Knowledge, attitudes, and practices of clerkship supervisors regarding the biopsychosocial approach at the University of Botswana’s Faculty of Medicine

Abstract

Background

The biopsychosocial and spiritual model (BPSM), commonly referred to as body-mind unity, complements the biological model by expanding health professionals’ understanding through the integration of psychological and eco-social elements as influential factors in health and disease. Clerkships are a phase of medical education where students transition from theoretical learning to practical application under the supervision of experienced health practitioners. This study investigates the knowledge, attitudes, and practices (KAP) of clerkship supervisors at the University of Botswana’s Faculty of Medicine (UB-FOM) regarding the BPSM.

Methods

We conducted a quantitative cross-sectional survey, distributing online (via Microsoft 365 Forms) and self-administered paper-based questionnaires to clerkship supervisors. KAP information was gathered using a five-point Likert scale and an open-ended question section that asked respondents to elaborate on factors they perceived as limitations to applying the BPSM.

Results

Only 34.3% of approximately 140 clerkship supervisors invited to participate in the study responded. Forty-eight supervisors completed the questionnaire. Most participants (n = 38, 79.2%) reported receiving training on the BPSM during their undergraduate or postgraduate education. Most UB-FOM clerkship supervisors appreciated the importance of considering all four dimensions of health in healthcare activities (mean score = 4.14 > weighted mean score of 4.04). They felt less comfortable instructing medical students on the model during clinical rotations (mean score = 3.98 < weighted mean score of 4.04), and they expressed less agreement about the ability of psychosocial processes and treatments to alter medical illnesses. Additionally, they less recognised the importance of incorporating spiritual evaluation into medical practice (mean score = 3.82 < weighted mean score of 4.04). Obstacles to implementing the BPSM included time constraints during consultations, a negative attitude towards the BPSM, a lack of updated training, and an absence of defined guidelines for the BPSM.

Conclusion

While most UB-FOM clerkship supervisors who participated to the study acknowledged the importance of considering all four dimensions of health in healthcare activities, they felt less comfortable instructing medical students on the BPSM during clinical rotations and expressed less agreement about the efficacy of psychosocial processes in medical treatment. We recommend implementing research that specifically targets the beliefs and attitudes of clerkship supervisors.

Introduction

In ancient Greece, health was perceived as a balance between an individual and their environment, emphasising harmony between mind and body, and the belief in natural causes of diseases [1]. The World Health Organisation (WHO) defines health as “a state of optimal physical, mental, and social well-being, encompassing all aspects of an individual’s life, rather than simply the absence of disease or infirmity.” Recently, spiritual well-being has been recognised as a fourth integral component of health [2].

The biopsychosocial and spiritual model (BPSM), often referred to as body-mind unity, does not contradict the biological model; rather, it acknowledges the rich history of the biomedical model while aiming to broaden health professionals’ understanding by integrating psychological and eco-social factors into health and disease [3]. Medical practitioners employing the BPSM prioritise their patients’ physical, psychosocial, and spiritual well-being. Incorporating the psychosocial dimension into patient care has proven beneficial in preventing and treating physical and psychiatric conditions [4]. This approach humanises patient care, enhances social functioning and patient satisfaction, and reduces healthcare disparities and annual medical expenses [4, 5].

The BPSM is part of the patient care curriculum at most medical training institutions. However, except in family medicine, implementing the BPSM in clerkship rotations faces significant obstacles [6]. Micro-level factors include knowledge, skills, personal beliefs, misunderstandings of clinical practice guidelines, and attitudes towards patients and time. Meso-level factors encompass clinical practice guideline creation, community factors, funding models, health service provision, resource issues, and workforce training challenges. Macro-level factors include health policy, organisational influences, and social determinants. All these factors may hinder clerkship supervisors’ ability to teach or practice the BPSM [7]. Clerkships are a critical phase of medical education where students transition from theoretical learning to practical application under the supervision of experienced health practitioners [8].

Although research on the BPSM in medical education is growing, its practical application remains limited. The findings from this study may serve as a catalyst for improving instructional methods and promoting further research in medical education, ensuring that future doctors are equipped to address the increasing prevalence of lifestyle and environmentally related diseases.

