Further Thoughts on the 4P Model

I am very grateful for the opportunity provided by the editor of this journal, Dr. Sadler, to read and respond to the comments of colleagues. Their observations on the article come from inside clinical medicine outward and outside inward. This makes them immensely valuable to those of us who reflect on what it is that physicians do at work. I am especially grateful for the comments of Drs. Brody and Lewis who I am lucky to have had as teachers. Rather than respond to each commentator individually, I consider themes to their responses.

George Engel as Hero

I was sorry that some commentators detected a dismissive tone to my examination of Engel’s work, as I, along with Lewis, consider Engel to be a hero in the history of modern medicine. His critique of biomedicine has had enduring value. The fact that, despite Engel’s direct warning to psychiatrists in his 1977 article, we continue to have to respond to those who would limit our attention as psychiatrists to biological derangements and who assert that these derangements are sufficient to define treatment and prognosis (as Porter rightly detects in Guze, Kupfer and others) suggests that each generation seems to have to have its own Engel. It is the spirit of Engel’s resistance to the biomedical model that I would like to celebrate, while reconsidering the form that his actual argument took.

The Biopsychosocial Model

My argument mostly considers the model that Engel developed to help clinicians to make sense of illness episodes. As Perring notes, Engel’s writings contain an implicit model of disease. He argued that disease is a disturbance of levels of organization. He placed great stock in the concept of isomorphy, that is, similar organization at different levels of organization, although somewhat confusingly he allowed that each level of organization has ‘its unique characteristics and dynamics.’ Presumably, isomorphy is the basis for the communication of signals up and down the levels of organization, either in disease or health (Tyreman 2014), and this would be the basis of a solution to the Humpty Dumpty problem. Here is not the place to fully explore whether isomorphy is true, and how well it accounts for emergent properties, such as consciousness. If it is true, then it would offer the basis for a model of disease, as described by Perring (2014). I think that clinicians can be allowed to remain agnostic on this aspect of the theory, at least for now until more of the patterns are elucidated. In the meantime, the 4P model of case formulation allows clinicians a way to ‘carry on.

A related issue is whether, as physicians, we are disease hunters only or disease hunters and something else as well. I do not deny the existence of diseases, although defining disease is actually quite difficult, as Perring points out. I do, however, deny that what we encounter in the clinic is disease only, or that we should limit our ‘gaze’ to disease. Diseases do not walk in, people with problems walk in, and not all of their problems are best made sense of as diseases, and not all of their requests of physicians are to (medically) treat the disease (Lazare et al. 1975).

The 4P Model and Narrative Medicine

Fundamentally, I agree that devising a case formulation for a patient involves constructing a story. I also agree with Lewis (2014) that the 4P model is one way of telling a story, and that this way of telling a story can have value for patients. However, the 4P model is unavoidably a physician-centered narrative device. It provides a structure by which to organize clinical information in a way that is useful to the physician. It is also problem-focused. With full respect to Tyreman’s (2014) salutogenic focus and related efforts to focus on growth and health (e.g., ‘positive psychology’), physicians and most clinicians are first and foremost asked to do something about problems that the patient has.

I am sympathetic to the...