George Engel and A Time for New Directions in Health Care

By: Jim Ward 

In April 1977, George L. Engel, then a professor of Psychiatry and Medicine at the University of Rochester, New York, published an article in Science entitled “The Need for a New Medical Model: A Challenge for Biomedicine.” In that article, Professor Engel argued for a more holistic approach to medicine in the western world. Engel believed that medicine had become more and more narrowly focused in its approach: that practitioners were almost entirely focused on a biomedical approach to human health concerns to the virtual exclusion of psychosociological concerns. Patients were increasingly being seen as biological machines, separate from their psychological and social experiences and environments. This tendency, Engel claimed, was even more apparent within the relatively new “medical science” of psychiatry. This latter discipline, he argued, had swallowed the biomedical model hook, line and sinker. This was seen to be problematic by Engel because the model was far too deterministic for mainstream medicine and, therefore, ludicrously so in psychiatry which many felt was more appropriately seen as a branch of behavioural science rather than medicine.

I came across this 37 year old article by pure serendipity, whilst searching the internet one day recently for information regarding approaches to mental illness. This was of interest to me because, up until recently, I taught a course called “A History of Madness” at Toronto’s Ryerson University. What really stunned me was how such a truly seminal article, published so long ago has been almost totally ignored.

In the past 37 years both medicine and psychiatry have become increasingly narrow and biomedical in their approach. In the modern world, psychiatrists and physicians know little about their patients’ lives: what they do for a living, the neighbourhoods they live in, their family situations, their financial situations, their hopes and dreams. Each patient is seen as a separate piece of machinery to be tinkered with. There is currently little difference between an automobile going in for its quarterly service and the annual check up of a human being.

This may not be such a problem except for the fact that the solution to physical and mental health problems is seen increasingly as the prescribing of one drug or another. This relates closely to the narrow biomedical approach. The most worrying aspect of this is that this tendency is difficult to halt or slow down because of the special interests that would lose out substantially were a more holistic approach to physical and mental health be taken.

A New York Times article recently featured a psychiatrist bemoaning the replacement of talk therapy with drug therapy over the past 30 years. He admitted that he made much more money by prescribing drugs rather than talking to patients because it meant he could see three times as many patients in the same time. Many critics in recent years have pointed out the huge profits 

being made in the pharmaceutical industry. One of the areas in which labour costs have increased enormously in recent years has been in medicine, both physical and psychiatric. New high tech gadgets such as cat scanners and brain imaging machines are enormously costly. Such gadgets increase the emphasis on a biomedical approach to physical and mental health issues.

Granted, it is virtually impossible to measure the effectiveness of dollars spent in health care. There are so many variables that can affect the health of an individual and a population, the health care itself is just one of many. Here in Ontario, the Ministry of Health attempted to avoid this complexity by simply measuring wait times to get health care. The reason such variables are singled out for measurement is that they are easily measurable. Whether or not decreased wait times has a positive impact on health is impossible to measure. One study that brings this point home vividly is The Spirit Level. This comparative study of health outcomes and costs in OECD countries notes that the United States has the highest health costs and the poorest levels of health, measured by morbidity and mortality rates.

Now, 37 years after it was written, it is time to revisit George Engel’s 1977 article and to ask some serious questions about whither health care, both physical and mental.