Family medicine is fundamentally about whole-person care. When a patient walks into your clinic with hypertension, a cough, or "tiredness," they are not just a disease label — they are a person embedded in a web of thoughts, feelings, family dynamics, and social circumstances that powerfully shape both why they became unwell and how they will (or won't) get better. This lecture teaches you the frameworks to systematically unpack those layers: the BATHE technique for efficiently assessing psychosocial status, Satir's models for understanding internal psyche and coping, the family life cycle for recognising stage-specific stressors, and the 4-P bio-psycho-social framework for organising everything into a formulation that drives management. ^[1]

1. Understand what is the BATHE technique and be able to use it to assess a patient's psycho-social status. 2. Recognize the different stressors that a person may face at different stages of family life cycle. 3. Understand the social determinants of health and be able to analyse a patient's problem using the 4-P (Predisposing / Precipitating / Perpetuating / Protective factors) bio-psycho-social framework. ^[1]

• The 4-P framework appears directly in past SAQ papers (e.g., 2017 Q10 on predisposing/precipitating/perpetuating factors). ^[7]
• The family life cycle has been tested in MCQ format (e.g., 2020 Q81 asking what information identifies a patient's family life-cycle stage). ^[8]
• Bio-psycho-social problem identification is a standard minicase question (e.g., 2022 minicase: "Identify three bio-psycho-social problems"). ^[9]
• BATHE is a core OSCE consultation skill — you will be expected to demonstrate it.

The whole-person care concept in Family Medicine integrates the Biological, Psychological, and Social dimensions of health and illness. ^[1]

Why does this matter? The biomedical model alone explains what disease a patient has, but not why this patient, why now, and why they are struggling. A 50-year-old researcher demanding anxiolytics (the Brene case in this lecture) cannot be understood without grasping her fears, expectations, and social context. The biopsychosocial model is not just philosophically nice — it changes the differential diagnosis, the investigations you order, and the management plan you construct.

Virginia Satir used the iceberg metaphor to illustrate the various components of an individual's 'internal psyche.' ^[1]

Think of a person as an iceberg:

How you think → determines how you feel → influences your behaviour. ^[1]

Unhappiness often stems from unmet expectations: expectations of self, expectations of others, expectations from others. ^[1]

The default ways that people react to or cope with problems. People adopt these stances to protect their self-worth. ^[1]

We change our coping stances constantly with different people in different contexts. But we usually have a major coping stance to protect ourselves from threats. ^[1]

Satir illustrated each coping stance in terms of a physical posture, and explained them in terms of their respect or disrespect of "context", "self" and "others." ^[1]

There are five coping stances:

Key details from the slides:

Blamers: discount the others and count only on themselves and the context. They hold a belief that they must not be weak. They harass and accuse others for continually making things go wrong. ^[1]

Placators: View the others and the context to hold more value than their own true feelings. They look nice when they do not actually feel good. They take the blame when things go wrong. Physiological effects that placators typically experience are unexplained headaches or digestive tract disorders (e.g., unexplained abdominal pain, constipation). ^[1]

Super-reasonable: discounts himself and the others but solely respects the context. He frequently knows lots of information and works solely from a logical or objective perspective. ^[1]

Irrelevant ('Clown'): Often seen as amusing or a clown. They distract attention away from any stressful situation. Their internal dialogue will be about anything other than the matter in hand. ^[1]

Congruent: The ultimate goal of Satir's Transformational Growth Model is congruence. The congruent person holds equal balance in terms of self, others, and the context. ^[1]

Why understand coping stances? Because:

1. You can identify your own default stance during difficult consultations (self-awareness prevents burnout and conflict).
2. You can recognise your patient's stance and respond more effectively (e.g., don't become a Blamer when facing a Blamer — it escalates; instead, model congruence).
3. It explains why some patients present the way they do — a placator may never tell you they're in pain until it's severe; a blamer may complain aggressively about everything.

The BATHE technique is used to assess a patient's psycho-social status. ^[1]

BATHE is a structured, efficient screening tool for psychosocial distress that can be completed in < 5 minutes. It stands for:

Why BATHE works:

• B gives you the social context (job loss, family conflict, bereavement).
• A screens for depression, anxiety, anger — the emotional layer beneath symptoms.
• T pinpoints the most distressing aspect, which may not be what you assumed.
• H assesses coping mechanisms and resilience — are they managing, or are they overwhelmed? This also screens for maladaptive coping (alcohol, substance use, self-harm).
• E is therapeutic in itself — feeling heard reduces patient distress and builds rapport.

Dr T is a first year trainee in family medicine. Brene is a 50-year-old researcher who consulted Dr T for hypertension and then requested several weeks of Lorazepam for insomnia. Despite Dr T's explanation about harmful effects of long-term anxiolytics, Brene insisted. Dr T gradually lost his temper and refused bluntly. Brene became very angry, saying Dr T was the worst and most unethical doctor she had ever seen, and threatened to lodge a complaint. ^[1]

What went wrong?

