8 April 1977, Volume 196, Number 4286 The Need for a New Medical Model: A Challenge for Biomedicine Ata recent conference on psychiatric ‘cducation, many psychiatists seemed to be saying to medicine, “Please take u5 back and we wall never again deviate from the ‘medical model’ " For, as one cftcal psychiatrist put it, “Poychiatey has become a hodgepodge of unsciemtife ‘opinions, assorted. philosophies and “sebools of thought,” mixed metaphors, role diftuston, peopsganda, and poltick ing for mental heath and other esoteric ‘goals U). In contrast, the test of medi ‘ine appears neat and iid. Ht has 2 fem tease in the biological sciences, enor mous technologic resources tt its eon mand, and a record of astonishing ‘achievement in clicidating mechanisms of disease and devising new trestments. 1 would seem that psychiatry would do ‘yell o emulate is sister medial dis- ciplines by finally embracing once and forall the medical model of disease Bat T do mot accept such a premise Rather, contend that all medicine isin crisis ang, further, that medicine's ensis ‘erives from the same basic fault as psy. chiaty's, namely, adherence to a model ‘of disease no longer adequate fr the sei- ‘emifc tasks and social responsibilities of ther medicine or psychiatry. The mn portance of how physicins conceptual> fre disease derives from how such con: cepts determine what are considered the proper Boundaries of professional re sponsibility and hove they inflaence at tides toward and behavior with patients Payehiary’s erisis revolves around the ‘question of whether the categories of hi fan distress with which its concerned are properly considered. "disease" 35 ‘currently conceptualized and whether exercise of the traditional authority of ape. 177 George L. Engel the physician is appropriate for their helping functions. Medicine's ersis stems from the logical inference that Since “disease” is defined in terms of 0- matic parameters, physicians need not bee concerned with psychosocial issues ‘which lie outside medicine's responsibil ity and authority. Ata recent Rockefeller Foundation seminar on the concept of healt, one authority urged thet medi ine “eoncentrate onthe real diseases fd not get lost in the psyehosociologial lnderbrush. The physician should not be ‘cle with prolems that have arisen from the abdication ofthe theologian and the philosopher.” Another participant called for "a dsentanglement ofthe or tanic elements of disease from the ps ‘chosocial elements of human maine: tion,” arguing that medicine should deal swith the former only @), ‘The Two Pastans Psychiatrists have responded to their crisis by embracing Wo ostensibly oppo- site positions. One would simply excise psychiatry trom the fleld of medicine, ‘while the other would adhere strictly to the “medical model” and limit payehia- tuy’s fed to behavioral disorders con sequent to brain dysfunction, The sts exemplified in the wetings of Sease and thers who advance the postion that ‘mental illness is a mth” since it docs rot conform with the accepted concept ot disease @). Supporters of this postion advocate the removal of the fonctions now performed by psychiatry from the conceptual and professional jrisdition fof medicine and their reallocation (0 8 SCIENCE new discipline based on behaves sc tence. Henceforth medicine would be = Spoasible for the treatment and cure af Asease, while the new discipline wool be concerned with the reeducaton of people with “problems of living.” tm pli inthis argument i the premise tht while the medical model constitutes Sound ftamework within which to under Stand and treat disease is not relevant to the behavioral and psychological problems classically deemed the domain of psychiatry. Disorders directly aserb able to brain disorder would be taken cate of by neurologists, while psychiatry 35 such would disappear as 2 medial Aiscipine The contrasting posture of stit ad- herence (0 the medical medel is caries ‘ured in Ludwig's view of the psyehiae test as physician (1). Acconfing to Lad ‘wig, the medical model premises “hat Sulcient deviation from normal repre- sents disease, that disease it due to known of unknown natural eauses, and that elimination ofthese causes wil e- saltin care o improvement in individual patients" (Logwig's ales). While 2c Knowledying that most psyehiatee diage noses have a lower level of confirmation han most medical diagnoses, he adds that chey are not“ qualitatively diferent provided that mental disease i assumed to arise largaly from ‘natural’ rther thas metapsychologial, interpersonal or 50- etal causes." “Natural” is defined a5, “biological brain dysfunctions, either biochemical or neurophysiological in n3- ture." On the ther hand, "disorders seh as problems of iving, social adjust. ment reactions, characer disorders, de pendency syndromes, existential depres Slons, and various social deviancy conde tions [Would be exelied from the con cept of mental illness since these Aisorders arise in individuals with pre- sumably intact neurophysiological fone ning and are produced peimarly by psychosocial variables.” Such “no Dyehiatrc disorder” are not property the concern of the physiciampaychiatist land are more appropriately handled by ‘nonmedical professionals ax the (nvverng of Richest Seto of Nees,In sum, psychiatry rages to clarity its status within the mainstream of mea cine, if indeed it belongs in medicine at all. The criterion by which this question Js supposed to be resolved rests om the degree to which the field of activity of psychiatry is deemed congruent with the ‘existing medical model of disease. But ‘racial to this problem i another that of Whether the contemporary model is, in fact, any longer adequate for medicine ‘much less for psychiatry, For iit isnot, then perhaps the crisis f psychiatry i part and parcel ofa larger crisis that has fis roots ithe model itself. Should that bo the case, then it would be imprudent for psyehiatry prematurely to abandon its models in favor of one that may also be awed. “The Biomedical Model ‘The dominant model of disease today is biomedical, with molecular biology its basi sient discipline. Kt assumes dis. ‘ease tobe fully accounted for by devia ‘iors from the norm of measurable bio- logical (somatic) variables. Kt leaves 00 room within is framework forthe soil, psychological, and behavioral dimen Sons of ines, The biomedical model rot only requires that disease be dealt ‘with as an ently independent of social behavior, iv also demands that behavior al aberrations be explained on the basis of disordered somatic (biochemical or ‘neorophysiologial processes. Thus the biomedical model embraces both reduc- ‘ionism, the philosophic view that com- plex phenomena are ultimately derived froma single primary principle, and mind-body dualism, the doctrine that separates the mental from the