New Framework Merges Consultation Structure With Holistic Patient Care

Primary care clinicians around the world face a persistent paradox: they are asked to treat the whole person—body, mind, social circumstances, and even spiritual concerns—within consultations that often last mere minutes. A new conceptual paper published in BMC Medical Education by Stephane Tshitenge and Yaone Bogatsu of the University of Botswana’s Department of Family Medicine and Primary Health Care proposes a way out of this bind. The authors integrate three established frameworks—the Stott and Davis consultation model, the biopsychosocial–spiritual (BPSS) model, and the Clinical Reasoning Cycle (CRC)—into a single, structured approach designed to work in real, time-limited, resource-constrained clinical settings. The result is a framework intended to serve simultaneously as a practical bedside tool and as a teaching scaffold for medical education.

The Stott and Davis model, first described decades ago, remains one of the most widely taught consultation frameworks in general practice. It organizes every encounter around four tasks: managing the presenting problem, modifying help-seeking behavior, managing continuing problems, and opportunistic health promotion. Its strength lies in efficiency and completeness—it reminds clinicians not to stop at the first complaint but to scan the consultation for missed opportunities. Its weakness, the authors argue, is that it says nothing explicit about the deeper dimensions of the patient in front of the doctor. A clinician can tick all four boxes and still fail to register the depression, the unemployment, or the spiritual distress that shapes why a patient came in at all.

The biopsychosocial–spiritual model addresses that gap on the theoretical side. Building on Engel’s classic biopsychosocial critique of reductionist biomedicine, the BPSS framework insists that illness is experienced simultaneously at biological, psychological, social, and spiritual levels. In principle, it offers a comprehensive map of patient needs. In practice, as Tshitenge and Bogatsu note, its application in routine consultations remains inconsistent, particularly where clinicians are pressed for time and have no structured method for translating a broad theoretical lens into concrete clinical actions. Holism, without a procedural backbone, tends to evaporate under the pressure of a ten-minute appointment.

The third ingredient is the Clinical Reasoning Cycle, an iterative model of expert thinking that moves through stages such as considering the patient situation, collecting cues and information, processing and interpreting those cues, identifying problems, establishing goals, taking action, and evaluating outcomes, with reflection feeding back into the next cycle. Clinical reasoning research has long shown that diagnostic errors often arise not from gaps in knowledge but from failures in the reasoning process itself—premature closure, inadequate cue gathering, and insufficient reflection. The CRC was designed to make those invisible cognitive steps explicit and teachable, which is precisely why the authors chose it as the connective tissue of their integrated framework.

The core technical move of the paper is an alignment operation. Each of the four Stott and Davis tasks is mapped onto the iterative stages of the Clinical Reasoning Cycle, so that managing the presenting problem, for example, becomes not a single act but a full reasoning loop: gathering cues about the complaint, interpreting them in light of the patient’s context, establishing goals with the patient, acting, and evaluating. At the same time, the four BPSS domains—biological, psychological, social, and spiritual—are embedded across every phase of every loop. This means that cue collection is not limited to biomedical data; it explicitly includes psychosocial and spiritual cues. Problem identification is not confined to diagnoses; it encompasses the broader patient situation. The framework thereby converts two parallel, disconnected traditions—structured consultation management and holistic care theory—into a single operational sequence.

The authors also describe how the framework functions educationally. Because the CRC stages are explicit, learners can be assessed on each one: Did the student gather social and spiritual cues, or only biomedical ones? Did the student consider health promotion opportunities within the consultation rather than deferring them indefinitely? Did the student reflect on the encounter afterward? The integrated model provides what the authors call a coherent scaffold for teaching consultation skills alongside clinical reasoning, promoting reflective practice and professional development rather than treating these as separate curricular silos. In settings where family medicine training is expanding rapidly, including across sub-Saharan Africa, such a scaffold could standardize expectations for learners while remaining flexible enough for experienced clinicians to apply intuitively.

Context matters here. The paper comes from Botswana, a health system characterized by high burdens of HIV, tuberculosis, noncommunicable diseases, and increasing multimorbidity, often delivered with limited staff and infrastructure. The authors position the framework as particularly applicable to primary care and diverse, resource-limited settings marked by complexity. In such environments, a consultation model that assumes a single uncomplicated problem and a well-resourced referral chain simply does not fit. By explicitly incorporating sociocultural and spiritual dimensions, the framework is also designed to support culturally responsive and patient-centred care—an important consideration in communities where spiritual explanatory models of illness strongly influence help-seeking behavior, adherence, and trust in the health system.

The paper is careful about its own epistemic status. It is a conceptual contribution, not an empirical trial; the authors explicitly state that no human participants, data, or animal subjects were involved, and that ethics approval was therefore not applicable. They acknowledge that further research is required to evaluate the framework’s feasibility, acceptability, and impact on clinician performance, learner outcomes, and patient care. This honesty is notable in a field where new frameworks are sometimes promoted as if conceptual elegance were equivalent to demonstrated effectiveness. The authors also report no specific funding and no competing interests, and the article is published open access under a Creative Commons licence, making the full technical alignment of the three models freely available to educators and clinicians worldwide.

What would evaluation look like in practice? Educational researchers could test whether trainees taught with the integrated framework gather more complete psychosocial histories or identify more health promotion opportunities than controls taught with the Stott and Davis model alone. Health services researchers could examine whether the framework improves patient-reported measures of person-centredness or reduces consultation-related dissatisfaction. Implementation scientists could ask whether the framework survives contact with real appointment schedules, electronic medical record templates, and the cognitive load of a busy clinic—the same pressures that have historically eroded holistic ideals. The authors’ mention of electronic medical records in their abbreviations suggests they anticipate these practical integration questions, even though the published abstract does not detail EMR-specific workflows.

The significance of the paper lies less in any single novel claim than in its synthesis. Medical education has long taught consultation models and clinical reasoning as separate subjects, and holistic care as a vague aspiration. By binding the organizational completeness of Stott and Davis, the dimensional breadth of BPSS, and the cognitive transparency of the Clinical Reasoning Cycle into one framework, Tshitenge and Bogatsu offer primary care a structured way to be holistic—something that can be taught, practiced, assessed, and refined. Whether it will change what actually happens in consultations between a clinician and a patient with three chronic diseases, a sick child, and a recent bereavement is an empirical question the authors themselves put squarely on the research agenda. For now, they have provided a testable blueprint for one of medicine’s most stubborn challenges: seeing the whole person in the time available.

Subject of Research: An integrated clinical reasoning and consultation framework combining the Stott and Davis model with the biopsychosocial–spiritual framework for primary care and medical education

Article Title: Integrating the Stott and Davis model with the biopsychosocial–spiritual framework: a comprehensive approach to clinical reasoning in primary care

Article References: Tshitenge, S., & Bogatsu, Y. (2026). Integrating the Stott and Davis model with the biopsychosocial–spiritual framework: a comprehensive approach to clinical reasoning in primary care. BMC Medical Education. https://doi.org/10.1186/s12909-026-10459-5

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10459-5

Keywords: clinical reasoning, Stott and Davis model, biopsychosocial–spiritual model, primary care, medical education, consultation models, Clinical Reasoning Cycle, person-centred care, holistic care, family medicine, resource-limited settings, reflective practice