More than 30 years ago, George Engel1 issued his seminal “Challenge for biomedicine” to address shortcomings in modern medicine's explanatory power, patient engagement, and illness management. Today, his biopsychosocial model is entrenched within academic medicine, yet many worry that its impact on the practice of medicine is lacking, or even absent. Advocates of the model ask and answer, “Has the challenge been met? Not at all.”2 Trainees are found to have not only little competence in the biopsychosocial understanding of patients but also questionable interest in it.3–5 Educators conclude that “medical training and practice have a considerable way to go before the biopsychosocial model” achieves its ends.4
The blame for this state of affairs is generally laid at the feet of “biomedicine.” According to Engel,6 the “most important reason” why physicians fail their patients is “the biomedical model of disease.” Subsequent promoters of the biopsychosocial model have carried this torch into the present day. Cantor7 speaks to the stability of this argument when he refers to a “standard narrative” of disease in the 20th century, in which “there are two diseased bodies … the reductive one of modern medicine, and the holistic one of its critics.”
I propose that biomedicine's role in the biopsychosocial argument is actually that of a straw man. If this idea is even partially true, it might help explain the perceived shortfall in the biopsychosocial model's progress. Maintaining a straw man over the long term requires that it be rebuilt each time it is torn down, rendering it effectively unbeatable. The energy and conviction required by this cycle of construction and destruction might also inhibit critique of biopsychosocial precepts. After illustrating the existence of the biomedical straw man, I will sample its adverse consequences via two important blind spots in the biopsychosocial argument. I will propose seeking a more productive approach to medicine and its problems in the recognition that medical endeavors cannot be beholden to any single conceptual model. Throughout, my focus will be on clinical medicine as the place where the biomedical straw man is most apparent and its effects most strongly felt.
The Biomedical Straw Man
In the “Challenge for biomedicine,” Engel1 quickly identifies the challenged:
The dominant model of disease today is biomedical, with molecular biology its basic scientific discipline. It assumes disease to be fully accounted for by deviations from the norm of measurable biological (somatic) variables. It leaves no room within its framework for the social, psychological, and behavioral dimensions of illness.
This image of the biomedical model seems self-evident at the outset, but soon transitions into hyperbole. It is also unreferenced. The preceding text cites a few psychiatrists' ideas about how their own field should be remedicalized, but the presumably already-biomedicalized specialties are not represented. In the remainder of the article, Engel mainly cites works by psychiatrists, critics of medicine, general systems theorists, and himself. He does not critically address, or identify, any advocates for biomedicine. His later characterizations of biomedicine seem similarly cut from whole cloth, as when he asserts that the biomedical clinical approach is “disease oriented and not patient oriented” and offers “unscientific and simplistic solutions to resolve the complaints of patients.”6
Engel's insufficient rigor matters for two reasons. First, it gives the appearance of logic to unqualified conclusions about clinical biomedicine's anonymous backers and practitioners. Taking matters directly to the bedside and physicians' conscious intentions, Engel defines the dominant medical model of his day as one that “encourages bypassing the patient's verbal account,”1 “encourages a view of the patient as a machine,”8 and abets “rejection of dialogue”9 (italics added). Though Engel identifies biomedicine as a “scientific model … of disease,”1 these statements are not attempts to indict the pernicious intrusion of laboratory methods into the clinic. To the contrary, he espouses his biopsychosocial approach as “a scientific model for medicine”9 and as the hallmark of “the truly scientific physician.”10 Engel portrays single models as guiding all medical tasks. Hence, the biomedical model does not just guide research but also serves as a narrow, inflexible, inhumane, and often ineffective approach to clinical care—as compared with the biopsychosocial model, which, ostensibly, is none of these things.
The second reason that Engel's manner of defining biomedicine matters is because it is frequently referenced by other writers.11–17 These writers then reference one another, giving the impression of scholarly legitimacy to their conception of clinical biomedicine. A representative example states that “modern medical care is based largely on a paradigm known as a ‘biomedical model,’” where “each disease has a single ‘cause’ … information from patients [is] of value primarily to suggest appropriate tests,” and treatment “involves only actions of health professionals.”18 The sources cited for these definitive statements are Engel's “Challenge” paper plus three papers by one of the authors.
