Approaches for Residents to Address Problematic Patient Behavior: Before, During, and After the Clinical Encounter
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A resident discusses dialysis with her elderly patient, who later says, "You look too young and pretty to be a doctor!"Microaggressions are "subtle, stunning, often automatic, and non-verbal exchanges which are 'putdowns.'"1(p272) Commonplace in medicine, these interactions can degrade one's health over time. Because of their subtle nature, they can be difficult to classify.1 Discrimination in medicine is multidirectional, and all perspectives are a crucial part of the conversation. Here, we focus on microaggressions that occur from patient to medical trainee to provide targeted teaching tools to mitigate the impact of microaggressions.Historically, medical training has promoted a culture of silence and submission—suggesting that, somehow, experiencing inappropriate behavior is a rite of passage.2 Problematic patient behavior contributes to physician burnout, poor work performance, and avoidance of specific patients.3,4 Medical education in the United States has not adequately addressed this problem. While many residents experience inappropriate behavior from patients, they lack specific strategies to respond.5 The hidden curriculum in medicine around problematic patient behavior should become explicit to build trainee resilience. Studies from other health disciplines suggest that training on how to respond to inappropriate patient behavior reduces its negative impact.6 Protecting our residents from the harm caused by inappropriate behavior is vital to ensuring the health of the workforce and, ultimately, our patients.Embedded in the patient-physician relationship is a complex power dynamic. We must acknowledge the privilege of the physician in understanding patients' biopsychosocial contexts to reflect on difficult encounters and improve clinical care. Psychiatrist James Groves elucidated the importance of this:The physician aims to get to know the patient better, forming a relationship built on mutual respect. The following tools may allow for reflection in order to build patient rapport, promote patient-centered care, and attend to resident well-being. While there is no one-size-fits-all approach to microaggressions, we offer an approach to the complex nuances of experiencing a microaggression that integrates a 3-pronged approach to address transgressions before, during, and after the clinical encounter.An Asian American resident anticipates his next patient interview at the VA, wondering what comment he will receive this time. In his previous interview, his patient asked, "Are you planning on returning to China after your training?"It is crucial to prepare faculty and residents for discriminatory events before they happen. Setting expectations provides residents and supervisors with appropriate in-the-moment responses and prepares them for meaningful reflection and debriefing. It is the attending physician's role and responsibility to create a positive learning climate.During orientation to clinical rotations, we learn about the values of team members, discuss how the team would prefer to address inappropriate patient behaviors, and prime residents with the skills to respond. Attending physicians make an explicit pledge to protect their learners as much as possible and invite open dialogue if their learners feel that supervisors are contributing to a negative clinical learning environment. Anecdotally, across multiple hospitals at our institution, this first step of reflection is well received by residents, who are grateful for the safe space created for discussion.Start the conversation about problematic patient behavior in an open-ended manner (table 1). Ask residents how they might respond and how they would like their supervisors to respond—if at all. Microaggressions can occur in the discrepancy between a patient's intentions and a target's perception; therefore, it may not always be appropriate to address a microaggression with a patient. If residents determine that they would appreciate a response, it could happen in the moment, after the encounter, with the patient alone, or with everyone present.Formal curricula may include implicit bias training, communication skills, and role-playing. These have been shown to empower residents to respond in the moment.5 Training structures can target a training level. Curricula for residents might involve practicing how to respond to problematic patient behavior directed at interns and students. As this occurs across all levels of training, it is crucial to address the roles within the existing hierarchy of medicine.An African American resident is discussing a care plan with her patient on the wards with the rest of the medical team in the room. The patient later asks, "Can you step out so I can just talk with my doctors?"Residents may lack the tools to respond in a way that avoids negative repercussions.8 Our approach (table 2) prioritizes patient care by first assessing the patient's clinical and mental stability before naming inappropriate behavior gracefully, clarifying roles, and (re)establishing respect. As in other stressful situations, practice the steps in a no-risk situation so you are prepared to respond in real-life situations. In our experience, we rarely have to progress past step 2 to redirect the conversation and demonstrate an environment of respect.When used in a stepwise fashion, patient care is prioritized while respecting learner well-being. Clarifying roles is a significant step of this process. Sometimes residents appreciate when their attendings speak up,9 while others may appreciate addressing the situation on their own. When a patient behaves inappropriately (assuming the patient is