One hundred and eight years ago, the Flexner Report elevated the standards and practices of the American medical education system. It ensured that the medical training moving forward would be firmly grounded in the “biomedical model,” incorporating physiology, biochemistry and the scientific method into the practice of medicine. For its time, the Flexner Report was revolutionary. However, while it helped medical schools in the United States compete with the well-established European schools in the early twentieth century, the Flexner Report was sorely lacking in its approach to humanism.
According to the Arnold P. Gold Foundation, humanism in healthcare is about the respectful, empathetic communication between physicians and their patient as well as the patients’ families. Learning only the hard sciences, such as biology, chemistry, and physics, prevents a student physician from developing the skills needed to “understand the patient’s subjective experience as an essential contributor to accurate diagnosis, health outcomes, and humane care.” The practice of humanism must be at the core of medicine, and this different model, entitled the biopsychosocial (BPS) model, permits and exemplifies this practice.
The BPS model is derived from the psychological practice of social cognitive theory, which explains how people acquire behaviors by recognizing the influence of personal factors and environmental influences. Thus, the BPS model recognizes the limitations of treating patients without understanding their psychosocial context. The biopsychosocial method drives the health care team to find solutions to patients’ barriers to receiving care. In doing so, the BPS model requires physicians to recognize their biases, develop their emotional intelligence and distinguish caring behavior from the outdated paternalistic physician-patient relationship. Ultimately, the BPS model recognizes that when a physician addresses a patient’s psychological and social stresses, the treatment plan becomes more effective.
Recently, the Medical College Admissions Test (MCAT) was radically upgraded to reflect portions of the BPS model. In the previous exam, there were three sections, which tested biology, general chemistry, physics, organic chemistry and verbal reasoning. There were 144 questions, and the exam lasted three hours and twenty minutes. When the Association of American Medical Colleges (AAMC) updated the MCAT in 2015, the aforementioned sections still remained as parts of the exam, but some of the physics, general chemistry and organic chemistry content was deemed irrelevant and removed. However, questions covering sociology, psychology and biochemistry were added. Currently, the examination is four sections, 230 questions and spans six hours and fifteen minutes. These changes were direct reflections of the beliefs central to the BPS model: The practice of humanism creates more empathetic physicians which yields better patient outcomes.
But for the philosophical concept of humanism to actually create patient-centered physicians, it needs to be practiced firsthand. Recently, I practiced this by taking part in a poverty simulation. A poverty simulation is a concept utilized by religious organizations and even Congress to give citizens insight into the stress, confusion and rigors of being impoverished in the United States. The simulation highlighted reasons why medical management plans, so carefully devised by physicians, often fail. I learned that citizens that comprise seven percent of the American population must give money for family members’ needs rather than their own health. Sometimes, the choice between going to work and seeing the doctor is not even an option, and the societal institutions, originally intended to help people, instead make them feel marginalized. Through this simulation, I was able to see the vast potential that the biopsychosocial model of health care offered.
Additionally, in my experience before medical school as an emergency department (ED) registered nurse (RN), I often saw patients who were unfortunately referred to by ED staff as “frequent fliers.” I remember working with one travel nurse who was very outspoken on the subject. He viewed “frequent fliers” as people ‘too stupid to care for themselves properly’ or ‘too ornery to follow simple discharge instructions. In his opinion, their failing health was their own fault so they kept coming back to the ED for further treatment. In reality, most of these people were neither stupid nor ornery; rather, they could not have the resources to have their personal, social and healthcare needs adequately addressed privately outside of the ED.
Applying the BPS model to “frequent fliers” provides a comprehensive approach to the problem. If patients cannot follow the biomedical treatment plan due to their psychosocial context, the rest of the inter-professional health care team must intervene. In their first contact with patients, health care professionals can assess and account for psychosocial stressors while also medically managing the disease. Through a shared decision-making process, the health care providers and the patients can find common ground to optimize patient health.
When I saw a “frequent flier” in the ER as a nurse, I did my best to engage in a conversation. If I adhered solely to the biomedical method, I would have handed these patients their discharge instructions and left the room. However, I found that within each exchange is a piece of information about what keeps leading a patient back to the ED. By engaging on a biopsychosocial level, I was better able to understand the patients and their illness. Because of this, I could more thoroughly inform physicians and improve patient care. In medical school and throughout my future career as a physician, I intend to follow the BPS model and keep humanism at the core in order to provide holistic health care to my patients.