somatic. Here the reductionisic primary principle is physialistie; that is, t assumes that the langage of chemistry and physics wil ultimately sufice 10 explain bio Tosicl phenomena. From the reduction- ist viewpoin, the only conceptual tools available to characterize and experimen tal tools te stidy biological systems ate physical in ature @). ‘The biomedical model was devised by ‘medical scientists for the study of ai tease. As such it was a scienife mode: that is, it involved a shared set of as sumptions and rales of conduct based on the scientfe method and constnated 2 ‘lucprint for research. Not all models fare scientic. Indeed, broadly defined, ‘model i nothing more than 2 belit sys- tem utlized to explain natural phenome ra, to make sense out of whatis puzzling for disturbing, ‘The more socially dis- ruptive or individually upsetting the phe rhomenon, the more pressing the need of hhumans t0 devise explanatory systems Such efforts atexpisnation constitute de Vices for social adaptation. Disease par ‘excellence exemplifies a category of nat ‘ural phenomens urgently demanding ex planation (). As Fabrega has pointed fut, “disease” in its generic sense is 2 linguistic term used to refer to a certo class of phenomena that members ofall social proups, a all times inthe history fof man, have been exposed to. "When people of various intellectual aa cal fal persuasions ase terms analogons to “disease, they have in mind, among oth- cr thing thatthe phenomena in ques- tioa invaive a person-centered, harnul and undesirable deviation or discontiny. ity... associated with impairment or Aiscomfor” 6), Since the condition Is not desired it gives rise toa need for car recive ations, Te latter involve blifs sand explanations about disease as wellas rile of conduct to rationalize treatment sctions. These constitute socially adept ive devices to resolve, forthe incivial as well as forthe society in which the sick person lives, the erses and uneer taintes surrounding disease (6) Such cultraly derived belief systems bout disease alro constitate mort, but they are not scientife models. These may be refered to 25 popular oF folk models. As efforts at social adapration, they contrast with seientile models, which are primarily designed to promote scientific investigation. The historical fact we have %0 face is that in modern Wester society biomedicine nat only thas provided a basis for the scientific study of disease, it has also become out ‘own culturally specific perspective about case, that is, our folk model. Indeed the biomedical model is now the domi- ‘ant fk model of disease in the Western world 5, 6) Ts our culture the atudes and belief systems of physicians are molded by this ‘model long before they embark on th professional education, which in tum ro faforees i without necessarily clariying how is use for social adaptation eon traste with is use for seientife research The biomedical model has thus besome cultural imperative its limitations ensily ‘overlooked, In brief, it has nw acquired the status of dogma. In science, a model is revised of abandoned when i fils to account adequately forall the data. A ‘dogma, on the other fan, requires that sserepant data be forced to fit the model for be excluded. Biomedical dogma re ‘ies that all disease, including "men tal” disease, be conceptualized in terms of derangement of undertying physical Imectanisms. This permits only two a ternatives whereby hetavior and disease can be reconciled: the reductionist, which says tha ll behavioral phenome ‘a of disease must be eoncepthalized in terms of physicochemical principles: and the exclusionist, whien says that what- ver is not capable of being so explained ‘ust be excluded from the eateory of disease. The reductionists concede that some disturbances in behavior belong in the spectrum of disease. They eategorize these a& mental diseases and designate psychiatry es the relevant medical dee Giplie. The exclusionsts regard meatal iyess as & myth and would eliminate psyehiany fom medicine. Among physi- cians and psychiatrists today the reine ttonsts are the true believers, the exch sionists are the spostates, while both condemn as heretics thase who dare a ‘question the ulimate trth of the bio- ‘medical model and advecate a more use- fal model ‘istrical Orkgns of the Reduetiosstic Biomedical Model In consideving the tequirements for a more inclusive sciatic medical model for the sudy of disease, an ethnormedical perspective is helpful @). tna societies, fncientand modern, pralterateerditer= ate, the major enteria for identification of disease have always heen behavioral, psycholoveal, and social in nature. Clas: siclly the onset of disease is marked by ‘changes in physical appearance that frighten, puzzle, or awe, and hy altera- tions in functioning, in felines, in per formance, in behavior, or in relation ships that are experienced or perceived as threatening, harmful, unpleasant, ‘devant, undesiable, or unwanted, Re ported verbally or demonstrated by the sullere or by a witness, these constitute the primary data upon which ate based frstorder judgments as to whether oF not a person is sick 7). To such disturb ing behavior and reportsall scictis yp icaly respond by designating individuals and evolving social institutions whose Primary fanetion is to evaluate, inter pret, and provide corrective measures 6, 6). Medicine as an institution and as 8 Aiseipine, and physicians as profession als, evolved as one form of response to ‘such sorial needs. tn the course of bis tory, medicine became sient ex phy- sicians and other scientists developed a taxonomy and applied scenic methods tothe understanding, treatment, and pre: ‘vention of disturbances which the publicfist had designated as “disease” or sickness.” Why did the reductionist, dualistic biomedical model evolve in the West? Rasmussen identifes one source in the ‘concession of established Christian of thodoxy to permit dissection of the h- rman body some five centurcs ago ). Such a concession was in Keeping with the Christin view ofthe body as weak and imperfect vessel forthe transfer of the soul from this world (othe next. Not surprisingly, the Church's permission 0 study the human body included atacitin- terdicton ageinst corresponding scent fe lavestigaton of man's mind and be- havioc. For in the eyes of the Chareh these had more 10 do with religion and the soul and henee properly remained its ‘domain, This compact may be conside ‘ered largely responsible for the anatom ‘celand stuetual base upon which scien- tile Westem medicine eventually was (0 be bull. For atthe same time, the basic principle of the science of the day, a5, ‘enunciated by Galileo, Newton, nd Descartes, was analytical, meaning that ‘entities tobe investigated be resolved ie 4 fsolable eausal chains oe units, from which it was assomed