Wynne (2003) states, "In the 'real' world of health care, systems thinking is more needed than ever before, but its increased complexity challenges both clinicians and researchers to the depths of their resources." Knowledge, attitudes, beliefs, emotions, behaviors, relationships, and social environmental interact to affect the experience of illness or well-being. Accordingly, physicians' ability to promote health and relieve suffering depends on their ability to engage effectively in this complex web of interrelationships. This is a daunting task that depends on fostering a quality relationship over time, gathering sufficient biopsychosocial data about a particular patient, and integrating data with theoretic understanding to inform interventions.
The challenge for even the most astute physician is to assess and address psychosocially important issues within the limited time available for each patient. In a 10- to 15-minute period, a detailed evaluation of all relevant psychosocial factors is an impractical goal. Using a pragmatic approach that balances this goal with time constraints, a physician can maintain awareness of psychosocial cues and information in all patient encounters while restricting direct inquiry, depending on the specific situation. A physician may not need to elicit a detailed psychosocial assessment with every patient who presents with an upper respiratory infection, but knowing if the patient smokes would be useful, leading to further inquiry and potential smoking intervention.
Following pragmatic considerations, a physician should work collaboratively with patients to identify problems of highest priority and to address different issues in different encounters. For example, in the case of domestic vio lence, immediate needs for patient safety must be addressed. Addressing long-standing issues, such as dysfunctional means of coping with stress, must be a secondary concern in the face of the primary need to achieve safety. Similarly, every physician learns to place high priority on patient complaints of chest pain, adjusting questioning depending on the patient's age, gender, family history of coronary heart disease, and patient medical history. Nevertheless, the physician must look for psychosocial clues, evaluate stressors, and be aware of factors that suggest an anxiety or somatization disorder. These secondary factors can be addressed in more depth when the physician is assured that a cardiac crisis is not imminent.
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