Do biomedical models of illness make for good healthcare systems?
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7479.1398 (Published 09 December 2004) Cite this as: BMJ 2004;329:1398All rapid responses
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This debate is essential for the continuing practice of mindful medicine. Let me explain through the perspective of an ethologist and the developmental perspective of a child and adolescent psychiatrist. I will conclude by introducing recent developments in understanding memory function which may help explain why integration of information concerning illness, disease, sickness and impairment (also conceptualised as ‘predicament’1)is so complicated.
Tinbergen’s quest for understanding animal behaviour was founded on a need to answer four questions:
o Why is the behaviour shown now?
o How did the person grow to respond this way?
o What is the function of the behaviour for people generally – its survival value?
o How has the behaviour evolved phylogenetically?2.
The biomedical model has concentrated on the first question. The developmental approach helps answer the second question, and additional contributions from neo-Darwinians and others assist with the last two. Wade and Halligan’s contribution to the debate is a mixture of factors contributing to the last three questions. Through identifying what a child needs to learn in order to present symptoms so that they achieve greatest survival value, would enhance the precision of their argument, and identify which factors could be modified in primary preventive strategies.
Prior to the child’s third year of life, their symptoms unravel as part of their state of discomfort driven primarily by their ‘pathology’ – be this a naturally occurring discomfort (dis-ease) such as associated with hunger or tiredness, or disease-based. During this time their symptoms gain or lose credence as part of their developing language of illness depending on their communicative and survival value within their close network.
During the second half of the second year and onwards until about four years old children are developing their main building blocks for their ‘theory of mind’ to account for how people respond to their utterances. They modify their language use to take into account the listener’s perspective. This applies as much to their presentation of bodily discomforts as it does to their other language use. We become ever more mindful of our children when we can take into account their attempts at being mindful presenters of their subjective distress – their illness. Medicine becomes mindful medicine when the strategic value of symptoms is acknowledged, and understood within a developmental paradigm without loading the patient with moral intents. Between 1 and 5 years old children learn to adapt the presentation of their discomforts so that they are strategically effective; and without this being a conscious process.
This is not advanced intention, and it would be inappropriate to attribute malintent to apparently conscious attempts at manipulation. It is here that understanding memory systems enables us to retain a balanced empathic attachment to our patients. The illness dimension to patients’ experience is remembered in their episodic memory for what has occurred to them – coloured by emotions and information from all their senses. In contrast our disease knowledge is applied from our semantic memory for facts. Episodic and semantic memory are located primarily in the opposite hemispheres. Prior to the corpus callosum becoming fully developed towards ten years of age integration of these two memory systems is relatively challenging.
The patients’ illness behaviour is part of their repertoire of behaviour drawn on from their implicit procedural memory for how motor patterns of behaviour have been adapted to particular situations. Motor responses, which have had greatest survival value when they have been in apparent danger or under threat, will be those which have greatest chances of being retained. These implicit memories are not accessible for reminiscing. They are like what happens when you ride a bicycle. You do not recollect how you learnt it in detail. And you cannot unlearn it by ‘lying dormant’ and avoiding a bicycle for years. Regardless you can still cycle. It is the same with illness behaviour. But what happens is that the behaviour becomes shaped as you experience more and more responses to your presentations of discomfort – and at the same time learn to mind read how others seem to be ‘reading’ you and so modify what you do to fit the circumstances. From riding a penny-farthing you manage the drop handlebars.
The sociological theories of sickness, in which diminished role performance is excused when disease is attributed as the cause of the change in function, maps onto the developmental perspective outlined above. Parents attribute sickness to their children when their relationship is altered and the cause is attributed to disease. Through that process the children learn to allocate disease labels to their subjective illness experiences. The primary source for learning about your subjective state is through the way in which it comes to influence those around you. Herein lies the importance of primary preventive practice directed at mother-child relationships early in life, including the attribution of states of sickness to their children and so introducing them to an illness vocabulary, which they believe is associated with disease and pathology.
