The results of the application of reductionism in modern biomedical research and practice has been nothing short of miraculous, but while wondrous for some things, reductionism alone is incomplete.
The basic premise of reductionism is that by breaking down (or “reducing”) complex biological or medical phenomena into their many parts, one is much more likely to understand a single cause and devise a cure.
Historically, the invention of the microscope, the defining of Koch’s four infectious disease postulates, the unraveling of the human genome, and even intelligent computers are salient examples of the dramatic benefits of biomedical reductionism.
Conversely, Sir William Osler (modernizing Hippocrates) always believed that the art of medicine would never be completely replaced by reductionist science.
In 1977 in the journal Science, Dr. George Engel, a highly regarded Rochester psychiatrist, codified a bio-psycho-social (BPS) model for healthcare in the United States.
More recently Dr. Steven Schroeder from UCSF reminded us that biomedical intervention alone has much less impact on health outcomes than is commonly believed.
Classical medical care interventions contribute only about 10% to reducing premature deaths compared to other elements such as genetic predisposition, social factors, and individual health behaviors.
Most contemporary medical researchers have concluded that the chronic degenerative diseases of modern Western humans have multiple contributory causes, thus not lending themselves to the single agent-single outcome model.
Physician Rick Lippin has suggested that the mantle of Dr. Engel’s bio-psycho-social model of healthcare be reaffirmed and added a S for spiritual, recognizing that our patients have needs in all four of these domains.
As one method of incorporating this concept into daily medical practice, Lippin has recently proposed to the Joint Commission that all primary healthcare providers ask two simple questions when taking the medical history.
Modeled after the so-called fifth vital sign of pain, and utilizing the BPSS model, each adult patient should be asked:
- How are things at work?
- How are things at home?
The answers should be scaled between 1, couldn’t be better, and 10, couldn’t be worse (in crisis stage).
The answers of patients to these questions would lead to more questions and possible referrals and standardized tests for further diagnostic workup for stress and depression.
Try adding these questions to your clinical routine to better understand your patients’ needs.
George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal of the American Medical Association.
Originally published in MedPage Today. Visit MedPageToday.com for more primary care news.
