A psychiatry resident (doctor-in-training) whom I was supervising took a thorough history, and then reported back to me about the patient’s symptoms, medical history, physical exam and laboratory findings. The resident had clearly been caring and had done a good job.
“So what was the breakup about?” I asked him. This was an unexpected question. The resident stammered a bit, looked uncomfortable and replied, “I thought that was too personal to ask about.”
This is an example of a widespread medical paradox: Doctors don’t hesitate to invade patients’ bodies but are often reluctant to discover who the patient is as a person. We manually examine prostate glands and uteruses, stick needles and catheters hither and yon, and overcome squeamishness to get detailed descriptions of bowel habits and genital problems. But ask about a breakup? That’s getting too personal.
The problem is that these personal matters are what many patients — not just psychiatric ones — often need and want to talk about. When patients know that their doctor knows even a little about their personal life, they usually feel calmer and better understood.
I think this situation might be improved if doctors could reimagine getting to know a patient as doing a different kind of “invasive” procedure: a biopsychosocial biopsy. Instead of taking a sample of bodily tissue to test it, this procedure collects samples of the patient’s biographical, psychological and social worlds.
Of course, no knife or needle is required to perform a biopsychosocial biopsy. Instead, as I proposed to my physician colleagues in a recent article in the American Journal of Medicine, doctors themselves are the instrument — and can use a straightforward template to guide them through the procedure.
The technique for the biopsychosocial biopsy capitalizes on a skill that all medical students are taught early on: to simply ask the patient to “tell me more about” their particular problem, and then to explore it systematically.
Usually, this problem is something like shortness of breath, abdominal pain, early contractions, “your child’s wheezing” and so forth. Doctors are taught to help patients in this inquiry by asking questions such as: “Can you describe the quality of the pain?” “What makes it better or worse?” “How long does it last?”
The strategy for performing a biopsychosocial biopsy involves only a change of the inquiry’s subject. The doctor asks the patient to “tell me more about” four things:
1. Where and with whom do you live?
2. How do you spend your days?
3. Who are the important people in your life?
4. What sorts of things give you pleasure?
To a layperson, such questions may seem obvious, but doctors often believe they are the domain of social work or psychology rather than medicine.
An interesting variation on this technique is regularly demonstrated by David Axelrod on his “The Axe Files” podcast. Axelrod, a political analyst who helped engineer Barack Obama’s rise to the presidency, begins many of his conversations with public figures by welcoming them and then immediately asking them to “tell us something about where you come from and what growing up was like.”
The effect is direct and disarming, and well-tolerated by the guests. Axelrod helps his guests reveal important details of their lives that are personal but never embarrassing. There are no obvious adverse side effects to his approach. It tends to make the rest of the interview more relaxed and open, not to mention compelling.
A biopsychosocial biopsy provides only a starting point for a more meaningful discussion.
Just as the opening moves of a chess game may be predictable, providing a framework for each player to follow until things settle down and get more interesting, the biopsychosocial biopsy aims to get doctors comfortably through the “opening game” of personal inquiry. From there, the doctor has the choice about whether and how to take things further, guided by experience and empathy.
There is more to the technique of the biopsychosocial biopsy. Although it can be performed while standing, it should feel like a conversation and is better done with the doctor sitting by the seated patient, or at the bedside. While tissue biopsies require that the doctor maintain a strictly sterile operative field, the biopsychosocial biopsy is a “nonsterile” procedure: the doctor should try to be warm and human rather than austere and distantly “professional.” Nonverbal cues are critical: body language, tone of voice and eye-contact often communicate curiosity, concern and safety more clearly than what the doctor actually says, and help a patient feel comfortable enough to share personal details.
Contrary to the protocol with medical procedures, no informed consent forms are needed for biopsychosocial biopsies. Most patients are willing to discuss nonmedical matters and will tell us when we’re nearing an emotionally sensitive area. When in doubt, a doctor can always ask whether it’s okay to keep asking questions — their cause of their relationship trouble, or gender identity issues or domestic violence. Patients can welcome using the doctor-patient relationship as an opportunity for revelation or confession — particularly if the doctor seems genuinely interested and caring.
The biopsychosocial biopsy is useful for all patients, not just psychiatric ones. I often consult with primary care physicians on what to do with their behaviorally challenging patients: the ones who don’t come to visits regularly, don’t take medications as prescribed, are depressed or hostile, and so forth.
With few exceptions the biopsychosocial biopsy is the treatment of choice in such situations, as it provides the context needed to understand why the patient is behaving the way he or she does.
Some doctors will naturally feel that performing a biopsychosocial biopsy is not for them, and some patients will not need or want one. But it is a useful skill for doctors to have in their clinical tool kit — and one I think medical schools should train their students in.
Greater physician comfort with modest invasiveness could improve patient care. Performing this kind of biopsy rarely leads to complications; instead, it can help patients feel more known and can remind doctors of the privilege that draws many of us to the field in the first place.
Michael W. Kahn is an assistant professor of psychiatry at Harvard Medical School and on the staff of Beth Israel Deaconess Medical Center.