In response to concerns about the continuous practice of the BPSM by final-year medical students, the curriculum committee of the UB-FOM appointed a team to address this issue. The team collaborated with a cohort of fourth-year medical students to tackle the challenge.

To identify specific microlevel factors that might impede the practice and teaching of BPSM by UB-FOM clerkship supervisors, we investigated their knowledge, attitudes, and practices (KAP) regarding BPSM.

Methods

Study design and period

This was a descriptive, quantitative cross-sectional survey. We collected data from December 1, 2023, to May 10, 2024.

Study setting

The University of Botswana Faculty of Medicine (UB-FOM) is a newly established institution providing comprehensive medical education. Clerkship training takes place in Gaborone (the capital city), where students gain hands-on experience in key medical disciplines such as anaesthesiology, emergency medicine, general surgery, internal medicine, obstetrics and gynaecology, and paediatrics. These rotations provide diverse clinical exposure and are essential for developing practical skills. In addition to Gaborone, psychiatry training is conducted in Lobatse, situated 72 km away, offering a unique setting for understanding mental health in different communities. Family medicine rotations occur in Mahalapye, 200 km away, and Maun, 915 km from Gaborone, exposing students to rural healthcare challenges and broadening their clinical perspectives.

Clerkship is phase spans three years, covering the third, fourth, and fifth years of the Bachelor of Medicine and Bachelor of Surgery (MBBS) program. Students rotate in small groups of about 20, spending eight weeks in each specialty. Supervision is provided by a team of dedicated UB-FOM postgraduate students and academics, alongside medical officers and specialists from the Botswana Ministry of Health.

Study population, and recruitment

The research population included medical officers and specialists from the Botswana Ministry of Health, UB-FOM postgraduate students, and UB-FOM academics who supervise medical students during clerkships in two settings (Gaborone for most disciplines and in Lobatse for psychiatry (Fig. 1). We invited every clerkship supervisor to participate in the study, as approximately 140 medical officers and specialists supervise UB-FOM clerkship students.

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Inclusion and exclusion criteria

We included UB-FOM clerkship supervisors from the paediatrics, obstetrics and gynaecology, general surgery, internal medicine, emergency medicine, anaesthesiology, orthopaedics, and psychiatry departments. To be eligible, individuals must have held a position at the university or health facility conducting the training for at least one year, during which they served as clerkship supervisors. We excluded family medicine supervisors from our survey, as this group consistently implements, promotes, and trains students in the biopsychosocial model.

Data collection and procedure

Based on the existing literature on KAP in BPSM, we developed a questionnaire that was evaluated and tested for reliability. We distributed anonymous (with no identifiers), self-administered questionnaires to UB-FOM clerkship supervisors across departments. Respondents could choose between an online questionnaire (Microsoft 365 Forms) and a paper-based version (supplementary document). We used the questionnaire to gather sociodemographic data such as age, sex, marital status, level of education, clinical domain or department, and cadres. The instrument collected data on prior training of UB-FOM clerkship supervisors in BSPM and its teaching to medical students at UB-FOM. It assessed KAP regarding the BPSM using a five-point Likert scale. An open-ended section invited participants to elaborate on factors they believed could limit their application of the biopsychosocial model in one or two sentences. Data collection occurred over a two-month period. We then compiled the data into a spreadsheet file for tabulation and storage.

Data analysis

Where applicable, we summarised the data using tables, frequencies, means (SD), and medians (± IQR). The 11 items assessing knowledge and attitude had a reliability (Cronbach’s Alpha) of 0.905, indicating that the statements were understandable to respondents. The reliability (Cronbach’s Alpha) of the two items assessing practice was 0.845, suggesting clarity in those statements as well.

We computed the weighted mean (the sum of the mean divided by the number of items) and compared it to the item’s mean to determine whether participants had a low or high perception of the KAP item statements. We used IBM SPSS 29.0.0.0 (241) for data analysis.

We manually created thematic indexes for the qualitative information. We methodically used the codes from the theme index and employed charting for data consolidation, grouping all data with identical codes and interpreted them.

Validity and reliability

Since family medicine clerkship supervisors were excluded from the main study, the team conducted a pilot study involving 16 clerkship supervisors from this group. This allowed for revisions to the questionnaire, enhancing its user-friendliness (Fig. 1). We asked them to evaluate whether the questionnaire effectively measured KAP regarding BPSM.

