Biomedical models and healthcare systems

Editor—Wade and Halligan's new model will be useful if it encourages alternative ways of managing so called functional illnesses.¹ Take the example of low back pain as a condition where context is all important.

Patients with typical mechanical low back pain aggravated by prolonged standing will have a serious problem if, say, they work as a hairdresser but not if they have an office job. Thus their occupation rather than the disease will probably determine whether they seek medical attention. The new model implies that changing the context (suggesting the patient change jobs) is an equally valid way of managing the problem as looking for a “cure” for the low back pain. However, the model will be of real benefit only if policy makers transfer resources from diagnostic and treatment modalities to rehabilitative, educative, and occupational programmes, making the option of retraining realistic and achievable.

The new model also highlights the tension between the responsibility of individuals and that of society in managing “dysfunction.” As a society we seem to be moving much more to the viewpoint that society's duty is to adapt to the dysfunction of individuals—see current disability regulations—rather than the individual's responsibility is to find ways of coping with a disability. Inevitably this view affects the range of “dysfunction” that healthcare systems are expected to deal with, and, as Wade and Halligan suggest, this needs to be openly debated.

Figure 1.

Proposed model of illness (BMJ 2004;329: 1398-401)