relationship. Fam Pract 1990;7:84-90.
19. Frankel R, Beckman H. Impact: an interaction-based method for preserving and analysing clinical transactions. In: Pettigew L, ed. Straight talk: explorations in provider and patient interactions. Nashville, Tenn: 1982.
20. Sommers PS, Muller JH, Saba GW, Draisin JA, Shore WB. Reflections-on-action: medical students’ accounts of their implicit beliefs and strategies in the context of one-to-one clinical teaching. Acad Med 1994;69(suppl):S84-6.
21. Mishler E. Research interviewing: context and narrative. Cambridge, Mass: Harvard University Press; 1986.
22. Riessman C. Narrative analysis. Newbury Park, Calif: Sage Publications; 1993.
23. Mishler E. The analysis of interview-narratives. In: Sarbin TR, ed. Narrative psychology: the storied nature of human conduct. New York, NY: Praeger Press; 1982;233-55.
24. Gumperz J. Discourse strategies. Cambridge, Mass: Cambridge University Press; 1982.
25. Addison RB. Grounded hermeneutic research. In: Crabtree BF, Miller WL, eds. Doing qualitative research. Newbury Park, Calif: Sage Publications; 1992;110-24.
26. Kaplan T. An intercultural communication gap: North American Indians vs the mainstream medical profession. In: Walburga von Raffler-Engel, ed. Doctor-patient interaction. Philadelphia, Pa: John Benjamins Publishing Company; 1989;45-60.
27. Leopold N, Cooper J, Clancy C. Sustained partnership in primary care. J Fam Pract 1996;42:129-37.
28. Stewart M, Brown JB, Weston WW. Patient-centered medicine: transforming the clinical method. Thousand Oaks, Calif: Sage Publications; 1995.
29. Quill TE, Brody H. Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Ann Intern Med 1996;125:763-9.
30. Kaplan S, Greenfield S, Ware J. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care 1989;27:S110-27.
31. Reid B. “It’s like you’re down on a bed of affliction”: aging and diabetes among black Americans. Soc Sci Med 1992;34:1317-23.
32. Kleinman A. The illness narratives: suffering, healing and the human condition. New York, NY: Basic Books; 1988.
33. Cohen MZ, Tripp-Reimer T, Smith C, Sorofman B, Lively S. Explanatory models of diabetes: patient practitioner variation. Soc Sci Med 1994;38:59-66.
34. Stange KC, Zyzanski SJ, Flocke SA, et al. Illuminating the ‘black box’: a description of 4454 patient visits to 138 family physicians in 84 practices. J Fam Pract 1998;46:377-89.
35. Nutting P. New knowledge, new tools: a look inside the ‘black box’ of family practice. J Fam Pract 1998;46:361.-
36. Callahan EJ, Bertakis KD. Development and validation of the Davis Observation Code. Fam Med 1991;23:19-24.
37. Inui T, Carter WB, Kukull WA, Haigh VH. Outcome-based doctor-patient interaction analysis. Med Care 1982;20:535-49.
38. Ben-Sira Z. Primary care practitioners’ likelihood to engage in a bio-psychosocial approach: an additional perspective on the doctor-patient relationship. Soc Sci Med 1990;31:565-76.
39. Mishler E. The discourse of medicine: dialectics of medical interviews. Greenwich, Conn: Ablex Publishing Corporation; 1984.
40. Elder NC, Miller WL. Reading and evaluating qualitative research studies. J Fam Pract 1995;41:279-85.
41. Miller WL, Crabtree BF. Clinical research. In: Denzin N, Lincoln YS, eds. Handbook of qualitative research. Thousand Oaks, Calif: Sage Publications; 1994;340-52.
42. Gilchrist VJ, Engel JD. Qualitative research and clinical care. J Fam Pract 1995;41:229-30.
43. Waitzkin H. The politics of medical encounters: how patients and doctors deal with social problems. New Haven, Conn: Yale University Press; 1991.
44. Singer M. Symposium on critical approaches to health and healing in sociology and anthropology. Med Anth Q 1986;17:128-40.
45. Crabtree B, Miller WL, Aita VA, Flocke SA, Stange KC. Primary care practice organization and preventive services delivery: a qualitative analysis. J Fam Pract 1998;46:403-9.
46. Hunter KM. Narrative, literature, and the clinical exercise of practical reason. J Med Philos 1996;21:303-20.
47. Pellegrino ED. Medical ethics: entering the post-Hippocratic era. J Am Board Fam Pract 1988;1:230-7.
48. Charon R, Brody H, Clark MW, Davis D, Maritnez R, Nelson RM. Literature and ethical medicine: five cases from common practice. J Med Philos 1996;21:243-265.
49. Lazarus E. Theoretical considerations for the study of the doctor-patient relationship: implications of a perinatal study. Med Anth Q 1988;2:34-58.
METHODS: Interactions between Dr M and 9 Native Americans with type 2 diabetes were audio-recorded following preliminary interviews. Interpretations of the interactions were elicited from Dr M through interpersonal process recall and interpretive dialogue sessions. The author analyzed this data using techniques from interpretive anthropology and narrative discourse analysis.
RESULTS: In a preliminary interview, Dr M described a sophisticated biopsychosocial approach to practice. However, she viewed her actual interactions with these patients as imbued with misunderstanding, mistrust, and disconnection. This occurred in spite of her experience and commitment to providing culturally sensitive primary care.
CONCLUSIONS: Biopsychosocial models of disease may conflict with patient-centered approaches to communication. To overcome difficulties in her practice environment, Dr M adopted a strategy that combined an instrumental biopsychosocial approach with a utilitarian mode of knowing and interacting with patients. The misunderstandings, mistrust, and constrained interactions point to deeper problems with the way knowledge is formed in clinical practice. We need further understanding of the interrelationships between physicians’ clinical environments, knowledge of patients, and theories of disease. These elements are interwoven in the physicians’ patient-specific narratives that influence their interactions in primary care settings.
For 2 decades the biopsychosocial model has been important for the practice of family medicine.1,2 Physicians using this model integrate biological, psychological, social, and cultural domains in solving clinical problems and developing therapeutic strategies.3,4 Most writing on the biopsychosocial model has focused on theory development and educational transmission.5,6 Little attention has been paid to whether community-based family physicians apply biopsychosocial strategies in their interactions with patients.7 This qualitative case study addresses the following question: How does a community-based family physician trained in the biopsychosocial model apply this understanding to interactions with patients with type 2 diabetes from different cultural backgrounds?