Especially noteworthy is when clinical biomedicine, so defined, is presumed to be “orthodox,”19 “traditional,”15 or endorsed by “most physicians.”20 Such characterizations of biomedicine imply that most physicians are purposefully complicit in efforts to promote inadequate patient care. However, few, if any, representatives of this majority seem to be advancing an impersonal biomedical clinical agenda in the contemporary literature. Still, Adler21 recently claimed that “a whole bunch of physicians in different specialties … do not adhere to Engel's and the author's comprehension of the biopsychosocial model.” Adding insult to diffusely directed injury is speculation that physicians cling to biomedicine because of their psychological shortcomings. Some biopsychosocial model advocates postulate that psychosocial understanding and empathic connectedness to patients are “threatening”12 to the apparently fragile psyche of the average doctor, who is afflicted with “fear of the emergence of [his or her] own feelings,”21 who suffers from “emotional inhibition, and patient engagement inhibition,”22 or who might “lack the spark of creative curiosity.”12
Occasionally, biopsychosocial works do cite biomedicine proponents. Abraham Flexner and the Johns Hopkins physicians who helped inspire his 1910 report are identified as starting the biomedical snowball rolling.11 The historical reference is important, but references to more recent authors are rare, with one exception: Donald Seldin, author of a frequently cited and denigrated11–13,23,24 address that provides some legitimately alarming copy (e.g., “Human problems and human agonies are medical problems and medical illnesses only when they can be approached by the theories and techniques of biomedical science”25). Unmentioned by Seldin's critics, unfortunately, are the foundation of this address in his testimony at and study of the trials of Nazi doctors, and his associated belief that limiting medicine's purview might stem its involvement in societal evils. The limits Seldin proposes are draconian, but his socially and ethically nuanced argument hardly exemplifies biomedical reductionism.
Engel's a priori definition of biomedicine, the muddled scientific and clinical usages of that definition, the implication of a ubiquitous yet anonymous mass of purposefully reductionist and inhumane physicians, and the narrowly framed image of a villain are the raw materials of a straw man argument. This manner of constructing an argument might help introduce a point, but the biopsychosocial model's straw man has been repeatedly built up and torn down for decades.
The “good old days”?
Often wedded to the biomedicine straw man is nostalgia for the “good old days” when physicians viewed their patients as whole persons.11,13,19,26,27 Good old days holism is said to have imparted on physicians greater compassion, trustworthiness, and, particularly for psychosomatic and chronic conditions, healing power; its revival, some believe, may yet “forestall patients' dissatisfaction with modern ‘high tech’ medical care.”28 Biopsychosocial advocates do routinely acknowledge modern medical advances, albeit usually en route to criticizing their reductionist consequences.29 But was the physician of the good old days really so holistically attuned, and did his patients appreciate it? If so, when was this idyllic era?
It was not in the 20th century, if one uses campaigns for less rigidly biological and specialized practice as a metric. Michael Balint30–32 most famously led that charge in the 1950s and 1960s, George Canby Robinson33 in the 1930s, and Francis Weld Peabody34 in the 1920s. Medical lectures and literature from the mid-19th through mid-20th centuries are peppered with cautions against deindividualized medicine.35–40 The language and themes during this period are remarkably similar to those found in the biopsychosocial literature, such as viewing patients as cases instead of sick people, mourning the loss of a bygone art of medicine, and making the illness–disease distinction. Of course, the years in question were ones during which newly explosive scientific innovation and influence in medicine demanded debate over their implications. Nonetheless, these works call into question the goodness of some of the potential good old days.