This is an abridged version of a long and complicated thesis involving how the basic sciences and humanities pertaining to medicine contribute to an understanding of the nature of symptoms and mindful medical practice. The detailed argument is presented elsewhere3.
1. Taylor DC. Hysteria, belief, and magic. Br J Psychiatry 1989;155:391-8. 2. Tinbergen N. The study of instinct. Oxford University Press: Oxford, 1951. 3. Wilkinson SR. Coping and complaining: attachment and the language of dis-ease. Brunner-Routledge: Hove, 2003.
Competing interests: None declared
Competing interests: No competing interests
Dear Editor,
Though we disagree with the notion that doctors still use a simple biomedical model to understand illness, we welcome Wade’s proposal of a new model (1).
By encompassing beliefs, attitudes, expectations and values, the personal context in Wade’s model is close to Kleinman’s Explanatory Model (EM)(2) used in cross-cultural psychiatry to understand patients’ perspectives in differing cultural contexts (3, 4) Wade’s model suggests that the importance of accounting for patients’ contexts extends beyond cross-cultural psychiatry. Yet, only few studies describe patients’ perspectives in other medical contexts.
We recently conducted a pilot study of young people’s perspectives on the illness for which they consult a general practitioner. We used the structured Short Explanatory Model Interview (SEMI)(5) to interview 56 patients (16 to 24 years old) about their perspective on their presenting symptoms. Patients’ answers fitted into five distinctive patterns. Most commonly, young people felt responsible for their illness, incriminating their actions or inheritance: “maybe I don’t blow my nose enough”. Less often, elements of the natural world were seen as causal: “maybe [my allergies] were caused by radiation?” Some young people also considered psychosocial causes to be important: “because… I had two papers due yesterday”. A rarer view involved the supernatural world: “maybe a punishment for doing bad” or the medical world “it’s because of the pill”.
The wide range of perspectives young people had on their illness highlights the value of assessing contexts individually to detect possible discrepancies with professional views. Such discrepancies are likely to affect patients’ engagement with health services providers and ultimately their health outcomes. We are currently conducting a study of the association between the patient’s perspective and the care provided to them by GPs. This will improve our understanding of the importance of this component in the provision of care.
The extent to which Wade’s theoretical model can be applied in clinical practice to favour better outcomes is unknown but we look forward to results of future research providing answers to this question.
References
1. Wade DT, Halligan PW. Do biomedical models of illness make for good healthcare systems? BMJ 2004;329:1398-401.
2. Kleinman A. Patients and healers in the context of culture. Berkeley: University of California press, 1980.
3. Helman CG. Culture, Health and Illness. London: Arnold, Hodder Healine Group, 2001.
4. McCabe R, Priebe S. Explanatory models of illness in schizophrenia: comparison of four ethnic groups. Br J Psychiatry 2004;185:25-30.
5. Lloyd KR, Jacob KS, Patel V, St Louis L, Bhugra D, Mann AH. The development of the Short Explanatory Model Interview (SEMI) and its use among primary-care attenders with common mental disorders. Psychol.Med. 1998;28:1231-7.
Competing interests: None declared
Competing interests: No competing interests
I enjoyed this article (1). Like Wade and Halligan I think there are serious limitations in our current medical thinking about illness, and this leads on to problems for doctors, patients and benefits administrators with diagnosis and certification. (2,3)
The classical medical model is based on a direct link between lesion and symptom. Medical teaching rightly emphasises the processes linking symptoms with lesions. On the basis of such ideas there are four possible groups of patients:-
1. Patients whose symptoms are due to disease. This is home territory for doctors and reasonably well dealt with by current medical knowledge.
2. Patients who have disease but no symptoms. This is the territory covered by screening, and although of debateable worth, medicine has developed strategies for making progress in this area such as the Wilson- Junger screening criteria.
3. People who have no symptoms and no disease. These people are healthy as far as medicine is concerned, and will not often attend the doctor.
