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The Medical Model—its Limitations and Alternatives David Zigmond What is the Medical Model? Although most doctors' working time is spent using the Medical Model, we might find the term difficult to define precisely. This reflects entrenched methods of thinking that are conditioned by our years of training and modelling ourselves on other doctors; we then find it difficult to stand outside our methodological framework and survey it from alternative viewpoints. The definition I would use of the Medical Model is something like this—the Medical Model assumes a simple mechanical view of illness and the body it occurs in. The illness is thus seen simply as a fault in the machine. Although lip-service may be paid to interfering concepts of the mind, the family and the environment, these are uncomfortable bedfellows of the Medical Model and the machine-body continues to be regarded as something that functions autonomously: a hermetic system. Diagnoses therefore tend to be formulated in terms of structural or functional failures of the machine alone. It follows that because treatment methods derive from diagnostic concepts, then medical treatment is likely to be equally mechanistic and exclusive of non-material or psychological factors. The Medical Model is thus most comfortably suited to subjects such as surgery where the diagnosis and treatment are extremely circumscribed and structual. The Reasons We Use the Medical Model The Medical Model is enticing because it is generally succinct, tangible, easily understandable and in accordance with a scientific method which relies primarily on objective and measurable observation. This has the advantage of offering terminology, formulations and explanations which can seemingly be unambiguously understood and handled in an identical fashion by all similarly trained people. We therefore have the comfort of knowing precisely what others are talking about and what they are doing in defined situations. This makes possible the standardisation of terminology and concepts that is essential for scientific communication and research. These activities can give us useful information about certain patterns of illness and the effectiveness of therapies. Less defensible reasons for our inflexible and often inept use of the Medical Model lies in habit and conditioning. Most of us were never taught to use anything else. Therefore we have developed skills only within a particular framework which we continue to use alone, even when a problem requires alternative or additional methods. Some Snares We Fall into Unconsciously At its best the Medical Model functions extremely well, providing guidelines for handling specific problems and predicting what the outcome will be, with or without therapy. Such important considerations are implied in the concept of diagnosis. This is precisely what a diagnosis should do for us if it is based on any real knowledge about what we are labelling, in which case I would term it a `Substantial diagnosis'. If, on the other hand, a diagnosis does not offer us accurate information about prognosis and therapy, then I would call this a 'Nominal diagnosis' because it gives only a long name to something we know very little about. Let us take an example of each. 1. Acute follicular beta-haemolytic streptococcal tonsillitis is a Substantial diagnosis. It tells us with relative certainty what the symptoms and signs are, what treatment is going to be effective and what the hazards are of leaving the complaint untreated. The Medical Model works well here. Our concepts and tools are effective. We know what to do and are rarely surprised by subsequent events if we do the right thing. The patient senses this, and he and the doctor will probably get along well in this situation. 2. Non-articular or seronegative rheumatoid arthritis * is a Nominal diagnosis. It really does not tell us much at all. It does not tell us how the patient's health will be affected in the future. In five years' time he may be perfectly well despite not having any treatment. On the other hand he may be crippled with arthritis, blind with iritis and have an ileostomy because of fulminating ulcerative colitis. Furthermore, he may have developed all this despite the best treatment available. The Medical Model is now working extremely badly. The doctor feels unsure and ineffective and is likely to be on the defensive. The patient senses this and reciprocally lacks confidence. The relationship between patient and doctor is now likely to be more strained. The patient may become 'difficult and demanding'. The doctor attempts to maintain his confident persona by whatever new kinds of investigation and therapy he can think of, because he does not know what else to offer. Substantial and Nominal Diagnosis The two diagnoses here are really quite different in their implication. The 'Substantial diagnosis' offers us extremely helpful information as to what we might do and what we should expect, while the 'Nominal diagnosis' does neither satisfactorily. At best it is a descriptive tag which we attach to some apparently similar phenomena which we do not understand. However, such is the power of words that we equate them with understanding. Just as a religious incantation is intended to dispel evil spirits or attract good ones, so the medical incantation of naming the diagnosis is meant to dispel uncertainty and indecision. However, as we can see from the above example it often fails to do this—nevertheless we continue to repeat the ritual and hope the rest will follow. Many ailments fall somewhere between the Substantial and Nominal end of the diagnostic spectrum. Often a particular illness will shift its position at different times. For example, a man who has the dyspepsia appropriate to a barium-meal proven duodenal ulcer* may well present the doctor with a Nominal diagnosis, as the course of his illness and the efficacy of therapy remain largely unknown. If this same man perforates his ulcer then the situation is one where a Substantial diagnosis becomes very important; treatment is incontrovertible and clear-cut and the prognosis with and without this therapy equally so. In formulating diagnoses we need to be aware of their position on this spectrum. Are we really making meaningful statements, or are we merely tagging labels onto phenomena we are ignorant about? If it is the latter, who is