1. Dr T did not explore the reason behind the request (no BATHE).
2. Dr T adopted a Blamer stance (refusing bluntly) in response to Brene's Blamer stance (demanding, threatening).
3. The consultation became a power struggle rather than a therapeutic encounter.
4. No attempt was made to understand Brene's expectations (Iceberg Model) — she expected to receive a medication that had "worked" for her; her expectation was unmet, triggering anger.

How to handle it better:

• Use BATHE to understand the psychosocial context.
• Explore Brene's understanding of benzodiazepine risks (explanatory model).
• Acknowledge her distress empathetically (Congruent stance).
• Offer alternatives: sleep hygiene, CBT-I, short-term non-benzodiazepine options if clinically appropriate.
• Set boundaries firmly but respectfully: "I understand how frustrating this is. I can't prescribe long-term Lorazepam because it can cause dependence and worsened sleep over time, but let's find something that works safely for you."

A family tree over generations that reveals important life events as well as showing the ties between children, their parents and their grandparents. ^[1]

A genogram is more than a family tree — it encodes:

• Medical history across generations (e.g., cancer clustering, psychiatric illness).
• Relationship quality (close, conflicted, cut-off, enmeshed).
• Life events (deaths, divorces, migrations).
• Patterns (e.g., recurrent depression in every generation, alcohol misuse in male members).

Why draw a genogram?

• Reveals genetic risk factors (predisposing factors in the 4-P model).
• Shows family dynamics that may be perpetuating illness (e.g., caregiver burnout, marital conflict).
• Identifies protective factors (supportive family members, resources).
• Required in psychiatric formulations. ^[2]

The stages of family life cycle — what are they? Can you name them and describe the characteristics of each? ^[1]

The family life cycle describes the predictable stages that most families pass through, each with characteristic tasks, stressors, and health implications. Understanding the patient's stage helps you anticipate problems and tailor care.

Why the family life cycle matters clinically:

• A patient's presenting complaint often makes perfect sense once you know their stage. A 55-year-old woman with insomnia and low mood? She may be in the "launching children" stage, experiencing empty nest syndrome, caring for ageing parents, and going through menopause simultaneously.
• Anticipatory guidance: knowing the stage lets you predict upcoming stressors and offer preventive counselling.

The WHO defines social determinants as the conditions in which people are born, grow, live, work, and age, shaped by the distribution of money, power, and resources. They include:

Why do social determinants matter?

• They account for 30–55% of health outcomes — more than healthcare access or individual behaviour.
• Two patients with the same disease (e.g., diabetes) will have vastly different outcomes depending on whether they can afford medications, understand their diet, live in a safe neighbourhood, and have family support.
• In Hong Kong's context: cage homes, subdivided flats, elderly living alone, new immigrant status, language barriers are all powerful social determinants.

The social determinants of health feed directly into the 4-P framework:

• Poverty is a predisposing factor for poor health.
• Job loss can be a precipitating factor for depression.
• Inadequate housing is a perpetuating factor for respiratory disease.
• Strong community support is a protective factor against mental illness.

By combining BATHE (to screen), the family genogram (to map), the family life cycle (to contextualise), and the 4-P framework (to formulate), you have a complete toolkit for whole-person assessment.

• Standard physical examination directed by the presenting complaint.
• Mental state examination if psychological concerns identified.
• Functional assessment in elderly (ADL, IADL). ^[5]

• Directed by the differential diagnosis.
• Key principle: Don't over-investigate when the formulation points to psychosocial aetiology (Miss Cheung had repeated normal investigations — this itself is a perpetuating factor via medicalisation of her problem).

1. Explore before explaining — use BATHE before giving medical advice.
2. Acknowledge the patient's perspective — even if you disagree with their request.
3. Negotiate, don't dictate — shared decision-making improves adherence and satisfaction.
4. Maintain boundaries with empathy — you can refuse inappropriate requests without being hostile.

For 4-P questions:

• "Predisposing factor (biological): anxious-prone personality predisposes to chronic pain syndromes."
• "Precipitating factor (social): workplace fall triggered the symptom onset."
• "Perpetuating factor (psychological): ongoing compensation claim provides secondary gain that maintains sick role behaviour."
• "Protective factor (social): supportive family network that encourages recovery."

For BATHE questions:

• "B — Background: 'What has been going on in your life recently?'"
• "A — Affect: 'How do you feel about that?'"
• Structure your answer using the BATHE acronym sequentially.

For bio-psycho-social problem identification:

• "Biological: hypertension requiring medication management."
• "Psychological: anxiety and insomnia likely related to work stress."
• "Social: 50-pack-year smoking history; social isolation since retirement."