A practical assessment of physician biopsychosocial performance

Figures & data

Table

Practice points
•Family physicians can describe the main components of a bio-psycho-social (BPS) approach to patient care.
•This approach may be implemented even within the time constraints of a short encounter with a patient.
•Observers can identify and evaluate a biopsychosocial consultation using a simple 9 item evaluation tool.
•This evaluation tool may be used to teach a biopsychosocial approach to patient care and to remedy deficiencies.

Table 1.  Ratings of clinical performance during the patient encounters of nine biopsychosocially oriented physicians and four biomedically oriented physicians

Variable	Average score (SE) of biopsychosocially oriented physicians (n = 9)	Average score (SE) of biomedically oriented physicians (n = 4)	P value	Interobserver   variance
Communication skills	79 (2.5)	17 (3.5)	<0.0001	29.3
Treatment	73 (2.3)	16 (3.2)	<0.0001	23.2
Response to patients’ expectations	76 (1.8)	7 (2.6)	<0.0001	59.3

Abbreviation: SE, standard error. Note: The P value was evaluated using the MIXED model, which takes into account variability between physicians and evaluators.

Table 2.  Scores of the various components of clinical performance during encounters between 44 Israeli general practitioners and real patients, before and after a teaching course that promoted a biopsychosocial orientation

	Average score (SE) of interactive-group members (n = 22)		P value	Average score (SE) of didactic-group members (n = 22)			P value of differences between the interactive-group and didactic-group average scores
Variable^a	Before intervention	After intervention		Before intervention	After intervention	P value	Before intervention	After intervention
Number of patient encounters	197	145	-	166	167	-	-	-
Communication skills	7 (1.3)	71 (1.3)	<0.0001	7 (2.0)	53 (1.9)	<0.0001	0.61	0.0002
Treatment	5 (1.3)	68 (1.4)	<0.0001	5 (1.8)	48 (1.8)	<0.0001	0.29	<0.0001
Response to patients’ expectations	4 (1.3)	75 (1.4)	<0.0001	5 (2.0)	45 (1.9)	<0.0001	0.31	<0.0001
Overall evaluation of the patient encounter	10 (2.3)	76 (2.4)	<0.0001	10 (1.7)	60 (1.7)	<0.0001	0.97	<0.0001

Abbreviation: SE, standard error. Notes: ^aThe nominal and operational definitions of the variables are detailed in the methods section.

Table 3.  Scores of the various components of clinical performance during encounters between 44 Israeli general practitioners and a simulated patient before and after a teaching course that promoted a biopsychosocial orientation

	Average score (SE) of interactive-group members (n = 22)			Average score (SE) of didactic-group members (n = 22)			P value of differences betweent he interactive-group and didactic-group average scores
Variable^a	Before intervention	After intervention	P value	Before intervention	After intervention	P value	Before intervention	After intervention
Number of encounters	22	22	-	21	22	-	-	-
Communication skills	8 (1.7)	75 (1.7)	<0.0001	9 (2.3)	55 (2.2)	<0.0001	0.88	<0.0001
Treatment	8 (2.6)	72 (2.6)	<0.0001	8 (2.5)	50 (2.5)	<0.0001	0.92	<0.0001
Response to patients’ expectations	5 (2.2)	86 (2.2)	<0.0001	5 (3.5)	50 (3.5)	<0.0001	0.81	<0.0001
Overall evaluation of the patient encounter	12 (2.0)	88 (2.0)	<0.0001	12 (1.8)	70 (1.7)	<0.0001	0.95	<0.0001

Abbreviation: SE, standard error. Notes: ^aThe nominal and operational definitions of the variables are detailed in the methods section.

Appendix 1 Summary of responses of an international panel of primary care physicians to the question “What types of observed physician behavior would characterize a biopsychosocial orientation during a doctor-patient encounter?” and relevant examples