Engel6 rejected the good old days concept, but only as far back as the mid-19th century—that is, the advent of biomedicine. However, it is not clear that paying attention to nonbiological factors in illness and healing ever bred respect among physicians for the personhood of individual patients. Medical historians repeatedly find that physicians were ambivalent in their relationships with patients. Mistrust of “stupid, lazy, deceitful” patients38 and their subjective reports41 is evident in the early days of the 19th century, and it may have always been the case. Physicians' placing their confidence in what they consider science in any given era stretches back to antiquity, as does their aggressive interventionism based on that science.42,43
Patients did not always share and thrive on their physicians' confidence. Porter44 notes that in the 13th through 17th centuries, people generally “took care before they took physick.” Shorter45 correspondingly describes “massive distrust of the traditional doctor,” who was dangerously interventional and to be avoided unless things got desperate. Likewise, the physicians of old occasionally preferred to distance themselves from their patients. Deployment of technical jargon is a timeless way of doing this figuratively.46,47 Physicians did so literally by providing diagnosis and counsel via messengers, who carried patients' urine in one direction and physicians' advice back in the other, during the Middle Ages47—a time when many physicians “would not even deign to see patients directly,” and patients often testified in court on behalf of quacks whom they found to be more attentive.48 Even a search for good ancient days reveals that physicians of ancient Greece, Egypt, and Mesopotamia often viewed noncurative relief of suffering and treatment of patients with poor prognoses as lying outside their job description.49
To stretch the straw man metaphor, the good old days physician is a scarecrow that wards off criticism of holistic precepts via nostalgia and shame. Ultimately, though, a scarecrow is still made of straw.
Summary: Raising questions
Other writers find fault in typical depictions of biomedicine and the good old days.50–52 Nonetheless, I have provided an admittedly selective review, only meant to call certain assumptions into question. I am not proposing a thesis for “bad old days” or against a clinical trend privileging objective information over subjective experiences and accounts. That trend is outlined rigorously by Reiser53 and Howell54; however, the presumption that it is new is flawed at best. Also flawed is the idea that the term “biomedicine” is attached to a clinical practice agenda outside the writings that criticize it. Engel invented the concept of clinical biomedicine along with the biopsychosocial model. Propping up the biopsychosocial model with straw constructs is fragile and unproductive. More insidiously, it obscures flaws in the biopsychosocial argument itself.
Problems With the Biopsychosocial Argument
If there is no biomedical plot against the biopsychosocial model, then the question remains as to why the latter has rhetorical momentum but practical inertia. It may be that biopsychosocial ideas fail to argue their way to the bedside in the first place. Wolpe55 suggests that a major stumbling block in the education of “good doctors” is that “we are trying to make doctors too good.” In his oft-presented case of “Mr. Glover,” Engel1,6,8 explicitly asks physicians to tend to a range of considerations spanning from “subatomic particles” to the “biosphere.” He preemptively and summarily dismisses any protests that his model is unmanageable, attributing them to “stubborn and pernicious … biomedical dogma.”6 This stance is maintained in the present day.2 Fixed as the biopsychosocial argument is on clinical biomedicine as its opposite number, it does not question whether there can be a point of diminishing returns in fighting reductionism with inclusionism.
Biopsychosocial medicine is said to incorporate “moral and political philosophy … government, economics, epistemology, sociology, psychology, and the broad biological sciences”56 as well as “anthropology, demography, … health statistics,”12 and semiology.21 Proponents assert that “modern medicine has become a social science.”57 Related pleas for greater humanism and inclusiveness in medicine propose that the profession “requires as deep an understanding of the social sciences as of the biologic sciences,”58 that medical notes require “writing skills as well honed as those of any novelist” because the physician's “wells of information about people and their lives … exceed those available to Shakespeare,”59 and that “the mystical, spiritual and common experience of humans must form the heart of all [medical] education.”60 Less abstract, but still daunting, are attempts to operationalize the biopsychosocial model using four-by-four61 or three-dimensional62 grids. More often, the biopsychosocial model's name is left to speak for itself.
When important clinical applications are offered by persons advancing the biopsychosocial model, they are sometimes framed in ways that seem far removed from everyday practice. For example, psychosocial considerations are conflated with the field of psychiatry when depression is lumped in with ordinary emotions like fear63 or whenever “the good chat is … dressed up as psychotherapy.”45 Basic aspects of doctoring, such as individualized communication, education, and support, can be overcomplicated by psychosocial translations.64 Engel8 was disdainful of psychosocial content being “referred to crudely as the ‘art of medicine,’ the ‘bedside manner,’ the Samaritan and healer role of the physician, and the doctor–patient relationship.” As part of his focus on replacing biomedicine as an across-the-board medical model, he strove to render these things scientific. But “being scientific in the human domain”10 may actually be a distraction from straightforward good doctoring.