that the whole ‘could be understood, both materially and conceptually, by reconstituting the parts. With mind ody dualism firmly es tablished under the imprimatur of the ‘Church, classieal science readily fos. tered the notion of the body as ama chine, of disease as the consequence of breakdown of the machine, and of the doctors task ax repair ofthe machine. “Thus, the seicatifc approach to disease. ‘began by focusing a fractional-analyic way on biological (fomatic) processes and ignoring the behavioral and psycho: social. This was #9 even though in prac- tice many physicians, atleast until the Doeinning of the 20 century, regarded emotions as important for the devel ‘opment and course of disease. Acwally, such arbitrary exclusion isan acceptable strategy in scientific research, especially ‘when coacepts and methods appropriato far the excel areas are not yet aval- able. But it becomes counterproductive ‘when such sirategy becomes poliey and the area originally put aside for practical reasons is permanently excluded, if not forgotten altogether. The greater the suc cess of the narrow approach the more likly is this to happen. The biomedical approach to disease has heen success beyond all expectations, but at a cost. Forin serving as guideline and justiioa. tion for medical care policy, thomedicine fas also contributed to & host of prob Tem, which I shall consider iter. Limitations ofthe Biomed] Mode We ace now faced with the necessity and the challenge 0 broaden the ap- proach to disease to include the psycho. Soeint without sacrificing the enormous advantages of the biomedicat approach Oa the importance ofthe lateral age, the reductionist, the exclasionist, nd the heretic. Ina recent critique ofthe ex: lusionist postion, Kety put the contrat between the two in such & way as to help define the issues ©). “According to the ‘medical model, a human illness does not become a specific disease all at onee and Fs not equivalent to it, The medical mod- lof an illness is 2 process that moves from the recognition and palliation of symptoms t0 the characterization of a specific disease in which he etiology and pathononesis re known ad treatment ational and specific." Thus taxenomy progresses from symptoms, 10 clisters of symptoms, to syndromes, and finaly to diseases with speciic pathogenesis, and pathology, This Sequence aceuritely Geseribes the successful application of the sciontific method to the elucidation Aad the classicaion into diserete en ities of disease inits generic sense (5, 8) “The merit of such an appreach needs no anqument. Wht do require serauay azo the distortions intraced by the rea tionistic tendency to rogud the cpocic Aisease as adequately, if ot best, char acterized in terms ofthe smallesisolable jcomponent having causal implications, for example, the biochemical of even ‘more eritial, i the eantenton thi the esignation “disease” does not apply in the absence of perturbations at the bio ‘chemical level ‘Kety approaches this problem by com paring diabetes metus and schi2aplve bla as paradigms of somatic and metal diseases, pointing eut the appropiate ress of the modieal model for both, “Both are symptom clusters or syne lromes, one described by somatic and biochemical abecrmalitis, the other by paychological Bach may have many et Dlogies and shows a range of intensity from severe and debilitating to latent or borderline. There is also evicence that ‘genetic and environmental influences op trate in the development of both.” In this desription, a leat in reictionstic terms, the scienic characterization of diabetes is the more advanced in that i has progressed. from the behavioe framework of symptoms 10 that of bio chemical abnormalities. Ultimately, the reductionist assume schizophenis will achieve a similar degre of resolution, In ‘developing his position, Kety makes lear that he does not regard the genet factors and biological processes in shiz ‘ophronia as are now knovin to exist or inay be discovered inthe fire) as the ‘only important influences in its etiology He insists that equally important i elie dation of “how experiential factors and thelr interactions wit biological valner ablity' make possible or prevent. the development of schizophrenia” Bot ‘whether such a caveat will suffce to ‘ounteract basic redvetionsey is far from ‘The Requirements of a New Media Moret To explore the requirements ofa mod cal model that would account for the reality of dibetes and schizophrenia as ‘human experionces as well as disease ab structions, let us expand Kety's analogy by aking the assumption that a spec fie biochemical abnormality capable of being infcenced pharmacologealy ex: ists in schizophrenia as wel sin abe: tes, certainly & plausible possiblity. By obliging obrseives to think of patients with diabetes, 2 "somatic disease,” and ‘ith schizophrenia, a “mental disease, tm exactly the same terms, we will see more clearly how incision of somatic and psychosocial factrsis indispenssble for both; or more pointedly, how com ‘entrain on the biomedical and exch sion of the psychosocial distorts pet spectives. and even interferes with Patent cure 1D Tn the biomedical model, demon ‘tration of the specie biochemical de Viation is generally regarded as a specific diagnostic erterion forthe disease, Yet in terms of the human experience of il- ness, Inborstory dacumentstion may on ly indicate disease potential, not the ac tuality of the disease atthe time. The ab- normality may be present, yet the patient rot be il. Thos the presence of the bie ‘chemical defect of diabetes or schizo- phrenia at best doines @ necessary Dut not sulciet condition forthe o°etr ‘ence of the human experience of the is. fase, the lines. More accurstely, the Biochemical defeet constitutes bat one factor among many, the complex inter action of whieh ultimately may culm rate In adve disease or manifest illness (G0), Nor can the biochemicst defect be made t account for al ofthe iiness fo fill understanding requites dation concepts and fames of reference. This, while the diagnosis of diabetes is frst Suggested by certain core eliniel mani festations, for example, polyuria, ply‘ipsa, polyphapia, and weight loss, and is thea confirmed by laboratory doc ‘mentation of relative insulin deficiency, how these are experienced and how they are reported by say one individual, and hhow they affect him, all require com sideration of peychological, social, and calural factors, not to mention other concurrent or complicating biological factors. Variability in the clinical expres- sion of diabetes as well as of schizo hrenia, and in the individual experi- fence and expression of these illness, fellects as much these other elements 1s it does quantitative variations in the Specie biochemical defect. 