Monthly Archives: December 2011

Hail the House Call

It is now 35 years since George Engel, an internist at the University of Rochester Medical School, formulated his biopsychosocial model of medicine (Science, 196:129, 1977).  Concerned with the reductionism and fragmentation inherent in scientifically guided specialist care, Engel called on his colleagues to locate biomedical interventions on a larger biopsychosocial canvas.  Drawing on the version of general systems theory popular in the 1970s, Engel argued that clinical assessment properly embraced a hierarchy of discrete biological, personal, and transpersonal levels, any combination of which might enter into the meaning of illness, whether acute or chronic.  Even in ostensibly biomedical conditions such as diabetes, cancer, and heart disease, Engel held, it was not simply deranged cells and dysfunctional organs that accounted for pathophysiology.  His model made a strong knowledge-related (i.e., epistemic) claim:  that hierarchically ordered layers of intra- and interpersonal stressors were causal factors in disease as it expressed itself  in this or that person.  It followed for Engel that personality structure; adaptive resources and “ego strength”; psychodynamic conflicts; two-person conflicts; family-related conflicts; conflicts in the workplace – these factors, in various combinations, entered into the scientific understanding of disease.

In devising the biopsychosocial model, Engels was influenced by the psychoanalysis of his day.  It is for this reason that biopsychosocial medicine is typically, and, I believe, erroneously, identified with the kind of “psychosomatic medicine” that analysis gave birth to in the quarter century following World War II (Psychosom. Med., 63:335, 2001). More generally still, it is conflated with psychosocial skills, especially as they enter into doctor-patient communication.  Because Engel’s model is not an algorithm for determining which levels of the patient “system” are implicated in this or that instance of illness, it has been criticized over the years for failing to guide clinical action, including the ordering of therapeutic goals (Comp. Psychiatry, 31:185, 1990).  Self-evidently, the model has proven very difficult to teach (Acad. Psychiatry, 28:88, 2004) and equally difficult to integrate into the conventional medical school curriculum (Psychosom. Med., 63:335, 2001).

These findings are hardly surprising.  It is difficult to teach doctors-in-training how to apply a biopsychosocial model when real-world doctoring rarely places them in regular contact with the transmedical “systems” invoked by the model.  This was not always the case.  Consider the house call, that site of biopsychosocial consciousness-raising throughout the 19th  and well into the 20th century.  It was in the home of the patient, after all, that the physician could actually experience the psychosocial “systems” that entered into the patient’s illness:  the patient’s personality, but also the patient as spouse, parent, sibling, son or daughter, all apprehended within the dynamics of a living family system.  And of course there was the home environment itself, a psychosocial container of medically salient information.  Wise clinicians of the early 20th century did not need the assistance of a biopsychosocial model to understand the role of the house call in cultivating the physician’s biopsychosocial sensibility.  Here is Harvard’s Francis Peabody in “The Care of the Patient” (1927):

“When the general practitioner goes into the home of a patient, he may know the whole background of the family life from past experience; but even when he comes as a stranger he has every opportunity to find out what manner of man his patient is, and what kind of circumstances make his life.  He gets a hint of financial anxiety or of domestic incompatibility; he may find himself confronted by a querulous, exacting, self-centered patient, or by a gentle invalid overawed by a dominating family; and as he appreciates how these circumstances are reacting on the patient he dispenses sympathy, encouragement or discipline.  What is spoken of as a ‘clinical picture’ is not just a photograph of a man sick in bed; it is an impressionistic painting of the patient surrounded by his home, his work, his relations, his friends, his joys, sorrows, hopes and fears” [JAMA, 88:877, 1927].