Just about any aspect of our lives and environment can influence illness. Clinical medicine is pragmatic, however. Ultimate truth is less important to physicians than are the components of that truth which they factually or experientially “know” advance the care of real patients.65 The biopsychosocial model may very well be “true,” and the general systems theory on which it is based applicable to every human endeavor. Yet medicine, as a profession, needs a focus in order to function effectively. Parsons66 addresses this idea in his controversial67 but enduring discussion of the sick role. He proposes that although physicians must attend to “intimacies” of patients' lives, they are “protected” from embroilment therein by the “functional specificity” of clinical medicine. In a complementary way, patients are protected by his dictate that if material “cannot be justified by relevance to the health problem it is ‘none of the doctor’s business.'”66
Taking a historical perspective, Temkin68 identifies that focus as health. As far as the object of that focus goes, Temkin writes, “there seems to be widespread agreement from antiquity through the Middle Ages and Renaissance and far into modern times that professional medicine dealt with man's body. With his soul medicine dealt only in so far as behavior was associated with somatic conditions.” Seeking themes in the “Western medical tradition” through the 17th century, Neve observes, “from Galen onwards … the task of replacing individual stories with a scientifically understood, physicochemical, and properly classified disease world … [and] a commitment to explaining illness by invoking diseases that have an independent natural existence.”69
When biopsychosocial model exponents demand that physicians place “psychological” and “social” knowledge on an equal footing with somatic and phenomenological factors in illness, they are not simply facing down some biomedical bully. They are taking on the physician's functional specificity. Blaming biomedical dogma for clinical medicine's tendency to focus on disease and the body is unproductive and retrospectively myopic. Western medicine's professional heritage, concept of progress, and imperative to action are rooted in the body, which, of course, interacts with its environment and exists in a complex relationship with the “mind.” Nonetheless, the body remains the real or presumed target of the diseases that doctors expect—and are expected—to deal with.
Challenging those expectations is a worthy endeavor. However, the kind of psychosocial emphasis noted above proposes to make medicine something new, with decompressed ideas about the doctor's role and the definition of medical illness. Such a proposal warrants careful, honest scrutiny. Because the biopsychosocial model has entertained only straw man opposition in a dualistic, good-or-bad choice, it has not been openly critiqued. By contrast, today's version of scientifically informed practice faced and overcame marked resistance on the way to its current status.38,39,70 It is tried, even if not wholly true. Right or wrong, is it any wonder that physicians turn to a bodily focus, rather than to the biopsychosocial model, when faced with real-world frustrations in their practices?
The biopsychosocial argument largely frames physicians' frustrations as being due to their application of biomedical solutions to psychosocial problems. Importantly, it implies that “cold, impersonal, technical, biomedically-oriented”71 physicians force their approach onto patients who long for more relationship-oriented, holistic care.72 Oppressive biomedicine is accused of co-opting both medical education and also public attitudes.12 Trainees are “indoctrinated with its nuances long before entering medical school.”15 Accordingly, proposals to remedy the problem of this indoctrination repeatedly push biopsychosocial training against perceived biomedical resistance.
Regarding the repetitive nature of reform proposals, Christakis73 notes that “absent … [is] a critical examination of the larger social and economic forces impinging on medical education.” A work group on the “goals of medicine” convened by the Hastings Center points out that “a transformation of medicine ideally requires a transformation of society; they can no longer be kept separate.”74 Many biopsychosocial advocates, who otherwise emphasize the power of social factors in illness and healing, fail to recognize that whereas medicine influences patients and populations, the influence flows both ways. For example, when addressing the possible impact of patient contact on whittling down medical students' biopsychosocial values, it is insufficient to say, “empathy is hard to direct toward the challenging patients when the treatment emphasis is on technology.”5 All blame again falls on biomedicine; yet the biopsychosocial model itself raises the question, “Why are so many patients challenging?”