Ethical considerations

The study was ethically approved by the University of Botswana’s Office of Research and Development (UBR/RES/UNDERGRAD/SOM/139/2023) and conducted in accordance with the principles of the Helsinki Declaration. We obtained informed consent from all respondents (either electronically or physically) and informed them that they could withdraw at any time without repercussions. Each respondent voluntarily agreed to participate.

The data was securely stored, and personal identifiers were removed to ensure anonymity and confidentiality. Only the research team had access to the data.

Results

Of the potential 140 participants, 34.3% of clerkship supervisors responded. Table 1 presents the sociodemographic characteristics of the subjects. Forty-eight UB-FOM clerkship supervisors completed the questionnaire from seven departments, with psychiatry having the most respondents (n = 15, 31.5%). Obstetrics and Gynaecology had the second highest response rate at 27.1%, followed by internal medicine at 18.8%. The sex ratio was approximately equal. About two-thirds of UB-FOM clerkship supervisors were between the ages of 30 and 39 (n = 29, 60.4%), married (n = 29, 60.4%), or served as medical officers (n = 31, 64.6%). Over half of the Botswana Ministry of Health employees (medical officers or specialists) were clerkship supervisors (n = 28, 58.3%).

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Table 2 presents the participants’ responses regarding their previous training in the biopsychosocial model and supervision of UBFOM medical students. Most participants (n = 38, 79.2%) reported receiving training on the biopsychosocial model during their undergraduate or postgraduate education. In the ward or consultation room, one-third (n = 17, 35.4%) of participants supervised UBFOM medical students in small groups of 4–7 students, while 12 (25.0%) participants reported supervising these students in smaller groups of fewer than four students.

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Table 3 shows that most respondents felt that all four health domains (biological, psychological, social, and spiritual) should be considered in every healthcare task (mean score = 4.14, greater than the weighted mean score of 4.04). They perceived that the goals of the BPSM were to provide compassionate, whole-person care, emphasising quality of life over clinical goals alone (mean score = 4.25, greater than the weighted mean score of 4.04). They believed that changes in one health domain could significantly impact the others (mean score = 4.39, greater than the weighted mean score of 4.04). They also acknowledged the complex interaction between psychological and physical health factors. Although physiological factors can influence a patient’s subjective experience, they cannot do so solely (mean score = 4.18, greater than the weighted mean score of 4.04). Various factors, ranging from biological (tissues, structures, and molecules) to environmental (social, psychological, and spiritual), can cause suffering, disease, and illness (mean score = 4.57, greater than the weighted mean score of 4.04). Most respondents perceived that throughout the treatment process or course of a disease, biological, psychological, social, and/or spiritual factors influenced a patient’s subjective experience, clinical outcomes, and effective treatment (mean score = 4.30, greater than the weighted mean score of 4.04). They less believed that biological factors alone influence some major medical conditions, such as the primary dysfunction in diabetes, advanced cancers, or advanced cardiovascular disease. They also less believed that psychosocial processes and interventions could change these conditions, and in some cases, they doubted that biological interventions could change them (mean score = 2.66, less than the weighted mean score of 4.04).

Most participants responded that psychological problems and/or multimorbidity require more time during consultations but should always be considered, regardless of time constraints (mean score = 4.14, greater than the weighted mean score of 4.04), and psychosocial factors may influence the prognosis of many medical conditions and surgical procedures (mean score = 4.16, greater than the weighted mean score of 4.04). However, they felt less strongly that mental habits could be the missing link between the biopsychosocial model and clinical reality (mean score = 3.91, less than the weighted mean score of 4.04) and that spiritual evaluation of a patient should be part of medical practice (mean score = 3.82, less than the weighted mean score of 4.04).

Most participants indicated that the BPSM was relevant to their field of practice (mean score = 4.30, greater than the weighted mean score of 4.04); however, they expressed that clinical and health education settings rarely use the BPSM, despite its frequent reference as the “overarching framework” for modern healthcare (mean score = 3.68, less than the weighted mean score of 4.04).

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Table 4 shows that most participants felt comfortable with applying the biopsychosocial model when they attended to patients (mean score = 4.09 > weighted mean score of 4.04). However, they felt less comfortable teaching a biopsychosocial model to medical students during their clinical rotation (mean score = 3.98 < weighted mean score of 4.04).