Three decades after Peabody’s lecture, I began riding shotgun when my father, William Stepansky, made his daily round of house calls in rural southeastern Pennsylvania.  Sometimes, especially with the older patients he visited regularly, I came into the house with him, where I was warmly welcomed, often with a glass of milk and home baked treats, as the doctor’s son and travelling companion.  From my time on the road, I learned how my father’s clinical gaze met and absorbed the anxious gazes of family members.  It became clear, over time, that his medical obligation was not only to the patient, but to the patient-as-member-of-a-family and to the family-as-medically-relevant-part-of-the-patient.  In a lecture to the junior class of his alma mater, Jefferson Medical college, in 1965, he made this very point in differentiating the scope of the family physician’s clinical gaze from that of the pediatrician and internist.  Unlike the latter, he observed, the family physician’s interventions occurred “within the special domain of the family,” and his treatment of the patient had to be continuously attentive to the “needs of family as an entity.”  It was for this reason, he added, that “family medicine must teach more than the arithmetic sum of the contents of specialties” (my father’s emphasis).  Here, in the mid-60s, my father posited a medical-interventional substratum to what would emerge a decade or so later, in the realm of psychotherapy, as family systems theory and “structural family therapy.” And then, 12 years before Engels came on the scene, he offered his conception of  “a solid intellectual approach to medicine”:

“To me this means relating the effects of the body systems one upon the other in health and disease through knowledge of the basic sciences – i.e., biochemistry and physiology – through some understanding of the social and environmental stresses on the patient, and finally through insight into the psychological influences of personality structure as it affects health and disease.”

Of course, physicians long before my father and long before Francis Peabody understood that medical treatment of the individual might entail interventions with transpersonal “systems.”  Witness the Victorian physicians of well-off American families of the 1870s and 1880s described by the historian Nancy Theriot (Amer. Studies, 26:69, 1990; Signs, 19:1, 1993; J. Hist. Behav. Sci., 37:349, 2001).  Making home visits to overwrought postpartum women in the throes of what was then termed “puerperal insanity” – we have only the far less evocative “postpartum depression” – these knowing family physicians dissuaded their patients from the drastic surgical interventions available to them (such as ovariotomy).  They recommended instead a change in the family “system” to accommodate the parturient’s urgent need for “time out” from the burdens of household management, childrearing, and husband-pleasing, to which care of a newborn was now superadded.  Is it any wonder that the matrons of these well-run Victorian households became “insane,” and that their insanity took the form, inter alia, of vile language, refusal to dress appropriately, refusal to resume housework, indifference to their children’s daily needs, and even – horribile dictu –  refusal to hold their newborns?  And yet these same women, flouting Victorian conventions with postpartum abandon, often returned to bourgeois sanity after the family physician, with the weight of medical authority, simply prescribed a daily period of solitude when the new mother, perhaps sitting alone in the family garden, was not to be disturbed – not by anyone.  Biopsychosocial intervention aimed at the family “system” was never so elegantly simple.

Interventions of this sort are hardly unknown among contemporary providers, some small percentage of whom continue to visit their patients in their homes.   Further, as one of my correspondents has reminded me, all family medicine residencies employ full-time behaviorists, usually psychologists, who help trainees develop a biopsychosocial model of care. But outside of these programs the biopsychosocial model remains where it has always been – on the fringe of a medical world of fragmented and technology-driven specialist care.  In this sense, it is no different than the house call, which lives on among some 4,000 physicians in the U.S. and through a very few university hospital-based “house call programs.”  But let there be no mistake:  these physicians and these programs are at the far margins of primary care.  When the American Academy of Family Physicians polled its active members in 2008 on the settings in which they saw patients, respondents from urban and rural regions alike reported an average of 0.6 house calls a week.  (My father, in the 50s and 60s, averaged 3-4 a day.)  If this figure represents the rate at which house call-making doctors make house calls, then it is fair to say that the house call has long since ceased to be an intrinsic – and intrinsically humanizing – dimension of primary care.  This is why I pay tribute to the Great American House Call.  It is a relic of an era when biopsychosocial medicine suffused general practice without the aid of a biopsychosocial model.

Addendum

Unbeknown to many, the healthcare reform bill passed by Congress in March, 2010 contains an “Independence at Home Act” that provides physicians with financial incentives to treat their oldest and sickest patients in their homes.  To wit, house call-making doctors will share in cost saving if they can “prove” their in-home care reduced hospital use and left their patients satisfied.   So much for the scientific bona fides of biopsychosocial medicine.  It’s about the money, stupid.

Copyright © 2011 by Paul E. Stepansky.  All rights reserved.