4. Patients who have symptoms but no disease
It is this fourth group that causes most of the problems in medical practice. In some of these people we can classify the symptoms into syndromes such as schizophrenia, depression, irritable bowel syndrome and so feel as if we are “diagnosing” an “illness.” With some symptoms we struggle even to do this. We can feel that we are trying to “knit fog” as we attempt to build a coherent picture out of multiple inexplicable symptoms.
We forget that we are trying to catch the symptoms within a disease matrix, which may not be a valid concept when there is no lesion present. There is a solidity, and validity, to the concept of any disease with a recognisable lesion that is lacking where no lesion has been shown.
Refs
(1) Wade, D. T. and Halligan, P. W. (2004) Do biomedical models make for good healthcare systems? BMJ 20044;329:1398-1401
(2) Nilsson, B and Heath, I, (2003) Patients, doctors and sickness benefits BMJ 327;1057
(3) Jenkinson, S. (2003) A brief history of time off work. British Journal of General Practice 53: 417 (May 2003)
Competing interests: None declared
Competing interests: No competing interests
Research into the psychosocial determinants of disease and illness has demonstrated the weakness of the “biomedical model”, in which symptoms are evidence of bodily malfunction which can be rationally explained, investigated and treated. Wade and Halligan challenge this model and encourage us to think of “health” in its wider context of “participation” - this is welcome. Using a "medical model" can limit our ability to explain or manage symptoms which cannot be attributed to disease, resulting in a cycle of over-investigation (by the clinician) and increasing dependency on health services (by the patient). Over reliance on the medical model may be one factor contributing to the “paternalistic” style of practice, still prevalent within the NHS. (1)
A “model” is a "copy" or "abstraction" of the real world, and the value of a model depends on the purpose to which it is put.(2) It is unlikely that any model of health and illness will adequately serve all purposes. A model which serves the needs of a GP caring for a patient may not help policy makers deliver nationwide organisational change; the context in which the model is applied is different and the purpose to which is being put is also different. One weakness of this paper is that it is nowhere explicit what the precise purpose of the model is, though it implies that the adoption of the model by policymakers would result in a reallocation of resources and reorganisation of health services.
Unfortunately, the authors have used a poor example as an illustration. The patient in question has suffered “serious” pathology (i.e. stroke) with significant prognostic implications and residual symptoms / signs. By contrast, the text focuses on patients who present “ill” but have no discernible pathology. The “objective” descriptions are rooted in a “medical model” (“he has returned to being a father and husband…” suggests that somehow these roles were “suspended” before). How useful it is for a model to accommodate two “contrasting” descriptions of a situation (both representing the professional “interpretation”), rather than one comprehensive description is unclear.
“Illness” is the patients' personal experience of a physical or psychological disturbance, whereas “disease” is the biological explanatory model for illness. The notion that someone may be “ill” but not believe that they are “ill” suggests a different definition of “illness” and is confusing. I feel comfortable about helping someone who believes they are ill and has no discernible pathology (“disease”), but uncomfortable with the notion of defining or treating “illness” (in the absence of disease) if a person does not believe they are “ill” – this, it seems, raises difficult ethical problems.
The authors conclude that the “continuing “health” of healthcare systems depends on members of society using a congruent model of illness and system of values….” This is a bold statement and quite unrealistic! The notion that our society might ever use a “congruent system of values” is neither achievable nor necessarily desirable. That society is made up of people who hold different values is part of its richness and interest - our role as medical professionals would certainly be much less interesting if this were not so!
1. Coulter A and Rozansky D. Full engagement in health. BMJ 2004; 329: 1197-8
2. Coiera E. Guide to Health Informatics. Arnold 2nd edition. 2003
Competing interests: None declared
Competing interests: No competing interests
The Problem with Medicine.