2) Fstablishing 2 relationship between prticular biochem) processes and the ‘nical data of ines requires a scieti- ically rational approach to. behavioral and psychosocial data, for these are the terms in which most cinies! phenomena are reported by patients. Without such, the reliability of observations and the v= lidty of correlations will be Hawed. It terves litle to be able to specify 2 bio- chemical defect in schizopheenia if one does not know how to relate this to par- ticular psychological and behavioral ex pressions of the cisorder. The biomedi= ‘al model gives insuficieat heed to this requirement. Instead it encourages by- passing the patient's verbal account by placing greater reliance on technical pro ‘cedures and laboratory measurements. Im actuity the task is appreciably more complex than the biomedical model er ‘usages one to believe. An examination ‘ofthe cortelations between cinieal and laboratory data requires not only reliable rethods of clinical data collection, spe citcaly high-level interviewing. skills, Dut also basic understanding of the psy chological, social, and cultural detetmb nants of how patients communicate symptoms of disease. For example ‘many verbal expressions derive from bodily experiences early i if, resulting ina significant degree of ambigity inthe Tanguage patents use to report symp toms, Hence the same words may serve {0 express primary psychological as well 28 bodily disturbances, both of which ray coexist and overlap in complex sways. Thos, vetally each ofthe syenp- toms classically associated with diabetes ‘may also be expressions of or reactions to psyehological distress, just as keto- acidosis and hypoglycemia may induce psychiatric manifestations, including Some considered charncterisic of shiz ‘open. The most essential skills of the physician invelve the ability to elicit ac furately and then snalyze correctly the patients verbal accouat of his illness ex: perience. The biomedical model ignores both the rigor required to achieve elisbi- Tty in the interview process and the ne= ‘essity to analyze the meaning of the patient's report in psychological, social, ‘nd cultural as well as jn anatomical, Physiologica, or biochemical term (7) 3) Diabetes and schizophrenia have in common the fact that conditions of life and living constitute significant variables Jnfluencing the time of reported anret of the manifest disease as well as of vata tions in its course. In both conditions this cesults from the fact that paycho- physiologic respomses tif change may interact with existing somatic factors to alter susceptibility and thereby infuence the time of onset, the severity, aad the ‘course of a disease. Experimental stud ies in animals amply document the role ‘of eat, previous, and curcent life expe- ence in altering susceptibility to a wide ‘arity of diseases even inthe presence ‘fa genetic predisposition (1). Cassel's demonstration of hither rates of health ‘amon populations exposed 0. in congrity between the demands of the social system in which they are ving nd working and the culture they being With them provides another iltstxtion among humans of the role of psycho ‘Social variables in disease causation (2). 4) Psycholopical and socal factors are also crucial in determining whether and ‘hon pationts with the biochemical b> normality of diabetes oF of schizapivenia, ‘coine to view themselves or be viewed Dy others as sick. Stil other factors ofa similar nature influence whether or not and when any individual enters a health care system and becomes. & patient “Thus, the biochemical defect may deter mine certain characterises of the dis care, but not necessarily the point in time when the person falls ill er acopts the sick role or the status of a patient ') “Rational treatment” (Kety's term) directed only at the biochemical abnormality does not necessarily restore the patient to health even ia the face of documented correction of major alevia tion of the abnormality. This fs no les tive for diabetes than it wl befor sei ‘ophrenia when a biochemical defect is ‘established. Other factors may combine to sustain patienthood even in the face of biochemical recovery. Conspicucusly Fesponsibie for such discrepancies be- tween correction of biological abnormal- ities and treatment outcome are psysho- logical od soctal variables. 6) Even with the aplication of ratio- ral thorapes, the behavior of the physi- cian and the relationship between paint and physician powerfully infuence ther peutic outcome for better ot for worse, These constitute psychological etfects which may diretty modify the iness ex perience or indirectly alfect underlying biochemical processes, the latter by vi tue of interactions between. psycho- piysiolopieal reactions and biochemical processes implicated in the disease (1) ‘Thus, insaln requirements of a diabetic Patient may factuate significantly ae- pending on how the patient porcoives his Felaionship with his doctor. Further- ‘more, the successful application of ratio= ‘al tharapios is limited by the physician's abllty to lnfuence and modify the palien’s behavior in directions. con oedant with health needs. Contrary 69 what the exiusionsts would have us be Teve, the physician's roe is, and always has been, very much that of edvcaior and psychatherapst, To know how one «duce peace of mind in the patent and en hance his fuith in the healing powers of his" physician requires psychological Knowledge and sls, not merely charis- sma, These [00 ae outside the biomedical framework ‘The Advantages ofa Bipeychorocial Mode! ‘This list surely is not compete but it shosld sutice to document that diabetes rmelitus and schizophrenia as paradigms fof “somatic” and. "mental disorders ze entirely analogous ang, as Kety ar pues, are approprine'y conceptualized Within the frameviork of a medical model ‘of cisease. But the existing biomedical medel doss not sufce. To provide brs for understanding the determinants ‘of disease and arriving at rational treat ‘nents and patterns of health care, a med fecal mode! must also take into account the patient the social context in which he lives, andthe complementary system sevised by society to deal withthe dis: nuptive effets of ines, that, the phy. ‘cian role and the heelth care system, ‘This requires a biopsychosocial model Us scope is dotormined by the histone function of the physician to establish whether the person soliciting belp is sick” or “well”; and i sick, why tick and in which ways sick; and then to de- Yelop rational program to teat thei ‘ess and restore and maintain health The boundaries between health and lisease, between well and sick, are fat from clesr and never wil be clear, for they are diused by eutural, social, ad psychological considerations, The tradi ‘onal biomedieal view, tht biological indices are theultimate criteria defining SCIENCE, VOL. 16disease, eas (0 the present paradox that some