Methods
Framing the Problem
This study was conducted in a Native American health center located in a multiethnic low-income urban neighborhood. The research focused on 3 interrelated contexts present in all physician-patient interactions: disease, patient, and physician. The significance of disease is often ignored in studies of physician-patient communication. Type 2 diabetes was selected to represent an important problem in family practice from within both biomedical and biopsychosocial paradigms.8 Native Americans were selected because type 2 diabetes is a serious concern in their communities, and use of the biopsychosocial model should be particularly important where significant sociocultural differences exist between patients and physicians.9 A diverse group of patients was recruited on the basis of duration of disease, tribal background, sex, and prescribed medical regimen Table 1. Dr M—a white, board-certified family physician with 6 years’ experience at this health center—was selected because of her sophisticated understanding of biopsychosocial theory and strong commitment to the health care of urban Native Americans.
Procedure
The overall design for this case study was interpretive.10-12 This approach to data collection and analysis assumes that meaning is constructed out of subjects’ everyday interactions with others and is situated in the particular contexts of their sociocultural activities.13,14 The researcher actively interacts with the subjects to describe and interpret their actions, the context of their actions, and the meaning they ascribe to their actions.15 Within this general design, specific methods were employed for gathering and interpreting data. Interviews with patients explored their understanding of type 2 diabetes, self-care practices, social backgrounds, and relevant life histories.16 Interviews with Dr M explored her understanding and treatment of type 2 diabetes, concerns specific to diabetes in Native Americans, and views about the context of practice and its relationship with diabetes care. Patient visits for diabetes care with Dr M were audio-recorded and replayed to elicit her interpretation of the interaction using a modification of interpersonal process recall (IPR).17-20 The transcribed interviews, interactions, and IPR sessions were then interpreted using methods adapted from narrative and discourse analysis,21-23 interactive ethnography,24 and grounded interpretive research.25 Themes that emerged from the review of the interviews, interactions, and IPR sessions were analyzed with Dr M in interpretive dialogue (ID) sessions. In the ID sessions, the interpretations of specific interactions and IPR sessions were discussed with Dr M to elicit her views about the broader context of the interactions. General interpretations were developed and reviewed in further sessions with Dr M. The process was closed when it appeared that more sessions would add little to the general interpretations of the study.
Results
Preliminary Interview
In the initial interview, Dr M held that type 2 diabetes in Native Americans had complex biological, psychological, and social causes Table 2. She emphasized that “as a family practitioner, my outlook is that of a generalist, so I like to look at as many levels as I can, because I think that is what being a generalist is about.” She viewed quality communication as central to multilevel care and saw herself as introducing metaphors into the way patients thought about their bodies to “get them to understand [diabetes] the way” she understood the disease. This approach involved translating her biopsychosocial model of type 2 diabetes into the patient’s language to explain how diet, exercise, medication, and glucose monitoring were key self-care behaviors. She considered her strategy successful if her patients “said they would do these things, and they actually did them.”
Initial Interpretive Sessions
During the IPR and ID sessions, Dr M discussed an array of problems with misunderstanding and distrust in her patient interactions. Although the interactions were problematic for all of the study patients, what varied between patients was the intensity and significance of the misunderstanding or mistrust Table 3.* Dr M talked about feeling manipulated, disbelieving statements, distrusting information, despairing over differences, and even detaching from any expectation of helping a patient she could never trust. She considered her approach constrained by basic value differences with her patients, believing that for many health was not a high priority. This value difference, combined with her perception of fatalism in her patients, caused her to believe it unlikely that she could convince them of the value of her approach. This created a central conflict, because she thought her approach would not work unless her patients accepted its value. Thus, Dr M concluded that she needed to change her patients’ values about their health. However, she did not know how to change their values, and she did not know if value change was possible. In one of our final interviews she concluded, “They [the 9 patients in this study] are over there. I’m over here. I feel this absence, this nothingness between us that I don’t know how to bridge.”
Reframing the Research Problem
Although it is not surprising that a white physician and Native American patients would have difficulties communicating with each other, what was unexpected was that misunderstanding and mistrust would be problematic between this physician and these patients. Characteristics of both the patients and the physician selected for this study made it much more likely that gaps in communication could be bridged. The patients were all bicultural and fluent in English. The study was situated in an urban environment, decreasing the likelihood of a more unified cultural understanding that might be present in an isolated rural Native American community.26 Dr M was aware of potential problems in communication with patients from different cultural and class backgrounds. She spoke of carefully translating medical information into the language of the patient and was knowledgeable about historical and political aspects of relations between Native Americans and whites and their relevance to the care of patients in her practice. The problems of mistrust and misunderstanding that emerged in this setting required further interpretation of the way Dr M’s knowledge of person, disease, and clinical context were interrelated and in the background during her patient interactions.
Knowledge of Patients
Dr M perceived that knowing patients well was “the single greatest thing” in her interactions with them. “I really have a lot of trust that my patients will red-flag those problems that are serious. I don’t have that with all my patients, but if I know a patient well, then I’ll trust that he won’t let it go if it’s important.” “Knowing a person” and “trusting a person” was not a conscious aspect of her decision-making process but an awareness that framed her stance toward each interaction. Dr M interpreted a patient’s story out of her own constructed story about the patient. Her interaction with Patient C is presented in this paper, but she had a story to tell about every patient involved in this study Table 4.
Knowledge of Disease
Dr M’s multilevel understanding of diabetes produced tensions in her clinical practice. These are exemplified in her views of the relationship between stress and diabetes care Table 4. In any given interaction, she needed to make decisions about what aspects of the disease required focus. Dr M developed an approach for determining what was important in particular situations. By “knowing a patient well from a medical perspective” she felt that she could very quickly assess what needed attention. This often meant directing the patient away from problems like stress and toward issues like exercise, diet, and medications, which were “the cornerstones of diabetic care” for Dr M. In this manner, she focused on the aspects of the disease she thought she could affect.
