Medical Paradigm Flashcards
Medical cosmology
The study of medical paradigms.
Medical paradigms
At any given time, the prevailing thoughts and knowledge (the medical paradigm) need to be internally consistent if medical knowledge is to represent a set of coherent views on all aspects of medicine. These views relate not only to the conceptualization of illness but also to the research methods used, teaching approaches and, most important, the way health care practitioners perceive their patients. Conversely, these views also influence what patients expect from practitioners – they affect the patient-practitioner relationship. Importantly, too, medical views change over time, and at any one time they are just a manifestation of prevailing thoughts and knowledge. The totality of views at a given time constitutes the medical paradigm
Foucault
The French philosopher Michel Foucault (1926–84) emphasized the importance of language for structuring knowledge and exerting power. To him, the way language (writing, talking) is used directs people to understand issues in certain ways that constitute their perception and knowledge of the world
In one of his key books, Madness and Civilization (1981), he explored the use of language, like an archaeologist digging through layer after layer and tracing how, in the western world, madness – which was once thought to be divinely inspired came to be thought of as mental illness. He showed that, depending on the historical period, the mentally ill were treated as outcasts, and later were imprisoned and treated as criminals, before reforms in the nineteenth century led to humanitarian treatment in asylums and the rise of psychiatry as a profession.
Why should you study the changing discourse on medicine and shifts in the medical paradigm? There are three reasons:
1 It helps you to understand the views held on patients and diseases.
2 It provides insight into some of the universal problems of modern health care, in particular the interaction between practitioners and patients.
3 As you will see later in this chapter, it helps you understand the strengths and limitations of clinical research.
Three major shifts in medical paradigms have occurred in western medical knowledge (Jewson 1976).
Bedside medicine
Hospital medicine
Laboratory medicine
Bedside medicine
Before 1800, doctors’ knowledge and their observation of patients were largely confined to visiting their middle and upper class patients in their own homes. The prevailing explanation of death and disease was imbalances in the four humours (key fluids) of the body – blood, choler (yellow bile), phlegm and black bile. This was a holistic view in which illness arose from a psychosomatic disturbance of the whole person. Doctors’ understanding was based on speculation and inference, and their role was to predict the future (prognosis) and apply therapy, such as bleeding the patient.
Hospital medicine
In the nineteenth century, Europe and North America witnessed progressive urbanization of the population as people left the land and moved to the new, rapidly expanding cities which offered jobs and higher income. One consequence was the development of institutions to accommodate or simply contain the more unfortunate members of society who could not benefit from the new opportunities– the disabled, the elderly and the sick. A variety of measures were taken by local and national governments. From the point of view of medical knowledge, the gathering of large numbers of the sick poor in institutions plus the employment of doctors to provide rudimentary care gave the opportunity for groups of patients to be studied.
In addition, when patients died, doctors could carry out post-mortems (autopsies) to see what had been going on (pathology). In addition, the physical sciences were making great advances and the application of new understanding in physics and chemistry led to the development of tools for doctors to investigate the body: the stethoscope to listen to the chest.
Combining these developments, statistically oriented clinical observation replaced speculation and inference. Illnesses were now seen as organic lesions and patients were ‘cases’ of specific diseases, as the classification of diseases developed. The role of the doctor shifted from prognosis to diagnosis.
Laboratory medicine
Technological advances in the twentieth century allowed increasingly invasive investigation of organs, tissues and finally cells
The focus of diagnosis and decisions shifted from the hospital ward to the laboratory as illness was seen as a biological process.
Holistic view
The focus on distinct, single processes has been called a reductionist view, as opposed to a holistic view that tries to conceptualize and understand the whole of a complex system. However, you should beware of simplifications – there have always been trends in medicine towards a reappearance of the holistic approach, for example seeing illness in terms of constitutional disorders (endocrine dysfunction, allergy).
A holistic approach is essential to health and, as you will see, particularly to primary care.
The loss of the holistic view in modern medicine may also explain the demand for alternative therapies.
Dangers of biomedical and clinical paradigm
1 Hospital clinicians only observe the diseased, so they may be unaware of the existence of people with similar symptoms who are not seeking care.
2 Observations are confined to the clinical setting. The environment itself might induce ill health
3 Clinicians are unable to assess factors outside the individual that may be contributing to a patient’s ill health such as their job or their housing
4 Clinicians inadvertently teach their patients to adhere to established categories of disease. The dangers of complicity between clinicians and patients have long been recognized
5 Clinicians may be reluctant to challenge established views.
Generally, clinical research takes two forms:
• the case study – detection of the odd, unusual or rare observation • the case series – identification of common, recurring associations.
Case series
Study of a series of cases to identify common or recurring features.
