Abstract
Family Medicine first formally confronted systems thinking with the adoption of the biopsychosocial model for understanding disease in a holistic manner; this is a description of a natural system. More recently, Family Medicine has been consciously engaged in developing itself as a system for delivering health care, an artificial system. We make this new system available to all people, whether sick or well, offering to manage not just their diseases, but their lives. However, a major difference between natural and artificial systems is that natural systems have smooth feedback loops to ensures homeostasis, whereas artificial systems do not. They can only adjust themselves by disruptive adaptive and renewal cycles. Further, Family Medicine aspires to base its creation of this artificial system on the key principles of Family Medicine - continuity, comprehensiveness, and compassionate care in the context of family and community. However, there are another set of principles driving the modern Family Medicine system of healthcare, principles that function like the hidden curriculum of medical education. These principles - risk thinking, health as a commodity, and individual responsibility - are part of a deeper current within healthcare called by some biomedicalization. On closer analysis, many of these characteristics are intimately tied with liberal economies that must grow. Yet this economic system is an artificial system that lacks feedback. It is imperative that we in Family Medicine reexamine our commitment to developing artificial systems.
Family medicine has a long history with systems; we were born and raised in systems thinking. When George Engel published “The Need for a New Medical Model: A Challenge for Biomedicine” in 1977, 1 we knew it was for us. His biopsychosocial approach was built on the emerging understanding of general systems theory, and the application of this to what we were doing was a perfect fit. It explained disease not as an isolated genetic, traumatic, or infectious insult but as an interrelationship of many factors—as a system.
Around the same time, it was becoming clear that our health care system overall was in trouble. One obvious systemic dysfunction was poor access and poor distribution of services. The liberal analysis said the problem was that we were trying to function within a “nonsystem”; what we needed was a national health insurance system. The more radical critique was that we had a very clear system, a free enterprise capitalist system—and that system was the problem. 2
But it was not just a problem of access. By the 1990s, Daniel Fox could write that “the contemporary disarray in health affairs in the United States . . . is the cumulative result of inattention to the burden of chronic disabling illness.” 3 How could this happen? A century-old system set up to deliver nearly miraculous therapies apparently had no feedback loop to tell it that the burden of disease had shifted during those 100 years from primarily acute and infectious to predominantly chronic and degenerative diseases. It is not that we forgot to notice this shift; it is that the system had no inherent mechanism to allow adaptive change.
This lack of feedback, according to Jacques Ellul, is a characteristic of artificial technological systems. The biopsychosocial system Engel described is a natural system. Natural systems—the ocean, the human body, a hunter-gatherer tribe—have evolved into their current complexity. They are stable because they are systems with feedback loops to ensure homeostasis. Artificial systems, on the other hand, are processes we create. Ellul called them technological systems, and among their chief characteristic, he said, was the absence of feedback. 4 Without the complex feedback loops of a natural system, small anomalies can lead to big aberrancies, which in turn take on a life of their own. Hence, artificial systems tend to become dysfunctional.
This important distinction between artificial and natural systems did not feature in a recent discussion of the applications of systems thinking to health care. Instead of feedback loops, this discussion speaks of adaptive and renewal cycles as the way complex systems adjust themselves. While accurate descriptively, these terms mask what is involved in these renewal cycles: sudden stress, creative destruction, and revolt. 5 Instead of smooth instantaneous feedback loops keeping the oceans’ wildlife in balance, or keeping the healthy human body’s temperature and blood sugar stable within a narrow range, these disruptive adaptive cycles are clear evidence of the lack of homeostatic feedback loops in technological systems. We will return to this shortly.
So, by the time Family Medicine was reviewing itself a decade ago with the Future of Family Medicine (FFM) project, we were very conscious of systems, both functional and dysfunctional ones. Systems thinking had penetrated everything we did. In just one of the FFM articles, the word “system” appears 150 times. 6 We were finally recognizing that the services we offered were just as complex as the biopsychosocial system in which we were offering them. We knew that for these complex services to be delivered efficiently and effectively, they needed to be part of a well-designed system.
In the process, healthcare became one word. Before, in the realm of health care, we were clinicians struggling to develop relationships with our patients in a system that had been designed to respond only to episodes of acute illness. 7 The FFM project recognized that inadequate systems could disrupt the patient–physician relationship; they determined to develop systems that supported continuous healing relationships. To design these systems, FFM said that we needed to be better managers: managers of processes, managers of information, and even managers of relationships. 8 In other words, to move from fragmented health care to unified healthcare, we needed to offer not just services, but a system.