Primary Care/Primarily Caring (IV)

If it is little known in medical circles that World War II “made” American psychiatry, it is even less well known that the war made psychiatry an integral part of general medicine in the postwar decades.  Under the leadership of the psychoanalyst (and as of the war, Brigadier General) William Menninger, Director of Neuropsychiatry in the Office of the Surgeon General, psychoanalytic psychiatry guided the armed forces in tending to soldiers who succumbed to combat fatigue, aka war neuroses, and getting some 60% of them back to their units in record time.   But it did so less because of the relatively small number of trained psychiatrists available to the armed forces than through the efforts of the General Medical Officers (GMOs), the psychiatric foot soldiers of the war.  These GPs, with at most three months of psychiatric training under military auspices, made up 1,600 of the Army’s  2,400-member neuropsychiatry service (Am. J. Psychiatry., 103:580, 1946).

The GPs carried the psychiatric load, and by all accounts they did a remarkable job.  Of course, it was the psychoanalytic brass – William and Karl Menninger, Roy Grinker, John Appel, Henry Brosin, Franklin Ebaugh, and others – who wrote the papers and books celebrating psychiatry’s service to the nation at war.  But they all knew that the GPs were the real heroes.  John Milne Murray, the Army Air Force’s chief neuropsychiatrist, lauded them as the “junior psychiatrists” whose training had been entirely “on the job” and whose ranks were destined to swell under the VA program of postwar psychiatric care (Am. J. Psychiatry, 103:594, 1947).

The splendid work of the GMOs encouraged expectations that they would help shoulder the nation’s psychiatric burden after the war. The psychiatrist-psychoanalyst Roy Grinker, coauthor with John Spiegel of the war’s enduring  contribution to military psychiatry, Men Under Stress (1945), was under no illusion about the ability of trained psychiatrists to cope with the influx of returning GIs, a great many “angry, regressed, anxiety-ridden, dependent men” among them (Men Under Stress, p. 450).  “We shall never have enough psychiatrists to treat all the psychosomatic problems,” he remarked in 1946, when the American Psychiatric Association boasted all of 4,000 members.  And he continued:  “Until sufficient psychiatrists are produced and more internists and practitioners make time available for the treatment of psychosomatic syndromes, we must use heroic shortcuts in therapy which can be applied by all medical men with little special training” (Psychosom. Med., 9:100-101, 1947).

Grinker was seconded by none other than William Menninger, who remarked after the war that “the majority of minor psychiatry will be practiced by the general physician and the specialists in other fields” (Am. J. Psychiatry, 103:584, 1947).  As to the ability of stateside GPs to manage the “neurotic” veterans, Lauren Smith, Psychiatrist-in-Chief to the Institute of Pennsylvania Hospital prior to assuming his wartime duties, offered a vote of confidence two years earlier.  The majority of returning veterans would “present” with psychoneuroses rather than major psychiatric illness, and most of them “can be treated successfully by the physician in general practice if he is practical in being sympathetic and understanding, especially if his knowledge of psychiatric concepts is improved and formalized by even a minimum of reading in today’s psychiatric literature”  (JAMA, 129:192, 1945).

These appraisals, enlarged by the Freudian sensibility that saturated popular American culture in the postwar years, led to the psychiatrization of American general practice in the 1950s and 60s.  Just as the GMOs had been the foot soldiers in the campaign to manage combat stress, so GPs of the postwar years were expected to lead the charge against the ever growing number of “functional illnesses” presented by their patients (JAMA, 152:1192, 1953; JAMA, 156:585, 1954).  Surely these patients were not all destined for the analyst’s couch.  And in truth they were usually better off in the hands of their GPs, a point underscored by Robert Needles in his address to the AMA’s Section on General Practice in June of 1954.  When it came to functional and nervous illnesses, Needles lectured, “The careful physician, using time, tact, and technical aids, and teaching the patient the signs and meanings of his symptoms, probably does the most satisfactory job” (JAMA, 156:586, 1954).

