restricted access 8 Teaching Eclecticism
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chapter eight Teaching Eclecticism In a 1980 retirement Festschrift, George Engel’s colleagues and former students emphasized that teaching was the most important aspect of his professional life (Ader and Schmale 1980). If the model was to shine anywhere, it should shine here. Instead, in many settings, the biopsychosocial model has not served well in teaching medical students and psychiatric residents. Although it might be presented in a more nuanced way, one sometimes observes, even in prominent academic centers, relatively simplistic scenarios in which a case will be presented, and the teacher will ask the students to describe the case in three facets: bio,psycho,and social. Often, two of the facets are weakly explored, and the student, for whatever reason, leans toward one particular aspect of the case. Or, alternatively, no facet is explored in any depth. Proponents of the BPS model might object that in their institution they may do a better job, and this may in fact be the case. It is not irrelevant, however, that the model can be, and often is, simplistically interpreted such that one only attains a relatively superficial understanding of a case. My suggestion is that this is not completely a fault of a poor use of the BPS approach but rather a consequence of the overinclusiveness of the model and its poor boundaries. Engel on Education Let us see what Engel himself had to say about how the BPS model could be used for medical education (G.L.Engel 1978).He describes how physicians using the biomedical model are often seen as“insensitive, callous, neglectful, arrogant, mechanical .” He blames Descartes for this state of affairs (there seems to be no end to the horrors of dualism). He claims that diseases are dynamic processes, not discrete entities with causes. The psychosocial aspects of illness are ignored by biomedicine , seen as neither accessible to scientific scrutiny nor essential for medical education . This leads to the shotgun use of laboratory and diagnostic procedures, resulting in patients feeling “used, abused, and dehumanized.” The laboratory tests sometimes say “no disease” yet the stubborn patient persists in feeling ill. (I recall an elderly hospitalized woman who looked pale and was less responsive verbally, yet her vital signs and blood tests results were mostly normal; the head nurse said, “Her numbers look better than she does.”She was in the midst of a stroke and died within six hours.) Engel does not claim that there is no role for reductionistic biomedicine but rather that it has become degraded from a once fruitful approach into a dogma. The leaders of biomedicine have responded to“public dissatisfaction”with the dehumanizing practice of medicine by turning to “a curiously regressive romanticism ” and recommending “a sentimental return to the past” (G. L. Engel 1978). (Engel sets himself up as unsentimental and nonromantic.) Such educators recommend exposing medical students to practitioners earlier in their training and other such measures. What they ignore, Engel says, is “apply[ing] the scientific method to the human dimensions of medicine. The picture naively conjured up is that the scientific competence of today’s physician can be blended with the legendary warmth, compassion, and common sense of the kindly family doctor of yesteryear.”He dismisses this view as“false and devoid of logic,”based on an overly romanticized view of the past; physicians were not more compassionate or humane in the past than they are now. The biomedical response, then, is to retreat to unscientific talk about the “art” of medicine, “based on intuition, professional rules, aphorisms, and maxims from the accumulated wisdom of experienced clinicians . . . . Nothing more than compassion, a humane attitude, and good common sense are needed” (G. L. Engel 1978). Most of these tasks can be delegated to other health professionals, such as nurses and social workers, Engel continues, leaving doctors free to do the hard work of biological diagnosis and treatment. With the biopsychosocial illness thus split up, adversarial relationships develop between 92 The Fall of the Biopsychosocial Model nurses (or other health professionals) and doctors, leading to unnecessary professional conflict. Engel wants to be more scientific. There is a science, he says, that is being neglected : the sciences of psychology and psychiatry and sociology and social work that can underlie scientifically based approaches to the psychosocial aspects of illness . The key, he argues, involves four essential attributes of all health care professionals (whether doctors or nurses or others): collaboration, communication, complementarity, and competence. Besides...