Intended for healthcare professionals

Rapid response to:


What is a good doctor and how can we make one?

BMJ 2002; 324 doi: (Published 29 June 2002) Cite this as: BMJ 2002;324:1537

Rapid Response:

Introducing the Biopsychosocial Model for good medicine and good doctors

Introducing the Biopsychosocial approach as the model for good
medicine and good doctors.

Development of a new model

Until recent decades the traditional approach towards health and
disease has been the medical or biological model where a person’s ill-
health was exclusively treated by medical means. At the time this seemed
satisfactory but recent research in psychology and the social sciences has
challenged this approach and sought to develop a new more extensive model
of health that can be applied in clinical practice.

In spite of the traditional dominance of the biomedical model, the
time seems right for expanding the model to the Biopsychosocial Model as
the social and psychological influences of today’s health problems do not
fit the narrow framework of the biomedical model. There has been much
discontentment with the medical model to the extent that Engel (1977)
suggested that it had acquired the authority and tradition of dogma. It
was this same author who devised the Biopsychosocial Model and stated in
his landmark paper that,

“We are now faced with the necessity and the challenge to broaden the
approach to disease to include the psychosocial without sacrificing the
enormous advantages of the biomedical approach”.

The Biopsychosocial Model of health and illness as proposed by Engel
(1977) implies that behaviours, thoughts and feelings may influence a
physical state. He disputed the long-held assumption that only the
biological factors of health and disease are worthy of study and practice.
He argued that psychological and social factors influence biological
functioning and play a role in health and illness also. This is a more
realistic model in light of the role lifestyles play in a society having
entered the new millennium. This new theoretical model therefore has been
developed in an attempt to improve on the disease approach and narrow view
with respect to health and illness held by the medical model so that
psychological and social factors of the individual can also be considered.

The Biopsychosocial Model is a very important step in medical care as
it broadens the scope with which health and illness can be examined in
clinical practice. Considering this model leads to the patient being
interviewed as a person with an individual lifestyle and not simply as a
patient with a disease which has deviated them from normal functioning.
Thus the clinician will have many avenues to explore before they make
their diagnosis and hopefully they will be able to provide preventative
information to the patient about how they may adjust their lifestyle in
order to have a better quality of life. This model can be used in medical
schools to train doctors in the art of good communication, understanding
and compassion.

The Biopsychosocial Model in Clinical Practice

One of the primary criticisms of new theoretical models is that they
may lack scientifically proved evidence that they can work. This would be
an unjust criticism of the Biopsychosocial Model however as there has been
substantial and extensive research into how this model can interface with
modern health problems and exert a considerable improvement. Many of the
modern illnesses such as heart disease and cancer have been found to have
psychological and social components to their aetiology. For example it has
been estimated that 30% of cancers are associated with tobacco use and
that diet accounts for some incidence of digestive tract cancers (Doll and
Peto, 1981). Psychological factors such as self-esteem and perceived
control have been identified as potential markers to help increase health-
promoting behaviours like exercise and reduction of over-consumption. Also
since it is known that individual’s susceptibility to coronary heart
disease is increased by factors such as hypertension, smoking, high
cholesterol and type A personality traits, then interventions can be
designed to seek change in a person’s lifestyle.

Possibly the most general biopsychosocial illness is that caused by
excess stress, that term used to describe situations in which individuals
are faced with environmental or other demands which exceed their immediate
ability to cope (Lazarus and Folkman, 1984). Very often these situations
produce adverse psychological and physiological changes and sometimes they
are associated with a disease outcome. With the Biopsychosocial model,
stress can be examined from each of these perspectives. Firstly,
biological factors like high blood pressure levels, muscle tension and an
individual’s decreased resistance to disease as a result of immuno-
suppression could be sources of investigation. Psychological factors like
increasing risk behaviours (smoking, large alcohol intake), coping
mechanisms and predisposition to anxiety could be examined. In fact a
study conducted on stress and burnout in psychiatric nurses showed that
the biggest factor in causation of burnout as measured on the Maslach
Burnout Inventory (MBI) was not job-demands but high trait anxiety levels
(Mc Inerney,1999).