Patients can be challenging when they do not get what they want. Many patients voice a frustrated desire to be treated as “whole persons.” Yet physicians are also regularly pressured to mobilize mechanistically oriented diagnostics and therapeutics.75 “Patients' unwillingness to change” lifestyle habits defies even physicians who take ownership of the duty to motivate and support them in this area.76 U.S. society often sees itself as overly medicalized, yet a remedy is paradoxically seen in providing “continuous” access to the “health care system” and “unfettered access to … medical information and clinical knowledge.”77
These states of ambivalence reflect historically consistent tensions in medicine, such as that of “systems” versus “specifics,”42 and pleas for both patients and physicians to curb their respective enthusiasms for aggressive therapeutics.38,42 The natures of disease models and of therapeutics change with the times but reflect contemporary values.78 Specialization,79 technological innovation,54 and the privileging of science80 did not and do not simply radiate outward from medicine. They are pervasive trends and priorities within nearly all sectors of society, and “it would be quite astonishing if medicine had failed to follow [their] path.”79
The West's post–World War II “social contract centered on science and its potential”81 exists in parallel with its more recent mistrust of science and authority. In medicine, mistrust fuels opposing emphases on contractual interactions82 and on more humane, egalitarian doctor–patient relationships.83 All the same, this mistrust has done little to curb doctors' and patients' expectations, demands, and hopes that the products of materialist medical science can solve any problem. Indeed, “the idea of medicine as a science” remains “the desperate assumption of patients.”65 Thus, we have a set of priorities that can be complicated, internally inconsistent, and frustrating for both parties in clinical interactions. Too much focus on the corrupting influence of biomedicine obstructs more nuanced examination of these sources of confusion and frustration in medical practice.
Summary: Debunking dogma
Biomedical dogma is not the primary impediment to the biopsychosocial model's vitality. Biopsychosocial perspectives on, among other things, the content of clinical medicine and the expectations physicians are held to as social functionaries are treated more like assumptions than areas worthy of academic debate. The absence of this debate produces repetitive efforts to “demonstrat[e] the advantages and lack of disadvantages of the biopsychosocial approach”22 relative to biomedicine. There is a failure, however, to acknowledge that there are real problems with the approach itself.
Mediating the Argument
What is the problem?
Some readers may take to task the idea that there is no biomedical agenda opposing biopsychosocial advancement. The preponderance of biologically based material in medical curricula, grant support, journal articles, promotion criteria, and reimbursement schemes might support this point. Obviously, such material influences clinical values. However, the fact remains that in the clinical domain there exists no serious academic movement encouraging the stereotype of “narrow, doctor-centered, technology-bound, and indifferent”15 biomedical practice. Few physicians set out or see themselves practicing in this manner. Yet it cannot be denied that some physicians do so—probably not the silent majority implied in some biopsychosocial works, but enough to be a problem.
This situation can be reconciled with the biomedical straw man. Earlier, I made the point that there have always been some physicians who are overconfident in their contemporary theories of disease and therapeutics. Ackerknecht84 chronicles 2,000 years of medical history, recurrently revealing “some brand of dogmatist that placed theories, hypotheses, and real and fictitious results of other sciences above mere clinical observation.” Seen through this lens, clinical biomedicine becomes simply an epiphenomenon of this dogmatism, which feeds human enthusiasm and the need for (even false) security.
The expression of this need can be exaggerated nearly to the point of “magic” in a field like clinical medicine, where uncertainty runs rampant.65 The biopsychosocial argument's concept of clinical biomedicine blames a modern domain of knowledge for a problem of human fallibility. Good and bad doctors have always been with us, and they probably share similar traits worth examining across generations. Viewing the challenges of clinical medicine as products of the human condition also warns us that the biopsychosocial model is just as prone as biomedicine to produce dogmatism in susceptible physicians.
