Wednesday, January 11, 2006

American Medicine's Denial of the Anatomical Existence of the Neck?

Ok folks. In my "Etiology" post of 3 Jan I wrote about six reasons why our US HealthCare system is real-time failing before our very eyes (and bodies). Last week, on Jan 6, I covered Paternalism which I hope was helpful? Today I am writing about the current limitations of what we call Reductionism especially as applied to the chronic diseases that we Americans now suffer and die from. Our health care (whoops-disease care) system, from bio-medical research to clinical practice, to reimbursement mechanisms is dominated by reductionism which in short attempts to isolate a single cause for a single disease or single health outcome. It all started with a "power of personality" 17th century French Philosopher- Rene Descartes (1596-1650) who struck a “deal” with the church that Docs would take care of the body but the mind and soul were to be excluded from the province of scientific medicine (that is not-mind you- a geographic Province in France) Well Descartes model actually worked well for a 3 centuries -give or take -because infectious diseases were killing so many global citizens. (They still kill people in "un" and underdeveloped countries) One you could say that the single cause model worked almost to a miraculous degree especially here in the good ole US of A. Smallpox has been eradicated -we are getting closer to worldwide polio eradication and so many heretofore lethal infectious diseases like tuberculosis and scarlet fever have been treated successfully with antibiotics. We'll as they say no good deed, medical model, or medical paradigm goes unpunished. By the 1950s in the US scientists began to notice that our fellow citizens were dying much more from chronic diseases such as heart attack, stroke and cancer than infectious disease. After billions were pumped into "finding the cause" of these modern killers (see Nixon’s failed reductionistic "War on Cancer" it became apparent that these chronic disease were indeed multicausal. So we now know that these chronic diseases are contributed to by genetics, diet, environment, lifestyle, and yes, even stress. Well in regard to especially the latter, poor Descarte began turning over in his grave -(See Descartes' Error : Emotion, Reason, and the Human Brain -- by Antonio R. Damasio 1998) and contemporary reductionists began to panic, but a new Bio-Psycho-Social-Spiritual (BPSS) model was being born. Some call it a holistic model. (see A debt of gratitude must be paid to pioneer Dr George Engel, an internist and psychoanalyst, (1913-1999) who mostly in the 1960's and 70s at the University of Rochester tried to advanced his Biopsychosocial model (he didn't dare touch spirituality leaving alone the work of the late great Carl Jung-too mystical for science). But alas Engel’s then was largely lateralized by both Bio-Medicine and Psychiatry because of resistance to change and perceived loss of power and money on both sides-often the curse of the pioneer. I began to use the phrase "Reductionism's last hurrah" in 1985 is essays I wrote and speeches I delivered. Now, please don't get angry, I am no anti-technology Luddite but bio-medicine alone is simply incomplete! Rather a BPSS model leverages the miracles of modern bio-medical technology by fully integrating contemporary psychology, sociology, and theology. Also, once one accepts that the Central Nervous System (CNS) or mind influences all health outcomes it must follow that anything in the universe from objective stimuli to anything perceived or even thought or imagined can and does impact our physiology and health outcomes. (Viruses, alas, still trump hope or prayer) So for 300 years plus the anatomical existence of the human neck which serves to attach the head to the body was denied by medical science despite the fact that everyone that I have ever met or every patient that I have examined seems to have one? (fyi-my collar -or noose?- size is 17 inches) Cervantes has also brought your attention in this blog and Stayin Alive the need for Sociology and to be fully integrated with modern bio-medicine. How can we afford economically, ethically and morally to continue to medicalize America's social problems like poverty, cultural xenophobia or outright bigotry. In short we can't! There is no pill for not having a job or no surgery for people of color not having access to basic health care. From a practical perspective I have personally lobbied JCAHO to require that physicians ask two simple questions to all patients- "How are things at work or school?" and "How are things at home?" Those two simple questions might get this model off to a good start? And patients, of course know this being way ahead of their providers. We could use the famous JCAHO "fifth vital sign" of pain on a 1-10 Likert scale that JCAHO requires be asked by providers to hospitalized patients as our model. (After all folks, hospitals do need that JCAHO certification for big Medicare dollars). But alas, however, JCAHO does not yet certify outpatient practices. Here are my five practical actions to advance the BPSS model.

#5 Practical Actions to Advance a Bio-Psycho-Social- Spiritual (BPSS) Model of Health Care

1) Support Mental Health Insurance Parity Laws. Encourage
patients to seek counseling or psychotherapy during any

2) Switch your primary care Doctor if he/she doesn’t ask you “how are things at work or home?” during every office visit (see Lippin-Simple Mandatory questions”)

3) Be certain that your Doctor(s) and other health care providers are aware of your religious and/or spiritual needs especially during major life transitions, crises, and at end-of life.

4) Try to find meaningful, safe and healthy lifelong work. Support job creation legislation and healthy workplace legislation/regulations. Encourage more research on meaningful work as a health outcomes issue.

5) If you are unable to find a meaningful daily job- find a
meaningful passion and integrate it into your life. Advance
research into this area as well.

This new model is also driven by stunning recent advances in neuroscience and will make the inflated promises of the "genomics revolution" (more reductionism) look like childs play. Is reductionism dead? Not quite yet. But it is very "Critical Condition" and is a major contributor to our moribund Disease Care system. For two very fine books in this area I highly recommend Manifesto for A New Medicine by James Gordon (1996) and the incomparable Larry Dossey book Reinventing Medicine (1999) My personal website at (whoops I revealed myself) explores this BPSS model


Blogger Cervantes said...

Indeed, a proper understanding of health requires a bio-psycho-social model, if you will, or perspective is perhaps a better term. Of course, for physicians and the health care institution, there are pitfalls and downsides to this as well. The objections are usually framed in terms of the "medicalization" of social problems. E.g., physicians indeed ought to know what their patients do for a living, and what problems this may be causing them. But if people have lousy jobs, it's not a medical problem. Doctors and psychotherapists can try to help them adjust to their crummy situations, and maybe treat their carpal tunnel syndrome, black lung disease, or depression; but what we really need are better working conditions and jobs that provide dignity, respect, and inherent satisfaction.

It's important to understand the whole person, and to build an alliance between physicians and patients to promote health. But it's also important for medicine to know its limits, and not beccome an apologist or enabler of an unhealthful social environment.

11:37 AM  
Blogger Blake said...

Cervantes-You are absolutely correct.Some estimates of Medicalization of America's Social problems are 1/3rd of all health care costs. But Docs might make good social planners-politicians etc. Many are smart and supposedly they have values and a healing temperament. More importantly the docs need to collaborate with psychologists, sciologists,theologins, ethicists,economists etc. Hospice Care (Palliative Medicine) is the best interdisciplinary model going. To edit an old military phrase about war and Generals -"Medicine is far too important to be left to the doctors". I would add word "alone" after "doctors". But please don't ask that Docs be only technicians? That would be a mistake as we have seen over the last 50 years.Thanks :)

12:27 PM  

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