Beyond the body: an emerging medical paradigm: as with so many other aspects of American society, the baby boom may be the catalytic factor that ultimately changes the way we treat our health

American Demographics, Dec, 1997 by Charles F. Longino

As with so many other aspects of American society, the baby boom may be the catalytic factor that ultimately changes the way we treat our health. The culture of medicine in the U.S. is changing because the population is changing. Our bodies are aging, but this is only the most obvious physical change. We are increasingly well-educated consumers, and our health-related attitudes and behavior are changing. As a result, the American medical community is heading toward a new paradigm that combines scientific knowledge with a humanistic approach.

The existing paradigm of modern scientific medicine may be called the Western biomedical model. It relies on an essentially mechanical understanding of causation, one derived from science. Repairing a body, in this view, is analagous to fixing a machine. Furthermore, this view leads to the remarkably optimistic expectation that each disease has a specific cause awaiting discovery by medical research. Finally, because the body is the appropriate subject of medical science and practice, it is also the appropriate subject of regimen and control. Although we may not consciously think of medicine in these terms, these are nonetheless the doctrines of the biomedical model. They form the subconscious cultural context out of which our thinking, medical education, and professional conduct arise.

Because it has been so successful in dealing with deadly infectious diseases, medicine has worked itself out of much of its original job. It now faces a growing population of patients and potential patients who expect the same successes and advances in dealing with the chronic diseases and conditions that are more prevalent in old age. Unfortunately, scientific medicine cannot cure these ills. Medicine has to change its essential self-understanding to succeed in the future. Out-of-Date Doctrines Just as societies evolve ideas of truth, justice, and beauty, they also develop philosophical conceptions of the human body, ideas that change from culture to culture and over time. The Western biomedical model is predicated on five related doctrines.

The first to arise was the doctrine of mind-body dualism, instigated by 17th-century French mathematician-philosopher Ren Descartes. The idea that the physical body is completely separate from the mind, soul, and other less tangible factors may have been useful as a starting point for biomedical science, but it is increasingly difficult to affirm in the modern practice of medicine. It is a barrier to understanding the psychosocial component of medicine, including the placebo effect, the connection between stress and illness, the importance of support groups, and the more general relationship between social support and health. Although the doctrine is no longer strictly adhered to, psychosomatic phenomenona are still often considered peripheral to scientific medicine.

The second doctrine is the mechanical analogy, which treats the body as a system of functionally interdependent parts and the physician as a mechanic. When disease is present, the structure of an organ is the first place to look for a cause. Thinking that a physician can repair one part of the body separate from others is, however, a simplistic view and one unfortunately reinforced by much academic medicine. Students often graduate without integrating their biomedical knowledge into an understanding of the human body as a whole, much less that of a total human being. Curriculum committees have struggled with the issue of integration, which usually flies in the face of departmental structure, funding allocations, and decision-making power. It's not that they don't recognize the concept; they just find it logistically difficult to execute.

The third doctrine is physical reductionism. This focus excludes all nonmaterial dimensions (social, psychological, and behavioral) in the search for causes and interventions. It is the tendency to look for answers at progressively more basic levels. In biomedicine, this takes its ultimate form in attempting to locate causes largely in the genes. Again, the relatively greater power of the basic sciences in academic medicine promotes this outcome. Exposing students to behavioral and social medicine in the basic sciences curriculum would move toward alleviating the problem.

The fourth doctrine is that the body is the appropriate focus of regimen and control. If disease exists in the body, then treat the body. With this approach, the patient is responsible for following the doctor's orders to get well, forming a power hierarchy with the doctor in control.

This doctrine is now under great strain because of the rise in medical consumerism--the idea that the patient has rights and is an equal partner in the doctor-patient relationship. This perspective empowers patients at the expense of at least some of doctors' professional autonomy. The effect of this view has spread from the realm of practice to the halls of academia. In patient-centered interviewing courses, student doctors are encouraged to "negotiate" a treatment plan with the patient. This is good medical practice because by buying into the plan, patients are more likely to comply with it and less likely to blame the doctor for negative outcomes. One must consider the widespread individualism and institutional skepticism found among members of the baby-boom generation to appreciate the origin and growth of consumerism in health care.