The problem with ‘medicine’ as the prime mover of health care development in the twentieth century was a philosophical one. Was the purpose of medicine to deal with pathology or address human suffering? There was also some confusion regarding pathology. Were health care professionals to attempt to prevent pathology (a largely political and socio-economic enterprise) or simply treat pathology once it had developed? In the end (driving forward health care whilst under the influence of business-oriented practices developed most highly in American psychiatry) the worst possible option was selected. This was (the ever increasing tendency) to treat all human suffering as if it could be reduced to individual biomedical pathology. One result of this has been to conceptualise health promotion and prevention in largely culturally de- contextualised terms. To focus only on individual coping and choice as the alternative to ‘passive treatment’ is to compound the error and once again avoid honestly addressing the causal factors embedded within our culture.
Competing interests: None declared
Competing interests: No competing interests
Wade and Halligan’s new model of illness will be useful if it allows and encourages doctors and patients to find new ways of managing so called “functional “ illnesses. Taking the example of low back pain (chronic pain being an area where the biopsychosocial model is well accepted) as a condition where context is all important. A patient with typical mechanical low back pain aggravated by prolonged standing will have a significant problem if for instance they work as a hairdresser but not if they have an office job ie it is their occupation rather than the pathology which will probably determine whether they seek medical attention. The new model implies that changing the context (ie suggesting the patient change job) is an equally (and perhaps more) valid way of managing the problem than rather than looking for a “cure” for the low back pain. However, the model will only be of real benefit if policy makers transfer resources from diagnostic and treatment modalities to rehabilitative, educative and occupational programs.
The model is also useful as a way of highlighting the attempts by the pharmaceutical industry to medicalise increasing areas of human experience – viz shyness as social phobia, teenage unhappiness as depression ( as discussed in this issue of the BMJ), childhood behavioural difficulties as ADHD and more recently “restless leg syndrome” as a neurological disorder – implying that these are disease entities with a biomedical cure.
Accepting this model, however, also throws up some interesting philosophical dilemmas regarding the responsibility of individuals v. society in managing their “dysfunction”. If an individual with severe hand eczema or low back pain chooses to become a hairdresser we would probably regard that as a poor career choice and feel it was their responsibility to find a more suitable career. If on the other hand a job changes in some way so that an individual is less well adapted to it and becomes unable to cope they may well acquire a (medical)label such as “stress related illness” or "depression" and consider themselves entitled to compensation in the form of sickness benefit. As a society (with current disability legislation) we seem to be moving much more to the viewpoint that it is the duty of society to adapt to the dysfunction of individuals rather than the responsibility of the individual to find ways of coping with a disability . Inevitably this view impacts on the range of “dysfunction” that healthcare systems are expected to deal with and as the authors suggest this needs to be openly debated.
Competing interests: None declared
Competing interests: No competing interests
It was useful to have Dr. Hall's letter paired with that of Professor Barker. The rising tide of dubious 'illness' has in no small part been generated by the alacrity of the medical profession to increasingly 'medicalise' any form of discomfort or aberrant behaviour, hence the growth of depression (see Healy, 'The Anti-Depressant Era') and wonderful diagnoses such as Oppositional Defiant Disorder, (See the International Classification of Diseases 10). There may be neurophysiological changes involved but these are inconsistent and do not conform to what Dr. Hall would rightly recognise as 'disease pathology'. One has to ask which 'skilful parasites' have benefited most, in terms of status, power and money from this trend?
Meanwhile the psychosocial determinants of vulnerability to ill health and suffering have been largely ignored by the 'health care professions', including my own. Where are the health care professionals fighting for social justice and equality of status, power and wealth, differentials in these dimensions demonstrated scientifically to be the most powerful determinants of vulnerability to poor health? (See Professor Wilkinson - 'Unhealthy Societies'& 'Mind the Gap'.) Which group of people are truly ideologically bankrupt? When tax evasion and tax fraud cost the country around ten times as much as all benefit fraud perhaps there should be more outrage regarding the rotting head of the fish rather than the impoverished tail. Or would that be a little too close to home?
