Reading: Engel, 1977 - A Need for a New Medical Model Flashcards
The main argument of Engel, 1977
- Rejects the notion that diseases show be solely viewed and identified by physicians according to their somatic parameters.
- Physicians should be concerned with psychosocial issues and not deem them is outside their ‘realm’ or as invalid/ wish-washy.
Two positions of physicians
-Exclusionists = argue for the exclusion of psychiatry from the field of medicine. Instead it should be treating it as a distinct discipline focused on behavioural change (“re-educating people who have problems of living”). The idea is to label the issues of psychiatry as non medical basically positing that mental illness is a ‘myth’ because it doesn’t conform with traditional ideas of what constitutes a disease.
Versus
-Reductionists = Strictly adhere to a medical model and limit the field of psychiatry to behavioural disorders consequent to brain dysfunction. It involves the assumption that all mental illnesses result from biological brain dysfunction (termed ‘natural causes’) and therefore a not qualitatively different from other diseases. This ignores the meta psychological, interpersonal + societal causes of mental illness. Additionally, some categories of mental illness such as social adjustment reactions, social-deviancy etc. would now be excluded from being labelled as illnesses and should instead be handled by those not medically trained.
(note: this is the core principle of the biomedical model).
The biomedical model
-Dominant model use in the assessment and treatment of disease today.
-It is scientific in nature and uses molecular biology as it’s core
-Posits: “Diseases can be accounted for by deviations from the norm of measurable biological (somatic) variables”. In other words embraces a reductionistic approach (illnesses can and should be explained using the terminology of chemistry and biology).
-Does not consider the social, psychological and behavioural dimensions of illness.
-Additionally the disease shouldn’t be able to be treated through an alteration of social behaviour (if so should not be classed as a disease but a ‘problem of living’)
-In this way supports mind- body dualism i.e. the disease is not resulting from an interaction of the mind and body these are separate entities with changes to the body/ biological processes the only viable consideration of what constitutes an illness.
Historical origins of the reductionistic biomedical model
- At a general level models emerge to explain concepts that are complex
- Medicine as an institution evolved to meet social needs to deal with those exhibiting signs (psychological, social, behavioural) of sickness.
- Reductionistic + dualistic view (mind/ body spilt) arose to permit the concession of the Christian view that it was wrong to dissect the human body (5 centuries ago). The church said the body could be studied (as simply a vessel) but the mind/ behaviour remained the domain of the church as it constitutes the ‘soul’ of the person.
- Therefore, the scientific approach of focusing on the biological/ somatic processes of the body and ignoring the behavioural and psychosocial processes began.
Limitations of the biomedical model using schizophrenia and diabetes as example
A mental illness like schizophrenia can be viewed much like diabetes could be in a reductionist way. That is you could purely focus on the genetic factors and biological responses that are known/ proposed to contribute. However, this would be a mistake : equally important is the elucidation of experiential (based on experience or observation) factors and how they interact with biological vulnerability.
Reasons why we need a new medical model in health care: a more holistic view
Need a model that considers both somatic and psychosocial factors for all illnesses whether they are ‘somatic’ diseases (e.g. diabetes) or ‘mental diseases’ (schizophrenia). If one aspect is focused on perception of illness can be distorted which is costly to the effectiveness of patient care.
Reasons why we need a new medical model in health care: biochemical symptom mismatch
- A patient make not have the specific biochemical variation generally considered diagnostic but still fell ill (invalidates their experience)
-Or the reverse could occur where the abnormality is present but the patient is not ill.
-The biochemical variation is just one factor contributing to the disease among many and full understanding requires a more holistic approach that takes into account varied clinical presentations among patients.
Reasons why we need a new medical model in health care: a rational approach to behavioural and psychosocial data.
- Need a rational approach to behavioural and psychosocial data in order to link them to particular biochemical processes and clinical data.
-This is important because patients often present with behavioural/ psychosocial clinical symptoms so it’s not much use knowing what biochemical deficit contributes to schizophrenia ,for example, if it is unknown how this relates to particular psychological and behavioural expressions of the disorder.
-Clinical interview skills in eliciting accurate accounts from patients and then correct analysis of responses is important.
Reasons why we need a new medical model in health care: conditions of life
Conditions of life and living constitute significant variables influencing the time and reported onset/ manifestation of a disease throughout its course therefore, should be considered (they are not under the standard biomedical approach).
Reasons why we need a new medical model in health care: psychosocial contribution to whether an individual becomes a patient in the first place
- Psychological and social factors are crucial in determining whether patients with the biochemical abnormalities for a given disease come to view themselves or are viewed by others as sick and therefore whether they enter the health care system and become a ‘patient’ in the first place
-It makes sense therefore that these factors should be considered in a model of healthcare.
Reasons why we need a new medical model in health care: treatment of biochemical abnormalities
-Treatment directed only at the biochemical abnormality does not necessarily restore the patient to health.
- Other factors may combine to prolong sickness even once the biochemical deficit has been resolved.
Reasons why we need a new medical model in health care: the patient- physician relationship
- Even with the application of rational therapies, the physician- patient relationship powerfully influences the therapeutic outcome.
- This means in order for treatments to be effective the physician requires psychological knowledge (outside of the biomedical framework) to know how to influence the behaviour of a patient and in still a sense of faith regarding the proposed treatment regime’s healing powers (to confer adherence).
Reasons why we need a new medical model in health care: list
-A more holistic view
-Biochemical symptom mismatch
- A rational approach to behavioural and psychosocial data.
-Conditions of life
-Psychosocial contribution to whether an individual becomes a patient in the first place
-Treatment of biochemical abnormalities (and remaining illness)
-The patient- physician relationship
Advantages of the biopsychosocial model
- A medical model needs to take into account the patient, the social context in which they live and the complementary system devised by society to deal with that illness (the healthcare system + physician) : the biopsychosocial model does this
- Useful for when a patient has the biological ‘markers’ of disease but do not feel the symptoms or vice versa (psycho-social aspects provide alternative explanations).
When is grief a disease? Or maybe better put is grief a disease?
- Grief is not typically viewed under a medical framework (i.e. as a disease) but should it be?
- Grief demonstrates a situation where psychological factors are primary and there are no pre-existing chemical or physiological defects or agents.
- However, it does (like a traditional disease) produce a discrete syndrome with predictive symptomatology which includes not only psychology disturbance but also bodily disturbance.
-Further, there is no way to ‘turn off’ grief despite an individual’s best efforts it has to run its course much like a disease.
- Phrases like “sick with grief” indicate a connection in between sickness and grief in people’s minds
- BUT provisions for the mourner are typically viewed as the responsibility of religion not medicine.
- Grief does not fit the category required to be considered a disease under a biomedical model in that the victim knows the clear cause of the grief: the loss of the loved one. In a biomedical model a disease traditionally has a cause unknown/ not fully understood by the patient for which they seek the guidance of a physician who ‘heals’ them.