people with postive laborato- ry findings are told that they ae in need of teeatment when i fact they are fecling auite wel, while others feeling sick are assured that they are well, tha is, they have no “disease” G6). A biopsychor social mode! which inclodes tho patient 5 well as the illness would encompass both circumstances. The doctor's task is to aceount forthe dysphoria and the dys: function which lead individuals to seek ‘medical help, adopt the sick role, ane ac= cept the status of patienthood. He must ‘weight the relative contributions of 5o- lal and paychological as well as of bio- logical factors implicated in the paticnt's dysphoria and dysfonetion 2s well asin his decision to aecept oF not accept pa $euthood and withit the responsibility t0 ‘cooperate in his oven heath cae By evaluating all the factors conte ‘ting to both illness. and patienthood, rather than giving primacy to biological factors alone, a blopsyehosociat model ‘would make it possible to explain why some individuals experience as “iliness”™ conditions which others regard merely as “problems of ving,” be they emotional reactions to life circumstances or somnat- ie symptoms, For from the individual's point of view his decision between ‘whether he has “problem of living” or ie "eck has basally to do with whet fer or not he accepts the sick role and ‘seeks entry into the health care system, ‘ot with What, infact, is responsible for his distess. Indeed, ome people deny the unwelcome reality of illnoss by dis isting 26“ problem of living” symp- toms which may in actuality be ine sicstive ofa serious orzanic process. It {s the doctors, not the patients, respon Sibilty to establish the nature of the problem and to decide whether oF not it is best handled in a meatal framework. Clearly the dichotomy between "dis. cease" and “problems of living” is by 90 ‘means a sharp one, either for patient oF for doctor. ‘When Is Grief Disease? To enhance our understanding of how {eis that problems of living” ae experi- enced as illness by some and not by oth fe, it might be helfal to coasider grief ‘paradigm of such bordetine con tion. Por while grief has never been con sidered in w medial framework, sini {iat umber of grieving people do co sult dactors because of disturbing sym toms, hich they do not necessarily relate to grief Fifteen years ago Pa dressed this question in a paper emitled “is grief a disease? A challenge for medi: cal research” 8). HS aim f00 was 10 False questions about the adequacy of the biomedical model, A better tile ‘might have been, "When is grief a ds cease?" just as one might ask when Schizophrenia or when diabetes i a dis ‘ease. For while there are some obvious analogies between grief and disease, there’ are also some important if ferences. But those very contradictions help to casfy the psychosocial dimen: sions of the biopsychosocial mode. Grief clearly exemplifies a situation in whieh psychological factors are primary: ‘no preexisting chemical or physiological defects or agents need be invoked. Yet as with clasle diseases, ordinary grief constitutes a diserete syndrome with & relatively. predictable symptomatology ‘hich inctoes, incidentally, both bodily and psychological disturbances. It dis: plays the autonomy typical of disease; {hat H runs Its course despite th sut- ferers efforts or wish to bring it to 2 clore. A consistent etiologic factor can be identted, namely, a signeant fore, (On the other hand, neither the sures nor society has ever dealt with ordinary pret an illoess even though such ex pressions as “sick wih ie?” would in ‘icste some connection in people's minds. And while every culture makes provisions forthe mourmer, these have ‘generally been regarded more as there Sponsiblity of religion than of medicine. ‘On the face of it, the arsuments ‘inst ineluding greta medical model ‘would seem to be the more persuasive. In the 1961 paper T countered these by comparing grief to a wound. Both are fatural responses to environmen trauma, one psyehologial, the other physica. Bur even at the time T fet & Vague uneasiness that this analogy did not quite-make the case. Now 13 years later a better gasp of the cltoral exgins fof disease concepts and medical care systems clarifies the apparent inconsis= tency. The critical factor underlying ‘man's need to dovetop folk models of disease, and to develop social adapt. tions to deal with the individea! and ‘roup disruptions brought about by dis tase, bas always been the vit’ igno- rance of what i responsible for his dys- phorie oF disturbing experience 4, 6). [Neither grief nor a wound fs fully into that category. In both. the reasons for {he pain, suffering, and usability are on ly too clear. Wounds or fractores in. ‘cured in batle or by accident by and large were selt-treated oF ministered 10 with folk remedies or by individuals who had acquired certain techaical skits in such matiers, Surgery developed ovt of the need for treatment of wounds andi Jites and bas diferent historical rts than medicine, which was always closer In origin to magic and religion. Only later in Westera history did surgery nd medi- cine merge as healing aris. But even fiom earliest times there were people Who behaved as though gretsicken, yetseemed nat to havesulered any loss: and others who developed what forall the world looked like wounds or frac- tures, yet had not been subjected to any Known trauma. And there were people who saffered losses whose grlef deviated iv one way or another from what the cul ture had come to accept as the normal ‘course; and others whose wounds filed to heal or festered or who became il fven though the wound hid epparentiy bread, Then, a now, two elements were crucial in defining the role of Paticat and physician and hence in deter Inining what shoold be regarded odie cease. For the patient thas been his not Knowing why he fet 0 functioned badly ‘or what to do about it, coupe wit the belie’ or knowledge that the healer oF physician did know and could provide elie For the physician in torn it has been his commitment to his professional role as healer, From these have evolved sets of expectations which ae reinforced by the culture, though these ae not nec: essarily the same for patient as fr physi |A biopsychosocial model would take allof these factors into account would acknowledge the fundamental fact that the patient comes to the physician be- esse either he docs aot know what is ‘wrong or, if does, he feels incapable of eiping himsele. The psychobiologisal tunity OF man requires thatthe physician socept the responsibilty to evaluate ‘whatever problems the patient presents and recommend 1 course of ection, n= luing feral to other helping profes: sions. Hence the physician's base pro fessional Knowledge and skill ust span tac social, psychological, and biological, for his decisions nd