BACKGROUND: The biopsychosocial model has been a cornerstone for the training of family physicians; however, little is known about the use of this model in community practice. This study, conducted in an urban Native American health center, examined the application of the biopsychosocial model by an experienced family physician (Dr M).
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.