Knowledge of Clinical Context
Dr M described a web of problems in her clinical context that constrained her interactions with patients. Every day she contended with numerous barriers to patient care created by a medical care system that ignored the health concerns of the poor. Chronic staffing and resource problems within the health center created situations where she spent a large proportion of her time away from direct patient care. Within this context, she developed an approach to make the most efficient use of her time with patients.
Dr M and Patient C: A Cycle of Hopelessness
Although interactions with all of the patients were used in developing these interpretations, the findings from a crucial discussion with Patient C show the way detachment emerged in practice for Dr M. In the fourth recorded interaction between Patient C and Dr M Table 5, Patient C first told Dr M that she was not taking her prescribed medicine. Dr M interpreted this revelation as shown in Table 4. Although Patient C’s truth telling could have opened up the relationship, instead it confirmed Dr M’s previous beliefs about Patient C. Within Dr M’s practice constraints, Patient C was viewed as a chaotic, noncompliant alcoholic, and thus Dr M’s time could be more effectively spent by detaching from Patient C and attending to other patients she might change. In contrast to Dr M’s constructed reasons explaining Patient C’s elevated blood sugars, Patient C tells a different story about her personal struggles with alcohol and diabetes while living in poverty. Patient C’s interview was conducted a few months after she moved from the streets to a low-income apartment and 3 months before the fourth recorded interaction Table 6.
Patient C distrusted the “white man’s medicine” and was preparing to tell Dr M about her reluctance to take the medicine. Patient C’s belief that some physicians “care” suggests that she valued attributes of a physician separately from their approach to illness. Although Patient C’s honesty may have opened up the possibility for dialogue about differing interpretations of diabetes illness experience and self-care, Dr M’s stance blocked her ability to enter into the very dialogue needed to potentially reconstruct the relationship with this patient.
Patient-Specific Narratives: Stories about People, Disease, and Clinical Context
Dr M implicitly used patient-specific narratives as powerful instruments to identify aspects of patients’ illness experiences that she considered clinically important and potentially manageable. To construct her story about a patient, Dr M combined narratives gathered from her cumulative interactions with a patient in the health center, her interactions with people in the community, and her discussions with others working at the health center. In addition, the stories were broadened by Dr M’s patient-specific application of disease theory and the particular pressures of her practice environment.
Discussion
Important theoretical models for primary care physician-patient relationships include sustained partnership, patient-centered care, and enhanced autonomy.27-29 Although they advance somewhat different theoretical claims, each of these models emphasizes knowing the “whole person,” fostering empathy and trust, and engaging in shared decision making. With a focus on “the patient” or “the relationship” in these models, “disease” is often marginalized or considered only as an important outcome variable for measuring the impact of physician-patient interactions.30 In contrast to patient- or relationship-centered models, the biopsychosocial model is frequently assumed to combine a holistic understanding of disease-illness processes with attention to the primary care relationship. This study demonstrates that biopsychosocial models of disease may actually conflict with patient-centered approaches to communication.
Biopsychosocial models are integrated theories of disease, not models for physician-patient interactions in family practice. There are at least 2 distinct strategies for working with biopsychosocial understandings of disease. In an instrumental approach, the family physician strives to change the patient’s perspective to adapt to the physician’s biopsychosocial understanding of disease and illness care. In a dialogical approach, the family physician interacts with the patient to understand the biopsychosocial disease and co-construct the approach to illness care over time. Both strategies can claim to be directly applying biopsychosocial models, and both might be successful in various clinical contexts. In this study, Dr M took the first approach and found herself left with an unbridgeable gap in communication.
The misunderstandings, mistrust, and constrained interactions found in this study point to deeper problems with the way knowledge is formed in clinical practice. Physicians construct their understanding of disease in individual patients through patient-specific narratives that combine knowledge of disease, patients, and clinical context. These narratives may gain richness, depth, and complexity over time, but they may also become static forms of representation. Knowledge of the illness experience of patients with chronic diseases like type 2 diabetes is expanding; however, our understanding of the practice experience of primary care physicians is limited.31-33
Recent use of direct observation of family physicians has provided a more thorough knowledge of “the black box” of community-based practice.34,35 This paper seeks to add to that literature by offering an in-depth multimethod qualitative approach for studying physician-patient interactions. Techniques using pre- and postencounter rating instruments cannot grasp what actually happens in interactions. Quantitative content or process analysis of physician-patient interactions cannot fully address the relationship between context and meaning in these interactions.36-39 However, the depth of meaning and context provided by qualitative studies in general and discourse analysis in particular are frequently dismissed because of concerns about generalizability.40,41
Critics might argue that the findings from this study derive from the practice of an uncaring physician and should not be generalized to the theoretical and practice issues drawn in the analysis. The evidence points in the opposite direction in regard to the integrity of Dr M. Although mistrust and misunderstanding were important issues to explore in Dr M’s interactions with patients, this was not immediately apparent from the content of the interactions themselves. This study required Dr M’s honesty and willingness to engage in the difficult process of disclosure and self-reflection over a busy 1-year period of clinical practice.
Limitations
Sampling strategies were used to address the generic critique of generalizing from a single case. The practice site was chosen to be exemplary of a community health center in a challenging low-income, urban, cross-cultural setting. The physician was selected to be an exemplary representative of a community-based clinician, and the patients were recruited to provide a sample of Native American adults with diabetes with varying degrees of social and cultural differences from the physician. If problems of distrust and misunderstanding exist in this setting, then similar patterns are likely to exist in other low-income cross-cultural contexts. Finally, this form of qualitative research allows the reader to judge the relevance of the findings to their own context.42 Are the problems Dr M described in her interactions with these patients understandable? Physicians may ask themselves: Am I getting through to this patient? Is this patient manipulating me? Is this patient telling the truth about their adherence to the regimen I have recommended? Do I have anything to offer this patient? Is there an unbridgeable gap in communication, or has the approach taken toward care of this patient been narrowed by an instrumental understanding of the person, the disease, and the context of care?
The organization of practice and the underlying structure of knowledge construction and use can create conflicts between the intentions of physicians and their actions in clinical practice.43-45 To understand and meet this challenge, we need further research of community-based physician-patient interactions that brings together theoretical and empirical forms of inquiry. Theoretical models, derived from ethics and the philosophy of medicine, seldom incorporate practice-based empirical study, while empirical work on physician-patient interactions frequently demonstrates a very limited attention to important theoretical concerns.46-49 Study of patient-specific narratives can bring together literature on biopsychosocial models, physician-patient interactions, patient illness narratives, physician self-awareness, and the organization of primary care practice. Further qualitative research should examine the way patient-specific narratives are developed by physicians practicing in different clinical environments and explore the interrelationships between patient-specific narratives and the content and quality of physician-patient interactions.
