The patient as a central construct: Shifting the emphasis

The biomedical model that has dominated health care and its institutions in the United States and other first-world countries throughout the 20th century has at its core an emphasis on pathophysiology; pharmaceutical, surgical, genetic, and other biotechnical approaches to eradicating and controlling disease; and an acknowledgment of the power of practitioners, most notably physicians (Brody, 1992). Waitzkin's (1991) critical analysis of discourse in medical settings illustrates the ways in which the social concerns of patients related to their health status are repeatedly marginalized and ignored by practitioners. Though 20 years ago psychiatrist George Engel (1977) posited the need for a more comprehensive, integrated approach that he called the biopsychosocial model, it is only recently and gradually that new paradigms of conceptualizing health care, both in the medical and public health arenas, are gaining ascendence. A prime example is the recent publication of Patient-Centered Medicine (Stewart et al., 1995), a compilation of more than a decade of efforts to formulate a new clinical method documented with research and based on a philosophy that the hierarchial power ascribed to physicians must be shared with patients. The notion of a more active and co-equal role for patients in clinical dyadic encounters has been discussed and debated for several years (Deber, 1994; Sharf, 1988; Steele, Blackwell, Gutman, & Jackson, 1987).