Teaching Health as a Biomedical Construct is Harming Patient Health and Burdening Our Health Services

In 1949 the British National Formulary contained around 250 drugs. Today it lists over 18,000 (Mir et al., 2021). The miraculous promise of modern medicine is that there seems to be a “pill for every ill”. The peril is overprescribing these drugs and patients suffering from side effects. Over the past 20 years, there has been a fourfold increase in prescriptions for diabetes treatments, sevenfold increase for antihypertensives, and twenty-fold increase for statins (OHE, 2009 ; NHS Digital, 2017). The National Overprescribing Review similarly reports that the number of medicines prescribed in England alone has doubled from 10 to 20 drugs per head in 10 years (DHSC, 2021). It’s unsurprising therefore to find that around 10 – 20% of in-patient hospital admissions are now due to adverse drug reactions (ibid.) In other words, the very drugs that were designed to revive, restore, and renew good health, are now causing ill-health due to their clinical overuse. The Review further estimates that at least 10% of medications prescribed in primary care are considered unnecessary, wasting £2 billion every year. At a time when the NHS is underfunded and overworked—with reports of a current shortage of 12,000 hospital doctors (Health and Social Care Committee, 2022)—overprescribing is creating more patients, more ill-health and increasing spending on drugs.

The problem, in part, is that medical students are taught to view health as a biomedical construct; where health is defined only by the functioning of bodily systems and their molecular makeup. The biomedical model of health initially arose from the conclusion that all illnesses are a result of cellular abnormalities (Porter, 1999), and therefore health is achieved through rectifying these aberrant cells. Though this is relevant for many disease-based illnesses, the model loses its explanatory power for most mental health illnesses, the well-evidenced impact of psychosocial factors on overall health and wellbeing (Wills et al., 1997), and new research on the relationship between mental and bodily states, such as psycho-neuro-immunology (Danese and Lewis, 2017). The World Health Organisation recognised these limitations from the outset in 1948, and gave a more comprehensive definition of health as “a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity” (WHO, 2022). In comparison, the biomedical model offers too narrow a conception of what health and illness is.

Consequently, the dominant use of the biomedical model in medical education creates a cultural tendency for future clinicians to reduce medical conditions—many of which are affected by complex biopsychosocial interactions—into simple diagnoses. The patient experience is minimised and isolated to biological symptoms, and the inevitable outcome is to favour biomedical interventions, that are not without their harms. If the problem is only seen as biomedical, then the solutions considered by clinicians will only be biomedical, leading to the overprescribing of drugs.

In 1977, Engel challenged the biomedical model and introduced the biopsychosocial model of health and illness to capture the oft-ignored social, psychological and behavioural dimensions of illness (Engel, 1977). The benefit of this holistic model of health is that it creates a wider paradigm for evidence-based medical interventions to be considered, beyond ‘plasters and pills’. If diseases can be accurately conceptualised by their underlying biopsychosocial context, then their remedies can take the form of non-pharmacological interventions, working at the root causes. It’s reimagining what effective and meaningful healthcare delivery can be. As Gavin Francis aptly wrote “drugs can be the least of healing, and the idea that therapies must be something that you swallow or inject – that they should be pills or syrups or infusions – is manifestly untrue” (Guardian, 2022).

Therefore, what’s currently missing in clinical education is the fundamental appreciation that though illness is a medical problem, it demands more than a medical solution. The former Chief Pharmaceutical Officer, Dr Keith Ridge, acknowledged this when he suggested solutions to tackling the overprescribing crisis, and recommended social prescribing as “a constructive alternative to drugs for many patients” (DHSC, 2021).

What Social Prescribing Taught me About Cures and Remedies

Social prescribing involves a patient referral to local, non-clinical services designed to support social, emotional and practical needs. Referrals involve a link worker, who takes the time to co-design a social intervention with the patient, addressing their specific concerns. Effects of social interventions have been positively evidenced on improving mental health outcomes (Kimberlee, 2013) and reducing primary care and emergency service use (Polley et al., 2019 ; Dayson & Bashir, 2014). Yet, a study in 2019 found that 93% of UK medical students had not heard of social prescribing before (Santoni et al., 2019). It is vital to fill this educational gap so that the future health workforce can move beyond overprescribing culture, and where necessary and most beneficial—seek alternative, evidence-based therapies with lower risks to patient health and the health system overall.

Two years ago, as a neuroscience undergrad, I volunteered at a weekly social prescribing drama workshop for early-stage dementia patients. I saw dementia beyond its neurofibrillary tangles and amyloid plaques, and found vibrancy in many who persisted through their disease.

There was David, a 77 year old retired priest. Every week he showed up in brightly coloured tracksuits covered in kooky patterns. At first I thought his eccentric dress-sense was a mark of him being mentally aloof. I considered his clothes as an expression of a confused perspective, dislocated from coordination and order, turning almost kaleidoscopic — a fragmented mind refracting the order of light into a psychedelic vibrancy. However, his partner Rachel explained that his sartorial flair was always present, even before his diagnosis. “He simply became more vibrant and daring once he joined the workshops”.

I saw that, despite his physical illness progressing, David and so many others found mental reprieve in these workshops. I saw how the benefits of traditional pills can be too singular and individualised as diseases diffuse across relationships, impacting whole families. But social prescribing offered something that no pill can — connection, validation, and acceptance. The patients, and their families, were better for it. And that is as great a remedy as any other.

Reorganising Healthcare Beyond Pills: A Hope for the Future

Currently the medical profession is swollen with feelings of despair and dissatisfaction. Patients’ waiting lists are growing longer, and the will of doctors is growing shorter. The health service, dulled by the pressures of the pandemic and current workforce crisis, is at a breaking point. At this time, the opportunity arises for us to reimagine a better, more sustainable health system. A system designed not just to respond to crises, but developed with a vision of health that is focused on prevention and recovery — a true National Health Service.

In truth, the overprescribing crisis is a crisis of education. Tackling overprescribing with better medical education presents the opportunity to reorganise healthcare; where the future health workforce is able to look beyond the pills and treat holistically. We are living in an age with more medicines, more therapies and yet also more illness. Envisioning health in its complete biopsychosocial form will ensure that when anyone falls ill again, their illness will not fall under the “hard hand of science”; their experience will not be reduced only to its biological symptoms. Their healing will be whole, and their care will be comprehensive, consistent, and compassionate. This is a hope for our future that can be made true.