What is the biomedical model #5

In the 5th of this series on the key principles of the biomedical model we look at reductionism, or the idea of dividing the body and health into systems and structures.

So far we have covered specific aetiology, germ theory, Cartesian Dualism, objectivity and experimentation, and there are two more pieces in the biomedical jigsaw after this week’s look at one of the most important structural elements of healthcare practice.

Early on in the history of medicine it was realised that the body and health were so complex that they would be better understood by being broken down into component parts. Ancient and pre-modern notions of health and the body had concentrated on broadly holistic notions – things like the humoral principle, in which a person’s health was governed by the circulation of four humors. But these ideas gradually gave way to scientific medicine which followed discoveries in astrology, biology, chemistry, geology, and physics in focusing on the component parts that made up the whole, rather than the whole as a unified entity.

The Industrial Revolution also played a part in shaping cultural attitudes towards the way society could be understood and managed. Governments have learnt to compartmentalise the way they thought about society, creating new distinctive fields of health, education, welfare, employment, housing, and defence, and giving specific powers to professions – like teachers, doctors, and lawyers – who could manage their specific responsibilities.

Medicine quickly settled on a reductive idea of health and designed healthcare in its own image. Specialisms in anatomy, orthopaedics, neurology, respiratory medicine, women’s health, and psychiatry were established early, and these specialties created the template for the way doctors learnt to become physicians and surgeons, as well as the way the healthcare system would be organised.

So, an orthopaedic ward in a hospital is designed, as such, because of medicines historically reductive attitude towards the body and health. Here the orthopaedic ‘system’ defines everything about the way that the patient is assessed, diagnosed, and treated, processed through the hospital, referred, and managed.

The obvious advantage of such a system is that it reduces the complexity of the body to manageable parts – much like the way that car production can be divided up into discrete tasks in order that each can be managed more efficiently. And in many ways there are close parallels between the way that the health care system has developed in the West, and the ‘Fordist’ model of car production developed by Henry Ford in the early part of the 20th century. Ford realised that car production could be massively increased if individual workers took responsibility for only one part of the car. This gave birth to the idea of the production line, in which each person performs a single task repetitively on a continuously moving treadmill, with raw materials entering at one end and a car rolling off the production line at the other.

Much of the talk of healthcare efficiency over the last half-century can be seen in a similar way, with the patient being ‘processed’ through a series of production-like steps, moving sequentially through admission and triage, differential diagnosis and testing, intervention and discharge planning, and finally referral on. This process is underpinned by a reductive idea of the body and health that shapes the way most of us experience the healthcare system today.

Not surprisingly, perhaps, physiotherapy fell directly in line with this approach as it became established in the public health system after WWI, and for much of the profession’s history has mirrored by medical reductionism. Physiotherapy curricula still emphasise the distinctions between musculoskeletal, neurological, and respiratory physiotherapy, and students are still taught about body systems and structures. Most physiotherapists work with a variety of reductive clinical specialists, who are rewarded with promotion when they demonstrate more refined specialism.

Reductionism, therefore, is an aspiration for many health practitioners who, in the current healthcare system, have learnt that dividing the body and health into discrete body systems and structures, carries much more currency than an holistic notion of health.

Next, normalisation.