Many generalists of the time, my father, William Stepansky, among them, practiced psychiatry.  Indeed they viewed psychiatry, which in the late 40s, 50s, and 60s typically meant psychoanalytically informed psychotherapy, as intrinsic to their work.  My father counseled patients from the time he set out his shingle in 1953.  Well-read in the psychiatric literature of his time and additionally interested in psychopharmacology, he supplemented medical school and internship with basic and advanced-level graduate courses on psychodynamics in medical practice.  Appointed staff research clinician at McNeal Laboratories in 1959, he conducted and published  (Cur. Ther. Res. Clin. Exp., 2:144, 1960) clinical research on McNeal’s valmethamide, an early anti-anxiety agent.  Beginning in the 1960s, he attended case conferences at Norristown State Hospital (in exchange for which he gave his services, gratis, as a medical consultant).  And he participated in clinical drug trials as a member of the Psychopharmacology Research Unit of the University of Pennsylvania’s Department of Psychiatry, sharing authorship of several publications that came out of the unit.  In The Last Family Doctor, my tribute to him and his cohort of postwar GPs, I wrote:

“The constraints of my father’s practice make it impossible for him to provide more than supportive care, but it is expert support framed by deep psychodynamic understanding and no less valuable to his patients owing to the relative brevity of 30-minute ‘double’ sessions.  Saturday mornings and early afternoons, when his patients are not at work, are especially reserved for psychotherapy.  Often, as well , the last appointment on weekday evenings is given to a patient who needs to talk to him.  He counsels many married couples having difficulties.  Sometimes he sees the husband and wife individually; sometimes he seems them together in couples therapy.  He counsels the occasional alcoholic who comes to him.  He is there for whoever seeks his counsel, and a considerable amount of his counseling, I learn from [his nurse] Connie Fretz, is provided gratis.”

To be sure, this was family medicine of a different era.  Today primary care physicians (PCPs) lack the motivation, not to mention the time, to become frontline psychotherapists.  Nor would their credentialing organizations (or their accountants) look kindly on scheduling double-sessions for office psychotherapy and then billing the patient for a simple office visit.  The time constraints under which PCPs typically operate, the pressing need to maintain practice “flow” in a climate of regulation, third-party mediation, and bureaucratic excrescences of all sorts – these things make it more and more difficult for physicians to summon the patience to take in, much less to co-construct and/or psychotherapeutically reconfigure, their patients’ illness narratives.

But this is largely beside the point.  Contemporary primary care medicine, in lockstep with psychiatry, has veered away from psychodynamically informed history-taking and office psychotherapy altogether.  For PCPs and nonanalytic psychiatrists alike – and certainly there are exceptions – the postwar generation’s mandate to practice “minor psychiatry,” which included an array of supportive, psychoeducative, and psychodynamic interventions, has effectively shrunk to the simple act of prescribing psychotropic medication.

At most, PCPs may aspire to become, in the words of Howard Brody, “narrative physicians” able to empathize with their patients and embrace a “compassionate vulnerability” toward their suffering.  But even this has become a difficult feat.  Brody, a family physician and bioethicist, remarks that respectful attentiveness to the patient’s own story or “illness narrative” represents a sincere attempt “to develop over time into a certain sort of person – a healing sort of person – for whom the primary focus of attention is outward, toward the experience and suffering of the patient, and not inward, toward the physician’s own preconceived agenda” (Lit. & Med., 13:88, 1994; my emphasis).  The attempt is no less praiseworthy than the goal.  But where, pray tell, does the time come from?  The problem, or better, the problematic, has to do with the driven structure of contemporary primary care, which makes it harder and harder for physicians to enter into a world of open-ended storytelling that over time provides entry to the patient’s psychological and psychosocial worlds.

Whether or not most PCPs even want to know their patients in psychosocially (much less psychodynamically) salient ways is an open question.  Back in the early 90s, primary care educators recommended special training in “psychosocial skills” in an effort to remedy the disinclination of primary care residents to address the psychosocial aspects of medical care.  Survey research of the time showed that most residents not only devalued psychosocial care, but also doubted their competence to provide it (J. Gen. Int. Med., 7:26, 1992; Acad. Med., 69:48, 1994).

Perhaps things have improved a bit since then with the infusion of courses in the medical humanities into some medical school curricula and focal training in “patient and relationship-centered medicine” in certain residency programs.   But if narrative listening and relationship-centered practice are to be more than academic exercises, they must be undergirded by a clinical identity in which relational knowing is constitutive, not superadded in the manner of an elective.  Psychodynamic psychiatry was such a constituent in the general medicine that emerged after World War II.  If it has become largely irrelevant to contemporary primary care, what can take its place?  Are there other pathways through which PCPs, even within the structural constraints of contemporary practice, may enter into their patients’ stories?

Copyright © 2011 by Paul E. Stepansky.  All rights reserved.