Gordon Waddell, back pain, the subversion of the biopsychosocial model, and the UK government's development of a victim-blaming approach to disability

[rvallee]

Gordon Waddell, back pain, the subversion of the biopsychosocial model, and the UK government's development of a victim-blaming approach to disability
https://mecfs.substack.com/p/gordon-waddell-back-pain-the-subversion

Although in theory the biopsychosocial model applies to all areas of medicine, in practice it’s most often talked about in the context of mental health conditions. No-one talks about the BPS model when they’re discussing how to set a broken bone, or how to provide the correct antibiotics for a bacterial infection. It is most often discussed in the context of complex mental health problems such as addiction or depression.

In his 1987 paper A new clinical model for the treatment of low-back pain, Waddell introduced something new: a biopsychosocial model of back pain. In it, he claimed that back pain can be caused by psychological and social factors. According to Waddell, a person can develop back pain because they are depressed or anxious, or because they are unhappy at work. He partly blamed the rise in back pain-related disability on doctors who coddle their patients; according to Waddell, people remain sick and disabled because their doctors tell them they are. He argued that it is important to distinguish ‘nominal’ from ‘substantive’ diagnoses; in ordinary language, this is the idea that some people are really sick (substantive), but others are not really sick at all (nominal). This is similar to the idea in UK government policy that there are deserving and underserving poor; an idea which is used to justify denying state benefits to those who are deemed ‘undeserving’. In Waddell’s view, most disability due to back pain is nominal; these patients should be expected to return to work, and should not be allowed long-term disability benefits.​

 

[rvallee]

I don't think I've ever seen a more perfect example of No true Scotsman outside of politics than the biopsychosocial model and what it claims to be. In real life it simply has no relation whatsoever to its core ideas.

The biopsychosocial model of medicine was introduced by the internal medicine doctor and psychiatrist George Engel in 1977. Engel argued that it isn’t enough for doctors to be experts in biological medicine, they must also understand psychological and social factors that affect their patients, and they must deal with patients holistically, that is, they must see the patient as a whole person, not just as a collection of symptoms, signs and diagnoses.

The whole thing makes no sense, and doesn't even require a model. Physicians are trained in biology and physiology, there is no believable way they could ever understand or contextually apply the "social factors that affect their patients".

No one can even do that reliably, even less so in the 30 seconds or so it takes the average MD to default to psychosomatic ideology. They can try, but the idea that they could develop expertise at those is as laughable as a benevolent aristocracy, it will simply never happen because of human nature. Even the people who spent their whole career are no better at it than a dice throw.

You may as well build a model of justice based on the idea of judges being able to tell who is lying and who isn't. You can always build such a model, it just will never work as stated. It's a fantasy.

 

[Kitty]

Physicians are trained in biology and physiology, there is no believable way they could ever understand or contextually apply the "social factors that affect their patients".

I think I know what you mean, but actually general practitioners do understand some of the social factors and would love to be able to mitigate them. But they can't get people out of cold, pest-riddled homes covered in black mould, they can't give parents enough money to feed their kids and still have something left for themselves, they can't do anything about poor, low paid, insecure work, and they can't help older or disabled people find less physical employment that doesn't aggravate pain and wear-and-tear joint damage so much.

Those factors cause a lot of illness, have a huge impact on mental health, and are going to result in a future workforce with significant numbers developing the chronic illnesses of middle age in their 30s and 40s because of poor diet, and/or who are very poorly educated because study's a low priority when you're regularly hungry and cold. Family doctors understand it, many are genuinely despairing about it, and some say they are leaving the profession because of a combination of the unmanageable workloads and moral injury that result from it.

 

[alktipping]

Gordon waddell was a hatchet man and like every hatchet man employed by governments was well rewarded for screwing over millions of people by changing the benefits system.

 

[rvallee]

I think I know what you mean, but actually general practitioners do understand some of the social factors and would love to be able to mitigate them. But they can't get people out of cold, pest-riddled homes covered in black mould, they can't give parents enough money to feed their kids and still have something left for themselves, they can't do anything about poor, low paid, insecure work, and they can't help older or disabled people find less physical employment that doesn't aggravate pain and wear-and-tear joint damage so much.

Those factors cause a lot of illness, have a huge impact on mental health, and are going to result in a future workforce with significant numbers developing the chronic illnesses of middle age in their 30s and 40s because of poor diet, and/or who are very poorly educated because study's a low priority when you're regularly hungry and cold. Family doctors understand it, many are genuinely despairing about it, and some say they are leaving the profession because of a combination of the unmanageable workloads and moral injury that result from it.

I definitely agree. But no one can effectively and reliably do this. Even less so in the 5-10 minutes or so that the average medical consult lasts. There are too many biases, it would take too much time, and there are no reliable methods. This requires general intelligence, which is rare and even harder to teach, a lot of empathy, psychological flexibility, and still not everyone can do it. Even less so doctors who tend to live on the complete opposite end of those social problems, who are trained in a hard science education process, where social skills are fully optional.

It's one of those "if we could do it, it would be great". And it would. Just like everyone having $100K/year income with no inflation and low cost of living. One day we'll be able to do it. Doesn't mean it will happen, but it will be possible. Right now, it's just fantasy. Fantasies don't make for effective systems in real life.