actions on patient's behal involve ll thee. Ts the Patient sofering normal grief or mela ‘holla? Ate the fate snd weskness of the wont who recently Jost her hese band conversion symptoms. psycho- physiological reactions, manifestations of a somatic disorder, or a combination ‘ofthese? The patient soliciting the sid of 4 physician must have confidence that the MID. degree has indeed eauered that physician competent to make such dliferentitions,A Challenge for Hoth Medicine ane Peyehiatry The development ofa biopsychosocia! medial model s posed asa challenge for both medicine and psyehiatry. Fer de- spite the enormous gas which have ac crued from biomedical research, there i a growing uneasiness among the public as well as among physicians, aed espe- ally among the younger generation, that health needs are not Geing met and ‘that biomedical research is pot having = salient impact in human terms. This i ‘osually ascribed 1 the al 100 obvious im adeqaacies of existing health care deliv- fry systems, But this certainly #8 not a complete explanation, for many who do Ihave adequate access to healthcare also complain that physicians are lacking in Interest and understanding, are pre fccupied with procedures, and. are ine sensitive to the personal problems of Patients and their fais” Medical inst lutions are seen a8 cold and impersonal the more prestigious they are as centers for biomedical research, the more com mon such complaints (4). Medicine's unrest derives from a growing awareness among many physicians of the com raion between the excellence of their biomedical background on the one ‘hand and the weakness of thee qualifca tions in certain aliibotes essential for ‘90d patient care onthe other 7). Many Fecognize that these cannot be improved bby working within the biomedical model alone. “The present upsurge of interest in pri mary care and family medicine clearly Feflects disenchantment among. some physicians with an approach to disease that neglects the patient. They are now more ready for 2 medical model whieh Would take psychosocial issues into ac- ‘count, Even from within scedemic cit- ‘les are coming some sharp challenges to biomedical dopmatism , 15). Thus Hot ran ascribes directly to biomedical re- ‘ductonisn and to the professional domi nance of iis adherents over the health ‘care system such undesirable practices fs unnecessiry hospitalization, overuse of drugs, excessive surgery, and ite fppropriste ulllzation of dlagnostic tests, He writes,“ While reductionism is ‘powerful too for understanding also creates profound misunderstanding ‘when unsesely applied, Reductionism is particularly harmful when it neglects the fmpact of nonbological circumstances Upon biologie processes." And, “Some medical outcomes are inadequate not be feause approprisie technical inter Yentions are lacking. but because our conceptual thinking is inadequate" (5). How ironic it would be wore psychiatry to insist on subscribing to. medical model which some feaders in medicine already are begioning to question. Psychiatrists, unconsciously commit. ted to the biomedical model and split, imo the warsing camps of reduetionists and exclusionlsts, are today 30. pre ‘occupied with their own professional identity and status in relation 19 ed cine that many are fling to appreciate that psychiatry now is the only clinica Siscipline within medicine concerned primarily withthe stady of mon sed the Jmuman condition. While the behavioral sciences have made some limited in carsions into medicel schoo! tecching programs, it is mainly upon psych Insts, and to lesser extent clinical psy eolopists, that the responsibility fll to “develop approaches othe understanding ‘of iealth and disease and patient care not readily accomplished within the more rmarmow Tramework and with the special: ized techniques of traditional biomed tine. Indeed, the fact is that the major formulations of more integrated ant ho- lise concepts of health and disease po- posed inthe past 30 years have come not from within the biomedical establish ment bot from physicians who have drawn upon concepts and mothods which originated within psychi Tably the psychodynamic approach of ‘Sixmand Freud and psychoanalysis and ‘he reaction-tolife-stress approach of Adolf Meyer and. psychobioleny (16), ‘Actually, one of the more lasting conti butions of both Froud and Meyer has been 10 provide frames of reference whereby psychological processes cand be included in concept of disease, Psy ‘chosomatic medicine the ferm Hself @ vestige of dualism—became the media ‘hereby the gap between the two para Tel but independent idealogies of medi «ine, the bolegial and the psychosocial, ‘was tobe bridged, Its progres hss been ‘low and halting, not only because of the extreme complexities intrinsic lo the Feld itself, but also because of wncemit- ting pressares, fom within as well 35 from without, to conform to sciatic methodologies basically mechsnistc and Fediyetoniste’ in conception and ite appropriate for many ofthe problens der study. Nonetheless, by now a sizable body of knowledge, based on clinical and ‘experimental stiies of man and annals has accumulated. Most, however, re ‘mains unknown fo the general medica public and to the biomedical community apd is largely ignored inthe edacation of Physicians, “The recent solemn pro- nooncemeat by an eminent biomedical Teader Q) that “tke emotional content of organic medicine (has beca} exaggerat fe” and “psychosomatic medicine is on the way out" can only be stctbed to the inding effects of dogmatism ‘The fact that medical schools have constituved unreceptive if not hostile en- Vironments for those interested in psy: chotomatie research and teaching, and ‘medical journals have all too often fl- loved a double standard in accepting pa pers dealing with psychosomatic rel U7). Forther, mich of the ‘work documenting experimentally in nie mals the signiicance of life circum Stances or change in altering susceptiii- ty to disease has been done by experi mental psychologists and. appears in psychology journals rarely read by physicians er basic biomedical scientists an. ‘General Systems Theory Perspective "The strugue to reconcile the psyehor social and the biological in medicine has ad its parallel in biology, lso dom rated by the reductionstic approach of ‘molecular biolagy. Among biologists 10 have emerged advocates of the need 0 develop holistic as well as redetionitic explanations of life processes, to ansier the "why?" andthe "what for?” 4s well asthe “how?” (Us, 19). Vou Bertdafly, arguing the need fora more fundamental reorientation in seientife perspectives in forder to open the way to holistic ap proaches more amenable 1 sient ne ‘uiry and conceptualization, developed Beneral systems: theory Qo). This 4p. ‘roach, by reaing set of related events collectively as systems