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Excerpt on the biomedical model and George L. Engel's Model
Barbara Ruth Campbell (CAMPBELL@ZODIAC.BITNET)
Sun, 24 Jul 1994 15:10:58 -0400
Dear Anthro-L Colleagues,
I asked if any of you had heard of George L. Engel's Biopsychosocial
Model. So far no one has which is great news. My mom's primary
physician had heard of him but not much and hopes to have the time
to call me. My best friend's husband - the psychiatrist at UMDNJ
thinks Engel falls into the category of assholistic medicine and
says that everyone in psychology knows of Engel but only gives his
biopsychosocial model lip service. Our bibliographer for psychology who
has a Ph.D. in psychology never heard of Engel so I hope that
M. is wrong (I don't want to broadcast names without their permission).
My outside committee member, the neurosurgeon, has just moved and doesn't
log on much so I'm still waiting to hear whether he knows of Engel.
Please bear with me as this is a work in progress - I keep stressing this
because sometimes some Anthro-L members flame people for not having
completely thought out everything.
So this is an excerpt from the draft of my dissertation:
Several pages precede this: passages expressing
dissatisfaction with the biomedical model - the
history of modern medicine and specific statements
about paradigm change. I start here so the stuff
on Engel is in context
Dean Ornish, M.D., Assistant Clinical Professor of Medicine,
President and Director of the Preventive Medicine Research Institute at the
School of Medicine, University of California, San Francisco cites Kuhn's
Structure of Scientific Revolutions in his interview with Moyers. Ornish
interprets the framework of Western medicine as an outgrowth of the
dominance of first the Catholic Church and its successor science.
Astronomical anomalies that could not be explained by the Church were
explained by Galileo and subsequent scientists gradually diminishing the
authority of the Church. Ornish bases his view of Western medicine as an
outgrowth of the scientific method
If we can't measure it, it doesn't exist, and it's not real. But
like the telescope, new tools are beginning to show us anomalies in
our worldview. To me the anomalies are the most interesting part.
But they can also be viewed as threatening. More often than not,
people want to suppress that information, or they want to discredit
it, or they want to kill the messenger, so to speak . . . You find
different models emerging now. You find the holistic health model,
or the religious model, or the so-called scientific model. But none
of those models gives us a complete picture. They're all powerful,
and they all have their uses, but they also, by definition, all have
their limitations (Moyers, p. 104).
The lack of a universally accepted Western model of medicine is clear from
Ornish's point of view. Most physicians would probably agree, however,
that Western conventional modern medicine as practiced since the 1940s is
intricately linked to the scientific method and that most of the research
in the field focuses on minute aspects of the body's functions and on the
direct observation of chemical and bacterial processes in the treatment of
disease. There is no attempt to model the body and mind in the same way
that physicists have attempted to model the universe nor is there any
scientifically sanctioned inclusion of anything that most scientists would
classify as falling into the category of religion, i.e. mind - spirit -
soul.
The only exception to the above is the work of George L. Engel,
Emeritus Professor of Psychiatry and Internal Medicine, who in 1977
proposed a biopscyhosocial model in Science. Engel quotes fellow
psychiatrist Ludwig's 1975 statement that psychiatry in the mid-1970s had
become a "hodgepodge of unscientific opinions, assorted philosophies and
`schools of thought'" (Engel 1977, p. 129). This Engel felt was the
general sentiment expressed at a conference on psychiatric education noting
that the prevailing view was that medicine, having a "firm base in the
biological sciences", new technologies and new treatments, was a superior
science because of its apparently successful medical model of disease.
Unlike his colleagues at that time, Engel felt that medicine itself
was in crisis and that
. . . medicine's crisis derives from the same basic fault as
psychiatry's, namely, adherence to a model of disease no longer
adequate for the scientific tasks and social responsibilities of
either medicine or psychiatry. The importance of how physicians
conceptualize disease derives from how such concepts determine what
are considered the proper boundaries of professional responsibility
and how they influence attitudes toward and behavior with patients
(p. 129).
