A 54 year old woman in Chicago recently lost her only child to opioid addiction. She had become depressed and had stopped taking her statins and other medication. Her smoking had increased. She is eventually brought to the ER by paramedics following a 911 call by a member of the public.
She describes crushing central chest pain, but within 20 minutes of arrival her consciousness level is slipping and no further history is obtainable. Tests quickly show evidence of heart failure, while venous and arterial bloods reveal that she is seriously hypoxic, has a raised blood sugar, and multiple biochemical upsets. She is dangerously ill. There is a significant risk she will arrest in the Emergency Room, but she is transferred to High Dependency Unit and over the next six hours her condition is stabilised. The following day she is taken to theatre where a blocked artery is repaired, and within 48 hours of admission she is mobilising well, eating meals, and watching TV with other patients in the day room.
The young female medical intern who was the first to treat her in ER takes an ongoing interest in her, for no better reason than that the patient is medically complex and happens to be exactly the same age as the intern’s mother. She visits her again and gets her permission to present her case at the hospital’s famous “Grand Round” a few days later.
The young doctor does her homework, and presents the case in its full complexity, drawing attention to the patient’s poorly controlled diabetes, her BMI, her smoking, and the fact that the woman had become despondent in recent months following her bereavement and had stopped taking her medication. The general tone of the presentation is rather sombre. Heroic intervention has turned things around for the time being, however, and on the day of discharge the young doctor chats to her once again in the hospital foyer and watches her walk across the snowy car park to a waiting taxi. She wonders what will become of her.
This little vignette might sound like a sentimental episode of ER or Grey’s Anatomy, but in truth this is a commonplace scenario and something similar will be acted out in every major Western teaching hospital on a regular basis (sans snow and young female intern, both added for dramatic effect).
More than that, it is a mise-en-scene which adumbrates some of the difficulties facing Western medicine in 2017. Doctors are highly trained in biomedical sciences, and have at their disposal a formidable arsenal of technologies and medicines. Indeed, many of them will have been drawn or pushed into medicine because they are “good at science”, but then they are catapulted out of medical school and into a messy, chaotic, and at times unfathomable world. How does their medical and scientific training match up to the exigencies of the complex and unpredictable societies they encounter? By extension, are their patients (and society as a whole) best served by this process?
In 1977 the American psychiatrist George Engel published an influential paper in Science which addressed these questions. Engel’s contention was that “the whole of medicine is in crisis” and, further, that “the crisis derives from the same basic fault as psychiatry’s, namely, adherence to a model of disease no longer adequate for the scientific tasks and social responsibilities of either medicine or psychiatry.” He proposed that the “biomedical” model was no longer enough, and that it should be superseded by a “biopsychosocial” model which took into account the complex interplay of biological, psychological and social factors as drivers for human health and illness.
Engel was quick to concede that Western medicine has been astonishingly successful in elucidating the causes of disease and devising new treatments. However, for him it was starting to creak at the seams and the biomedical model no longer took into account all of the important variables. At an individual level, a patient’s attitudes and behaviour might modify the expression of the disease process, and at a population level the rates of prevalence of diseases would vary according to several psychological and social factors rather than pure biology. He uses the examples of schizophrenia and diabetes, but he could equally well have chosen heart disease or musculoskeletal problems such as chronic back pain.
The past 40 years have witnessed a steady accumulation of data supporting Engel’s thesis, but despite this his model has never been entirely embraced by the medical profession. Indeed, after some early enthusiasm from epidemiologists and psychiatrists, it has been quietly ignored. There are many reasons for this. Firstly, the clumsy (indeed downright ugly) neologism “biopsychosocial” was never going to trip lightly off the tongue. More importantly, biomedical science has been even more triumphant in the past 40 years than the preceding 40, leading some to suggest that you don’t change a winning formula. Some authors have gone so far as to declare that the biopsychosocial model “isn’t a model at all” but merely a statement of the obvious.
The triumphalism is genuine, and fully deserved. But there is a danger of complacency here. One of my colleagues remarked to me that “now the human genome has been decoded, most of these problems will be quickly sorted out”. Well, no they won’t. Not when childhood mortality varies dramatically from region to region in the UK, or when average life expectancy varies by 20 years from the poorest postcodes in the UK to the richest. It is hard to sustain a purely biological model of ischaemic heart disease (the leading cause of mortality in the UK, the USA, and Australia) when death rates vary from city to city and from postcode to postcode, unless those with hereditary conditions are somehow drawn into fatal clusters.
