Key Points

• Factors that influence health include age, gender, and sexual orientation.

• Religious, ethnic, and cultural groups affect individual functioning.

• Individuals are affected by family composition, structure, and functioning.

• The health of an individual is influenced by work and school status.

• Individuals are affected by their social support network and significant others.

• Financial resources, including health insurance status, affect health status.

• Personal and family history of major loss, trauma, or illness should be integrated into the assessment of a patient's health status.

• Psychological functioning, including personality, defensive style, and current mental status, warrant evaluation.

• Data about the patient's physical environment, including home, neighborhood, and environmental hazards, are essential.

• The physician should elicit an account of recent stressors and changes in the patient's life.

• Collaborative physician-patient relationships that emphasize physician listening form the context for sensitive psychosocial care.

• An overweight 11-year-old boy with abnormal lipids tells his family physician that his favorite activity is playing online video games.

• A middle-aged woman emphatically asserts that her blood pressure is elevated only when she has it taken in a medical setting.

• A single mother with a part-time job but no health insurance tells her doctor that she can only take medications that have a co-pay of a few dollars.

Psychosocial factors influence health. Assessing and treating patients in a manner that integrates psychosocial and biologic aspects of care are the essence of excellent family medicine and its greatest challenges. The following example is illustrative.

Mr. Ramirez is a 52-year-old man who lost his well-paying job as a software engineer several years ago. After 8 months of unemployment, he took a less satisfying job for less money. Mr. Ramirez has type 2I diabetes, diagnosed when he was 45 years old and well-controlled before he lost his job. He has taken diabetes education classes and can accurately describe what he must do to maintain good glucose control. Reluctantly, Mr. Ramirez acknowledges to his physician that he doesn't follow his diet as closely as he once did and more frequently eats fast food. He also misses the exercise facility at his former workplace and struggles with motivation to exercise. His marriage "isn't as good as it used to be," and he reports decreased interest in sex. When the physician asks him about feelings of depression, Mr. Ramirez says that he never thought he was a weak person, but he just doesn't enjoy things as he once did. His physician emphasizes the changes Mr. Ramirez has experienced in the past few years and the emotional toll of such stress. She briefly describes how stress and depression make diabetes more difficult to control, and how she and Mr. Ramirez can collaboratively work on strategies to improve his health and quality of life.

This case highlights the following three imperatives for providing care that is appropriately responsive to psychosocial issues:

1. The physician sees the person first, conceptualizing symptoms and behaviors in their social and psychological context and responding with sensitivity to the patient's experience and priorities.

2. The physician understands the interactive nature of multiple biopsychosocial variables and communicates this effectively to the patient.

©2011 Elsevier Ltd, Inc, BV

DOI: 10.1016/B978-1-4377-1160-8.10003-X

3. The physician fosters a supportive and empathic physician-patient relationship to provide the foundation for gathering information and intervening effectively.

As the case illustrates, biomedical factors may be only a small part of what patients bring to their physicians. The biomedical model, based on the assumptions of mind-body dualism, biologic reductionism, and linear causality, has resulted in miraculous achievements of high-technology medicine, but primary care physicians who restrict their attention to purely medical considerations are of limited use to their patients. Nevertheless, the shift from a biomedical to a bio-psychosocial paradigm has been a major challenge to modern medicine.

In 1977, psychiatrist George Engel proposed a biopsychosocial model that included social and psychological variables as crucial determinants of disease and illness. According to his new framework, the subsystems of the body interact to produce successively more complex biologic systems, which are simultaneously affected by social and psychological factors. The organism is thus conceptualized in terms of complex interacting systems of biologic, psychological, and social forces, and neither disease nor illness is seen as understandable only in terms of smaller and smaller biologic components. Engel (1980) believed that systemic interactions of biopsychosocial factors were relevant to all disease processes and to the individual's experience of illness. Accordingly, understanding a person's response to a disease requires consideration of such interacting factors as the social and cultural environment, the individual's psychological resources, and the biochemistry and genetics of the disorder in the population (Brody, 1999).

In the following section, we present a number of conceptual models and perspectives that emphasize different but overlapping psychosocial dimensions that influence health (Table 3-1). These models can aid practicing physicians in thinking about their patients in a psychosocial context and conceptualizing potentially helpful interventions. Subsequently, we elaborate on practical strategies for gathering and using psychosocial information in clinical practice and discuss a pragmatic approach to addressing psychosocial considerations in primary care. We conclude with brief discussions of evidence-based practice and how current challenges and trends in the health care system may affect the practice of family medicine.

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