And now we have come to the crux of the story. We knew that disease processes were complex—a whole biopsychosocial system—and we knew that what we offered for treatment was equally complex, also involving systems. We needed a way to bring these two complex systems together. The solution was both inevitable and momentous: we would invite people—all people, not just those who felt ill—to join this evolving system of health care. They would join a “joint adventure” with medical providers for which we providers would offer “optimal life trajectories” 9 for people to follow. To confront the dysfunctional system of health care, we created a new, expanded, more complex artificial system of health care, one that even well people must join. Now all people are patients, but since they do not all feel ill, we now call them clients. Having already medicalized all individual deviations and dysfunctions as “diseases,” we have now medicalized health itself.
Look at the “basket of services” that the new model of Family Medicine offers: it includes assessment, prevention, promotion, education, and advocacy 10 ; it is for all people, not just those with chief complaints. Family Medicine has become the gatekeeper, not just to medical services but also to “the managerially optimized life.” 11 We have moved from the management of illness to what Arney and Bergen call the management of living. And all must be included; we disdain as “refugees from care” those who dare go through life without having their growth plotted, their risks assessed, and their interiors screened.
But we disdain them for a good reason: evidence. Evidence has shown us that the population of apparently well people who are plotted, assessed, and screened demonstrate statistically significant improvements: fewer medical events, or less pain, or better sleep and sex, or longer lives. With this proof in hand, we feel morally obliged to actively recruit all people into this system of contemporary health care.
However, we should proceed carefully before fully adopting the Management of Living as our primary job description. Scientific evidence is only as good as the questions we pose to it. Have we fully probed all the anxiety-producing effects of screening, all the consequences of lengthening the lives of people with chronic diseases, all the implications of making everyone patients? Are we sure that this new health care system that we offer to all people will enhance health in the full WHO sense of “a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity?”
We must remember: as an artificial, technological system, this new system is only a substitute for a natural healing system. Natural healing systems were those that existed before biomedicine: family and community support when people were suffering; traditional healers skilled in bone setting, wound care, and the use of herbs; and cultural and religious customs and rituals for making sense out of misfortune. These natural systems endured because they had evolved effective means for people to confront suffering, and often to relieve it. Of course, contemporary health care is far more powerful and efficient than those natural systems, especially in curing or changing the course of most diseases. It is so effective, in fact, that natural healing systems atrophy—and lose even those benefits for which there is no substitute in modern health care. 12
But modern biomedical health care is still an artificial technological system. That means it lacks feedback; it cannot adjust itself. The signs of this are everywhere: in run-away costs that can no longer be sustained, in an epidemic of iatrogenic illness, in our inability to say “no” to any new technology, no matter how marginal the benefit. We are inviting all people to join an artificial system that has no built-in mechanism to ensure that what it offers will always promote and sustain heath. We are offering everyone virtual health.
This virtual health consists of the FFM services, noted above, that we now manage. But in addition, there is a “hidden curriculum” of what we do in this new Family Medicine system. It functions like the “hidden curriculum” in medical schools—the “set of influences that function at the level of organizational structure and culture,” which can be as influential in the formation of doctors as the formal curriculum. 13 There is likewise in contemporary Family Medicine an implicit “hidden system,” which is just as influential as the explicit formal system. A consensus is now developing about the characteristics of this hidden system, a system we share with the rest of biomedicine. While Clarke and her colleagues have catalogued several of these characteristics under the rubric of what they call “biomedicalization,” 14 many other social scientists have looked in depth at each individual factor. Three recur frequently.
Risk
The concept of risk—the possible but unknown outcome of a certain activity—is not new, but the careful measurement of it is. It is this measuring that has allowed us to use the idea of risk in medicine, especially to evaluate small differences in tests, treatments, or behaviors in large populations. Risk analysis is an excellent tool, especially for understanding these populations; in fact, the concept of mathematical risk always refers to a population.
However, we have not been so careful to limit our use of risk only to populations, and there are “risks” in using it with individuals. It may help us as doctors decide how to advise or treat a patient—but for that patient, knowing their risk may produce more anxiety than benefit, 15 because risk is by definition unseen and unknown. Risk thinking encourages us to act to reduce the risk; we begin to think of risk factors as actual diseases in need of treatment. But risk refers to whole populations; therefore, our treatment must be of whole populations. When a very large Number Needed to Treat shows us how many people need to be treated in order for a single one to benefit—how many people we treated, in fact, that received no benefit—we are surprisingly accepting. The logic of treating every risk, no matter how small, requires this.
Commodities
Medicine has always dealt with commodities: education, services, procedures, and above all drugs. These commodities—goods and services—cost something to produce, and need to be paid for. They always have been, and still are, an indispensable part of healing, complemented by all the religious and cultural forces that are part of natural healing systems. Yet most of us are uncomfortable with reducing medical practice to merely a business of selling commodities. We feel remnants of an ethical responsibility to those who are sick, and until 1982 assumed that advertising our services (as pure commodities for sale) was unethical.
However, more and more of what used to be parts of natural systems are now for sale, a phenomenon that has increased especially since the 1980s. Services that were part of family or community life are now offered by Family Doctors—everything from supportive counseling to how to raise children and how to breastfeed. Of course, the medical system still sells drugs and procedures to treat disease. But now to remain healthy, well people purchase immunizations, screening tests, and medications to lower risk factors—and Family Doctors are on the front lines of this “preventive medicine.” Health itself has become a commodity that can be bought and sold. 16
Individual responsibility
Surely people are responsible for their own health, and part of our role as Family Physicians is patient education and health promotion. Lifestyle issues—smoking, exercising, eating—are matters of individual choice, and therefore individual responsibility. Of course, not all disease is our own fault; we have genetic tendencies and environmental insults. Or we just do not know why we get sick. But even when disease is genetic, environmental, or idiopathic, there can be risk factors that suggest we are on the way to getting sick—and it is our responsibility to be aware of and modify those factors.
But how much of our health is really under our personal control? Nortin Hadler suggests that only 25% of ill health comes from these “chosen” lifestyle behaviors for which we are “responsible.” The rest is more related to our total environment and socioeconomic status. 17 The structural reasons for these factors are admittedly harder to address individually, but our response in the new health care is remarkable: we simply ignore them. Patient education implies a patient’s individual responsibility to change. By default, illness becomes the responsibility of the one who is ill. 18
These are all interrelated parts of the Management of Living, 19 which Family Medicine now oversees. In the new health care, it is my responsibility as a patient to become aware of my risks, and it is equally my responsibility to do something about them, often by purchasing commodities. Risk analysis enables Family Medicine to more accurately map out optimal life trajectories for our patients, to design educational interventions to help them be more responsible, and to provide for them the commodities they need to become and remain healthy.
In other words, we have confronted the biopsychosocial model of diagnosis with a biopsychosocial system of treatment and health maintenance. It is a total system, headquartered in a “personal medical home that serves as the focal point through which all individuals . . . receive a basket of acute, chronic, and preventive medical services.” 20 It is a system everyone has a responsibility to buy into in order to reduce risks to their health.
Thus, though we have consciously built our new model on the principles of Family Medicine—continuity, comprehensiveness, and compassionate care in the context of family and community 21 —another set of principles is driving it. The principles of this hidden system of biomedicalization—risk, commodities, and individual responsibility—are more influential in determining what we do in Family Medicine because we are part of this larger system. We become doctors before we become Family Physicians.
Look more closely at these principles: they are predominantly economic. Commodities are goods for sale. Risk analysis has many applications, but the earliest were in economics—insurance and investing. And personal responsibility, although not primarily an economic concept, has been recruited by free enterprise economics as pivotal: I have an individual responsibility to work hard and creatively and should be personally rewarded when I succeed. Biomedicalization, which began 25 years ago (“about 1985,” say Clarke et al. 22 ), has flourished since unfettered free markets have invaded even formerly communist countries.
But as we showed above, large complex artificial systems such as biomedicine lack feedback. They are, says Ellul, “given to pure growth.” 23 That is also a characteristic of modern economies: they must grow. This helps explain why we have such difficulty in containing our runaway health care costs, or in saying “no” to any new drug or technology. This health care industry, some 16% of our entire growing economy, is too big and too important to slow down. As a subsystem of the larger economic and technological systems, it mirrors their growth imperative. The lack of feedback to limit growth in this larger system has been transformed from a flaw to an inherent characteristic.
So where are we in our Family Medicine waltz with systems? This nice partnership, where we hold each other and take each step together, has begun to look like a danse macabre. But the music is Saint-Saёns Danse Macabre, a waltz so melodic that it makes us want to dance and forget that we are dancing with death. We have begun to believe that artificial systems function just like natural systems—only better, because we can control and improve them. We have not fully confronted their lack of feedback; we have not yet admitted that systems sometimes make us serve them instead of serving us. When we put natural healing systems aside, we find ourselves accepting a statistical definition of health—virtual health—instead of a holistic or spiritual definition.
Family Medicine has a long history with systems. It is time to reassess that relationship. We have been at the forefront of those who affirm that disease causation is multifactoral, and the only way to truly understand disease is to invoke systems thinking. We should remain at the forefront. However, we must be very cautious about fashioning ourselves as a complex artificial system. It is time to return to the wisdom of natural healing systems, to see how we can enhance and be part of them, rather than substitute for them.
Footnotes
Acknowledgements
Gratitude to Janice Armstrong and Tom Gates for valuable critique.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.