benefited by the Nominal diagnosis—the doctor or the patient? Complex terminology is often used as a defence against substantial ignorance. If the doctor is lost, bemused and largely ineffective, then at least he can fall back on some long words and complicated concepts which he hopes will maintain his position in his own and the patient's eyes as the potent and unassailable authority. Such unconscious defences and collusions are not always a bad thing, but they can often block the doctor's opportunities to explore more fruitful avenues of rapport and investigation. What the Medical Model Misses Out Because it has its roots in the scientific method, the Medical Model can only really incorporate phenomena that are measurable and quantifiable. That is, it copes well with the physical or organic components of illness, has much less assurance with other factors, the most important of which are psychological. Only those who are inflexible scientific purists would deny the importance of external stresses and inner emotional conflicts in the precipitation, course and eventual outcome of many illnesses. Yet the problem of being unable to directly measure stress or emotional conflict is always problematic. There have certainly been attempts to rate and scale such reactions as anxiety and depression, but on scrutiny these endeavours only measure phenomena which are assumed to have a direct relationship with the inner experience, which itself remains elusive and unmeasurable to our tools of scientific enquiry. True, we can measure and classify certain of the simpler aspects of behaviour—that is, habit spasms, alcohol consumption, compulsive rituals etc — but never the emotional life that motivates them. Rating scores of described experiences are beset with ambiguities and potential distortions. If the usual Medical Model is incapable of dealing with this aspect of illness then we have two alternatives. We can ignore the non-organic, non-measurable aspects of medicine and remain always within the respectable territory of scientific strictness, or we can use alternative methods and models — in addition to the more traditional medical diagnoses. Such a whole-person or even whole-family approach to illness has received increasing attention in recent years. Perhaps the most influential work in this area pertinent to the general practitioner was begun by Michael Balint. Much of his work indicates that the traditional medical diagnosis used alone is often severely limited in the amount of help it gives to the doctor in understanding the patient's illness, what he can do about it, and what he might expect in the future. These serious limitations can only be countered by the doctor entering into new, speculative territory where the unscientific skills of empathetic imagination might attempt to formulate the position of illness within its matrix of family relationships and internal emotional tensions. Such formulations cannot give us the same sort of uniform agreement of the more traditional diagnoses, but this venture is well worthwhile in terms of understanding and management. The following case illustrates this position. A Case from General Practice Mr. C.T. is 65 years of age. One month before his date of retirement he developed ankle oedema and ascites. His general practitioner first saw him late one night when he developed acute and severe dyspnoea. Examination indicated mild hypertension, biventricular cardiac failure and slight cardiac enlargement. Routine investigations yielded only the one additional useful finding that his cardiac failure was probably caused by ischaemic heart disease (ECG evidence). Unfortunately, fairly large doses of Digoxin and diuretics had no effect on his ascites and oedema, although his blood pressure was well controlled with Methyldopa. He had no further attacks of pulmonary oedema. One month later, therefore, he was hospitalised with a view to controlling his right-sided heart failure. Even with complete bed rest and massive doses of Frusemide and Spironolactone this problem was extremely difficult to manage. At this time he became increasingly anxious, irritable and demanding. It became difficult to keep him in bed or to get him to take his medication, which he seemed to view with suspicion. Eventually this ended in a mixed manic-paranoid reaction. He claimed to be in perfect health and said that he was in hospital to help his wife's illness (she was in good health). While embarking on numerous impractical projects simultaneously, he would make grandiose and untrue proclamations about how wealthy he was. His distractibility made it difficult for him to sleep or eat, and his motor restlessness made him a difficult nursing problem. At times he showed fluctuating paranoid delusions about the nursing staff, saying that they had poisoned him and stolen his money. On the other hand he became unprecedentedly sexually suggestive and familiar with the same nurses. Although showing undoubted manic signs when interviewed, the depression was just below the surface. He became extremely distressed and tearful when certain important and personal and life topics were discussed. Although Chlorpromazine was needed to contain the immediate situation, the bulk of his improvement came from helping him come to terms with his underlying emotional problems. Before we move into this alternative and additional diagnostic area, we might formulate the medical diagnoses thus: mild controlled hypertension with ischaemic heart disease causing decompensated right ventricular failure. Superadded mixed manic-paranoid psychosis. Method or Madness? Let us now look into the matrix of this man's life and see how his illness fits in. The hallmarks of Mr. C.T.'s life were caution, safety, orderliness and continence. He only took the minimum and essential risks in life, and then only with the maximum preparation. He had married 40 years ago and had lived in the same house since that time. Furthermore, he had worked in the same clerical job during this period, though with minor promotions. In his work he was diligent to the point of obsession and found criticism especially hard to take. His marriage was contained in a similar framework of orderliness and safety. His wife never worked outside the home because he found the idea threatening. Their life together was safely but drably harmonious, and structured by well-worn routine. Although never particularly