Conclusions
To apply biopsychosocial disease models in practice, physicians construct stories about patients as persons. These patient-specific narratives may be opened up or constrained by clinical context, and they both frame and are framed by physicians’ approaches to disease in particular interactions. To advance our use of integrated disease models, we need further study of the way patient-specific narratives are constructed in clinical practice. Application of integrated models of disease and construction of stories about patients may involve problems of misunderstanding and mistrust by either the patient or physician. The presence of these factors does not necessarily close off the possibility of meaningful and effective physician-patient interactions. The challenge is to strive to recognize misunderstanding and mistrust and to develop new strategies for reconstructing problematic interactions in community-based family practice.
Acknowledgments
The fieldwork for this study was conducted while Dr Bartz was a fellow in the Clinical Scholars program at Stanford University, with funding from the Robert Wood Johnson Foundation.
Dr Bartz gratefully acknowledges Richard Addison, PhD, Benjamin Crabtree, PhD, and Halsted Holman, MD, for advice on the initial design and implementation of this research; and Suzanne Fleischman, PhD; William Miller, MD, MA; Jessica Muller, PhD; and Guenter Risse, MD, PhD, for their thoughtful feedback and comments on earlier drafts of this paper.
METHODS: Interactions between Dr M and 9 Native Americans with type 2 diabetes were audio-recorded following preliminary interviews. Interpretations of the interactions were elicited from Dr M through interpersonal process recall and interpretive dialogue sessions. The author analyzed this data using techniques from interpretive anthropology and narrative discourse analysis.
RESULTS: In a preliminary interview, Dr M described a sophisticated biopsychosocial approach to practice. However, she viewed her actual interactions with these patients as imbued with misunderstanding, mistrust, and disconnection. This occurred in spite of her experience and commitment to providing culturally sensitive primary care.
CONCLUSIONS: Biopsychosocial models of disease may conflict with patient-centered approaches to communication. To overcome difficulties in her practice environment, Dr M adopted a strategy that combined an instrumental biopsychosocial approach with a utilitarian mode of knowing and interacting with patients. The misunderstandings, mistrust, and constrained interactions point to deeper problems with the way knowledge is formed in clinical practice. We need further understanding of the interrelationships between physicians’ clinical environments, knowledge of patients, and theories of disease. These elements are interwoven in the physicians’ patient-specific narratives that influence their interactions in primary care settings.
For 2 decades the biopsychosocial model has been important for the practice of family medicine.1,2 Physicians using this model integrate biological, psychological, social, and cultural domains in solving clinical problems and developing therapeutic strategies.3,4 Most writing on the biopsychosocial model has focused on theory development and educational transmission.5,6 Little attention has been paid to whether community-based family physicians apply biopsychosocial strategies in their interactions with patients.7 This qualitative case study addresses the following question: How does a community-based family physician trained in the biopsychosocial model apply this understanding to interactions with patients with type 2 diabetes from different cultural backgrounds?
Methods
Framing the Problem
This study was conducted in a Native American health center located in a multiethnic low-income urban neighborhood. The research focused on 3 interrelated contexts present in all physician-patient interactions: disease, patient, and physician. The significance of disease is often ignored in studies of physician-patient communication. Type 2 diabetes was selected to represent an important problem in family practice from within both biomedical and biopsychosocial paradigms.8 Native Americans were selected because type 2 diabetes is a serious concern in their communities, and use of the biopsychosocial model should be particularly important where significant sociocultural differences exist between patients and physicians.9 A diverse group of patients was recruited on the basis of duration of disease, tribal background, sex, and prescribed medical regimen Table 1. Dr M—a white, board-certified family physician with 6 years’ experience at this health center—was selected because of her sophisticated understanding of biopsychosocial theory and strong commitment to the health care of urban Native Americans.
Procedure
The overall design for this case study was interpretive.10-12 This approach to data collection and analysis assumes that meaning is constructed out of subjects’ everyday interactions with others and is situated in the particular contexts of their sociocultural activities.13,14 The researcher actively interacts with the subjects to describe and interpret their actions, the context of their actions, and the meaning they ascribe to their actions.15 Within this general design, specific methods were employed for gathering and interpreting data. Interviews with patients explored their understanding of type 2 diabetes, self-care practices, social backgrounds, and relevant life histories.16 Interviews with Dr M explored her understanding and treatment of type 2 diabetes, concerns specific to diabetes in Native Americans, and views about the context of practice and its relationship with diabetes care. Patient visits for diabetes care with Dr M were audio-recorded and replayed to elicit her interpretation of the interaction using a modification of interpersonal process recall (IPR).17-20 The transcribed interviews, interactions, and IPR sessions were then interpreted using methods adapted from narrative and discourse analysis,21-23 interactive ethnography,24 and grounded interpretive research.25 Themes that emerged from the review of the interviews, interactions, and IPR sessions were analyzed with Dr M in interpretive dialogue (ID) sessions. In the ID sessions, the interpretations of specific interactions and IPR sessions were discussed with Dr M to elicit her views about the broader context of the interactions. General interpretations were developed and reviewed in further sessions with Dr M. The process was closed when it appeared that more sessions would add little to the general interpretations of the study.
Results
Preliminary Interview
In the initial interview, Dr M held that type 2 diabetes in Native Americans had complex biological, psychological, and social causes Table 2. She emphasized that “as a family practitioner, my outlook is that of a generalist, so I like to look at as many levels as I can, because I think that is what being a generalist is about.” She viewed quality communication as central to multilevel care and saw herself as introducing metaphors into the way patients thought about their bodies to “get them to understand [diabetes] the way” she understood the disease. This approach involved translating her biopsychosocial model of type 2 diabetes into the patient’s language to explain how diet, exercise, medication, and glucose monitoring were key self-care behaviors. She considered her strategy successful if her patients “said they would do these things, and they actually did them.”
