key: cord-0877428-ivvwiy7s
authors: Davidson, John H.
title: Engel in the Time of COVID-19
date: 2020-12-23
journal: Mayo Clin Proc
DOI: 10.1016/j.mayocp.2020.12.012
sha: 8e9018bee41cbc52fd2cade3c0776a6d5d53c39c
doc_id: 877428
cord_uid: ivvwiy7s

nan

Over forty years ago, George Engel, a University of Rochester-based physician and scholar, confronted the biomedical community of his time. He posited the inadequacy of viewing patient problems only through a biomedical lens and suggested that inclusion of psychosocial determinants as relevant to understanding disease states was more scientifically sound. He argued persuasively for the replacement of a dogmatic biomedical "folk model" with a more inclusive "biopsychosocial model" which stressed not only physicochemical, molecular, and biological numerics, but also individualized psychological and social descriptors. 1 His trenchant argument included the following:

An examination of the correlations between clinical and laboratory data requires not only reliable methods of clinical data collection, specifically high-level interviewing skills, but also understanding of the psychological, social, and cultural determinants of how patients communicate symptoms of disease. 1 Since those decades past, Engel's name and model have faded from the awareness of many in the biomedical world. It has taken a pandemic to remind us again of his insights and their continued relevance. In this issue of Mayo Clinic Proceedings, latter-day colleagues of Dr. Engel from the University of Rochester revisit "the tradition of the biopsychosocial model" while addressing the "psychosocial costs" of the present pandemic which "parallel the biomedical ones." 2 They focus primarily on the biopsychosocial dynamics of three groups: those secluded J o u r n a l P r e -p r o o f in the community by virtue of disease exposure or disease itself; those isolated in hospital settings for more attentive care; and, clinicians caring for and interacting with all these patients on a day-to-day basis.

The article's distilled message is that regardless of group, a continuum of emotional and physical responses may be expected in the wake of the pandemic's stresses -whether those of social isolation, illness experienced, illness anticipated, moral quandaries over resource triage, or death. Pre-pandemic medical and psychiatric comorbidities, basic demographics, substance abuse, and prior experiences of trauma and loss are among specific psychosocial variables which act as determinants of how patients and providers respond to the situations faced.

The variety of potential response is obvious. So also is the need for tailored interventions to meet individual needs. These may vary from structured telemedicine interviews, to peer support groups, to close monitoring for mood and cognitive fluctuations, to being watchful for any initiation or rekindling of a post-traumatic stress disorder. One intervention should not be expected to fit all. Discriminant, discerning care is the charge.

Among the practical therapeutic interventions available is the adoption of an attitude of trauma-informed care in relating to both patients and peers. 3 This entails maintaining a focus on patient-centered communication; holding an understanding of trauma effects on overall health; utilizing active professional collaboration; seeking and understanding of one's own J o u r n a l P r e -p r o o f history of trauma and loss; and, acquiring an ability to explore trauma and loss issues with patients and colleagues without causing even greater distress.

Undoubtedly, the most challenging of these elements is that of a clinician's considering their own history of trauma and loss, and how this might impact their ongoing care of patients.

Outside psychiatric practices, we clinicians are rarely inclined toward or encouraged in these explorations. It is an aspirational goal to which Dr. Engel would undoubtedly accede.

More than a year with COVID-19 has passed. It has had an undeniable human ecological impact beyond the tents, wards, clinics, and intensive care units where its victims are treated. There is widespread societal loneliness, unemployment, and uncertainty as to the future. Just as there are fewer hospital beds and more professional burnout, there are also fewer available outpatient appointments and more delayed responses to routine patient queries. To work in any medical venue now is to know some element of this multi-determined biopsychosocial chaos.

Imagine an isolated elder who forgets the directions for her weight-adjusted diuretic regimen and is readmitted with decompensated heart failure. Imagine a teenage diabetic who lives with the stress of being quarantined from her friends and then succumbs to impulses for self- The time of COVID-19 is one calling out again for Engel's biopsychosocial lens in our efforts to generate and sustain solutions in moments such as these. But it must also be acknowledged that many among us now carry our own histories of loss and unalterable change from this scourge. We have come to realize different identities, intentionally or not, as increasingly fatigued healers feeling mostly called to the duty of our professions, not as heroes, but as individuals trying repeatedly to just do the right and decent thing. 4 In this doing, we find ourselves face to face with the prospect of limping forever like the biblical Jacob, after our own fated wrestling with a malevolence that has strained body as well as spirit. 5 Though healers, we stand now also among the wounded.

J o u r n a l P r e -p r o o f

The need for a new medical model: a challenge for biomedicine

Mental health, covid-19, and the invisible pandemic on the horizon

Trauma informed care in medicine: current knowledge and future directions

Camus on the coronavirus. New York Times website