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When asked what they believed or felt would restrict the practice of the BPS model, most participants stated that time constraints during consultations and workload were the most significant barriers:

“Time and patient load. Because it is not something we have been practising regularly it takes longer to incorporate it on our day-to-day practice” (Female, medical officer, internal medicine).

“Patient-doctor ratio plays a role as the volume of patients may require that time spend on a patient be limited not to ask about the psychosocial aspect of the approach” (Female, medical officer, psychiatry).

They indicated that the negative “attitude” towards the BPS model, as well as a lack of updated training and a defined guideline for the BSP model, were obstacles to implementing a BPS approach:

“I think we often focus on the biological and forgets other aspects of health. I mean a lot of times you find patients do not even know what they are being treated for in the hospital.” (Female, medical officer, internal medicine).

“I would need a refresher on the model” (Female, medical officer, anaesthesiology).

“…a structured guideline for the BSP model” (Female, lecturer, paediatrics).

They also expressed that privacy challenges during the ward round, lack of continuity of care and the shortage contributed to their inability to implement a BPS model in their routine practice:

“On the ward rounds that are often crowded with no less than five people around the patient who are also often new to her each time, as you probe into these questions if the setting doesn’t feel private and secure, they may not respond much.” (Female, senior lecturer, obstetrics and gynaecology).

“In the public sector a patient will be attended consistently by a specific doctor to build trust with them as they address all the aspects of their disease since all may not emerge at the initial consult or review but progressively.” (Female, senior lecturer, obstetrics and gynaecology).

“…personal may mean that other allied healthcare workers such as social workers, psychologist are not.

easily accessible to patients.” (Female, medical officer, psychiatry).

Discussion

This study identified specific micro-level factors (knowledge, attitude, and practice) that might impede the application of the BPSM by UB-FOM clerkship supervisors. Most participants (79.2%) reported receiving training on the BPSM during their undergraduate or postgraduate education. Despite this, many medical schools still primarily rely on the traditional, reductionist biomedical paradigm [6, 8].

Most respondents in this survey expressed the belief that any healthcare task should consider all four aspects of health (biological, psychological, social, and spiritual). Similarly, Astin et al. conducted a study among primary and non-primary health care experts in Boston and found that two thirds of the respondents believed that incorporating BPSM would result in “moderate” or “significant” enhancements in treatment outcomes [9].

In our study, respondents acknowledged that the relationship between psychological and physical health elements can be extremely complex. Respondents didn’t seem to believe that biological factors alone influence some major medical conditions, such as the primary dysfunction in diabetes, advanced cancers, or advanced cardiovascular disease. Recent research suggests a connection between psychological well-being—which includes positive emotions, optimism, a sense of meaning and purpose in life, overall life satisfaction—and physical health. Researchers specifically studied this connection in relation to mortality rates and the development and progression of chronic diseases [10]. DuBois et al. reported in their systematic review that positive psychological constructs were associated with a 23% reduction in rates of rehospitalisation or mortality (p <.001). Additionally, positive psychological constructs appeared to be prospectively associated with health outcomes in most studies, but not all [11].

In this study, respondents didn’t believe that psychosocial processes and interventions could change these conditions, and in some cases, they didn’t believe that biological interventions could change them. In their study, Astin et al. conducted focus group interviews with physicians in Boston, USA, who recognised the importance of addressing psychosocial concerns and believed that doing so would lead to better outcomes [9]. Psychosocial factors have a direct influence on physical health outcomes. Chronic exposure to stressors is associated with hypertension, the onset of diabetes, and ischemic heart disease. Also, they exert a significant impact on health-related behaviours, including alcohol consumption, smoking, dietary choices, and physical exercise. The correlation between social, economic, and environmental factors and health is intricate and does not follow a straight line [12].