Initial Interpretive Sessions
During the IPR and ID sessions, Dr M discussed an array of problems with misunderstanding and distrust in her patient interactions. Although the interactions were problematic for all of the study patients, what varied between patients was the intensity and significance of the misunderstanding or mistrust Table 3.* Dr M talked about feeling manipulated, disbelieving statements, distrusting information, despairing over differences, and even detaching from any expectation of helping a patient she could never trust. She considered her approach constrained by basic value differences with her patients, believing that for many health was not a high priority. This value difference, combined with her perception of fatalism in her patients, caused her to believe it unlikely that she could convince them of the value of her approach. This created a central conflict, because she thought her approach would not work unless her patients accepted its value. Thus, Dr M concluded that she needed to change her patients’ values about their health. However, she did not know how to change their values, and she did not know if value change was possible. In one of our final interviews she concluded, “They [the 9 patients in this study] are over there. I’m over here. I feel this absence, this nothingness between us that I don’t know how to bridge.”
Reframing the Research Problem
Although it is not surprising that a white physician and Native American patients would have difficulties communicating with each other, what was unexpected was that misunderstanding and mistrust would be problematic between this physician and these patients. Characteristics of both the patients and the physician selected for this study made it much more likely that gaps in communication could be bridged. The patients were all bicultural and fluent in English. The study was situated in an urban environment, decreasing the likelihood of a more unified cultural understanding that might be present in an isolated rural Native American community.26 Dr M was aware of potential problems in communication with patients from different cultural and class backgrounds. She spoke of carefully translating medical information into the language of the patient and was knowledgeable about historical and political aspects of relations between Native Americans and whites and their relevance to the care of patients in her practice. The problems of mistrust and misunderstanding that emerged in this setting required further interpretation of the way Dr M’s knowledge of person, disease, and clinical context were interrelated and in the background during her patient interactions.
Knowledge of Patients
Dr M perceived that knowing patients well was “the single greatest thing” in her interactions with them. “I really have a lot of trust that my patients will red-flag those problems that are serious. I don’t have that with all my patients, but if I know a patient well, then I’ll trust that he won’t let it go if it’s important.” “Knowing a person” and “trusting a person” was not a conscious aspect of her decision-making process but an awareness that framed her stance toward each interaction. Dr M interpreted a patient’s story out of her own constructed story about the patient. Her interaction with Patient C is presented in this paper, but she had a story to tell about every patient involved in this study Table 4.
Knowledge of Disease
Dr M’s multilevel understanding of diabetes produced tensions in her clinical practice. These are exemplified in her views of the relationship between stress and diabetes care Table 4. In any given interaction, she needed to make decisions about what aspects of the disease required focus. Dr M developed an approach for determining what was important in particular situations. By “knowing a patient well from a medical perspective” she felt that she could very quickly assess what needed attention. This often meant directing the patient away from problems like stress and toward issues like exercise, diet, and medications, which were “the cornerstones of diabetic care” for Dr M. In this manner, she focused on the aspects of the disease she thought she could affect.
Knowledge of Clinical Context
Dr M described a web of problems in her clinical context that constrained her interactions with patients. Every day she contended with numerous barriers to patient care created by a medical care system that ignored the health concerns of the poor. Chronic staffing and resource problems within the health center created situations where she spent a large proportion of her time away from direct patient care. Within this context, she developed an approach to make the most efficient use of her time with patients.
Dr M and Patient C: A Cycle of Hopelessness
Although interactions with all of the patients were used in developing these interpretations, the findings from a crucial discussion with Patient C show the way detachment emerged in practice for Dr M. In the fourth recorded interaction between Patient C and Dr M Table 5, Patient C first told Dr M that she was not taking her prescribed medicine. Dr M interpreted this revelation as shown in Table 4. Although Patient C’s truth telling could have opened up the relationship, instead it confirmed Dr M’s previous beliefs about Patient C. Within Dr M’s practice constraints, Patient C was viewed as a chaotic, noncompliant alcoholic, and thus Dr M’s time could be more effectively spent by detaching from Patient C and attending to other patients she might change. In contrast to Dr M’s constructed reasons explaining Patient C’s elevated blood sugars, Patient C tells a different story about her personal struggles with alcohol and diabetes while living in poverty. Patient C’s interview was conducted a few months after she moved from the streets to a low-income apartment and 3 months before the fourth recorded interaction Table 6.
Patient C distrusted the “white man’s medicine” and was preparing to tell Dr M about her reluctance to take the medicine. Patient C’s belief that some physicians “care” suggests that she valued attributes of a physician separately from their approach to illness. Although Patient C’s honesty may have opened up the possibility for dialogue about differing interpretations of diabetes illness experience and self-care, Dr M’s stance blocked her ability to enter into the very dialogue needed to potentially reconstruct the relationship with this patient.
Patient-Specific Narratives: Stories about People, Disease, and Clinical Context
Dr M implicitly used patient-specific narratives as powerful instruments to identify aspects of patients’ illness experiences that she considered clinically important and potentially manageable. To construct her story about a patient, Dr M combined narratives gathered from her cumulative interactions with a patient in the health center, her interactions with people in the community, and her discussions with others working at the health center. In addition, the stories were broadened by Dr M’s patient-specific application of disease theory and the particular pressures of her practice environment.
Discussion
Important theoretical models for primary care physician-patient relationships include sustained partnership, patient-centered care, and enhanced autonomy.27-29 Although they advance somewhat different theoretical claims, each of these models emphasizes knowing the “whole person,” fostering empathy and trust, and engaging in shared decision making. With a focus on “the patient” or “the relationship” in these models, “disease” is often marginalized or considered only as an important outcome variable for measuring the impact of physician-patient interactions.30 In contrast to patient- or relationship-centered models, the biopsychosocial model is frequently assumed to combine a holistic understanding of disease-illness processes with attention to the primary care relationship. This study demonstrates that biopsychosocial models of disease may actually conflict with patient-centered approaches to communication.
Biopsychosocial models are integrated theories of disease, not models for physician-patient interactions in family practice. There are at least 2 distinct strategies for working with biopsychosocial understandings of disease. In an instrumental approach, the family physician strives to change the patient’s perspective to adapt to the physician’s biopsychosocial understanding of disease and illness care. In a dialogical approach, the family physician interacts with the patient to understand the biopsychosocial disease and co-construct the approach to illness care over time. Both strategies can claim to be directly applying biopsychosocial models, and both might be successful in various clinical contexts. In this study, Dr M took the first approach and found herself left with an unbridgeable gap in communication.