General Principle/Behavior	Observable Skill/Example
Therapeutic (patient-centered) interview
The doctor expresses respect and interest throughout the interview	The doctor maintaining eye contact and a body posture slightly bent forward. Listens to the patient without interrupting and encourages his/her narrative by nodding
The doctor inquires about the concern(s) that made the patient seek medical help	“What made you visit me at this particular time?”
The doctor acknowledges and explores the patient's feelings and sources of distress	“How does that make you feel?” “It is my impression that your main concern is from the cost of surgery. Is this impression correct?” “Which of your problems makes you worry most?”
The doctor is empathic and aware that his or her verbal and non-verbal behavior affects the patient; aware of his own feelings and copes with them	“I can understand how difficult all this is for you” “I can imagine how upset you were”
The doctor expresses respect for the patient's health beliefs and difficulties in coping.	“You ascribe your headache to financial worries”
The doctor considers and respects the patient's views and preferences and is responsive to both patient's needs and health beliefs.	“You may be right in thinking that your financial troubles partly caused your heart attack”
The doctor's behavior implies the message: “I am here for you, my job is to help you”	“Do you have any questions regarding your condition?” “Please don't hesitate to turn to me also for any problem you want to share with me. I shall certainly try to help”
A systems orientation and family-centered approach to care
The doctor considers all factors that may affect the patient's well being, including apparently marginal issues such as waiting time	“How do you manage your new job?”, “I assume it was not easy for you to wait so long before you came in”
The doctor acquires an insight into the meaning of the patient's complaint for him/her and his/her family	“How does this affect you at home/ at work?” “How does your spouse feel about this?” “How does this affect your performance at home/ at work?”
The doctor enquires about the contribution of significant others to the patient's decision, e.g., to seek medical help	“Did you decide about this alone or with somebody else?”
The doctor enquires about opinions of other care-providers / spouse on the patient's problem	“How does your spouse feel about this?”
The doctor explores the possibility that the patient's complaints are associated with a conflict / crisis in the family	“What do you think about the coincidence of your headache and your troubles?”
The doctor involves the patient and his family in the treatment	“It is very important to test your breathing every morning and adjust the treatment according to the results. May I explain this also to your spouse and ask him/her to remind you about this?”
An integrated biopsychosocial problem-solving approach to care
The doctor attempts to address and resolve the immediate patient's problem/source of concern within the time limits of the encounter. Makes appropriate decisions regarding immediate vs delayed diagnostic work-up	“I would like to address this second problem you mentioned more thoroughly at another time. Please make an appointment to see me about this. In the mean time let us focus on your back pain”
The doctor is familiar with updated practice guidelines. Makes appropriate decisions regarding a parsimonious use of time and health resources	“Yes, nifedipine is good for high blood pressure; however, considering your tendency to palpitations, I would still suggest that you begin with hydrochlorothiazide: it is more effective in preventing complications and has little effect on the heart. If this does not work then we shall have to reconsider”
The doctor creates realistic expectations	“I am not sure we’ll find a complete cure for your pain, but let us try to ease it a little and help you cope with daily tasks”
The doctor offers not only medications, but also advice on patient's health promoting behavior, handling of emotions and on the interaction between emotional and physical well being	“I think that the chances of benefit from antibiotics do not justify their side effects. However, I hope you understand that smoking is the real cause of your cough and threatens your health. I think I can help you if you decide to stop smoking”
The doctor uses suggestive/hypnotic messages to increase the placebo effect, and refrains from increasing unnecessarily the patient's anxiety	“Let's try this medication cautiously and at the exact amount you have to take. Please let me know how you feel it affected you”
The doctor suggests a working diagnosis that includes biomedical and psychosocial components	“What you seem to have is migraine headache, which appears particularly when you are upset, and which incapacitates you at home and at work; do you agree with me?”
The doctor suggests a treatment approach that assumes an interplay between emotional, social and physical well being	“If we do not begin by resolving the stress, it may interfere with further investigations or treatment. Do you agree with me?”
The doctor suggests a management plan that encourages the patient to seek help also for emotional and behavioral problems	“I agree with you/ with your spouse that it would be a good idea to postpone further investigation of your back pain until you resolve the problems at work”
The doctor considers possible effects of the proposed management on the patient's performance at work	“Do you think this treatment will help in your work with a computer?”

Appendix 2 Instrument used to evaluate a physician's biopsychosocial orientation during an observed doctor-patient encounter

Please indicate your rating on a range between 0 (not at all) to 100 (very much). The doctor ….
(1) Addresses the psychosocial background of the patient and family (occupation, family status, family history, health beliefs and fears).	(4) Integrates the biomedical treatment plan with the psychosocial treatment.
(2) Is reassuring during the physical examination (verbal & non-verbal).	(5) Checks whether the patient agrees with the suggested treatment.
(3) Checks whether the patient's agrees with the suggested diagnosis.	(6) Offers help beyond patient's expectation.
Overall evaluation of the doctor-patient encounter (including parsimonious use of time and health resources as well as updated practice guidelines)