Engel summarizes by challenging both medicine and psychiatry
. . . despite the enormous gains which have accrued from biomedical
research, there is a growing uneasiness among the public as well as
among physicians, and especially among the younger generation, that
health needs are not being met and that biomedical research is not
having a sufficient impact in human terms. This is usually ascribed
to the all too obvious inadequacies of existing health care delivery
systems. But this certainly is not a complete explanation, for many
who do have adequate access to health care also complain that
physicians are lacking in interest and understanding, are preoccupied
with procedures, and are insensitive to the personal problems of
patients and their families. Medical institutions are seen as cold
and impersonal; the more prestigious they are as centers for
biomedical research, the ore common such complaints (cites Dugg &
Hollingshead 1968). Medicine's unreest derives from a growing
awareness among many physicians of the contradiction between the
excellence of their biomedical background on the one hand and the
weakness of their qualifications in certain attributes essential for
good patient care on the other (cites self 1974). Many recognize
that these cannot be improved by working within the biomedical model
alone.
The present upsurge of interest in primary care and family
medicine clearly reflects disenchantment among some physicians with
an approach to disease that neglects the patient (p. 134).
Citing Holamn 1976, Engel goes on to outline the negative results of
"biomedical dogmatism" in similar terms to those already cited (Table 7).#
Working under the assumption that the biomedical model has failed, Engel
suggests that his biopsychosocial model utilize Von Bertalanffy's General
Systems Theory Perspective and take folk models, environmental, social,
pscyhological and biological factors into account when evaluating a patient
holistically and recommending course of action which may involve referral
to another practitioner. Engel does not go so far as to include
alternative/complementary medicine however.
I have a table here of main points made by
various "medical authorities"
Engel in 1977 did not mention human spirit but more recent proponents
have. In May 25-26, 1989 in Rotterdam, the Netherlands, at the opening of
the Helen Dowling Institute for Biopsychosocial Medicine, a group of
participants at an international meeting called for a paradigm shift within
Western medicine. Marco J. De Vries, professor of general pathology at
Erasmus University Rotterdam, and General and Scientific Director of the
Helen Dowling Institute, states that in 1989 psychosocial factors were
still considered to be of "marginal import for the susceptibility to and
the treatment of disease" (1990, p. 65). De Vries concludes by calling for
a new model that may "contribute to the emergence of a new and modern
spirituality. This spirituality is concerned with the values of human
dignity as reflected by autonomy, care and compassion as expressed through
social support, recognition of the uniqueness of the person and those who
suffer, which may lead to purpose and meaning in life for all concerned,
patients as well as health professionals" (p. 76). It is this
interpretation of what a new medical model should be that will be presented
here as what the non-Western model already entails noting that Engel's
model highlights the biomedical component whereas the non-Western model
does not.
The non-Western model is, as an exact opposite to the Western model,
exceedingly complex and includes elements which in many instances cannot be
translated into English. The model, embedded in religion and sympathetic
magic includes a cosmic world view of the patient as an element in the
universe interacting with various invisible forces. Thus, the patient is
viewed as an agent whose spirit, soul, aura or karma is affected and
affects the body's functioning and overall health. For example, Majumadr
(1971) writes
Vedic treatment often follows a set formula of propitiation of the
angered gods, appeasement of malignant forces, magic formulas with
the auxiliary use of material remedies like amulets, external
applications and internal medicines . . . a psychiatric approach in
the shape of frequent appeals (by suggestions and mesomeric
repetition) to the patient who is constantly assured of progressive
healing and ultimate care . . . (p. 218).
Thus, the models can be shown as:
Another table is inserted here
>From here on (and it's way to long to upload) is a description taken from
several works on what each system is.
End of Part 2.
Barbara Ruth Campbell
Dissertation in progress
Campbell@Zodiac.Rutgers.Edu
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