The misunderstandings, mistrust, and constrained interactions found in this study point to deeper problems with the way knowledge is formed in clinical practice. Physicians construct their understanding of disease in individual patients through patient-specific narratives that combine knowledge of disease, patients, and clinical context. These narratives may gain richness, depth, and complexity over time, but they may also become static forms of representation. Knowledge of the illness experience of patients with chronic diseases like type 2 diabetes is expanding; however, our understanding of the practice experience of primary care physicians is limited.31-33
Recent use of direct observation of family physicians has provided a more thorough knowledge of “the black box” of community-based practice.34,35 This paper seeks to add to that literature by offering an in-depth multimethod qualitative approach for studying physician-patient interactions. Techniques using pre- and postencounter rating instruments cannot grasp what actually happens in interactions. Quantitative content or process analysis of physician-patient interactions cannot fully address the relationship between context and meaning in these interactions.36-39 However, the depth of meaning and context provided by qualitative studies in general and discourse analysis in particular are frequently dismissed because of concerns about generalizability.40,41
Critics might argue that the findings from this study derive from the practice of an uncaring physician and should not be generalized to the theoretical and practice issues drawn in the analysis. The evidence points in the opposite direction in regard to the integrity of Dr M. Although mistrust and misunderstanding were important issues to explore in Dr M’s interactions with patients, this was not immediately apparent from the content of the interactions themselves. This study required Dr M’s honesty and willingness to engage in the difficult process of disclosure and self-reflection over a busy 1-year period of clinical practice.
Limitations
Sampling strategies were used to address the generic critique of generalizing from a single case. The practice site was chosen to be exemplary of a community health center in a challenging low-income, urban, cross-cultural setting. The physician was selected to be an exemplary representative of a community-based clinician, and the patients were recruited to provide a sample of Native American adults with diabetes with varying degrees of social and cultural differences from the physician. If problems of distrust and misunderstanding exist in this setting, then similar patterns are likely to exist in other low-income cross-cultural contexts. Finally, this form of qualitative research allows the reader to judge the relevance of the findings to their own context.42 Are the problems Dr M described in her interactions with these patients understandable? Physicians may ask themselves: Am I getting through to this patient? Is this patient manipulating me? Is this patient telling the truth about their adherence to the regimen I have recommended? Do I have anything to offer this patient? Is there an unbridgeable gap in communication, or has the approach taken toward care of this patient been narrowed by an instrumental understanding of the person, the disease, and the context of care?
The organization of practice and the underlying structure of knowledge construction and use can create conflicts between the intentions of physicians and their actions in clinical practice.43-45 To understand and meet this challenge, we need further research of community-based physician-patient interactions that brings together theoretical and empirical forms of inquiry. Theoretical models, derived from ethics and the philosophy of medicine, seldom incorporate practice-based empirical study, while empirical work on physician-patient interactions frequently demonstrates a very limited attention to important theoretical concerns.46-49 Study of patient-specific narratives can bring together literature on biopsychosocial models, physician-patient interactions, patient illness narratives, physician self-awareness, and the organization of primary care practice. Further qualitative research should examine the way patient-specific narratives are developed by physicians practicing in different clinical environments and explore the interrelationships between patient-specific narratives and the content and quality of physician-patient interactions.
Conclusions
To apply biopsychosocial disease models in practice, physicians construct stories about patients as persons. These patient-specific narratives may be opened up or constrained by clinical context, and they both frame and are framed by physicians’ approaches to disease in particular interactions. To advance our use of integrated disease models, we need further study of the way patient-specific narratives are constructed in clinical practice. Application of integrated models of disease and construction of stories about patients may involve problems of misunderstanding and mistrust by either the patient or physician. The presence of these factors does not necessarily close off the possibility of meaningful and effective physician-patient interactions. The challenge is to strive to recognize misunderstanding and mistrust and to develop new strategies for reconstructing problematic interactions in community-based family practice.
Acknowledgments
The fieldwork for this study was conducted while Dr Bartz was a fellow in the Clinical Scholars program at Stanford University, with funding from the Robert Wood Johnson Foundation.
Dr Bartz gratefully acknowledges Richard Addison, PhD, Benjamin Crabtree, PhD, and Halsted Holman, MD, for advice on the initial design and implementation of this research; and Suzanne Fleischman, PhD; William Miller, MD, MA; Jessica Muller, PhD; and Guenter Risse, MD, PhD, for their thoughtful feedback and comments on earlier drafts of this paper.
1. Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977;196:129-36.
2. Campbell TL. Medical interviewing and the biopsychosocial model. J Fam Pract 1998;47:339-40.
3. Engel GL. The clinical application of the biopsychosocial model. Am J Psych 1980;137:535-44.
4. Burkett G. Culture, illness, and the biopsychosocial model. Fam Med 1991;23:287-91.
5. Medalie JH. Angina pectoris: a validation of the biopsychosocial model. J Fam Pract 1990;30:273-80.
6. Brody H. The validation of the biopsychosocial model. J Fam Pract 1990;30:271-2.
7. Marvel MK, Doherty WJ, Weiner E. Medical interviewing by exemplary family physicians. J Fam Pract 1998;47:343-8.
8. Greenfield S, Kaplan S, Ware J, Martin Y, Frank H. Patients’ participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med 1988;3:448-57.
9. Hagey R. The native diabetes program: rhetorical process and praxis. Med Anth 1989;12:7-33.
10. Stake RE. Case studies. In: Denzin N, Lincoln YS, eds. Handbook of qualitative research. Thousand Oaks, Calif: Sage Publications; 1994;236-47.
11. Yin RK. Applications of case study research. Newbury Park, Calif: Sage Publications; 1993.
12. Geertz C. Thick description: toward an interpretive theory of culture. In: Geertz C. The interpretation of cultures. New York, NY: Basic Books; 1973;3-30.
13. Rabinow P, Sullivan WM. The interpretive turn: emergence of an approach. In: Rabinow P, Sullivan WM, eds. Interpretive social science: a reader. Berkeley, Calif: University of California Press; 1979;1-21.
14. Taylor C. Interpretation and the sciences of man. In: Taylor C, ed. Philosophy and the human sciences: philosophical papers 2. Cambridge, Mass: Cambridge University Press, 1985;15-57.
