Remember George Engel, MD

Our institution has recently started using NRC PIcker to collect patient feedback and grade clinical providers.  When I learned of this, I was anxious, defensive, offended and prepared to be angry at the prospect of being graded by data from some feedback form. I suspect my reaction is pretty common among providers. My discovery that the data includes some very useful material - and that I score well - has been a surprise, somewhat confusing, and led me to do some self-observation while with patients. 

Some of my approach to clinical medicine and patients clearly comes from intrinsic things like personality style and character. And some clearly comes from my family of origin and a collection of early formative life experiences. These are things one cannot apply as ‘remediation’ to other providers.  However, watching myself over several months and asking some of my patients for their opinions has led me to several things in my professional career that have had a huge impact on the way I approach patient interactions, and that probably ARE things that could be helpful for others. The first was my exposure to George L. Engel, MD. (More here.)

I was fortunate to spend five (yes, it took me five years to finish medical school - I was a troubled trouble maker) at the University of Rochester where the biopsychosocial model of medicine was created, and to be taught there by Dr. Engel, the originator of thebiopsychosocial model, while he was developing it and before he first published about it in Science.

Dr. Engel believed that the patient could only be understood - and was best treated - as part of a three piece interlocking system of biology (human and disease), psychology (patient and significant others), and their social context (home, work, job, friends, hobbies...). He considered no evaluation completed until it described the issues from all these perspectives. He told us again and again that the biology was fun but simple, that illnesses are only partly biological, that the psychology and context were necessary to understand the patient and their illness (whose importance he ranked in that order), and that this approach was necessary to create the relationship that was essential for healing.  His clinical approach and tools were all based on the concept that, while the physician brought knowledge of biology to the mix, this was rarely enough. In addition, one had to consider psychology and context, which had to be from inside the patient and not just from their own professional perspective. His approach to the patient was incredibly patient-oriented. So painful at times that most of us went through all the stages of grief when introduced to it. But many of us came to see it’s incredible value. I still use his book and think about his approach regularly. 

His interviews were open-ended and patient-driven journeys through the patient’s experience of their illness. He taught us to use questions like these:

  • Hmmm. And how was that for you?
  • Interesting. What did you think was going on at that point?
  • There was lots going on. What was most important (most noticeable, most frightening, most distressing, most reassuring) for you then?
  • You’ve been having (symptom, problem, diagnosis, treatment) for a long time and it’s obviously had an impact. What’s your theory about what’s happening?
  • We’ve talked about a lot of things. Are there other things you think it would help me to know?
  • Hmmm.
  • I see.
  • And, perhaps one of the most under-appreciated: simple attentive silence.

These were generally accompanied by eye contact and a forward lean. He was willing to wait as long as necessary for an answer. He rarely interrupted patients, and usually apologized when he did. (“I’m sorry for interrupting, but I’d like to hear more about X before we move on.”) He told us, again and again, that as soon as the patient thinks we are in a hurry or impatient, they see themselves as being demoted on our priority list, will start to filter what they tell us, and will withdraw from us as people.

We audio taped interviews and later played them back in a group with one of the psychiatric liaisons to moderate, discussing what we did, what we said, what was happening, and what we did and didn’t know. While I can’t (or choose not to) do the 90 minute diagnostic interviews he taught us in my busy family practice, the principles are applicable in the 15 minute respiratory infection visit, the 20 minute well child visit, the on-call phone conversation and the 30 minute assessment of insomnia.  I have been at medical conferences and heard or read snippets of physician-patient interactions and been able to recognize someone who has crossed paths with the Rochester approach.

I am grateful for two things. First, the central insight that we were not dealing with a disease, but with a patient experiencing a disease in a social and psychological context that greatly impacted the patient’s experience and ability to take care of himself or herself. And second, for training in the use of tools that help me work with the patient on the patient’s issues, at least partly from within the patient’s universe.

Thank you, Dr. Engel.



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