Physicians of the future: Renaissance of polymaths? - SAGE Journals

The Journal of The Royal Society for the Promotion of Health; December 2002, 122 (4), pp. 233-237

Article

Physicians of the future: Renaissance of polymaths? B F Piko, W E Stempsey Bettina F Piko, MD, PhD, University of Szeged, Faculty of Medicine, Department of Psychiatry, Division of Behavioural Sciences, Szeged 6722, Hungary Tel/Fax: +36 62 420 530 Email: [email protected] William E Stempsey, SJ, MD, PhD, College of the Holy Cross, Department of Philosophy, Worcester, MA 01610-2395, USA Corresponding author: Bettina F Piko Received 17 February 2001, revised and accepted 27 August 2001

Key words Biopsychosocial model; medical education; polymath; theory of paradigm

Abstract Science and technology are crucial in modern medicine; societies devote enormous amounts of time, money and effort to developing new diagnostic and therapeutic procedures. However, the fact that people now report higher rates of disability, symptoms and general dissatisfaction with their health and well-being calls us to rethink the functions of health care and medical education. There is a need for a new medical paradigm, which should involve and reconcile the natural and the social scientific paradigms (‘two cultures’). Medicine should be viewed as an integrative, biopsychosocial science. Therefore, medical education must involve the study of the biological structures and psychosocial functioning of human beings not as separate systems, but as interactive ones. This mandate suggests that the physician needs to become a sort of ‘neo-polymath’ in a ‘new Renaissance’. The new paradigm, however, should not demand the acquisition of more and more information. Instead, the crucial principle would focus on the appropriate selection of information.

Changing paradigms of science Human desire to explore the world has probably always existed. For the past several hundred years, science has been our primary tool for this exploration. Despite occasional claims that scientific research is carried out for the sake of pure understanding, the primary goal of scientific research has always been - directly or indirectly - to improve the quality of our lives. Science has always been proclaimed as the pioneer of development and progress. There are debates, however, about how development and progress should be understood. Dubos1 has argued that common to both primitive people’s and civilized societies’ thinking is belief in the possibility of an ideal state of health and harmony. This idea, that perfect health and happiness can be achieved, has flourished in many forms throughout history, beginning in ancient Greece. The Stoics2 saw this ideal state as stemming from a harmony between human life and nature, while Plato3 and Aristotle4 saw human flourishing in terms of the proper ordering of the parts of the soul that govern our biological, emotional, and rational functioning. Similarly, the World Health Organization’s definition of health emphasises harmony in its claim that health is not merely the absence of disease but the state of complete biological, psychological and social well-being.5 Although this definition has been heavily criticised since the WHO introduced it in 1946, it makes the important point: that health is a multifaceted phenomenon involving the biopsychosocial nature of human beings.6 There is an important conceptual difference between the ideal states of ancient times and the modern world, however. Ancient thinkers were wont to place this idyllic state of paradise in a ‘golden age’ of the remote past, while modern thinkers look to future prospects and believe that only scientific/technological development can bring the progress necessary to achieve perfect health and happiness. Expectations placed upon biomedicine, and molecular biology in particular, are especially manifest. Science and technology are crucial in modern medicine. Modern societies devote enormous amounts of time, money and effort to preserving health, developing new diagnostic and therapeutic procedures, and obtaining medical care. However, despite the substantial improvement of collective health in developed nations in the past several decades, people now report higher rates of disability, symptoms and general dissatisfaction with their health and well-being.7 This calls us to rethink the functions of health care and medical education in promoting our well-being. Modern science is ‘boxing science’. In ancient times, with a relative dearth of data, it was possible to explore the world with a holistic view of nature and the human being’s