To be sure, many acute medical episodes can be understood entirely as biological events (from a perforated eardrum to a ruptured aortic aneurysm) but modern healthcare systems are increasingly bogged down by chronic or relapsing conditions in which psychosocial factors play a significant role.
It is also fair to say that healthcare systems around the world really are now facing a major challenge, and not for the reasons identified by Engel. On the political left, critics of current healthcare argue that it fails to address the wide variances between one community and another. On the right, there is increasing alarm that the healthcare industry is growing at an unstoppable rate, consuming ever-increasing percentages of GDP in most developed nations, reaching 17% of GDP in the USA in 2014.
This problem is only going to get worse with ageing populations and a constant supply of more expensive technologies and treatments. Public expectation is ratcheted up with every new reported breakthrough, so that what was regarded as “state-of-the-art” treatment 5 years ago is now seen as sub-optimal or unacceptable.
Sometimes it seems we are facing a dystopian future in which modern healthcare will consume entire societies from within.
As for the “obviousness” of the biopsychosocial model, this is not really a valid criticism at all. Those who say that it is “just common sense” ought to be reminded that common sense is the least common of all the senses. Time and time again, medicine retreats into a biological model while policymakers are rendered helpless bystanders.
The real beauty of the biopsychosocial approach is that it has application to the individual (both in terms of causal explanation and of treatment offered), to the wider population, and to research. At the individual patient level, it gives a formal description of causes and treatments. At a population level it generates testable hypotheses. What is the cause of obesity, for example? Or what is the cause of diabetes? A biological explanation would be confined to a discussion of the pancreas, insulin, carbohydrate metabolism, and genetic predisposition, but the biopsychosocial model moves beyond linear causal chains to look at a complex network of precursors.
Many chronic illnesses are “overdetermined”: there is not one cause but many small additive factors. Factors such as self-efficacy, temperament, perseverance, and even self-control, will all influence a person’s risk of becoming ill in the first place, the way that illness is manifested, and their probability of sticking with treatment once diagnosed. The variance in cancer death rates across European countries is related to many differences in healthcare-seeking and in organisation of services, rather than reflective of biological variance. Only a full biopsychosocial approach can explain the widely differing levels of liver cirrhosis between and within European populations.
And this is not a call for expensive top-down social engineering either, because the evidence shows that small, local, community-based interventions have efficacy and cost-effectiveness. Telling people to eat less and exercise more is hardly going to help, but well-organised exercise classes and group-based weight-reduction programmes can actually work, although they are hard to implement.
Finally, sociology itself has sometimes been a sleeping partner in all of this. Potentially one of the most important fields of human enquiry, sociology surely has a role in helping to explore and shine a light on some of these mysteries. Too often in recent years, though, sociology has developed a preoccupation with the “social construction of illness” rather than linking with the natural sciences.
There is too much talk about medical knowledge being “constructed and developed by claim-makers and interested parties” rather than actually joining the search to identify the main drivers of human health and illness. Even for the most culture-bound syndromes (for example bulimia nervosa which made a dramatic and unheralded entrance on to the stage of Western medicine in the 1970s) there are fascinating biological correlates involving serotonin chemistry and the neural mechanisms involved in satiety.
And yet a lot of research is still trapped between the twin perils of “mindlessness” and “brainlessness”. The biopsychosocial model is a true interdisciplinary model, and at a research level it echoes Anomaly and Boutwell’s call in Quillette for scholars and scientists from different backgrounds to break out of their niche specialisms. As those authors remark, generalists will be the new specialists.
Returning to our wintry scene, our young hero goes back to the ward and in a quiet moment makes a few phone-calls. There is a group that meets to go bowling once a week, and a group that meets in the gym twice a week, and there is some-one who knows about unpaid voluntary work in a local animal sanctuary. Our 54 year old patient is regularly phoned by a social worker who checks up on how she is doing. She reports that she is smoking less and is socialising more.
It’s a start; the biopsychosocial model sounds like a grand unifying theory and indeed for policymakers and researchers it should be. But sometimes at the personal level, even the smallest things are of importance.
Tim Rogers is a consultant psychiatrist in Edinburgh. Follow him on Twitter @timrogers2016