The allure of models
Resemblances between the biopsychosocial model and its depiction of biomedicine should come as no surprise. Their most important connection is the previously mentioned aspiration of the former to take over the latter's roles. Although I have focused on the straw man representation of clinical biomedicine, Engel and his successors also portray biomedicine as operating in medicine's research/scientific endeavor. (Public health medicine, although important, will not be addressed here). As such, the biopsychosocial model, per Engel,1 must function as a “blueprint for research, a framework for teaching, and a design for action in the real world of health care.” Engel's commitment to the biopsychosocial model's ability to bring “science” into clinical practice is quite intense. Ideally, he argues, in “any consideration of a scientific model for medicine that would qualify as a successor to the biomedical model … the fundamental issue is whether physicians can in their study and care of patients be scientists.”9
Abundant overlap exists between medicine's clinical and scientific tasks; yet in the end, Brown85 writes, “physicians and scientists have to approach their tasks differently … [because] processes that work for one are devastating for the other.” Using information gained from medical science, whether biomedical or biopsychosocial, is not a problem. Behaving as if variables can be isolated in an individual human being is, however. Portrayal of the biomedical straw man's fixation on biological factors in illness turns out to be another distracting epiphenomenon, this time related to the peril of using a single untranslated model to serve both science and patient care in medicine. The biopsychosocial model is again shown to run the same risks here as its straw man counterpart—so much so that one suspicious writer sees in the biopsychosocial model an attempt to make “social science subservient to the biomedical enterprise.”86
Biopsychosocial aspirations mirror the biomedical straw man's portrayed failings at the bedside as well—that is, in the indiscriminate application of the same model to every clinical problem. In this case, Engel6 argues that “all three levels, biological, psychological, and social, must be taken into account in every health care task.” Although this mandate may seem like a safer bet than biomedicine's supposed reductionism, it cannot guide physicians through every clinical duty and dilemma. As an example, consider the teaching intervention based on “precepts of a biopsychosocial consultation” that was recently found to work better when doctors saw simulated patients than real ones. The authors noted that real patients did not consistently approximate their simulation prototype.87 Biomedicine has been built up as promising (and torn down as failing) to be a universal best-fit model, but even the broader biopsychosocial model cannot accommodate every clinical problem.
Alternatives to the biopsychosocial model have been proposed.88–93 One notable aspect of all of these competing models is that they are tailored to particular tasks, such as psychiatric diagnosis and treatment or the ethics and interpersonal content of the doctor–patient relationship. A single model cannot accomplish all that is demanded in clinical care, let alone clinical care and scientific inquiry. In this vein, the psychiatric models of Ghaemi,88 Brendel,89 Sadler and Hulgus,90 and McHugh and Slavney91 function as meta-models or philosophical maps of sorts between clinical problems and corresponding approaches that address them. For my purposes here, the content of these models is less important than their support of the idea that no one model can guide the practice of medicine. Also, no one model, even the biomedical straw man, is without its usefulness.
The biopsychosocial argument conspires against its own advancement not only through its use of a straw man, but also through its monolithic, across-the-board self-promotion. Radical though it may sound, supporters of the biopsychosocial model should put aside their preoccupation with the biomedicine illusion and abandon the vision of a “new” global medical model. Doing both of these things would allow them to assess the strengths and limitations of a biopsychosocial approach and direct their efforts toward finding the areas where there is the most potential for its efficacy.
Summary: Acknowledging complexity
Just as biomedicine is not the cause of all that ails clinical medicine, the biopsychosocial model is not the panacea. The biopsychosocial model shares many of the potential pitfalls that it attributes to clinical biomedicine. The complexity of contemporary medicine is such that it cannot be served by just one model at either the macro (i.e., scientific and clinical) or micro (i.e., within clinical) levels. If the biopsychosocial (or any other) model is analogous to a Swiss Army Knife,94 what medicine needs instead is a tool box filled with different and dedicated tools suited for specific tasks.
Clinical biomedicine does not endure in spite of biopsychosocial advocates' efforts; it endures because of them. The biomedical straw man was created by Engel and persists as a key element of the biopsychosocial argument. Despite its unreality, it distracts from the important problems besetting the biopsychosocial model. Finally, portraying biomedicine as a sort of unjust ruler of medicine spurs biopsychosocial strivings to usurp it as the sole medical model. Contemporary medicine, however, is not suited for a single model. Jettisoning the straw man version of clinical biomedicine and scaling back biopsychosocial ambitions might lead to more of medicine's current problems being addressed openly and effectively.
The author would like to thank Nicole Simi, PhD, and Think Tank for encouragement and editorial advice during the writing of this article, as well as George B. Murray, SJ, MD, for the permission to challenge conventional wisdom.
This work was supported by the Eleanor and Miles Shore 50th Anniversary Fellowship Program for Scholars in Medicine via Harvard Medical School and Cambridge Health Alliance.
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