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Physicians of the future place in it. In modern times, however, this approach is no longer feasible. The sheer mass of scientific knowledge necessitates specialisation and study, within a certain paradigm, of only a certain aspect of the world. Each scientific field has its own paradigm, which becomes a box that serves to contain and systematise its own scientific results.8 Medicine has largely become biomedicine based on the application of the pure natural scientific paradigm, which defines health as the lack of diagnosable disease.9 The development of genetics, biochemistry and microbiology reinforces the biomedical model of medical care. Both theory and practice concentrate on the structure and function of the human body at the level of cells and molecules. Rapid technological development and the medicalisation of our lives have brought the unrealistic expectation that health care should provide perfect health and happiness. Disease, suffering, and even death become avoidable states that scientific/technological development should ultimately be able to control. Two contradictory trends in medicine today force us to rethink this view. First, the growing mass of information presses medicine toward an increasingly felt need to specialise and sub-specialise. Second, since individual specialties have arrived at a point where it is difficult to synthesise this growing amount of information with the larger whole, disciplines have started to reconnect themselves in new interdisciplinary fields of study. Not surprisingly, medicine has proved to be a most appropriate scientific field for multi- and inter-disciplinary research. Medicine, as a ‘big scientific umbrella’, must investigate human beings in their biopsychosocial complexity, from molecules and cellular activity through cognitive and emotional processes to the socio-cultural determinants of health and illness.10 This places medicine at the crossroads of the natural and social sciences. Trends of specialisation have caused these two basic scientific paradigms to become detached, however. Both social and natural sciences are based on their own paradigms, using different principles, methods, terms and interpretive frameworks. These trends might properly be leading us to a period of scientific revolution and to an 234

impending paradigm change in medicine.

Need for a new medical paradigm Kuhn8 emphasised that a paradigm is never free of the values of the surrounding social environment. On the contrary, it reflects the underlying world view of scientists in their work. Modern biomedicine is based on a materialist principle, in which psychosocial processes may have a role in the genesis of disease, but only insofar as they affect biological processes. This biological reductionism has made possible the investigation of the human body at the cellular level, which can be viewed as an ‘objective’ process. Human beings, however, are never ideal experimental objects for natural scientific investigations as they always exist in their biopsychosocial complexity. What brought us to the recognition of the limitation of biological reductionism? The changing pattern of diseases was the most important phenomenon that directed our attention to the necessity of introducing a new approach to health and disease. Thus far, biomedicine has tended to think about disease in terms of a linear cause-and-effect model.11 Infectious diseases served as a paradigm of this thinking. The disease was seen to be caused by a single invading organism. However, this model is not representative of most disease today. The decline of mortality from various infectious diseases such as measles, diphtheria, smallpox and whooping cough has been followed by an increase of mortality from cardiovascular disease, cancer, liver cirrhosis and other chronic conditions. McKeown12 argued that these changes in the disease spectrum were mainly due to social, environmental and behavioural factors. Moreover, Doll and Peto13 suggested that nearly half of the mortality from the ten leading causes of death was due to behaviour and lifestyle. Smoking, accounting for 30% of all cancer deaths, is a good example of a risk factor that has a precisely explained biochemical effect. Still, the frequency of tobacco consumption is substantially determined by our psychosocial environment.14 Alcohol consumption, dietary habits, drug use, reproductive and sexual behaviour are all responsible for welldefined pathological effects. However, sepa-

rating biological and psychosocial risk factors is almost impossible.15 The changing pattern of diseases further complicates our view on disease causation.16 Chronic non-communicable diseases are most plausibly attributed to several interacting biological, psychological and social causes.17 Moreover, as opposed to an exactly determined causal factor, risk factors only elevate at the population level the statistical probability of developing a disease.18 Hence, there is considerable population-based variability, and a particular individual’s risk might be quite different from the risk in the population as a whole. People may fail to appreciate these nuances and believe their own cases to reflect nothing more than fortune or misfortune. Syme and Berkman19 suggested that there was a need for a new causal model. This was the next step in the development of causal models to complement monoand multi-causality. They found that persons with weak social networks usually have relatively higher mortality risks of several diseases (e.g. ischaemic heart disease, cancer, cerebrovascular disease, etc.) as compared to those with strong social support and social networks. Similarly, unemployment, as a social risk factor, generates similar patterns of morbidity and mortality.20 Chronic noncommunicable diseases are often called diseases of civilization as their pathogenesis is influenced by the adaptation processes to the challenges of civilized culture. Stress itself is not harmful; it is maladaptation to the environment that brings about harm.21 Modern society generates many possibilities for experiencing stress that can exhaust our adaptive capacity.22 This is the major cause of ill-health in modern life. This modern view of disease causation revised lay beliefs about the role of medical care and people’s own responsibility for their health. An important aspect of disease prevention and health promotion is that individuals should be active participants in the process of health maintenance, that they are responsible for their own health through their lifestyle choices.23 Because of this heightened awareness of health, people give medical care an overriding importance in their lives, and societies spend more and more money on health care.24 People con-


Physicians of the future sult physicians more frequently than ever before, even for conditions that were previously considered to be outside the realm of medical practice, e.g. alcoholism, child abuse, violence, unhappiness with facial features or breast size, fatigue and jet lag.7 This medicalisation of daily life has brought sometimes rather unrealistic expectations of medicine. While physicians tend to work in the frame of biological reductionism, at least in their musings about the mechanisms of disease, patients view their health in a more holistic way.10 Consequently, there is a rising public dissatisfaction with personal health and medical care that highlights the limitation of biological reductionism.25 Laypersons have special beliefs about the cause, significance and treatment of their conditions, beliefs that lie outside the scientific paradigm of Western medicine.26 In many cases, a considerable gap exists between medical and lay perspectives on illhealth. The limitations of biological reductionism show the need for interdisciplinary research.27 Relying on only biological reductionism or only social reductionism in research will yield understanding of only a small and one-sided part of pathogenesis. A big challenge for scientists of the twentyfirst century is to reconcile the two scientific paradigms, which could lead to a change in the paradigm of medical care and to a complex and more satisfactory understanding of disease causation and patients’ needs.

Future physicians as polymaths? The new paradigm of medicine should involve both the natural and social scientific paradigms (‘two cultures’) in clinical practice and health education.28 We should accept that biological functioning of the human body is not isolated from emotional and social well-being. Indeed, we cannot understand psychosocial phenomena if we do not take into account the effects of our general biological constitution on human behaviour. Medicine is the most promising field for this reconciliation because of its unique biopsychosocial complexity. This reconciliation of the two basic scientific paradigms, natural and social scientific, will ideally lead to a new medical paradigm.

This new paradigm, however, does not mean an interchangeability of the methodological guidelines of research in the natural and social sciences, but a synthesis of research findings into one complex view of life. The methods used in natural and social sciences are often quite similar, but they also have important differences. The positivist approach and application of sophisticated statistics to social sciences have significantly increased our understanding of human beings. However, we should not fail to appreciate that we require qualitative studies to get information on people’s psychosocial functioning.29 Medicine should be viewed as an integrative, biopsychosocial science, at the meeting point of natural and social sciences. Both health and disease are concepts that include objective facts and subjective evaluations of these facts. If we fail to take the subjective evaluative functions of humans into consideration, we neglect the biopsychosocial complexity of humans, and this diminishes the efficiency of the modern technology to which we look to improve our lives. The importance of psychosocial factors on health hardly needs documentation.30 Smoking and excessive alcohol consumption are well documented contributors to morbidity. Different sexually transmitted diseases wax and wane as a result of varying patterns of social interaction. Domestic violence brings many people to seek medical care. Physicians must be aware of the manifold and complex contributions of these social factors to the aetiology of disease. Moreover, they must know how they might bring about changes in at least some of them in order to effectively treat disease. How active physicians should be in advocating social change is a matter ripe for debate. Psychosocial factors also play a conceptual role beyond their contribution to biological dysfunction. As Engelhardt31 has emphasised, the language of medicine is based upon many assumptions about the nature of explanation, and such explanatory models structure the way we see and experience disease. Before the nineteenth century, fevers and pains were seen as diseases in their own right. However, Foucault32 showed how the shift of medical research to the laboratory and the dissection room

turned fevers and pains into mere symptoms, surface manifestations of the disease, which became sited in the internal organs. Thus, the social factors that led to the shift in the medical ‘gaze’ have fundamentally altered what constitutes a disease. Medical education must involve the study of the biological structures and psychosocial functioning of human beings not as separate systems, but as interactive ones. This puts a heavy burden on the medical profession and an especially heavy burden on medical educators. This mandate would almost seem to require the physician to become a sort of ‘neo-polymath’ in a ‘new Renaissance’. Perhaps the paradigm polymath of the Renaissance is Leonardo da Vinci. Although his masterpieces were his paintings, his activities spanned the gamut of human interests. He was remembered in the court of François I of France as a philosopher, a learned person, perhaps even more than as a painter. He wrote not only on art and philosophy, but on geology, optics, acoustics, music, mathematics, anatomy, hydraulics, ballistics, naval armaments, botany and physics. He was appointed both painter and engineer to Louis XII. He designed flying machines and made several (unsuccessful) attempts to fly.33 Every generation seems to bring forth physicians who possess multiple talents. While perhaps not on the polymath plane of Leonardo, these physicians nonetheless pursued varied interests. Several of them became more known for their non-medical talents. The poet John Keats was an apothecary. William Carlos Williams was a paediatrician before turning to writing of the poetry that brought him fame. John Locke is today known as one of the most important philosophers of the 17th century, but in fact was engaged in a range of pursuits for the public interest. However, in the midst of his occupation with questions of philosophy, finance, education, trade and theology, he never lost his love for medicine. His friends continued to speak of him as ‘Dr Locke’.34 Many physicians today pursue several avocations at which they are remarkably skilled. Several have proved to be successful novelists and writers and others are remarkably talented musicians.


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Physicians of the future The question is: Can today’s physicians return to the polymath models of the Renaissance? Given the huge and exponentially growing amount of information we possess today, this seems impossible. This is the greatest challenge of the new paradigm we are suggesting. The new paradigm should not demand the acquisition of more and more information. McManus35 argues that 80% of today’s factual knowledge is unnecessary and rapidly forgotten. Instead, the crucial principle of the new paradigm of medicine would focus on the appropriate selection of information. To see today’s physician as a polymath may require us to rework our image of the polymath. It must be granted that the polymath examples given were truly exceptional people. However, this need not force us to abandon the idea that physicians ought to become polymaths. The real genius of people like Leonardo da Vinci probably lies less in the breadth and depth of their knowledge than in the breadth and depth of their imagination. Leonardo saw the possibility that machines might fly. This certainly required knowledge of gravity, ballistics, and the principles of engineering, but knowledge of bird anatomy and an overall aesthetic sense were undoubtedly at work in Leonardo’s imagining. The creative process is not always easy to describe in precise scientific terms. The practice of medicine may be more a creative practice than our emphasis on science will allow us to believe. There is no reason to believe that there are not still such creative people among the ranks of our physicians. This creativity, the ability to see possibilities, probably arises at least in part from the possession of a wide-ranging set of interests and the resulting acquisition of a broad-based body of knowledge. If this is so, then important implications for medical educators follow.

Educational implication of the new medical paradigm The main message of the integrative model is to help physicians accept the mental and social aspects of health and illness beyond the biological reductionism. That is the prerequisite for effectively dealing with the wider spectrum of disease. Moreover, as research has revealed, patient complaints 236

about physicians usually do not deal with clinical competence but the human aspects of doctor-patient relationship.36 Medical curricula usually involve subjects of behavioural sciences, e.g. medical psychology, anthropology, sociology, bioethics, communication skills and humanities. Even in Eastern Europe, where teaching applied humanities and behavioural sciences has no tradition in medical schools, more and more medical educators recognise that teaching medical psychology or bioethics should become an integrated part of medical education.6 Recently, the rapid development of behavioural medicine that emphasises both biobehavioural and psychosocial theories in the clinical setting has added an important focus on applying the biopsychosocial model in patient care. The main target of behavioural medicine is to develop psychosocial interventions that reduce distress, enhance quality of life, support patients’ coping and self-management of disease and to prevent disease by controlling psychosocial risk factors.37 Since there is increasing evidence for psychosocial factors influencing risk of coronary heart disease or cancer, behavioural medicine should be introduced to students during their clinical years as an example of the integrated approach in medical care. Experience, however, shows that teaching the humanities and behavioural sciences does not necessarily produce humane physicians.38 The method of teaching should change to provide an effective and practical guide for future physicians in the psychosocial aspects of encounters with their patients. Lectures may stimulate the imagination of students, but more often they stifle it. Increasingly, both American and Western European medical schools are reforming their curricula centred on problem solving in small groups.39 This undoubtedly stimulates the student to take a more active part not only in learning answers to questions, but also in formulating the questions themselves. Such learning, compared with the traditional lecture format, seems far more likely to stimulate just the sort of creativity and imagination that is required not only to handle the sheer mass of medical information available, but also to deal humanely with patients and other health

care workers.40 Another very helpful trend in American and European medical education is the introduction of students to patient care early in their studies. Only in the clinical setting can students gain a real appreciation of the basic principles of the natural and behavioural sciences that they are learning in the classrooms and laboratories.41 At the bedside, the psychological and social issues and the ethical considerations that beset real patients can bring medical students to understand that behavioural sciences and humanities are not only theoretical subjects but also practical and essential parts of patient care.38 While medical students in their pre-clinical years are rather motivated to learn behavioural sciences, there is usually a decrease in their motivation as students progress to the clinical years.42 Therefore, teaching biopsychosocial aspects of medicine should also be continued in the hospital setting reflecting the everyday clinical practice. Some authors suggest a biopsychosocial model for the analysis of conflicts that arise in doctor-patient relationships.43 Others suggest patient-centred conferences based on the biopsychosocial model to provide opportunities for active student learning and interaction with patients in a multidisciplinary context.44 The years of medical education also involve the process of professional socialisation, i.e. learning the social role and social responsibilities of the physician.45 The biopsychosocial model provides a common ground for developing a socially responsible and patient-centred attitude. Medical education must include both biomedical and behavioural sciences. It must train students to understand both the biological functioning and the psychosocial functioning of human beings. However, what is needed is a new approach that includes fewer isolated bits of information and more integrating principles and guidelines on how these world views interact. Selection of what information is most necessary and appropriate for physicians to know will be the greatest challenge for the future medical educators. The greatest scientific discoveries have proved to be the epoch-marking ones that see beyond the specific facts of a particular discipline. Med-


Physicians of the future icine may be essentially scientific, and ‘boxing science’ will continue to exist and bear fruit for medicine. However, medical scientists as future polymaths will need to break out of the boxes. The task is not to get rid of the boxes, but rather to see the information in those boxes not just from the inside but from the outside as well.

References 1 Dubos R. Mirage of Health. New York: Harper Colophan, 1979 2 Epictetus. The Encheiridion. In: Newberry PA, editor. Theories of Ethics. Mountain View, California: Mayfield Publishing Co, 1999. p. 149-60 3 Plato. The Republic. Bollingen Series LXXI. Princeton, New Jersey: Princeton University Press, 1989 4 Aristotle. Nicomachean Ethics. Indianapolis: Hackett Publishing Co, 1985 5 WHO. Constitution. Geneva: World Health Organization, 1946 6 Piko B. Teaching the mental and social aspects of medicine in Eastern Europe: role of the WHO definition of health. Adm Policy Ment Health 1999;26:435-8 7 Barsky AJ. The paradox of health. N Engl J Med 1988;318:414-8 8 Kuhn TS. The Structure of Scientific Revolution. Second edition. Chicago: University Press of Chicago, 1970 9 Gillick MR. Common-sense models of health and illness. N Engl J Med 1985;313:700-3 10 Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977;196:129-36 11 Najman JM. Theories of disease causation and the concept of a general susceptibility: a review. Soc Sci Med 1980;14:231-7 12 McKeown T. The Role of Medicine. Oxford: Blackwell, 1979 13 Doll R, Peto R. The Causes of Cancer. New York: Oxford University Press, 1980 14 Goddard E. Why Children Start Smoking. London: HMSO, 1990 15 Henry JP. The relation of social to biological processes in disease. Soc Sci Med 1982;16:369-80 16 Mackenbach JP. The epidemiologic transition theory. J Epidemiol Community Health 1994;48:329-32 17 Mechanic D. Health and illness behaviour and patient-practitioner relationships. Soc Sci Med 1992;34:1345-50 18 Renton A. Epidemiology and causation: a realist view. J Epidemiol Community Health 1994;48:79-85 19 Syme SL, Berkman LF. Social class, susceptibility and sickness. Am J Epidemiol 1976;104:1-8 20 Bartley M. Unemployment and ill-health: understanding the relationship. J Epidemiol Community Health 1994;48:333-7 21 Selye H. The Stress of Life. New York: McGrawHill, 1956 22 Pollock K. On the nature of social stress: production of a modern mythology. Soc Sci Med 1988;26:381-92

23 Alonzo AA. Health behaviour: issues, contradictions and dilemmas. Soc Sci Med 1993;37:1019-34 24 Illich I. Medical Nemesis. London: Calder Boyars, 1974 25 Foss L. The challenge to biomedicine: a foundations perspective. J Med Philos 1989;14:165-91 26 Helman CG. Limits of biomedical explanation. Lancet 1991;337:1080-3 27 Breslow L. Risk factor intervention for health maintenance. Science 1978;200:908-12 28 Snow CP. The Two Cultures. Cambridge: Cambridge University Press, 1999 29 Wulff H. The two cultures of medicine: objective factors versus subjectivity and values. J R Soc Med 1999;92:549-52 30 Mechanic D. Role of social factors in health and well-being: biopsychosocial model from a social perspective. Integr Psychiatry 1986;4:2-7 31 Engelhardt HT. The Foundations of Bioethics. Second edition. New York: Oxford University Press, 1996 32 Foucault M. The Birth of the Clinic. New York: Vintage Books, 1975 33 Bramly S. Discovering the Life of Leonardo da Vinci. New York: Edward Burlingame Books, 1991 34 Osler W. An Alabama Student and Other Biographical Essays. New York: Oxford University Press, 1908 35 McManus IC. How will medical education change? Lancet 1991;337:1519-21 36 McManus IC, Vincent CA, Thom S, Kidd J. Teaching communication skills to clinical students. BMJ 1993;306:1322-7 37 Garofalo JP, Baum A. Behavioural medicine: treating disease and mental health. Curr Op Psychiatry 1998;11:597-9 38 Stempsey WE. The quarantine of philosophy in medical education: why teaching the humanities may not produce humane physicians. Med Health Care Philos 1999;2:3-9 39 Norman GR. Problem-solving skills, solving problems and problem-based learning. Med Educ 1988;22:279-86 40 Almy TP, Colby KK, Zubkoff M, Gephart DS, Moore-West M, Lundquist LL. Health, society, and the physician: problem-based learning of the social sciences and humanities. Eight years of experience. Ann Intern Med 1992;116:569-74 41 Ashley EA. Medical education - beyond tomorrow? Med Educ 2000;34:455-9 42 Piko B. Beyond biomedicine: the challenge of teaching preventive medicine. Med Educ 2001;35:808-9 43 Yamada S, Greene G, Bauman K, Maskarinec G. A biopsychosocial approach to finding common ground in the clinical encounter. Acad Med 2000;75:643-8 44 Cohen J, Krackov SK, Black ER, Holyst M. Introduction to human health and illness: a series of patient-centered conferences based on the biopsychosocial model. Acad Med 2000;75:390-6 45 Sidel VW. The social responsibilities of the physician. J R Soc Health 1998;118:363-6


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