The good physician treats the disease; the great physician treats the patient who has the disease.
Sir William Osler, circa 1900
The position of clinician is one of privilege. Patients entrust clinicians with the most intimate details of their lives, and society rewards them with prestige, job stability, and a decent standard of living. With this privilege comes responsibility. Patients expect support, understanding, explanation, relief from their symptoms and/or cure of their ailments, and society expects clinicians to act in the best interest of their patients, subordinating their own self-interest.1
Modern medicine was built on the foundations of the biological sciences to improve the diagnosis and treatment of human suffering. The resulting biomedical model focused narrowly on the pathophysiology of disease caused by anatomic, biochemical, and/or neurophysiologic deviations from the norm. Within this framework the clinician's task was to focus on identifying, describing, and determining the cause of diseases and then preventing, managing, and/or curing them. This focus led to the discovery and management of many genetic, infectious, and other medical diseases. However, scholarship over the past nearly four decades has underscored some critical limitations of the biomedical model. For example, the model did not address symptoms that are caused by factors other than disease or abnormalities in anatomical, biological, and/or neurophysiologic states. The model also largely ignored the social, psychological, and behavioral dimensions of illness.2,3 Indeed, some medical professionals believed that “mental illness is a myth,” and some argued that it was not appropriate for medical professionals to attend to psychosocial issues—a stance that perpetuated the suffering of many patients and the healthcare professionals whom they sought for help.4
By the latter part of the 20th century, it had become clear that the biomedical model was “no longer adequate for the scientific tasks and social responsibilities” of medicine.4 The human condition was noted to be too complex to be fully described and explained by the biomedical model. Engel4,5 proposed a biopsychosocial model to better explain how the symptoms and course of one patient with a particular disease can be completely different from those of another individual with the same disease. The biopsychosocial model explicitly acknowledges the interdependence of patients’ biological (disease), psychological, and social characteristics, making it consistent with general system theory (Fig. 1-1) (see Appendix A for Engel's foreword to the first edition of this text to learn more about the biopsychosocial model).
The hierarchy of natural systems.
According to general system theory, disturbances in a system at one level have implications for other levels in the hierarchy of natural systems.6–8 A person is part of a hierarchy of systems that ranges from the smallest organelle to the largest community and culture and can be profoundly ...