15. Addison R. Grounded interpretive research: an investigation of physician socialization. In: Packer M, Addison R, eds. Entering the circle: hermeneutic investigation in psychology. Albany, NY: State University New York Press; 1989;39-57.
16. Crabtree B, Miller W. A qualitative approach to primary care research: the long interview. Fam Med 1991;23:145-51.
17. Kagan N. Interpersonal process recall: a method of influencing human interaction. Mason, Mich: Mason Media; 1975.
18. Arborelius E, Timpka T. General practitioners’ comments on video-recorded consultations as an aid to understanding the physician-patient relationship. Fam Pract 1990;7:84-90.
19. Frankel R, Beckman H. Impact: an interaction-based method for preserving and analysing clinical transactions. In: Pettigew L, ed. Straight talk: explorations in provider and patient interactions. Nashville, Tenn: 1982.
20. Sommers PS, Muller JH, Saba GW, Draisin JA, Shore WB. Reflections-on-action: medical students’ accounts of their implicit beliefs and strategies in the context of one-to-one clinical teaching. Acad Med 1994;69(suppl):S84-6.
21. Mishler E. Research interviewing: context and narrative. Cambridge, Mass: Harvard University Press; 1986.
22. Riessman C. Narrative analysis. Newbury Park, Calif: Sage Publications; 1993.
23. Mishler E. The analysis of interview-narratives. In: Sarbin TR, ed. Narrative psychology: the storied nature of human conduct. New York, NY: Praeger Press; 1982;233-55.
24. Gumperz J. Discourse strategies. Cambridge, Mass: Cambridge University Press; 1982.
25. Addison RB. Grounded hermeneutic research. In: Crabtree BF, Miller WL, eds. Doing qualitative research. Newbury Park, Calif: Sage Publications; 1992;110-24.
26. Kaplan T. An intercultural communication gap: North American Indians vs the mainstream medical profession. In: Walburga von Raffler-Engel, ed. Doctor-patient interaction. Philadelphia, Pa: John Benjamins Publishing Company; 1989;45-60.
27. Leopold N, Cooper J, Clancy C. Sustained partnership in primary care. J Fam Pract 1996;42:129-37.
28. Stewart M, Brown JB, Weston WW. Patient-centered medicine: transforming the clinical method. Thousand Oaks, Calif: Sage Publications; 1995.
29. Quill TE, Brody H. Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Ann Intern Med 1996;125:763-9.
30. Kaplan S, Greenfield S, Ware J. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care 1989;27:S110-27.
31. Reid B. “It’s like you’re down on a bed of affliction”: aging and diabetes among black Americans. Soc Sci Med 1992;34:1317-23.
32. Kleinman A. The illness narratives: suffering, healing and the human condition. New York, NY: Basic Books; 1988.
33. Cohen MZ, Tripp-Reimer T, Smith C, Sorofman B, Lively S. Explanatory models of diabetes: patient practitioner variation. Soc Sci Med 1994;38:59-66.
34. Stange KC, Zyzanski SJ, Flocke SA, et al. Illuminating the ‘black box’: a description of 4454 patient visits to 138 family physicians in 84 practices. J Fam Pract 1998;46:377-89.
35. Nutting P. New knowledge, new tools: a look inside the ‘black box’ of family practice. J Fam Pract 1998;46:361.-
36. Callahan EJ, Bertakis KD. Development and validation of the Davis Observation Code. Fam Med 1991;23:19-24.
37. Inui T, Carter WB, Kukull WA, Haigh VH. Outcome-based doctor-patient interaction analysis. Med Care 1982;20:535-49.
38. Ben-Sira Z. Primary care practitioners’ likelihood to engage in a bio-psychosocial approach: an additional perspective on the doctor-patient relationship. Soc Sci Med 1990;31:565-76.
39. Mishler E. The discourse of medicine: dialectics of medical interviews. Greenwich, Conn: Ablex Publishing Corporation; 1984.
40. Elder NC, Miller WL. Reading and evaluating qualitative research studies. J Fam Pract 1995;41:279-85.
41. Miller WL, Crabtree BF. Clinical research. In: Denzin N, Lincoln YS, eds. Handbook of qualitative research. Thousand Oaks, Calif: Sage Publications; 1994;340-52.
42. Gilchrist VJ, Engel JD. Qualitative research and clinical care. J Fam Pract 1995;41:229-30.
43. Waitzkin H. The politics of medical encounters: how patients and doctors deal with social problems. New Haven, Conn: Yale University Press; 1991.
44. Singer M. Symposium on critical approaches to health and healing in sociology and anthropology. Med Anth Q 1986;17:128-40.
45. Crabtree B, Miller WL, Aita VA, Flocke SA, Stange KC. Primary care practice organization and preventive services delivery: a qualitative analysis. J Fam Pract 1998;46:403-9.
46. Hunter KM. Narrative, literature, and the clinical exercise of practical reason. J Med Philos 1996;21:303-20.
47. Pellegrino ED. Medical ethics: entering the post-Hippocratic era. J Am Board Fam Pract 1988;1:230-7.
48. Charon R, Brody H, Clark MW, Davis D, Maritnez R, Nelson RM. Literature and ethical medicine: five cases from common practice. J Med Philos 1996;21:243-265.
49. Lazarus E. Theoretical considerations for the study of the doctor-patient relationship: implications of a perinatal study. Med Anth Q 1988;2:34-58.
1. Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977;196:129-36.
2. Campbell TL. Medical interviewing and the biopsychosocial model. J Fam Pract 1998;47:339-40.
3. Engel GL. The clinical application of the biopsychosocial model. Am J Psych 1980;137:535-44.
4. Burkett G. Culture, illness, and the biopsychosocial model. Fam Med 1991;23:287-91.
5. Medalie JH. Angina pectoris: a validation of the biopsychosocial model. J Fam Pract 1990;30:273-80.
6. Brody H. The validation of the biopsychosocial model. J Fam Pract 1990;30:271-2.
7. Marvel MK, Doherty WJ, Weiner E. Medical interviewing by exemplary family physicians. J Fam Pract 1998;47:343-8.
8. Greenfield S, Kaplan S, Ware J, Martin Y, Frank H. Patients’ participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med 1988;3:448-57.