clinically stable), the care of the team can be directed toward the target of the problematic behavior. Business as usual is not an acceptable response.After returning to the team room, a resident states, "I just don't know how to get patients to take me seriously! It makes me feel inadequate when they call me 'sweetie' or 'honey.' I don't want to go back to the patient's room."Debriefing is crucial after a patient behaves inappropriately. As suggested in table 3, start by inquiring how the situation felt to the residents. They might think about what felt empowering or disempowering, discover defense mechanisms, or reflect on their response. Faculty can highlight the importance of depersonalizing the event to redirect the team's energy toward the goal of "do no harm."5 Residents should provide feedback on what could have gone better. Sometimes supervisors do not recognize the problematic behavior or know how to respond, which leads to silence. By reflecting on these situations, negative consequences may be mitigated.In addition to debriefing, wrap-up sessions after rotations can improve morale and camaraderie. During these sessions, teams can review their patient cases from a biopsychosocial view. This fosters a healing discourse and long-term insight, potentially reducing the likelihood of lasting moral distress.The patient-physician relationship is nuanced and may require intense reflection in order to promote patient care. Reflection is crucial in preventing burnout. Silence is not an option in the face of problematic patient behavior. We can address discriminatory patient behavior while preserving relationships and promoting outstanding care. Preparing, having a framework to respond in the moment, and reflecting represent significant steps to improve both resident and patient well-being. This 3-step approach can empower everyone to speak up to protect the learning and working environment for residents and encourage a diverse medical workforce that can improve care for future diverse populations.Keywords:
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e d N u r si n g 2 5 (3) , 1 0 3 4 3 4.
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The current main guidelines recommend management of musculoskeletal conditions within a biopsychosocial framework [1]. From time to time, a question arises whether this is too early as there is not...
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1. The history of the biopsychosocial approach in medicine: before and after Engel 2. The theoretical basis of the biopsychosocial model 3. Remediable or preventable social factors in the aetiology and prognosis of medical disorders 4. Remediable or preventable psychological factors in the aetiology and prognosis of medical disorders 5. The biopsychosocial approach: a note of caution 6. Can neurobiology explain the relationship between stress and disease? 7. Fear and depression as remediable causes of disability in common medical conditions in primary care 8. How important is the biopsychosocial approach? Some examples from research 9. Complementary and alternative medicine: shopping for health in post-modern times 10. A case of irritable bowel syndrome that illustrates the biopsychosocial model of illness 11. Are the patient-centred and biopsychosocial approaches compatible? 12. What are the barriers to health-care systems using a biopsychosocial approach, and how might they be overcome? 13. Final discussion: how to overcome the barriers 14. Beyond the biomedical to the biopsychosocial: integrated medicine
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The state-of-the-art in the diagnosis and therapy of low back pain is presented from a biopsychosocial point of view. Among low back pain patients, those dominate in whom psychosocial factors play an eminent role. The early comprehensive (biopsychosocial) integrative diagnosis is essential for further development of the illness. Conversion pain, psychoprosthetic pain and pain-proneness are the most important concepts for establishing a round diagnostic assessment and realistic therapeutic measures.
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This comprehensive review explores the integration of biopsychosocial approaches in the management of low-back pain (LBP). LBP is a multifaceted condition influenced by biological, psychological, and social factors. The review examines the evidence supporting the biopsychosocial model of LBP, the impact of biopsychosocial factors on pain perception and disability, and the effectiveness of integrated interventions. Emphasizing a holistic approach, the review highlights the importance of addressing biological, psychological, and social aspects in LBP management to optimize outcomes and improve the overall well-being of individuals with LBP.
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This chapter examines the biopsychosocial model in psychiatry. The term ‘biopsychosocial’ is most strongly associated with George L. Engel, whose most famous article on the biopsychosocial model was published in 1977. In advancing the model, Engel aimed to make explicit how the biological, the psychological, and the social all had a place in conceptualizing mental disorder, and to systematize and enshrine this recognition in the way in which psychiatry is practised. In making decisions about how to treat mental illness, or a given patient, adopting a biopsychosocial approach should involve keeping in mind that the most effective treatment may involve a solely biological intervention, a solely psychological one, a solely social one, or a combination of these. Indeed, a useful and effective biopsychosocial approach reminds one to consider all of these possibilities, and select the most promising one, based on the available empirical evidence.