manifesting fone tions and properties on the specifi level ofthe whole, has made possible recogni tion of isomorphies across diferent lev ls of organization, ss molecules, cells, ‘organs, the organism, the person, the family, the society, or the biosphere From such isomorphies ean be devel coped fundamental laws and principles that operate commonly tall levels of. nization, a5 compared to those which 16 unique for exch. Sine systems theo- ‘holds tha all levels oforeanzation are linked to each other in a Biorarchleal relationship so that ehange in one affects cehango in the others, its adoption a3 2 Sclentine approach should do much to ritigate the holistreduetionist dichoto ‘iy and improve communication across sclontfc disciplines, For medicine, sys- tems theory provides & conceptual ap- proach suitable not only forthe proposed biapsychosectal concept of disease but also for studying disease and medical fare as interrelated processes (0,21). IC SCIENCE, VOL. 18and when a goneral-systems approach becomes part of the basic scenic and philosophic education of future physi- ‘cans and medical scientists, a greater readiness to encompass a biopsyehos0- cal perspective of discase may be antici- pated. Biomedicine s Sclence and as Dogme Th the meantime, whats beingand can be done 10 neutralize the dogmatism of biomedicine and all the undesirable 20- dal and scientific consequences that ‘ow thereftom? How can a proper bal- ‘ance be established between the xc Aionalsnalytic and the atu history approaches, both so integral for the work ‘ofthe physician and the medical sientist, (@2)? How can the clinician be helped 0 ‘understand the extent to which bis Scien tile approach to patients represents @ distinely “humad science,” one. In ‘which “reliance is on the integrative powors of the observer of a complex ronrepicable event and on the exper ‘ments that are provided by history and by snimals ving in particuar ecological setings," a8 Margaret Mead pace it 23)? ‘Thehistry of the rise and fll of ecient. ie dogmas throughout history may give some clues. Certainly mere emergence ff new findings and theoees rarely sut- Fees to overthrow well entrenched dos ‘mas. The power of vested intrest, 30: al, pola, sid economic, are form able deterrents to any effective assault fon biomedical dogmatism. The delivery ff health care is 2 major industry, com sidering that more than 8 percent of our ‘ational economic product is devoted to health @). The enormous existing and planned investment in diagnostic and therapeutic technology alone strongly fa vors approaches 10 clinical study and care of patients that emphasize the in personal and the mechanical @4). For example, from 1967 to 1972 there was an increase of 33 percent in the number of Taboratory tests conducted per hospital ssimission Q5). Planning for systems of mofical care and their financing is exces- sively influenced by the availability and promise of technology, the application nd effectiveness of which ae offen used fs the criteria by which decisions are ‘made as to what constitutes illness and ‘who qualifies for medical care. The fru tration of those who find whit they be lieve to be their legitimate health needs ‘inadequately met by too technologically ‘oriented physicians is generally misiater: preted by the biomedical esublshinent 2s indicating “unrealistic expectations” tn the part of the public rather thay being recognized as reflecting a genuine discrepancy between illaess 26 actually experienced by the patient and as it Is conceptualized in the biomedical mode (26). The professioealiztion of biomed ine constiates still another formidable barrier @, 15). Professionaization has ‘engendered caste system among heath cere personnel a & peck order con fermion what constitute appropriate areas for medical eoncern and care, with the most esoteric disorders atthe top of the list. Professional dominance "has perpetuated provaling practices, dofet ed eriicisms, and insulated the proes ‘sion from alternate views and social rela ‘ions that would illuminate and improve healthcare" U5, p. 21). Holman argues, snot unconvincily, that "the Medical establishment isnot primarily engaged in the disinterested pursuit of knowledge And the trnsation ofthat knowledge n= te medical practic; rather in significant part itis engaged in special interest advo. ‘acy, pursuing. and preserving social power" (15, p. 1D. Under such conditions itis tical to see how reforms can be brought about. Certsinly contributing another exticel essay is hardly likely to bring about any major changes in aittude. The problen is hardly new, forthe fist efforts toi ‘oduce a more holistic approach ito the londerpeadvate medical curtculimy ac ‘wally date back to Adolph Meyer's po sram at Johns Hopkins, which was in tated before 1920 07). At Rochester, a program directed to medical stodents And to physicians during and fer their fesidency taining, and designed ton culeate psychosocial knowledge and ‘ills appropriate for ther future work a5 ‘liicians oF teachers, has been in exis fence for 30 years 28). While dict to measure outcome objectively. its im pact, as indicated by 2 questionnaire on Ihow studenis and graduates view thei ‘ves involved in lines and patient ear, Appears to have been appreciable 29). La other schools, especially inthe immedi late post- World War Il period, similaref forts were launched, and while some flourished briefly, most soon faded away under the competition of more glam forous and acceptable biomedies! te fee's. Today, within many mical schools there again a revival of interest mang some faculty, but they Are few in number and lack the influence, prestige, power, and necess to Finding from peer review groups thai goes with conformity to the prevailing biomedical structxre ‘Yet today, inwrest among students ‘and young pliysiians is high, and where learning opportunites exist they guickly overwhelm the available meager re sources. It would appear that given the ‘opportunity, the younger genoraion is very ready to accept the importance of Tearning more about the psychosocial d- mensions of illness and health care and the need for such education 0 be soundly based on scientific principles, Once exposed to such an approach, most recognize how ephemeral and ine substantial are appeals to humanism and compassion when uot based on rational rrincipes. They reject as simplistic the rotion that in past generations doctors understood their patients better, a myth that has persed for centuries 0), Cleat, the gap to be closed i beeen teachers realy to teach and students ea f2rto learn. But nothing wil change un Tess or unl those who control resources have the wisdom to venture ofthe beat en path of exclusive reliance on biomed cine asthe only approach to health eae “The proposed biopsyehosocial_ model provides a blueprint