9. Hagey R. The native diabetes program: rhetorical process and praxis. Med Anth 1989;12:7-33.
10. Stake RE. Case studies. In: Denzin N, Lincoln YS, eds. Handbook of qualitative research. Thousand Oaks, Calif: Sage Publications; 1994;236-47.
11. Yin RK. Applications of case study research. Newbury Park, Calif: Sage Publications; 1993.
12. Geertz C. Thick description: toward an interpretive theory of culture. In: Geertz C. The interpretation of cultures. New York, NY: Basic Books; 1973;3-30.
13. Rabinow P, Sullivan WM. The interpretive turn: emergence of an approach. In: Rabinow P, Sullivan WM, eds. Interpretive social science: a reader. Berkeley, Calif: University of California Press; 1979;1-21.
14. Taylor C. Interpretation and the sciences of man. In: Taylor C, ed. Philosophy and the human sciences: philosophical papers 2. Cambridge, Mass: Cambridge University Press, 1985;15-57.
15. Addison R. Grounded interpretive research: an investigation of physician socialization. In: Packer M, Addison R, eds. Entering the circle: hermeneutic investigation in psychology. Albany, NY: State University New York Press; 1989;39-57.
16. Crabtree B, Miller W. A qualitative approach to primary care research: the long interview. Fam Med 1991;23:145-51.
17. Kagan N. Interpersonal process recall: a method of influencing human interaction. Mason, Mich: Mason Media; 1975.
18. Arborelius E, Timpka T. General practitioners’ comments on video-recorded consultations as an aid to understanding the physician-patient relationship. Fam Pract 1990;7:84-90.
19. Frankel R, Beckman H. Impact: an interaction-based method for preserving and analysing clinical transactions. In: Pettigew L, ed. Straight talk: explorations in provider and patient interactions. Nashville, Tenn: 1982.
20. Sommers PS, Muller JH, Saba GW, Draisin JA, Shore WB. Reflections-on-action: medical students’ accounts of their implicit beliefs and strategies in the context of one-to-one clinical teaching. Acad Med 1994;69(suppl):S84-6.
21. Mishler E. Research interviewing: context and narrative. Cambridge, Mass: Harvard University Press; 1986.
22. Riessman C. Narrative analysis. Newbury Park, Calif: Sage Publications; 1993.
23. Mishler E. The analysis of interview-narratives. In: Sarbin TR, ed. Narrative psychology: the storied nature of human conduct. New York, NY: Praeger Press; 1982;233-55.
24. Gumperz J. Discourse strategies. Cambridge, Mass: Cambridge University Press; 1982.
25. Addison RB. Grounded hermeneutic research. In: Crabtree BF, Miller WL, eds. Doing qualitative research. Newbury Park, Calif: Sage Publications; 1992;110-24.
26. Kaplan T. An intercultural communication gap: North American Indians vs the mainstream medical profession. In: Walburga von Raffler-Engel, ed. Doctor-patient interaction. Philadelphia, Pa: John Benjamins Publishing Company; 1989;45-60.
27. Leopold N, Cooper J, Clancy C. Sustained partnership in primary care. J Fam Pract 1996;42:129-37.
28. Stewart M, Brown JB, Weston WW. Patient-centered medicine: transforming the clinical method. Thousand Oaks, Calif: Sage Publications; 1995.
29. Quill TE, Brody H. Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Ann Intern Med 1996;125:763-9.
30. Kaplan S, Greenfield S, Ware J. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care 1989;27:S110-27.
31. Reid B. “It’s like you’re down on a bed of affliction”: aging and diabetes among black Americans. Soc Sci Med 1992;34:1317-23.
32. Kleinman A. The illness narratives: suffering, healing and the human condition. New York, NY: Basic Books; 1988.
33. Cohen MZ, Tripp-Reimer T, Smith C, Sorofman B, Lively S. Explanatory models of diabetes: patient practitioner variation. Soc Sci Med 1994;38:59-66.
34. Stange KC, Zyzanski SJ, Flocke SA, et al. Illuminating the ‘black box’: a description of 4454 patient visits to 138 family physicians in 84 practices. J Fam Pract 1998;46:377-89.
35. Nutting P. New knowledge, new tools: a look inside the ‘black box’ of family practice. J Fam Pract 1998;46:361.-
36. Callahan EJ, Bertakis KD. Development and validation of the Davis Observation Code. Fam Med 1991;23:19-24.
37. Inui T, Carter WB, Kukull WA, Haigh VH. Outcome-based doctor-patient interaction analysis. Med Care 1982;20:535-49.
38. Ben-Sira Z. Primary care practitioners’ likelihood to engage in a bio-psychosocial approach: an additional perspective on the doctor-patient relationship. Soc Sci Med 1990;31:565-76.
39. Mishler E. The discourse of medicine: dialectics of medical interviews. Greenwich, Conn: Ablex Publishing Corporation; 1984.
40. Elder NC, Miller WL. Reading and evaluating qualitative research studies. J Fam Pract 1995;41:279-85.
41. Miller WL, Crabtree BF. Clinical research. In: Denzin N, Lincoln YS, eds. Handbook of qualitative research. Thousand Oaks, Calif: Sage Publications; 1994;340-52.
42. Gilchrist VJ, Engel JD. Qualitative research and clinical care. J Fam Pract 1995;41:229-30.
43. Waitzkin H. The politics of medical encounters: how patients and doctors deal with social problems. New Haven, Conn: Yale University Press; 1991.
44. Singer M. Symposium on critical approaches to health and healing in sociology and anthropology. Med Anth Q 1986;17:128-40.
45. Crabtree B, Miller WL, Aita VA, Flocke SA, Stange KC. Primary care practice organization and preventive services delivery: a qualitative analysis. J Fam Pract 1998;46:403-9.
46. Hunter KM. Narrative, literature, and the clinical exercise of practical reason. J Med Philos 1996;21:303-20.
47. Pellegrino ED. Medical ethics: entering the post-Hippocratic era. J Am Board Fam Pract 1988;1:230-7.
48. Charon R, Brody H, Clark MW, Davis D, Maritnez R, Nelson RM. Literature and ethical medicine: five cases from common practice. J Med Philos 1996;21:243-265.
49. Lazarus E. Theoretical considerations for the study of the doctor-patient relationship: implications of a perinatal study. Med Anth Q 1988;2:34-58.