The Rise and Fall of the Biopsychosocial Model: Reconciling Art and Science in Psychiatry

12 Osler’s Ghost

chapter twelve Osler’s Ghost A specter hovers over this debate, the spirit of the person with arguably the greatest influence on medical education in the past century, a man widely viewed as the founder of modern scientific medicine: William Osler. Osler’s ghost reminds us that the biopsychosocial (BPS) approach is not the only alternative to a dehumanized biomedical model.The biomedical model that George Engel set himself against was something of a straw man: Engel kept emphasizing that patients were tired of medicine being only technological, uninterested in human beings, dehumanized. In examining the attraction of his students to the BPS model (chapter 5), we saw that they were largely drawn to it as a humanistic alternative to the biomedical model.Engel himself resisted this line of reasoning.He insisted that the BPS model was not simply a humanistic philosophy but rather more scientific than the biomedical model—an extension of scientific methods from biology into the psychosocial worlds as well. We also saw in chapter 2 how Ludwig von Bertalanffy, the leading exponent of general systems theory (GST, often seen as the philosophical basis for the BPS model), ridiculed humanistic approaches to psychology as variations on countercultural hippiedom. The pretenses of Engel and von Bertalanffy’s are all fluff. Engel’s view of the sci- ence of psychology involved psychoanalytic theories that can hardly be called scienti fic by most definitions of that term. GST also has not panned out as the scienti fic basis of modern biology.As scientific programs, Engel’s BPS and von Bertalan ffy’s GST have failed. If instead one supports the BPS model on humanistic grounds,not only is that view explicitly opposed to Engel’s perspective but also one has to explain how it improves on another alternative: the biomedical model with humanism added to it—the ghost of William Osler. William Osler the Man The mention of William Osler in medical circles these days tends to produce two mental associations: medical humanism and the importance of clinical examination (that is, bedside teaching and careful observation of clinical cases; Osler 1948). Osler is justifiably regarded as a modern Hippocrates, if we see a major feature of the Hippocratic worldview as the notion that we should rely on observation of cases, rather than theory, as the basis for medical judgment. Like Hippocrates, Osler emphasized a conservative approach to practice, erring on the side of nontreatment in doubtful situations so as to avoid inflicting unnecessary harm (Bliss 1999; McHugh 1987). Ironically, given his later fame as a medical humanist, what was unique about Osler in his early career was that he was widely seen as a leader in the introduction of scientific methods into modern medicine. In the late nineteenth century, clinical use of the microscope was new, as was pathological autopsy. These two factors revolutionized medicine. By opening the body after death and examining the tissue microscopically, the pathologist could actually see the disease. He could then give a verdict, like an all-knowing deity: the clinician’s diagnosis before death was either right or wrong. This is the famous “clinicopathological” method in medicine, and Osler, perhaps more than anyone, implemented it (Bliss 1999). The clinicopathological method was revolutionary partly because it did away with medical eclecticism: I could not have my diagnosis and theory of disease, and you your diagnosis and theory of disease—the pathologist would tell us who was right and who was wrong. There was a truth to the matter, and no one could deny the verdict of the microscope. Osler was both pathologist and clinician. He spent countless hours dissecting bodies and showing students the inner workings of pathological study;1 yet he spent even more hours at the bedside observing signs and symptoms, obtaining history, and making diagnostic judgments. Osler’s scientific genius was that he was Osler’s Ghost 129 a stellar clinical diagnostician and a superb pathologist: so he could observe patients clinically for extended periods of time, and after they died, he himself would look inside those patients’ bodies and determine if he had been right or wrong. If wrong, Osler would adjust his clinical approach until he became more and more accurate in his diagnosis, as confirmed at autopsy (Bliss 1999). Osler then took this clinical experience to students, popularizing bedside teaching . In his famed medical “rounds,” he...