sexually active, he had latterly been rendered impotent, probably because of his Methyldopa. His leisure time drifted: passive and unexplorative. He watched television indiscriminately and fell asleep after supper while reading the Daily Express. Occasionally he would potter in the garden, but would take little else in the way of physical activity. He had no particular hobbies or interests and hence tended to become bored and irritable at weekends: time and freedom became enemies. His anger was never overt; he would similarly avoid or appease other people's anger, which he evidently found threatening. In his social relationships he had friendly but ritualised contacts, hence no committed or intimate friends. Because of his passive nature, his experience was to be exploited at work as a result of his diligence and compliance. He was resentful that after 40 years of service to his employers, he received little promotion, perfunctory compliments and a gold watch. Secretly he had hoped for grand applause and a big send-off. Last, but not least, this man had never been seriously ill. Understanding and Management How does this backcloth help us in our understanding and engagement with this man? One of the most striking features about him is his inability to assert himself as an individual, or act in any way that would lead to dissonance with others. In fact, this is quite understandable from his parents' background. He experienced his father as authoritarian, overpowering, distant and intermittently violent when drunk or frustrated. Consequently, his mother and his other siblings learned that the only way to be safe was to be obedient and unnoticed. He had carried this legacy of submissive resentment, apparently uncomplaining, throughout the rest of his life. Until the onset of his illness. In his fantasy life he had hoped that retirement would bring some of the fulfilment and satisfaction that he felt life had deprived him of. The reality, of course, was very different. Even without his illness, his addiction to many years' routine, his inflexibility and lack of constructive interests made retirement an extremely demanding testing-ground for his appeasing and fearful personality. It is even possible that he recognised this unconsciously, and that his heart-failure represented a last battleground defence against his having to face the intolerable realisation that this was all there was to his life. What is certainly true is that his serious illness then brought to consciousness the possible imminence of his death. This implied to him the futility of his life, because of all the things he wished he had achieved, yet had avoided. He could not endure such a demeaned view of his life, and so defended against it with a manic reaction; hence his grandiosity, his multiple and unrealistic plans, his display of hypersexuality and the demanding postures he had kept so well contained for so many years. Equally he could not cope with the way in which his physical illness had underlined his self-perception of passivity and weakness; hence the denial that he himself was ill, and that any illness within him was the result of others poisoning him. Another facet of this problem was the way in which the whole structure of his marriage had been radically changed. Although a sedentary man, he was the undisputed dominant marital partner: his submissive wife offered him some sense of domestic power. His illness, however, had reversed their roles. Now he was the partner who had to stay at home and be provided for—her role until he fell ill. He struggled painfully with coming to terms with these realities, as his tears showed when talking about his life. His mania and paranoia were defences against his deep-rooted frustrations and sense of loss. It was bravado in the face of grief. He was grieving for his life, both past and present. The important core of this formulation lies outside classic scientific and medical methods. It can neither be proved nor disproved, because his feelings and his entire inner world cannot be objectively observed or measured. With unprovable plausibility they can be logically inferred; with imagination intuitively felt. Yet without this meeting in the regions of uncertainty he must endure his grief, fear and primitive anger alone. Enabling him to share these have brought compassionate palliation and relief. His manic and paranoid defences are no longer necessary. Understanding his rage has done much to dispel it. He is coping very much more realistically with his illness and time, and although sorrowful he is not 'ill' in the strict psychiatric sense. Interestingly his heart failure now seems under much better control. One could perhaps speculate that his cardiac function has improved because his heart is no longer subject to the autonomic-nervous and hormonal storms that beset it in his previous state of emotional turbulence. Happily he no longer needs his Chlorpromazine because he has been able to draw on his own resources to adjust more constructively to his situation. Conclusion This case illustrates how one can use the Medical Model within a wider framework of alternative models. From the strict scientific angle these other concepts do not avail themselves so readily to the disciplined scrutiny of empirical testing. Yet the price of ignoring these areas and methods is high. Mr. C.T. would probably have continued his mania, paranoia and depression and never have recovered as fully as he has done. It is also possible that his cardiac failure would have remained intractable and that he would not have made his definite and (otherwise) unaccountable improvement. These more subtle pursuits require more flexibility in approach than we are generally trained for. In return our understanding and rapport with the whole patient becomes richer. Through these, we may well prevent or curtail some important morbidity - and ourselves derive greater interest and satisfaction from our work. D. Zigmond, MB, CH.B, DPM, is Registrar in the Department of Psychological Medicine at University College Hospital, London WC1. AUGUST 1976/HOSPITAL UPDATE: 424-427 Version: 14th April 2012
Copyright ©; Dr David Zigmond 1976, 2010 Interested? Many articles exploring similar themes are available via David Zigmond’s home page on www.marco-learningsystems.com David Zigmond would be pleased to receive your FEEDBACK
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