Respondents from the present study acknowledged that psychological problems and/or multimorbidity require more time during consultation but should always be considered, regardless of time constraints. However, they felt less strongly that mental habits could be the missing link between the BPSM and clinical reality, nor that the spiritual evaluation of a patient should be part of medical practice. When one encounters dichotomies, is perplexed by problems, or confronts uncertainties, the most effective actions include invoking specific patterns of intellectual behaviour that have become ingrained in mental habits [13]. These habits of mind include attentiveness, peripheral vision, curiosity, and informed flexibility. Proficiency in medicine extends beyond clinical skills, incorporating mental attitudes such as understanding the circumstances and establishing a connection with the patient [14, 15]. Increasing evidence indicates the incorporation of spirituality into medical treatment. Religion generally has a beneficial effect on health, although doctors may differ in their willingness to address patients’ religious and spiritual concerns [2, 14].

This study’s respondents acknowledged the relevance of the Biopsychosocial Model (BPSM) to their field of practice, but they also noted its infrequent use in clinical and health education settings. Negri et al. conducted a study revealing that approximately 66% of general practitioners recognised the potential benefits of psychological intervention for many patients. However, they consistently referred only a small percentage (9%) of these patients to a psychologist [16]. The challenges in reconciling the BPSM with clinical reality stem from the ambiguity surrounding its nature. There is uncertainty regarding whether the BPSM is a theory that can be empirically tested, a philosophy that is logically coherent, a descriptive model that broadens the scope of clinical investigation, a belief system that cannot be proven empirically, a practice guide with an implicit or explicit methodology, or a vision for a particular approach [14].

Additionally, respondents in this study expressed confidence in employing the BPSM when treating patients; however, they felt less at ease teaching medical students about the model during their clinical rotations. Obstacles to implementing the BPSM included time constraints during consultations, a negative attitude towards the BPSM, a lack of updated training, and an undefined guideline for the BPSM. They also stated that the inability to incorporate the BPSM into their routine practice was due to staff shortages, lack of continuity of care, and privacy challenges during ward rounds. Since the initial descriptions of the BPSM, practicing physicians have faced challenges aligning the model with clinical reality [17]. Even after undergoing BPSM training, physicians often perceive the training as inadequate in addressing the role of biopsychosocial elements. Consequently, they experience diminished self-confidence in dealing with and effectively treating biopsychosocial issues [18]. Several studies have revealed that the beliefs and attitudes of healthcare workers are the primary barriers preventing the implementation of the BPSM [18, 19]. Additional factors influencing practice habits include the desire to uphold a positive relationship between clinicians and patients, as well as the challenge of addressing patients’ expectations and the limited expertise of healthcare professionals in managing psychosocial factors related to pain treatment [20]. A positive mindset and mental habits for the BPSM can help overcome the obstacles identified by the respondents in this study.

The limited number of respondents (34.3%) and the nature of the study design (cross-sectional) may restrict the generalisability of this study’s findings. We did not investigate the percentage of clerkship supervisors who practice and teach the BPSM. Furthermore, we did not assess the adequacy of their reported previous BPSM training or the potential impact of educational attainment on the knowledge, attitude, or practice of the BPSM.

We recommend clerkship supervisors to incorporate in their routine practice BPSM as students can learn from their supervisors and integrate the BPSM into their own practice once it becomes ingrained in their routine. Future research should investigate how to integrate the BPSM into clinical practice using digital health technology [21]. Implementing BPSM-standardised management protocols for specific disorders will streamline research efforts. The positive outcomes of this approach may motivate healthcare providers to adopt the model in their practice, leading to ultimate benefits for patients, carers, and healthcare professionals. We suggest implementation research that addresses the beliefs and attitudes of clerkship supervisors. We recommend that clinical guidelines be designed to incorporate the BPSM and promote mental habits that facilitate its practice and teaching.

Conclusion

The majority of clerkship supervisors at UB-FOM appreciated the importance of considering all four dimensions of health in any healthcare activity. Most participants noted the intricate interaction between psychological and physical health elements and expressed confidence in using the BPSM for patient treatment. However, they felt less comfortable instructing medical students on the model during clinical rotations and expressed less agreement about the ability of psychosocial processes and treatments to alter medical illnesses. The majority of participants did not believe that mental habits could bridge the gap between the BPSM and clinical reality. Additionally, they did not see the importance of incorporating spiritual evaluation into medical practice.

We did not examine the proportion of clerkship supervisors who engage in and instruct using the BPSM. Furthermore, we did not assess the potential impact of educational achievement on knowledge, attitude, or behaviour related to the BPSM.