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The biopsychosocial model, the current method in psychiatric assessments, is reviewed and critiqued. The history and original intents leading to the conception of the biopsychosocial model are briefly discussed. Five inherent problems with the use of the biopsychosocial model in psychiatric assessments and training programs are presented. Two alternative approaches are discussed and promoted for clinical, educational, and research practices in medicine.
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Background The biopsychosocial model of pain may aid the understanding pain and its clinical presentations.Objectives This paper presents a discussion of the past, present and future state of the biopsychosocial model of pain within physiotherapy.Main Findings The biopsychosocial model of pain acknowledges the dynamic interdependent biological, psychological and social dimensions of peoples pain experiences and has been widely endorsed. However, the biopsychosocial model is not beyond criticism and its applicability to clinical practice has been questioned. Researchers have investigated how clinicians understand and apply the biopsychosocial model in clinical practice. Evidence suggests that physiotherapists demonstrate varying levels of confidence and proficiency in their psychosocially-oriented clinical knowledge and practice. Psychologically informed physiotherapy treatment approaches have been described and trialled and show inconsistent results and effect sizes with respect to patient-related outcomes. In addition, commentators suggest that the '-social' dimension of the model has been relatively neglected. While there is some evidence that the biopsychosocial model is evolving, and efforts are underway to develop and validate clinically-applicable tools, physiotherapy clinicians, educators and researchers have been invited to consider existing barriers and enablers to the implementation of the biopsychosocial model in clinical practice in order to improve its understanding and application within healthcare.Conclusion The biopsychosocial model invites clinicians to understand and address the biological, psychological, and social dimensions of patients pain. Understanding and implementation of the biopsychosocial model of pain in physiotherapy is mixed. Improving education and training and developing and evaluating innovative biopsychosocial-oriented interventions appear to be important ways forward. The biopsychosocial model of pain is evolving in response to scientific and clinical developments.
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Abstract Objectives All pain research combined advances the different domains of the biopsychosocial model and its interactions. However, there may be discrepancies between individual countries in their biomedical, psychological or social focus to pain research. As a proxy for this possible discrepancy, we analysed the biopsychosocial orientation of presentations at a recent major international pain conference. Methods The primary aim was to investigate whether there are geographical differences across Europe regarding the biopsychosocial orientation of workshop presentations at the 12th EFIC congress. The secondary aim was to investigate whether there were differences between female and male presenters regarding the biopsychosocial focus of their presentations. All available workshop abstracts were blinded and categorised by two independent reviewers as biomedical, psychosocial, biopsychosocial, or not applicable. Psychosocial and biopsychosocial were merged to non-biomedical. Results Of the 140 available abstracts, 126 abstracts could be categorised (biomedical: 51 %; non-biomedical: 49 %). Three clusters of countries emerged: (1) countries with a clear majority (≥80 %) of non-biomedical presentations (The Netherlands and Belgium); (2) countries with a balance between biomedical and non-biomedical presentations (United Kingdom, Denmark, Norway, Sweden and Finland); and (3) countries with a clear majority (71–100 %) of biomedical presentations (Italy, Germany, Switzerland and France). Overall, women delivered more presentations than men (70 vs. 56 presentations), and delivered proportionally more non-biomedical presentations (57 %) whereas men delivered proportionally more biomedical presentations (61 %). Conclusions Analysis of the 12th EFIC congress revealed geographical and gender differences in biopsychosocial orientation. Whether this reflects established differences in pain research requires further investigation.
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Abstract The biopsychosocial model was defined by George L. Engel to propose a holistic approach to patient care. Through this model, physicians can understand patients in their context to aid the development of tailored, individualized treatment plans that consider relevant biological, psychological, and social–cultural–spiritual factors impacting health and longitudinal care. In this article, we advocate for the use of the biopsychosocial model in neurology practice across outpatient and inpatient clinical settings. To do so, we first present the history of the biopsychosocial model, and its relationships to precision medicine and deep phenotyping. Then, we bring the neurologist up-to-date information on the components of the biopsychosocial clinical formulation, including predisposing, precipitating, perpetuating, and protective factors. We conclude by detailing illustrative neurological case examples using the biopsychosocial model, emphasizing the importance of considering relevant psychological and social factors to aid the delivery of patient-centered clinical care in neurology.
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