Figuring out what the @!%$ Biospychosocial means
I’m going to start this one off with a confession…
Two years ago, when I first moved to Boston to become a part of the Boston PT & Wellness team, I was HUNGRY to learn and to start focusing on becoming a better clinician. I was so hyped to finally be in a place where I could treat autonomously with an emphasis on the biopsychosocial (BPS) model. I can remember sitting down with Zak, bringing up some of our recent evaluations as case studies, and going through the subjective and objective exams. We would list, in columns on a piece of paper, which findings were considered “bio” and which were considered “psychosocial.” Using the list we would determine where our initial focus would be in the plan of care.
We “got it”, but we didn’t quite GET IT.
Don’t get me wrong...what we were doing and how we were implementing the BPS was a great place to start, and there is nothing wrong with diving into it as a means to help you construct your plan of care. But, what we would learn later on as we hit some dead ends with patients and continued to read and listen to more philosophy and psychology, was that you cannot dichotomize BPS. Bio and psychosocial are “one in the same,” if you will. Just as though you can’t separate mind and body, you can’t separate “B” and “PS.” Each informs, interacts with, and influences the other and are unique to every person (more on this in a bit…).
What I think happens a lot, and what I am guilty of, is that clinicians will learn about and gain a superficial understanding of the BPS model and feel as though they have immediately adopted this “new and better way of treating people.” The problem is that it is not a “skill” or “technique” that you implement at work on Monday and immediately start to see changes with your patients and clients. When clinicians realize this, and don’t see changes right away, they often fall back into “the way they have always done things”, though still consider themselves to be operating under a BPS framework simply because they have “learned about it.”
Yup. I have definitely been guilty of this in the past. 🙋
There is a positive to this.
It comes in the form of digging a little deeper into the origins of the BPS model and how it has evolved over time, with influences from psychology, philosophy and epistemology. So, here goes…
George Engel (the “father” of the BPS model), published his landmark paper in 1977 within which he warns of the shortcomings of the biomedical model. He was adamant that clinicians realize that they are, first and foremost, treating HUMANS, not a disease or illness. What most took away from Engel’s early work, was a general understanding that treating humans is multifactorial and that you need to “add in” psychosocial factors to to equation. [This was the list Zak and I made of “B” and “PS” factors with our patients].
This was absolutely a step in the right direction, but wasn’t the whole picture.
People “got it”, but they didn’t GET IT.
Saraga et al. offered up a really insightful “re-interpretation” of Engel’s work in their 2014 paper. They proposed that a focus on JUST the patient may also be somewhat too narrow, and that characteristics and beliefs of the clinicians themselves also need to be weaved into the messy experience that is the biopsychosocial patient-clinician relationship.
“Physicians expectations of their patients, their conceptions of what qualifies as “true disease”, their emotional state, and other characteristics of the individual physician shape clinical activity in general as well as the individual consultation”
“Engel said that the clinician always begins with the patient at the person level; we argue here that clinicians also begin with themselves at the person level.”
Okay so here is the POSITIVE PUNCH: by embodying the core values of The Level Up Initiative such as growth mindset, humility, critical thinking, and communication, and really focusing first on being a better human, you ARE starting the long term process of genuinely practicing through a biopsychosocial model and framework.
But that is just it- like I mentioned above about clinicians getting frustrated with not seeing results right away after learning about the BPS model, IT TAKES TIME. Hell, it took from 1977 to 2014 for humans in this field to take that big step back and publish ideas that consider the bigger picture of all of this.
So, here is what I have taken away from a combination of the above mentioned research, various rabbit holes of reading, my involvement with The Level Up Initiative, my clinical experience, my life experience, and my clinical failures…
- You cannot expect your practice to change with each new thing that you learn- it takes time, trial and error, and failure to truly understand how it fits into the messy human relationships you have with yourself and with your patients.
- Biopsychosocial cannot, and should not, be dichotomized into bio- and psychosocial- it is not that black and white.
- Focusing on yourself as a good human first, and beginning with yourself at the person level, is going to better inform your practice as a BPS practitioner.
- Read, read, READ about things outside of the clinical and physical therapy world- philosophy, sociology, psychology, etc. This will enrich your world view and your ability to appreciate and empathize with others’ world views, aka. being a better human and being better able to connect with others.
- There is going to be new information and research in the future on all of this, and what we are pushing as “best practice now” is going to change and be updated and we will be wrong. Get over that. Roll with it. Embrace being wrong and the uncertainty that will always underlie what we do. You will be better able to adapt and better serve your patients and yourself.
To quote/paraphrase a couple of clinicians I respect highly…”All models are wrong, but some are useful.” I believe that is a hybrid between quotes from Derek Miles and Scot Morrison...but whatever, you get the point 🤷♀️
I want so much for these concepts and this information to have some lightbulbs go off in your heads and spark some curiosity in other realms besides the clinical. This @!#$ is important and is the raw material, for becoming the highest level practitioner you can and for setting yourself apart in the best way possible.
There have been many avenues within which I have grown personally and professionally. By being a part of The Level Up Initiative, finally “getting it”, and honing my ability to use phronesis1 within a true BPS model of care, I have noticed the most direct positive changes in my clinical practice.
To me, this is why The Level Up Initiative is more than a mentorship.
References:
- Frank AW. Asking the right question about pain: narrative and phronesis. Lit Med. 2004 Fall;23(2):209-25. PubMed PMID: 15690839.
- Saraga, Michael, et al. "George Engel’s Epistemology of Clinical Practice." Perspectives in Biology and Medicine, vol. 57 no. 4, 2014, p. 482-494. Project MUSE, doi:10.1353/pbm.2014.0038.
- Malpas, Jeff, "Hans-Georg Gadamer", The Stanford Encyclopedia of Philosophy (Fall 2018 Edition), Edward N. Zalta (ed.), URL=<https://plato.stanford.edu/archives/fall2018/entries/gadamer/>
- The Level Up Podcast, Episodes 8 & 9: “The Need for a New Medical Model [Part 1 and 2]: