Of all the questions that I get asked when running Know Pain courses, there is one which stands out. I say this because this particular question highlights the present day clinical conundrum facing all healthcare professionals.
Where does the “bio” fit into the biopsychosocial model?
Of course, the first thing to say is that the “bio” bit must fit within the framework. To negate structure, biomechanics and anatomy is to suggest that human beings consist purely of neural structures. Or, as Mick Thacker recently put it, we run the risk of becoming “brain bound”. As clinicians, we must constantly strive for panoramic, contextual thinking. This “big picture” logic sounds easy, but when confronted with the cluttered complexities of a busy clinical caseload, it’s extremely easy to categorise our reasoning into neat, simple boxes.
However, try as you may, human beings cannot and should not be placed into neat, simple boxes.
When answering this question, I often refer to Frank Sinatra’s lyrics in the song “Love and Marriage”.
Love and marriage, love and marriage
They go together like a horse and carriage
This I tell you brother
You can’t have one without the other
Try, try, try to separate them
It’s an illusion
Try, try, try, and you will only come
To this conclusion
Frank’s right. We’re mistaken if we think that we can separate the bio from the psycho and the social. As Dr Bronnie Thompson recently considered in her excellent, thought provoking blog, “the biopsychosocial model is a framework for thinking and integrating various aspects of human life.” https://healthskills.wordpress.com/2015/02/23/what-does-biopsychosocial-practice-really-mean/
Another essential factor to consider when answering this question is the inevitable consequences of progression. Within healthcare, we hear a lot about progress. Contained within our drive for progress are the much needed and continual processes of reflection (both in and on action) and service development. However, in order to achieve true progression, we must recognise the importance of change and the upheaval that such change brings.
Where I live on the North Kent coast in Margate, there are stunning blue flag beaches, run down amusement arcades and a rich history of world renowned art. Of all the artists who’ve graced Margate’s shores, it is the English Romanticist landscape painter, water-colourist, and printmaker Joseph Mallord William Turner who is most well known. Turner was considered a controversial figure in his day, but is now regarded as the artist who elevated landscape painting to an eminence rivalling history painting.
Although renowned for his oil paintings, Turner is also one of the greatest masters of British watercolour landscape painting. He is commonly known as “the painter of light”. Turner came to Margate for the exceptional light and, in 1838 he painted arguably one of his best pieces of work: The Fighting Temeraire.
Here it is…
The HMS Fighting Temeraire was a 98 gun ship and was the Royal Navy’s lead battle ship at The Battle of Trafalgar in 1805. However, despite her glorious history, Turner’s famous painting depicts the Temeraire, being towed by a paddle-wheel steam tug towards its final berth in 1838 to be broken up for scrap. Through his painting, Turner was also conveying a metaphor of progress. In the Victorian age of steel and steam, progress meant that the mighty and much loved HMS Tameraire was to be pulled apart and broken into it’s useful, component pieces.
In his recent, wonderfully constructed blog in the BMJ, Jorgen Jevne argues, “Structure, biomechanics and nociception will continue to play a role in back pain management, but they can no longer be the cornerstones of our interventions. We must cater to the more fundamental needs of our patients, not their ‘short muscles’ or ‘worn out’ disks.” http://blogs.bmj.com/bjsm/2015/02/01/stabbed-in-the-back-moving-the-knife-out-of-back-pain/
Just like the Fighting Temeraire, it is time for HMS Biomedical to be broken down into it’s, useful component parts. As Turner’s brushstrokes skilfully highlight, the inevitable process of progress must and will continue. The much needed and carefully considered paradigm shift from biomedicalism to biopsychosocialism is essential if we are to meet the multifaceted needs of our modern day societies. In his call for a transformative medical education system, Quintero (2014) states, “In order to respond to the current needs of society, which is education’s main objective, the learning processes of physicians and their instruction must change.” The clinical landscape has changed and we must change with it.
So, if the biomedical to biopsychosocial paradigm shift looks like a large, illustrious navel vessel being pulled into her resting berth by a small steam tug, what does the biopsychosocial model look like?
Once again, one of Margate’s own, the renowned modern artist, Tracey Emin provides a helpful, artistic representation. Emin’s My Bed was shortlisted for the Turner prize in 1999.
Here it is…
The artwork generated considerable media furore, particularly over the fact that the bedsheets were stained with bodily secretions and the floor had items from the artist’s room (such as condoms, a pair of knickers with menstrual period stains, other detritus, and functional, everyday objects, including a pair of slippers). The bed was presented in the state that Emin claimed it had been when she said she had not got up from it for several days due to suicidal depression brought on by relationship difficulties.
Unlike the neat and tidy certainty of the biomedical model, the biospychosocial model of practice is, like Emin’s bed, an untidy mess of cluttered uncertainties. However, amid the clutter lies a simple truth. People are complex, pain is complex and therefore, like it or loath it, what we do is also littered with complexity.
Finally, in the interests of cultural parity, I should also point out that Margate is also known for it’s “Kiss Me Quick” hats, dirty weekends by the sea and is all too often frequented by these gentleman…
As always, thanks for reading.