A paradigm shift in medicine

In The Myth of Normalcy: Trauma, Illness, and Healing in a Toxic Culture, family physician Gabor Maté presents a new formulation for understanding health and disease. Maybe it’s fair to call it a paradigm shift. Mate’s wording implies that those of us who work in healthcare should practice differently. What might such a healing practice look like?

First, the healer takes the side of the patient and the family – against the toxic culture around us. One component of the toxic culture identified by Maté is capitalism, the valuing of corporate profits over human life, the relentless drive to extract private wealth while killing our ecosystem. Under capitalism, in order to remain financially solvent, pregnant women stay on the job until they go into labor. They return to their place of work a few weeks after giving birth. Work-related stress during pregnancy or the infant’s need for nurturing and attention receive little attention.

Another component of toxic culture is patriarchy, the control exercised over the bodies of women and children by men. In its ugliest form, this takes the form of sexual abuse and rape. Mate presents a number of case examples showing how such past events manifest as illness, not only psychological but also physical. Author, activist and playwright V, who wrote The Vagina Dialoguestells Mate how his biological father’s abuse led to his endometrial cancer.

Mate examines the scientific basis of how our toxic culture leads to disease. As evidenced by behaviors as seemingly insignificant as failing to pick up a crying baby for crimes such as sexual abuse, the toxic culture of contemporary capitalism, patriarchy and white supremacy leads to trauma.

What is a trauma? As I use the word, “trauma” is an inner hurt, a lasting break or split inside oneself due to difficult or hurtful events. According to this definition, trauma is primarily what happens to someone as a result of the difficult or hurtful events that happen to them; it is not the events themselves. (p.20)

This trauma then leads to somatic and psychological dysfunction that manifests in both bodily and psychiatric illnesses as well as problematic behaviors such as attention deficit and addiction. It should be noted that this disease narrative is dynamic and changes over time. Rather than an entity one possesses (e.g. “my cancer” or “my bipolar disorder”), Mate sees illness as a temporal process rooted in the toxic culture we all live in, as well as in events that might not even be subject to conscious recall.

Thus Maté seeks to transcend conventional biomedical analysis methods. The biomedical paradigm is reflected in traditional medical education. Pre-medical students must take basic science courses such as biology, physics, chemistry, and organic chemistry as prerequisites for medical school. In the conventional medicine program, medical students learn the basic sciences such as anatomy, physiology, pathology, and pharmacology before learning clinical medicine. The biomedical paradigm is reductionist in the sense that it seeks explanations at increasingly fundamental levels of analysis: Thus, the search for genes that cause such and such a disease, or deregulated neurotransmitters as explaining such and such a psychiatric disorder.

The biopsychosocial model was formulated by psychiatrist George Engel in the 1970s in opposition to the biomedical model. Engel incorporated atoms, cells, organs, cognitive and emotional factors, and social influences such as family, community, and even nation-state into the model. (See figure.) As such, the biopsychosocial model is comprehensive and potentially powerful in its explanatory scope, but the details of how it works, i.e. the underlying mechanisms, have not been sufficiently fleshed out. by Engel.

Indeed, the role of large-scale social forces on health and disease has long been the concern of social medicine. Social medicine practitioners take a step back and look at the root causes of disease. The social medicine practitioner continues to ask questions until she tackles the root cause of illness: social structure. The late Paul Farmer was a practitioner of social medicine. Howard Waitzkin, Alina Pérez and Matthew Anderson provide us with a practical manual on how to become a practitioner of social medicine in Social medicine and the transformation to come.

While Maté sees himself as working within the paradigms of biopsychosocial and social medicine, his contribution is to elucidate the epigenetic, psychological, neurological and immunological mechanisms by which the oppressive social structures and toxic culture of “hypermaterialist and consumerist capitalism” ( p. 198) manifest as disease.

Additionally, Mate criticizes the reductionist program of behavioral psychology, originally formulated by B.F. Skinner, who derived his theories of behavior modification via rewards and punishments through experiments with caged pigeons in boxes. . Mate is particularly critical of child-rearing practices based on operant conditioning principles, for example advising parents not to comfort crying infants lest they feel “rewarded” for their behavior. ” bad behaviour “.

In discussing contemporary practices relating to the treatment of young or the treatment of pregnant mothers-to-be, Maté references ethnographic accounts of the practices of cultures more in touch with nature, as well as how mammals other than humans raise their young.

Mate reviews many cases to illustrate his point, but he also references his own failures. He attributes his sensitivity to the idea of ​​his wife not picking him up from the airport to fears of abandonment stemming from being placed in the care of strangers as a child when the Nazis attacked. occupied Hungary. He regrets that his workaholic drove him away from his children’s lives when they were little. By pointing out his own flaws and sharing how he always tries to overcome them, he gives us hope to heal ourselves too.

In the Structure of scientific revolutions (1962), Thomas Kuhn described how paradigm shifts work in science. Normal science under the old paradigm, for example the Aristotelian view of the cosmos with the earth at its center, seems to work quite well, but there are just a few anomalies that cannot be explained. Over time, these anomalies and contradictions accumulate – until someone, say Copernicus, comes up with a new way to look at the data. The new way of looking at things works much better, of course, and has much better explanatory and predictive power.

When I introduce medical students to family medicine, I often refer to Chapter Five, “Philosophical and Scientific Foundations of Family Medicine,” in the 2009 edition of McWhinney’s Handbook of family medicine, the last edition before the death of Ian McWhinney in 2012. In chapter five, McWhinney discusses the paradigm shift in medicine – from the biomedical model to the biopsychosocial model – in the Kuhnian sense. Of course, the reductionist and biomedical paradigm continues to advance medicine. Take a look at the studies reported in any issue of the New England Journal of Medicine. In the clinical setting, however, we need to better understand our patients’ backgrounds, their emotional lives. Organized medicine needs to do a better job of ending the hypermaterialistic, consumerist capitalism that is making our patients sick.

I have championed the biopsychosocial model during my own medical and teaching career, although I admit (after Farmer) at times to have emphasized “structural violence” and (after Waitzkin) “social medicine at other times. (Farmer actually left out the “psycho” part and called his own approach “biosocial,” Pathologies of power, p. 19.) Mate puts the “psycho” back into the biopsychosocial.

What is the practice of biopsychosocial medicine, informed by The myth of normalcy look like? How do I envision the practice of medicine in the new paradigm?

First, I will have to examine my own flaws and shortcomings – the same way Mate submits to self-examination. In order to be an effective instrument of healing, I must first work on my own healing. Mate suggests how one might engage in “compassionate self-inquiry” (p. 431).

Second, I will pay more attention to children’s social life. Are they able to play freely? Do their parents have the means to bond with them? Do I encourage parents to respond meaningfully to their children’s emotional needs?

Third, I will work to adopt a trauma-informed attitude with patients. A first approximation will be to ask about negative childhood experiences (ACE). Many of those who share their stories of illness with Mate tell him, “None of my doctors ever asked me about it.” I hope to help patients recognize the roles their disease plays in their life trajectory. I hope to help them heal.

Comments are closed.