Medical Models

The term "medical model" of health or of health care is often used as a term of criticism, even contempt.  As usual, reality is more complex, and the "medical" approach to illness and to its care is evolving rapidly and is under continuous and critical review from within the profession. 

In simple form, the medical model implies a reductionist approach to health problems, viewing them primarily in mechanical terms.  True believers in this faith include those who suggest that decoding the human genome will reveal solutions to our health problems.  We can discuss the place of genetics separately, but the rank a society gives to genetic research may serve as an indicator of its adherence to a medical model.  A more traditional example of the medical model is found in the writings of Lewis Thomas:

" Or if we're going to have laws, I'll make up two of my own. The first is that we really don't comprehend the underlying mechanisms of (...) today's diseases, and we have an enormous amount still to learn.   The second is also a guess: for every disease there is a single, central, causative mechanism that dominates all the rest, and if you are looking for effective treatment or prevention you have to find that mechanism first, and start from there....  In short, I am an optimist, and a true believer in the effectiveness and indispensability of the science of medicine".  From Lewis Thomas, M.D., "Medicine in America" TV Guide, Dec.31, 1977, pp 25-26

A fundamental problem concerns how far to simplify reality.  A moment's thought will indicate that all aspects of our existence are interrelated, and that to take any particular perspective is like examining a room with only a single candle held in one position: much will remain in the dark.  Explanatory models must simplify to be useful, but over-simplification can be naive, and it is very hard to decide on the optimal level of simplification.  Consider, for example, this "simple" model of cardiovascular disease risk factors.  How helpful is it?  Is it better than a model with, say, only five boxes?  Which is more suitable for what purposes? 


Le développement de la pensée médicale
Le prestige acquis par les sciences exactes a suscité en médecine de nombreuses tentatives pour substituer des mesures quantitatives rigoureuses aux appréciations qualitatives.  Cette innovation   ne s’est toutefois pas imposée sans peine.  Elle finira par triompher au XIXe siècle, sous l’impulsion des biologistes et des promoteurs de la méthode numérique qui a préfiguré la statistique médicale (p. 72, Histoire de la médecine).

 La médecine moderne prend son départ au XIXe siècle. Cinq courants fondamentaux la caractériseront : la clinique (les moyens d’investiguer la maladie, Laennec, De l’auscultation médicale); la description et la classification des maladies (chaque maladie a une cause particulière établissant le dogme de la spécificité étiologique); l’histologie pathologique (la médecine cellulaire de R. Virchow, La structure microscopique des cancers); la physiopathologie (C. Bernard énonce les règles philosophiques de la biologie scientifique, Le normal et le pathologique); la bactériologie (les découvertes par L. Pasteur de nombreux agents pathogènes comme causes spécifiques, les microbes; R. Koch développe la technique bactériologique).


Criticisms of the Medical Model and more recent developments
The fundamental problem with the medical model arises from the the questionable impact of medical interventions on the overall health of populations.  As shown in the data in the linked page, the broad health of populations appears due to far more than the biological processes of disease.
Bien que la médecine moderne a une efficacité technique incontestablement plus grande qu’il y a quelques décennies, certains paradoxes persistent:

 Ce ne sont pas les pays qui investissent le plus dans les soins (médecins et lits d’hôpitaux) qui ont les meilleurs indicateurs de performance comme le taux standardisé de mortalité causée par des maladies traitables, l’espérance de vie en bonne santé ou divers taux de morbidité. (Marmot MG, Smith CD. Why are the Japanese living longer? British Medical Journal 1989;299:1547-51) See also Caldwell JC. Routes to low mortality in poor countries. Population and Development Review 1986;12:171-220 .

This, of course, has been recognized for centuries, but the promise of biological breakthroughs is seductive because through science we may be able to remain healthy without having to take full responsibility for our health.  If we reject a "medical model", do we hold that people who get sick are the authors of their own misfortune?  Or, if we see them as the victimes of their circumstances, do we conversely espouse a "sociological model" of illness?  What, indeed, is the role of free will in illness?

Link to discussion of molecular biology versus psychophysiological models.  This article discusses the impact of current genetic research on widening the gap between the biomedical model and studies of the social and psychological influences on health.

Criticisms of the Medical Approach to Health Care

Again, the debate has reigned for a century or more.  See, for example, the rival views of Osler and Garrod over the role of medicine. 

The Institute of Medicine is part of the US National Academy of Sciences.  In 2001 it produced a report "Crossing the quality chasm: a new health system for the 21st century."   This proposed 10 ways to re-orient the health care system that may be summarized as follows:

Current system

New roles

Care is based on visits Care is based on continuous healing relationships
Professional autonomy drives variability Care is customized according to patient needs and values
Professions control care The patient is the source of control
Information is a record Knowledge is shared and information flows freely
Decision making is based on training and experience Decision-making is evidence-based
Do no harm is an individual responsibility Safety is a system property
Secrecy is necessary Transparency is necessary
The system responds to needs Needs are anticipated
Cost reduction is sought Waste is continuously decreased
Preference given to professional roles over the system Cooperation among clinicians is a priority