••Summer 2004/Vol. 8, No. 3

Book Reviews

The Biopsychosocial Approach: Past, Present, Future | pdf >> by Richard M Frankel, Timothy E Quill, and Susan H McDaniel, editors Book review by Paul Jay Fink, MD Rochester (NY): University of Rochester Press; 2003. ISBN: 1580461026 (hardback); 1580460615 (soft cover). 298 pages. $65.00 (hardback).

I read this book with avid interest and with future generations of physicians, psychiatrists, and nonpsychiatrists alike in mind. I hope these professionals will be imbued with the same philosophical approach to patient care as is described by the authors. I recommend that every psychiatric educator in America read this book to truly understand why the profession of medicine is deteriorating and why patient care is so one-sided.

The biomedical approach to clinical care has clearly made remarkable strides during the past half century while the person has been receiving progressively less importance, both in the hospital and in the office setting. Counteracting this clinical trend of assigning diminishing importance to the person as a whole entity, the remarkable work done at the University of Rochester over the past 50 years has influenced hundreds of physicians currently practicing across the country. Introduced by George Engel and John Romano, the University of Rochester curriculum--which became the pervasive ethos of that institution--blended internal medicine and psychiatry in a unique way. Students had to understand patients in a way that accounted for their multiple dimensions--biological, psychological, and sociocultural--so that these often very different and counterintuitive aspects of the person could be integrated in a single treatment plan that placed the patient squarely at its center.

The book The Biopsychosocial Approach: Past, Present, Future describes George Engel's decades-long work at the University of Rochester and how this work formed the curriculum that is still used by almost all the University's clinical faculty in most departments. This predominance of Engel's approach was made possible through the extraordinary influence of John Romano (the first Chair of Psychiatry at the University) and with the support of the Dean, who accepted the conceptual framework wholeheartedly. (Subsequent Deans of the University tried to undermine the work; however, by that time, the institution was dotted with trainees who had learned at Engel's knee--and Engel remained active, teaching until his death.)

Two of Engel's papers are reprinted in the book so that someone unfamiliar with the concept can use the original source material as a reference. A 1977 article by Engel¹ was published as the lead article in Science and showed how both schizophrenia and diabetes are biopsychosocial. The remarkable subtlety of two basic concepts--listening to patients and placing caring at the core of clinical effort--are byproducts of Engel's concept. He trained as an internist, but many commentators have said that he was a better psychiatrist than many who received formal training in that field.

In response to its widespread use of Engel's approach, the University of Rochester has had its detractors and naysayers. Saboteurs have trivialized the effort and, from seats of power, have intruded on the biopsychosocial curriculum. This phenomenon is detailed in one chapter, which is countered with a chapter based on letters of praise received by Engel from grateful students over a 40-year period.

Although it does not detail every experiment in medical education attempted during the past five or six decades, this approach to practice is the one that has truly lasted and that has been used continuously to train students in all clinical fields, residents in primary care, psychiatrists, and other specialists to think differently. From 1956 to 1962, a similar concept--the "Comprehensive Clinic"--was implemented at Temple University School of Medicine. The clinic was open every afternoon from 1:00 to 5:00 PM and included 30 or 40 examining rooms along a very long hallway. Residents and medical students in internal medicine and in psychiatry were stationed in the rooms while a Board-certified internist and a Board-certified psychiatrist remained in the hallway for consultation by the residents and students, who could consult with either specialist or with both. This clinic was miraculous; it was the most significant attempt at clinical integration I have ever been part of. It was terminated by a new Dean, who claimed that the clinic was "unnecessary." Similarly, in the early 1970s, medical education grants for experiments in "humanism" tried to initiate analogous efforts across the country, but none lasted. The biomedical typhoon was upon us, and the patient became less and less relevant to both diagnosis and treatment.

For me as a physician, reading this book was inspirational because I have been a devotee of the biopsychosocial hypothesis throughout my career. To work, however, this hypothesis cannot be owned by psychiatry; the entire medical school, hospital, and health care center must embrace it and learn how to live it. Maybe, with a little effort, we could see a change in how medicine is practiced.

George Engel once told me the following story: He was making his usual rounds with medical students, and one of them briefed him on a patient who had congestive heart failure and who the student said was "calm" and recovering quite well. When the group entered the room, instead of a calm patient, Dr Engel found an extremely upset and agitated patient. Dr Engel looked at the chart and noted that during the last several hours, the patient had tried to urinate many times but produced very little urine. Dr Engel asked the man what was bothering him and why he suddenly felt the need to urinate 10 or 12 times per hour. The patient kept saying, "I must, I must, my doctor said I have to 'get the water out.'" Apparently, the patient's cardiologist had used this metaphor without any explanation and thus had unknowingly disturbed his patient, who had no idea what "get the water out" meant. For Dr Engel, this episode was a perfect example of a doctor's failure to take an extra minute to sit down with the patient and talk to him at his own level of understanding.

I hope this book will be widely read and that medical educators as well as practicing physicians will see the value in changing the medical care system to favor the patient and a philosophy of caring.

Reference

1. Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977 Apr 8;196(4286):129-36.

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