by Dagen Hughes
Choosing a major is one of the most important decisions college students face as they seek an education. This choice requires much thought and consideration; it not only influences future employment opportunities, but determines a student’s focus while in school. At first, it was stressful for me to make this decision. I knew I wanted to be a pre-med student, but I did not want to go the traditional route and major in biology. Instead, I chose to focus on two branches of science I have always found interesting, areas I felt would benefit me the most in my future as a medical professional—chemistry and psychology. Choosing an education that combines biology, chemistry, and psychology has enabled me to address several fundamental questions: how things work, why they are the way they are, and why people say and act the way they do. I chose this path because I believe that it is a beneficial one for a perspective doctor in that it is a more holistic approach to medicine—it teaches both technical and personal aspects of the medical field.
In my second year of college, I took a class called Health Psychology. This course was structured around the ideas of a man named George L. Engel. Engel believed that to fully understand and adequately respond to a patient’s suffering, clinicians must attend simultaneously to the biological, psychological and social dimensions of illness.[i] He was an internist, psychiatrist, and psychoanalyst at the University of Rochester, and was infatuated with the links between the mind and the body. In a 1977 article, he coined the term “biopsychosocial” as alternative to the biomedical model.
Engel did not deny the important advancements acquired from biomedical research, but he criticized the excessively narrow focus of leading clinicians that tended to reduce patients to objects.[ii] In the 1977 article, “The Need for a New Medical Model: A Challenge for Biomedicine,” Engel writes, “The dominant model of disease today is biomedical […] it leaves no room within this framework for the social, psychological, and behavioral dimensions of illness.” Engel did not think his theory discredited science or medicine—instead, he viewed it as a mutually beneficial scientific proposal.
For the past three hundred years, the biomedical model has governed the way of thinking for most health practitioners. Shelley Taylor, who wrote the textbook for my Health Psychology class, cites a number of growing critiques of this popular model. She notes that the biomedical model maintains that health is the absence of symptoms and illness, and that illness is the direct result of biological factors. Although the biomedical model has obvious benefits for the study of some diseases, it also introduces many limitations. First, as Taylor suggests, the biomedical model reduces illness to low-level biological processes with no recognition of social and psychological factors. Second, she argues that the biomedical model strongly emphasizes illness over health by focusing only on the factors that lead to illness, and not the conditions that promote health. In other words, attention is given only to what can go wrong with people, but not what can go right. Taylor also asserts that the biomedical model does not have any way to account for the situations that defy biology or are influenced by nonbiological factors.[iii] In contrast, the biopsychosocial model suggests that true health is only achieved when the biological, psychological, and social factors are addressed, and only by realizing this will the healthcare system be able achieve greater health of the people.
The Health Psychology class I took focused the application of the biopsychosocial model into medical practice, an application that at the time seemed theoretical rather than practical. However, as reflected by forthcoming changes to the Medical College Admissions Test (MCAT), it is becoming evident that the medical field may be shifting to adopt the ideas found within the biopsychosocial model; what I studied in Health Psychology may become reality in the near future.
This is interesting, given that Engel began exploring these ideas in 1977. So why is the medical field just now adopting ideas that Engel publicized nearly forty years ago? One explanation is that the biopsychosocial model failed to anticipate the stunning success of pharmacotherapy. Engel introduced his holistic approach to patients just as the pharmacy industry released a host of new drugs for a range of diseases. Doctors began addressing psychological issues by prescribing benzodiazepines and selective serotonin reuptake inhibitors. Borrell-Carrió argues that Engel’s message was drowned in several decades of drug hype, some of which proved true, some of which did not. Now, though, some of the weaknesses of the pharmacological approach to illness have been revealed, and medicine has a much greater receptiveness to non-pharmacological approaches to the problem of illness. Medical thinking has slowly evolved to incorporate psychosocial components into its practice, with interesting results. Borrell-Carrió[iv] argues that by integrating the biological, psychological, and social factors as components of medicine and science, science and humanism are becoming linked.
I became slightly nervous when I first learned that the MCAT was changing, and that anxiety has not gone away entirely. When medical school comes up in a conversation, the first thoughts that come to my mind are science, math, science, and more science. I have spent time reading, studying, and doing practice exams for the MCAT in its current form, all of which focus on biology, chemistry, physics, calculus, and genetics. When I chose to minor in psychology, it was because I wanted a better understanding of people; it has become clear, though, that I was actually taking medical school prerequisites—before they were established as such.
The Association of American Medical Colleges (AAMC) released a statement in 2012 explaining that as of 2015, the MCAT would undergo a dramatic change. In the “Preview Guide for the MCAT2015,” the AAMC writes that, “Science advances rapidly, the health care system is transforming in big ways, our population is becoming more diverse every day―and tomorrow’s doctors need to be prepared.”[v] The committee tasked with creating this new exam aims to “preserve what works about the current MCAT exam, eliminate what isn’t working, and enrich the exam by giving attention to the concepts tomorrow’s doctors will need.”[vi]
Though healthcare professionals have biological and medical training, they cannot intuit the patient’s psychological and social health history. If greater emphasis is placed on the psychosocial connections to health, a strong emphasis must be placed on the patient-provider relationship in order to properly treat a patient. As medical professionals strive to build a stronger relationship with their patients, they will move from a position of unyielding authority to a more open, equal, and reciprocal relationship. Taylor suggests that, as a result of this change, diagnosis and treatment will depend more fully on the information patients present, as well as the information the medical professional can provide. Patients should expect to spend more time at the doctor’s office each visit, during which a doctor would not only evaluate symptoms, but would also build a strong and trusting relationship with each individual patient.
Sir William Osler, who has been called the “father of modern medicine,” once said, “The good physician treats the disease; the great physician treats the patient who has the disease.” Osler continuously emphasized the importance of the patient-provider relationship, a message that seems a founding premise of the biopsychosocial model. Even if this model is not fully adopted into the medical field, George Engel’s enduring contribution is that he has broadened the eyes of healthcare professionals. His biopsychosocial model was a call to change our understanding of the patient and to expand the domain of medical knowledge to address the needs of each individual—a call to treat the patient, not just the disease.
[i] Borrell-Carrió, F. “The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry.” The Annals of Family Medicine 2.6 (2004): 576-82. Print.
[iii] Taylor, Shelley E. Health Psychology. 8th ed. New York, NY: McGraw-Hill, 2011. Print.
[iv] Borrell-Carrió. “The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry.”
[v] “MCAT 2015: A Better Test for Tomorrow’s Doctors.” AAMC.org. Association of American Medical Colleges, Sept. 2012. 1-154. Web. 08 Jan. 2013.