We recommend implementation research that specifically targets the beliefs and attitudes of clerkship supervisors. We advise incorporating the BPSM into the development of clinical guidelines and encouraging mental habits that support its application and instruction.

Data availability

No datasets were generated or analysed during the current study.

References

Svalastog AL, Donev D, Jahren Kristoffersen N, Gajović S. Concepts and definitions of health and health-related values in the knowledge landscapes of the digital society. Croat Med J. 2017;58(6):431–5.

Juškienė V. Spiritual Health as an integral component of human wellbeing. Appl Res Health Social Sciences: Interface Interact. 2016;13(1):3–13.

Egger JW. Biopsychosocial Medicine and Health the body mind unity theory and its dynamic definition of health. Psychologische Medizin. 2013;(1):24–9.

Makivić I, Klemenc-Ketiš Z. Development and validation of the scale for measuring biopsychosocial approach of family physicians to their patients. Fam Med Com Health. 2022;10(2):e001407.

Chen M, Guan Q, Zhuang J. Patient-Centered Lean Healthcare Management from a Humanistic Perspective [Internet]. 2024 [cited 2024 Jul 31]. Available from: https://www.researchsquare.com/article/rs-4237579/v1

Martins P. The Biopsychosocial Model in the curriculum of a medical school in Minas Gerais.

Ng W, Slater H, Starcevich C, Wright A, Mitchell T, Beales D. Barriers and enablers influencing healthcare professionals’ adoption of a biopsychosocial approach to musculoskeletal pain: a systematic review and qualitative evidence synthesis. Pain. 2021;162(8):2154–85.

Dornan T, Tan N, Boshuizen H, Gick R, Isba R, Mann K, et al. How and what do medical students learn in clerkships? Experience based learning (ExBL). Adv Health Sci Educ. 2014;19(5):721–49.

Astin JA, Soeken K, Sierpina VS, Clarridge BR. Barriers to the integration of psychosocial factors in Medicine: results of a National Survey of Physicians. J Am Board Family Med. 2006;19(6):557–65.

Hernandez R, Bassett SM, Boughton SW, Schuette SA, Shiu EW, Moskowitz JT. Psychological Well-Being and Physical Health: associations, mechanisms, and future directions. Emot Rev. 2018;10(1):18–29.

DuBois CM, Lopez OV, Beale EE, Healy BC, Boehm JK, Huffman JC. Relationships between positive psychological constructs and health outcomes in patients with cardiovascular disease: a systematic review. Int J Cardiol. 2015;195:265–80.

Bell R. Psychosocial pathways and health outcomes: informing action on health inequalities. 2017.

Costa A. DESCRIBING 16 HABITS OF MIND. 2000.

Epstein RM, Borrell-Carrio F. The biopsychosocial model: exploring six impossible things. Families Syst Health. 2005;23(4):426–31.

De Brito Sena MA, Damiano RF, Lucchetti G, Peres MFP. Defining spirituality in Healthcare: a systematic review and conceptual Framework. Front Psychol. 2021;12:756080.

Negri A, Zamin C, Parisi G, Paladino A, Andreoli G. Analysis of General practitioners’ attitudes and beliefs about psychological intervention and the medicine-psychology relationship in primary care: toward a New Comprehensive Approach to Primary Health Care. Healthcare. 2021;9(5):613.

Borrell-Carrio F. The Biopsychosocial Model 25 years later: principles, practice, and Scientific Inquiry. Annals Family Med. 2004;2(6):576–82.

Moser EM, Stagnaro-Green A. Teaching Behavior Change concepts and skills during the third-year. Med Clerkship: Acad Med. 2009;84(7):851–8.

Egerton T, Diamond LE, Buchbinder R, Bennell KL, Slade SC. A systematic review and evidence synthesis of qualitative studies to identify primary care clinicians’ barriers and enablers to the management of osteoarthritis. Osteoarthr Cartil. 2017;25(5):625–38.

Caneiro JP, Bunzli S, O’Sullivan P. Beliefs about the body and pain: the critical role in musculoskeletal pain management. Braz J Phys Ther. 2021;25(1):17–29.

Ahmadvand A, Gatchel R, Brownstein J, Nissen L. The Biopsychosocial-Digital Approach to Health and Disease: call for a paradigm expansion. J Med Internet Res. 2018;20(5):e189.