Different interventions for modifying risk behaviours and so
incidence of disease can
be carried out on an individual or small group basis using stress-
management or relaxation techniques. However, it has been found that it is
very difficult for individuals to give up risky behaviours and adopt more
healthy lifestyles. It is therefore necessary to alter the cognitions
(beliefs, perceptions and attributes) that patients have about their
health and illness which play a role in determining their behaviour.
Cognitive-behavioural therapy, once exclusively used in the domain of
clinical psychology has proved successful in dealing with illnesses that
would previously have been viewed as requiring medical intervention e.g.
cardiovascular disease.

Social factors like loneliness, lack of participation in social
activities like exercising, the effects of unemployment and the effects of
working in an environment where long and unsociable working hours are the
norm are examples of where interventions may be implemented. Good research
will need to be continued to identify the health risks associated with
different behaviours and social conditions. This data should then be
brought to the attention of the Government to bring about changes at a
political, economic and social level so we may seek to eliminate
conditions like poverty, unemployment and loneliness. Since many high-risk
behaviours are often associated with these adverse social conditions, it
may only be after changes occur at a political level that the vicious
cycle of social circumstances affecting psychological and medical
circumstances will be broken.
At an individual level, families can exert a range of either positive or
negative influences on the health status and psychosocial adjustment of
patients. Family support can reduce the stressful impact of illness,
assist in the development of coping mechanisms by the patient and
encourage compliance with medical regimens (Flor& Turk,1985)
Biopsychosocial interventions may be achieved in clinical practice by
introducing these psychological or social interventions at the primary
care level. For example, GPs and hospital doctors should be able to apply
some psychological techniques themselves to intervene in the patients
lifestyle to avoid them needing medical treatment given that there is an
increased amount of training in these areas being offered in medical
schools. It is no longer sufficient that doctors feel that they only deal
with broken bones; they must also seek to mend the mind.

There are far-reaching implications of this model to the training of
good doctors and for good medical practice. An interesting area where this
model is being used is in the psychiatric hospital where a multi-
disciplinary team consisting of a consultant psychiatrist, junior doctor,
psychologist, social worker and psychiatric nurse consider the patients
problem firstly as a whole and then divide their resources. This has a
very effective result as all the needs of the patient are met and the team
is aware of the needs of the patient to improve their quality of life.

Sadly, it appears that there is a scarcity of psychological or social
intervention in Irish general hospitals. Hospital doctors should have
clear guidelines about what health professional they should contact if
they believe that a patient may benefit from psychological or social
intervention. Also junior doctors, having benefited from exposure to
behavioural science should be able to apply some psychological techniques
themselves to intervene in the patients lifestyle to reduce the likelihood
of them needing medical treatment for conditions like coronary heart

World Health Organisation (WHO) Challenge

“Health is a positive concept emphasising social and personal
resources, as well as physical capabilities.” WHO,1986.

As a basis of meeting the WHO challenge proposed by this statement,
medical professionals will need to be familiar with the research
identifying the health risks associated with different behavioural and
social conditions and not just the biological illness itself. Therefore it
is no longer sufficient for clinicians to state that treatment is
successful in terms of its effect on a specific biological illness but it
is now also necessary to know whether the treatment gives significant
improvement in the way in which a person lives.

The model inherently places a lot of emphasis on the individuals
control over their body and health and this may be difficult and confusing
for the chronically ill or those who battle in vain with weight, smoking
or drinking habits. However this is where the doctor uses his or her
expertise and experience in knowing how to approach the sensitive issues
of a patient’s daily life.


Doll,R., Peto,R. (1981) The causes of cancer. New York: Oxford
University Press.

Engel,G. (1977) The need for a new medical model: a challenge for
biomedical science. Science, 196:126-9.

Flor, H., Turk, D.C. (1985) Chronic Illness in an adult family
member: Pain as a prototype.

Lazarus,R.S., Folkman,S. (1984) Stress, appraisal and coping. New
York: Springer-Verlag.

Mc Inerney,S. (1999) Unpublished MSc Thesis. University of Dublin.

Competing interests: No competing interests

09 July 2002
Shane J Mc Inerney
Research Psychologist(Part-time); Medical syudent
University College Hospital Galway, reland