• Nemesis

Factor #1: Clash of healthcare models: biomedical versus (bio)psychosocial

Health services run most smoothly when clinicians can draw on their core training models in treating patients. In Western healthcare, the biomedical model is the framework of choice, a model which privileges anatomically or physiologically distinct and objectively measurable or detectable pathology or disease. In this model, disease is often differentiated from illness, the latter generally describing the subjective experience of ill-health (though 'illness' is increasingly used strategically to describe the psychological elements of ill-health, when these psychological elements are viewed as the primary issue). Illnesses or disease lacking diagnostic biomarker(s) go by many names, but are often referred to as medically contested or (in the NHS) medically unexplained symptoms (MUS) or persistent physical symptoms (PPS).


Lack of medical legitimacy surrounding MUS often leads to patients being treated with (at best) suspicion or (at worst) systematic disbelief and dismissal by healthcare professionals. Currently, there is no diagnostic biomarker or set of biomarkers for Long Covid (as opposed to active infection with SARS-CoV-2 ) and patients are accordingly finding themselves begging to be taken seriously by their doctors, not infrequently without success. An additional difficulty is that some Long Covid patients have not tested positive for SARS-CoV-2 and so cannot prove that they ever had the virus.


When illnesses do not fit the biomedical model, there is a tendency in healthcare to apply what is known as a biopsychosocial model. This model allegedly considers biological, psychological and social factors, and the interaction of such, in conceptualising and treating illness. Many healthcare professionals will argue that they use the biopsychosocial model as a matter of course because it counters Cartesian dualism (mind-body splitting) and encourages a more holistic approach to health and illness. It’s a nice theory, but in reality the biopsychosocial model is not used holistically, at least not in the realm of medically unexplained symptoms.


What is important to consider in this respect is which pillar (bio, psycho, social) is being foregrounded and why. When dealing with medically unexplained symptoms or pathology evading objective detection, the ‘psychological’ or ‘psychosocial’ component of the biopsychosocial model is typically foregrounded. This means that it is possible to re-frame a physical illness (with no current biomarkers) as depression, or anxiety, or even mass hysteria. This is particularly easy for healthcare professionals to do because depression, anxiety and mass hysteria do not have diagnostic biomarkers, so such re-framing cannot be medically proven or disproven.


The biopsychosocial model is important for Long Covid patients to understand, because this model underpins cognitive behavioural therapy (CBT) and graded exercise therapy (GET), two biopsychosocial inspired treatments that have long since been advocated by biopsychosocial proponents for ME/CFS, despite clear evidence of harm to many patients, particularly in the case of GET.


When the issue of prolonged Covid-associated symptoms first became apparent, worryingly high numbers of healthcare professionals and policymakers advocated CBT and GET (or some derivative thereof) as means of recovery, despite warnings from ME/CFS patients and patient organisations, scientists and medical professionals who are suffering with Long Covid.


Although NICE issued a statement in July clarifying that their current recommendation of GET for ME/CFS patients should not be assumed to apply to Covid patients, it could be argued that some members of the medical establishment and scientific community are heavily invested in pushing this line of treatment under some guise or other. Meanwhile, the fact that NICE have not issued a warning on their guidelines for ME/CFS (currently under review) has understandably been criticised by ME/CFS patients and their advocates.


The biopsychosocial model is also relevant for Long Covid patients because some biopsychosocial proponents argue that the greater number of symptoms a patient has, the more likely it is that their condition is primarily psychological. Furthermore, biopsychosocial literature discourages healthcare professionals from investigating patients with such numerous and disparate symptoms beyond routine bloodwork, on grounds that their illness is primarily psychological and that continued biomedical investigations may do more harm than good. Notably, it is argued, allowing continued biomedical investigations would be to ‘collude’ with the ‘dysfunctional’ illness beliefs and behaviour of the patient.


The relevance of this to Long Covid is clear: many patients suffer with an overwhelming plethora of symptoms and many patients are findings that basic tests come back negative or ‘nothing abnormal detected’. According to biopsychosocial philosophy, this is a good indication that such patients have a primarily psychological or psychosomatic issue which requires no further medical investigation. Hence, Long Covid patients’ concerns and attributions of their symptoms to biological pathology are dismissed, minimised and psychologised.


Long Covid researchers are beginning to catch on to this dynamic of multiple and disparate symptoms being a barrier to healthcare professional belief; indeed they seem somewhat surprised by it. A report issued by the National Institute for Health Research (NIHR) entitled ‘Living with Covid 19’ details a number of barriers to care faced by Long Covid patients due to the multisystem, disabling, poorly delineated, difficult to prove nature of the illness. These barriers apply to a number of other chronic illnesses which are multisystem, disabling, poorly delineated and difficult to prove, and all of these barriers have been repeatedly pointed out by people with illnesses such as ME/CFS. The UK press has duly picked up on the NIHR report findings and, predictably, presented these barriers as somewhat of a revelation.


Had sufficient portions of the medical profession, scientific community and mainstream media listened to patients with polysymptomatic and contested chronic illness over the last few decades, there would be no surprise over this, and the NHS would now be better equipped to help people with Long Covid. What is also not being said is that this dynamic of dismissing patients has much to do with (bio)psychosocial model of medically unexplained symptoms. There’s much more to say about this model, and the politics that underpin it; this will form part of a further blogpost.


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