Competing interests: None declared
Competing interests: No competing interests
Wade and Halligan attempt to explain "illness without disease" but make no attempt to examine the metaphorical status of 'illness' (per se) and only allude to the inevitable power relationships when metaphorical 'illnesses' are 'diagnosed'. That great scholar of psychiatry, Thomas Szasz, has spent fifty years challenging the medicalisation of various 'problems of living'(see Schaler 2004). My comments are no more than footnotes to his prodigious critique.
As Szasz noted, when people (including physicians) talk of 'illness' or 'sickness' frequently this is metaphorical: in the same sense that a building might 'suffer from sick building syndrome' or a distasteful joke might be 'sick'. Clearly, these refer to 'problems', but are in no way akin to the problems associated with carcinoma or diabetes.
Wade and Halligan argue that "illness is a dysfunction of the person in his (or her) physical and social environment[even when] the (ill)person does not...consider himself ill (for example if someone is deluded)". This is the model used by Soviet psychiatry to diagnose political dissidents with 'sluggish schizophrenia' and lies at the heart of the committal process under the Mental Health Act. It is also the model used to medicalise everything from suicide to sexuality. 'Dysfunctional' people who make others feel 'ill-at-ease' - whether political dissidents,'psychotic' family members, or rowdy teenagers, can be described as problematic. However, to suggest they are 'ill' risks abusing them and confusing them with those with 'genuine illness'. Attempting to frame a wide range of human problems within an illness paradigm is revisionist, and may obstruct the development of alternative models of helping people in difficulty. "People in the criminal justice system" might well benefit from an alternative model of provision, but not one that presupposes 'illness'.
Perhaps unwittingly, Wade and Halligan have made a small contribution to the deconstruction of medicine in contemporary health care.If it is time to critically examine the illness discourse, then a critical appraisal of the power and status of medicine is long overdue. We cannot continue to use what Wade and Halligan acknowledge to be redundant medical terminology to describe complex human states, of which only a small part might properly relate to what once was understood as medicine. Time for a health care neologism, perhaps?
Neither can we continue to ask medical practitioners to 'judge' the 'illness legality' of some 'dysfunction of the person'. Medicine has cultivated, over generations, a mythical authority on every conceivable human 'ill'. Now it struggles to cope with the expecations that accompany all hero-myths. Time for a redefinition of the social role of medicine, perhaps?
Schaler J (2004) Szasz under fire: The psychiatric abolitionist faces his critics. Chicago: Open Court
Competing interests: None declared
Competing interests: No competing interests
Exploitation of the advantages of playing the ‘sick role” by skilful parasites has inflated health care costs to a degree which is becoming a serious threat to most types of insurance systems, not only the NHS. Doctors are unsurprisingly reluctant to challenge the validity of claims for benefit of one sort or another. It is extremely politically incorrect to imply that greed, idleness, or selfishness play any part in seeking support when ‘illness’ is asserted. It is hard to see how the systems approach adumbrated here can avoid the confrontations which will be required if ‘illness’ is allowed to include disorders without verifiable and tangible pathology. Widespread abuse of a provision which depends on solidarity and trust will lead to deep resentment and ultimate failure. Although the holistic approach to individual problems, ie, recognizing the contribution of disturbances of biology, psychology, and sociology, has much to commend it, it does not get over the fundamental philosophical differences in these modes of understanding. The scientific paradigms (Kuhn) are quite different and cannot be combined into a ‘superparadigm.’ It is certainly possible to envisage distinct scores on each of these axes: the total score would be a measure of disability, but only the biomedical proportion would be paid for as only this could be independently verified. Yes, and that does mean neuroses would not qualify. It is time that the interests of the golden goose, ie the working taxpayer, are taken into account before he or she decides that insurance schemes are too open to corruption and exploitation.
Competing interests: None declared
Competing interests: No competing interests
Detection of biopsychosocial health risks may improve health care systems: The INTERMED project.
