Health care providers are often asked to deal with the "whole" patient; complaints that physicians and institutions fail to do so are all too common. Engel (1977) pointed out that medical science itself has failed to focus on the social and psychologic aspects of illness. In so doing, science has reduced its focus of concerns to the biologic confines of life process. The fact that patients have never subdivided their experience and expectations in this fashion makes the interface between patients and medical practice somewhat of a mismatch. Patients continue to attach individualistic and life-based experiences to their concerns.

Categorization, Labeling, Subdividing, Biomedicine proceeds, and as each new technology it employs becomes known and marketed, new expectations and concerns appear in the clinic. Environmental contaminants, AIDS, cholesterol, and prostatic ultrasound; these become the stuff of the media, common knowledge, and they become part of the concerns and questions brought to illness. Even a well-defined biologic term like allergy develops its own life as part of society's popular lexicon. Patients come to clinics using "allergy" to explain headaches, feeling tired, being depressed, losing weight, dysfunction at work, and so on. Human concerns and fears are thus clothed in the garb and language of powerful systems—science and biomedicine—and underlying difficulties at home, in relationships, and in life process masquerade in the guise of biologic dysfunction. The physician triages, sorts, and, faced with the data, tries to describe what's wrong.

Much of human concern has become the "soft data" of biologically oriented medicine. Medicine focuses on "truths" that are measurable, reproducible, and statistically validated. This becomes part of the "dogma" alluded to by Dr. Engel. These directions are driven, in part, by the overwhelming power of the scientific method. Hidden beneath the surface lie issues that tie modern medicine to the archaic past of healing traditions. Modern practitioners are faced with the same dilemmas as practitioners of earlier healing traditions, traditions that were based on blood letting, herbalism, charisma, magic, shamanism, and religion. No one wants to be blamed for a death, a bad outcome. Cause must be discovered, blame attributed or diffused, and therapy considered with care. These issues are hidden factors in the tendency of practitioners to shy away from "soft data." Scientific explanations (which have replaced blame) lack judgmental qualities and thereby have neutral, amoral meanings. Practitioners, at least, would like to think so.

There are other powerful influences coming into play. Listen to the language in vogue. Patients have become "target populations," "consumers," and are the "clients" of health care systems. Even the providers, who thought they were engaged in the art and science of medicine, are being relabeled as the "product lines" of major health care purveyors. This intrusion of business and marketing goals into the human interactions necessary in health care have further complicated a system that was drifting far afield from psychosocial concern in dealing with patients.

The chapters that follow describe the characteristics of selected special patient populations as well as methodologies for considering and interacting with them. There is a rich literature about patients and populations as they are affected by special issues such as: alcohol or drug abuse, sexuality, contagion, developmental disorders, sensory and physical impairments, ethnicity, economics, or diseases such as diabetes, cancer, and Parkinson's disease. In fact, physicians constitute one of the populations studied, and there is evidence that they have their own special problems with health care and symptoms. What do providers do when they themselves are patients? Why? As students, physicians-to-be experience symptoms in the context of their training—interpreting bodily sensations and developing fears in the context of presumed pathologic processes. Physician families use amniocentesis and cesarean section at rates that far exceed the general population. The reasons for this disparate physician use of preventive and predictive as well as invasive obstetric technologies are unclear. However, understanding these and similar health-seeking behaviors could add significantly to our understanding and management of the care process.

But physicians, as Kleinman (1980) has pointed out, are pragmatic. The relative good of an action or an approach to care is measured in terms of its value to the care process and under constraints of time and fiscal rewards. For example, the utility of knowing about the frequency of social disruptions in a primary care setting may be unclear to a provider who lacks the time, the resources, and/or the inclination to deal with such problems, or whose clinical methods and training, as well as payment sources, do not validate issues such as marital stress. Consider the following:

A 28-year-old woman came to a clinic after a number of brief emergency room visits that were ascribed to hyperventilation. Her history revealed an abusive husband, and violence or fright preceding the episodes. The patient had a long history of unwillingness to deal with her marital circumstances, and rejected advice as well as referrals for help. Billing for "marital problems" was disallowed by Blue Cross. A resubmission of the bill under the problem label "breathlessness" was promptly paid.

The attribution of a psychosocial cause to an episode of illness was unacceptable, and, interestingly enough, it was unacceptable to both the payer and the patient! It appeared that both found the neutral, amoral meanings of "scientific" problem description more acceptable. Imagine a planning system for medicine based on summaries of medical incidents described under these constraints. Systems develop skewed perspectives about "What's wrong?" based on programmatic and methodologic biases.

Medicine's challenge is to broaden its perspective, and to attend to a methodology that is less restrictive in assessing causalty, a methodology that validates and attends to multiple interacting issues in life process. Life process contributes to illness in ways that go beyond biomedical notions of etiology. Of necessity these life processes cross the lines of physiologic, psychologic, and social systems. As you read on, consider that medicine may need to alter its basic approaches in order to move toward an orderly, systematic inclusion of broader concerns in its day-to-day interactions with patients.