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ABSTRACT: The best known model for case formulation in the last 50 years was George Engel's Biopsychosocial model. It expanded the compass of medical investigation and it promised a scheme by which to organize clinical information for more adequate understanding and more effective interventions. Despite its claimed advantages, it has not been adopted by clinicians. This article examines reasons for this failure. It argues for the therapeutic value of case formulation (as a complement to diagnosis), and presents an alternative schema by which clinicians can organize information into the four moments of a clinical problem: its origins (preconditions), precipitating factors, perpetuating factors, and protective factors. Unlike Engel's hierarchically organized, synchronic schema, the 4P schema is developmental, diachronic, and clinically intuitive. The 4P schema encourages 'thick' case formulations as the basis of wise treatment interventions. The last section describes two seminar series in which the structure and elements of the 4P schema were presented to third-year psychiatry residents.
KEYWORDS: Biopsychosocial model, diagnosis, medical education, illness behavior, sick role, interpretation, practice.
"Case formulation is considered passé." (In-patient attending psychiatrist 2012)
WOULD THIS VIEW , if true (and it seems to be), confirm George Engel's late-life despair about medicine after he had spent so much energy trying to get physicians to broaden their understanding of illness? Ironically, it might have been, at least in part, because of Engel's efforts that clinicians are now disinclined to try to understand their patients from biological, psychological, and sociological perspectives. In this article, I review Engel's Biopsychosocial model as a schema for case formulation. I then defend the utility of case formulation in practice and present an alternative model that avoids some of the conceptual and practical problems of the Biopsychosocial model. Finally, I describe the organization of a seminar that was designed to train psychiatric residents how to formulate their cases within this alternative model, which I call the 4P model. Although the seminar was designed for psychiatric residents, the organization and much of the content are applicable to trainees in other medical disciplines and medical students more generally.
ENGEL'S BIOPSYCHOSOCIAL MODEL
Engel proposed his Biopsychosocial model of disease as a corrective to what he called the Biomedical model. As he described it, the Biomedical model was (or is,...