In their article “Do biomedical models of illness make for good healthcare systems” Wade and Halligan discuss the restrictions of the classical biopsychosocial model and present an alternative based on the biopsychosocial approach as introduced by Engel (1). The system they propose is an adjustment/elaboration of the WHO’s international classification of functioning, disability and health. The adjustments have been derived from guidelines for stroke and multiple sclerosis.
We read their article with interest and agree with the formulated critique on the biomedical model. Our group has developed a comparable generic method as part of a European grant with as far as we can see a series of advantages worth to be mentioned. We have presented the INTERMED in 1999 as an operationalisation of the biopsychosocial model as formulated by George Engel (2,3,4). The primary focus is to discern whether a patient has in addition to the current presenting problem or illness additional risks such as other –including psychiatric -morbidity which might interfere with the treatment of the primary clinical problem.
It allows clinicians from different professional backgrounds to analyse the bioplsychosocial health risks and needs of their patients. The several risks (n=16) and prognoses (n=4) assessed are organized in a schema (Table 1). The information is documented, scored and visualized in colours representing risks (green, yellow, orange and red). The documented information is transferred in an automatic letter. So the additional features of this system make it a feasible instrument in clinical practice as a decision support tool. It allows clinicians to decide whether patients are fit for standard evidence based care or their morbidity is so complex that individualized patient oriented care should be applied as well as the framework for its content. The instrument can be used for in- and exclusion, stratification and control of unexplained variance as well as disaggregation to explore which subgroups have the main effects in research (5). The tool is supported with a generic electronic module being part of the hospital management system. This facilitates its integration in medical and multidisciplinary rounds. Ongoing randomized clinical trials are being currently conducted to evaluate the benefit of targeted interventions in complex medical patients. The INTERMED has been implemented in daily clinical practice in the department of general internal medicine in the University Hospital in Groningen as well as the department of neurology Free University Amsterdam, the Netherlands, and in Sion, Switzerland, in the rehabilitation clinic for victims of professional accidents: the Clinique romande de réadaptation Suva Care.
FJ Huyse
FC Stiefel
W Söllner
P de Jonge
JPJ Slaets
References
1. Wade DT, Halligan PW. Do biomedical models of illness make for good healthcare systems? BMJ 2004;329:1398-1401.
2. Huyse FJ, Lyons JS, Stiefel FC, Slaets JPJ, de Jonge P, Fink P, Gans ROB, Guex P, Herzog Th, Lobo A, Smith GC and Strack van Schijndel R. "INTERMED": A method to assess health service needs: I. Development and reliabil-ity. Gen Hosp Psychiatry 1999;21:39-48.
3. Stiefel FC, de Jonge P, Huyse FJ, Guex P, Slaets JPJ, Lyons JS, Spagnoli J and Vannotti M. ”INTERMED”: A method to assess health service needs: II. Results on it validity and clinical use. Gen Hosp Psychiatry 1999;21:49-56.
4. Huyse FJ, Lyons JS, Stiefel FC, Slaets JPJ, de Jonge P, Latour C: Operationalizing the Biopsychosocial Model. The INTERMED. Editorial. Psychosomatics 2001;42:5-13.
5. de Jonge P, Huyse FJ, Stiefel FC, Slaets JP, Gans RO. INTERMED--a clinical instrument for biopsychosocial assessment. Psychosomatics. 2001;42(2):106-9.
Table 1: variables of the INTERMED scoring grid
HISTORY
CURRENT STATE
PROGNOSES
Biological
Chronicity
Diagnostic dilemma
Severity of symptoms
Diagnostic challenge
Complications and life threat
Psychological
Restrictions in coping
Psychiatric dysfunctioning
Resistance to treatment
Psychiatric symptoms
Mental health threat
Social
Restrictions in integration
Social dysfunctioning
Residential instability
Restrictions of network
Social vulnerability
Health Care
Intensity of treatment
Treatment experience
Organisation of care
Appropriateness of referral
Coordination
Copyright Huyse, Lyons, Stiefel, Slaets, de Jonge, with permission by Elsevier (2)
Competing interests: None declared
Competing interests: No competing interests