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Almost two-and-a-half millennia have passed since Hippocrates, in his Airs, Waters and Places,1 noted the importance of the social milieu in disease aetiology, and a millennium since Ibn Sina (Avicenna) examined the interrelation between psyche and soma.2 In one memorable case a person in the royal household sought Ibn Sina's advice during an attack of acute lumbago. Suspecting a psychosomatic aetiology, the great man asked an aide to publicly remove her scarf. Seeing that this did not produce the intended outcome he then raised the stakes—to the horror of others present—and ordered the aide to remove the patient's trousers. Faced with this threat the patient immediately jumped from the couch and ran out of the room. In a second case he was asked to see a young man whose affliction had baffled the most brilliant medical minds in his area. Ibn Sina talked at length with the young man about his day-to-day habits, carefully monitoring his pulse as they spoke. He noted how the young man's pulse began to race when the subject turned to the local baker's shop, to which it transpired he made regular visits. Once on the scent, Ibn Sina quickly observed that the pulse quickened yet further when mention was made of the baker's sister. The diagnosis was love sickness, and his prescription of marriage (fortunately acceptable to all concerned) proved effective. Ibn Sina was thus able to demonstrate that important criterion of a causal association, reversibility.3
Perspectives changed greatly in subsequent centuries—especially when the Enlightenment in Western Europe removed the religious shackles from science and the new freedom to dissect the human body allowed the study of anatomy and physiology. It was this focus on the organic that catalysed the emergence of biomedicine as the dominant paradigm, yielding manifold advances in the understanding of disease processes, their treatment and their prevention.4 But medical thought tends to proceed in cycles, and a return to the concept that illness has important social as well as physical components was marked by the 1946 declaration from the World Health Organization that ‘Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’.5 Since then, the behavioural and social sciences have gained firm footholds in medical and nursing curricula.
Biopsychosocial Medicine: An Integrated Approach to Understanding Illness6 is the product of a two-day conference held under the auspices of One Health—an organization that seeks to promote a system of healthcare based on this approach—and the Novartis Foundation. In his preface the convenor, Peter White tells us that his rationale for organizing the conference was a concern that medicine is travelling up a blind alley in its attempt to help patients improve their health and reduce their disability. ‘This blind alley is the biomedical approach...’ The twenty-eight participants, who represented psychiatry, medical history, general practice, epidemiology, and psychology, were asked to deliberate on whether the model is a luxury or a necessity, and a key reference point was George Engel's famous 1977 paper in which the term biopsychosocial medicine first appeared.7 But it was Engel's follow-on paper, looking at clinical applications of the model,8 that generated special passion among the contributors.8 So far as my own discipline is concerned, I confess to puzzlement about this whole enterprise: primary care, in its quest to deliver holistic patient-centred care, has long since embraced the biopsychosocial approach—as was indeed made clear at the conference.
Among the many thoughtful contributions I would single out Edward Shorter's history of the biopsychosocial approach, including an account of Engel's personal metamorphosis from internist to psychoanalyst and then psychiatrist. Ultimately, Engel gained a joint appointment as both internist and psychiatrist, from which position he endeavoured to make bridges between the warring schools of psychiatry. Another is Michael Marmot's summary of the Whitehall studies on the influence of social position on health outcomes, in which he offers some ideas on possible biological mechanisms through which social and psychological factors may impact on molecular processes. Marmot's chapter, however, is closely followed by a warning from George Davey Smith against the too ready assumption that an association signifies cause and effect. To illustrate the pitfalls of confounding and bias he offers a striking set of ‘cautionary tales’. An example is the peptic ulcer story: such was the consensus that this condition was stress-induced that otherwise careful researchers overlooked important epidemiological and other evidence pointing to an infective causation. Whilst Davey Smith is undoubtedly right on the need to distinguish association from causation—something that Hippocrates famously failed to do—his second main conclusion is harder to accept. He contends that, in public-health terms, if a chain of causation could be broken—for example, by removing tobacco from the chain linking social class and lung cancer—the social and psychological factors would cease to be important. This is surely too simple an interpretation. Even if tobacco could be eliminated from the equation—which is very doubtful when we remember the US experience with alcohol prohibition—we could expect the tobacco habit to be replaced often by other forms of self-destructive behaviour.
How does Biopsychosocial Medicine move the subject on? Despite valiant attempts by Simon Wessely and Peter White to draw practical messages, I have to say not greatly.