for research, a framework for teaching, and adesiga for action in the real world of health eae Whether itis usefl oF not rains €9 be Seen. But the answer will 30t be forth= coming if conltions ate not provided to ‘do 50. Ina fee society, outcome wil de pend upon those who have the coirage to try new paths nd the wisdom to pro vide the necessary support Summary “The dominant model of disease tay js biomedical, and it leaves no room within i framework forthe social, poy chological, and behavioral dimensions of Tess. A biopsychosocial mode is pro- posed that provides a biveprint for re search, a Framework for teaching, and a design for action in the real world of health ear pasteles testis Bee Sch ae le sen he Rela of Grn yee Tg lis Bre Ne a hes ‘ Fee eg ram, Speen er ts EE Bega Bu oh ces ara Hp hGioeltan Panel eae i Eee eee egos 5 ler erie egTREE Boer don en ae ce eer 0. ieee Soa ae Ni Mm a ere at Eee eam tas ered: fis Comic Mas BHC: e Sper, EBehen von Aare ‘rae Ute, Fr, " Siegler Ba ea i ta Bacal hhc New Yai Bib BOOS 21. eA, he Vital ace hig, New ‘York, 98H A. Shekon, m Syieme and Mea a ge fe Shason baer Cb Mea a aa 1 OE ag Ply, Ein od P- Etienne, cen en, 2 RO oe etage Spm CEs, Second Phases in Steel New analyti methods can identify the types and amounts of complex precipitates in steel For many years better analytical met fs for the determination ‘of ‘second phases in slce! have been needed, be Ease these phases are often more closely Felated to the heat eatment and mechan Feal properties of the stel than the ele- ‘meatal composition. 1 discuss here some of the recent appreaches to solving this problem. ver since steel was fist manure: tured, metallurgists have been searching for methods of changing its mechanical properties so that specific grades can be ‘made for particular applications. Often soch changes are brought about by the ‘addicon of one or more alloying elements tothe tel, and atleast 35 elements hve ‘been added for this purpose. Most of ‘those elements can be preseat i slid so- lation i ton, but they often change the ‘mechanical properties of the steal by ‘combining with oxygen, mitogen, car tom, oF sulfur Co form precipitates inthe steel thatare referred to as second-phase compounds. Sometimes the seovnd phase will contain two metals such as bickel and titanium combining t0 form ‘te Unled Stats Stee Corporation Researeh a es Marta" paas sa W.R. Bandi [NisT, but most often the second phases are ovides, nitrides, carbides, slides, cartonitrides, earbosuldes, and sila compounds. ‘Thase compounds may be Formed it the molten bath, dusing sli feation, during rlling or forming, during beat ireatment, and sometimes even dur. ing storage at ambient temperature Table | shows how precipitates can af: feet some ofthe mechanical and physical properties of steel. Only a portion ofthe approximately 200 precipitates found in low-aloy,high-alloy, and specialty stels aad some of the important mechanical properties are listed. Often metallurgists ‘can associat precipitates with addtional ‘changes in the mechanical, physi, and ‘chemical properties of stel. No atempt has been made in Table Ito note whether ‘a paicular precipitate has a detrimental ‘or beneficial elfect on the mechanical properties of steel because many ine ances the effect can be either postiveor negative depending on the amount, size, and distibution ofthe precipitate. Pre cintate concentration can vary from 25 ‘much as 10 pereent (oy weight (cement: ite, FeyC) toa ite ws 0.02 percent (bo- ron nitride (BN) and ferrous sulide es). The determination of where a preipi- gone bene dma Me 8,708 0. BP bs ne Meo, 4 9 Ba Rei Ne Re Pt a i a pee Eatin ean Goma, ie ee ‘Ne acpi edd een ‘ates located in the iron matrix is of reat Jimportance in terms of what eect (can have om the properties ofthe steel. Even very small quantities of a precipitate lo cated at a grain boundary cin induce cracking or corosion, wheseas a larger amount ofthe same material Located ra ‘horny throughout the stet wall no have thesameeffect. Sal particles of carbide for mitride arranged in rows wil form a barrie to slip and dislocation movement in the crystals ofthe ia matrix and are therefore much more effactivo in confer ving strength than randomly arranged par ticks, The particle size of the precipitated ‘hase i also important. As an example, the strength ofa sce is changed more by particles of carbide and nitride thatare 30 to 400 angstroms in size than by larger particles because these smaller particles ate much more effective in preventing sain growth, and fine grained steels are stronger. Frequently very large particles ofeabide orntrideare detrimental tothe steel, whereas smal particles of the same ‘compound can be beneficial ‘he magnitude of the analytical chean- ical problem canbe appreciated whenone Fealizes that more tha 50 titrogen com pounds can be present in simple and com plex sels, Theee include simple nieces such as titanium nitride CN) oF more compen nitrides such as niobium arbor nitride (NDCAN,), manganese silicon 1 tide [OASi}N,}, and aluniouen oxy {ride(AIO.N). lke number ofcabides and oxidas and a smaller number of sl. fides and carbosulfides may aso be found in steels. There are thus several hundred ‘compounds that can exist i the carbon, alloy, and specialty steels presently ei prodiced inthe United States. As are Slt, the denueation and determination ‘ofsecond.phase compounds in steel have been areal challenge inthe development ot tnproved steels SCHENCE, VOL. 16http:/Awww.jstor.org, LINKED CITATIONS ~ Page I of I- You have printed the following article The Need for a New Medical Model: A Challenge for Biomedicine George L. Engel Science, New Series, Vol. 196, No. 4286. (Apr. 8, 1977), pp. 129-136. Stable URL: nip inks strony sicisici-06 207544281 9774082629326. 196163 A4286Y4 C2902 ATNEANMAED 0 COREE This article references the following linked citations. If you are trying to access articles from an off-campus location, you may he required to first logon via your library web site to access JSTOR. Please visit your library's website or contact a librarian to learn about options for remote access to JSTOR. References and Notes “The Need for an Ethnomedical Science Horacio Fabrega, Jr. Science, New Series, Vol. 189, No. 4207. (Sep. 19, 1975), pp. 969-975, Stable URL: inks stor ore sici(36.8075%42819 750019829 A THOMA AD ESY3E20.COMSB2-E ™ Biology and the Nature of Science George Gaylord Simpson Science, New Series, Vol. 139, No. 3550. (Jan. 11, 1963), pp. 81-88 Stable URL spins stor ocoscisiei-0036-80759%4281969011194293%3A 139263 355075981463 ABATNOSY3E?.0.002%382.2 = Towards a Human Science Margaret Mead Science, New Series, Vol. 191, No. 4230. (Mar. 5, 1976), pp. 903-909. Stable URL: \ NOTE: The reference numbering from the original has been maintained in this citation list.