Being Scientific in the Human Domain: From Biomedical to Biopsychosocial

We include as biology not only the data obtained by observing other individuals and things but also those that we reach through [our own inner experiences of living]. The biologist is himself of the same material of which are composed the living things that he studies.

H.S. Jennings, 1933

Biologist Herbert Spencer Jennings’ early insistence that “inner experiences” are proper data for biology was my first encounter with the idea that the use of subjective data need not violate the conventional requirement for scientific respectability. Quite by chance, in 1937 as a college student, I had stumbled on Jennings’ Behavior of the Lower Organisms.1 As a biologist, Jennings deemed his inner experience as a living organism no less integral for understanding living systems than his outward observations that were customarily relied on for information about the physical (nonliving) universe. However, some 20 years would pass before the complementarity of outer observation and inner experiencing fully took hold for me as a physician and helped me define the requirements for being scientific in the human domain.2–9

As a profession and an institution, medicine owes its origin to three distinctively human attributes. First, we humans are aware of death and its inevitability and we realize that feeling and/or looking bad (“sick”) may be its portent. Second, we suffer when our interpersonal bonds are sundered and we feel solace when they are reestablished. Third, we are capable of examining our own inner life and experience and of communicating them to others via a spoken and written language. Critical for all three and for the work of the physician is the distinctively human capability of using words to communicate both what is being observed in the outer world, as well as what is being experienced within the inner world. For each of us the distinction between sick and well is preeminently manifest as inner experience, which must be communicated verbally in characteristic ways to become known. Surely, as scientists dedicated to organizing our experiences and formulating observations, we should be careful to define science in such a way as to be able to include verbal reporting as legitimate data.

From biomedical to biopsychosocial refers to an historical transition in scientific thinking that has been taking place over the past century and a half.6 Particularly pertinent for medicine is its explicit attention to humanness. That alone identifies biopsychosocial as a more complete and inclusive conceptual framework for guiding clinicians in their everyday work with patients. Physicians have always depended on what patients have been able to tell them about the experiences that led them to seek medical attention. This is testimony that the importance of verbal exchange between patient and physician is the primary source of the data required for the clinician’s task. Scientists studying sick, diseased, or even dying animals or plants do not have a comparable resource; they are limited to what can be observed, as are all scientists dealing with physical or infrahuman systems.

That we humans are able to participate actively in our own study by looking inward and by contributing information that is otherwise not available should be a great scientific advantage. Yet, paradoxically, biomedical thinking, a 20th-century derivative of 17th-century natural science, categorically excludes from science what patients have to tell us on the grounds that it is nonmaterial in form and not measurable or subjective and not objective. On those grounds alone even posing such a question is axiomatically disallowed. Instead, the human domain as a whole is seen as the art of medicine, subject neither to systematic inquiry nor to the possibility of teaching.

However, the history of medicine as far back as the papyri of Egypt of 5 millennia ago documents that information provided by patients was deemed sufficiently valuable to justify writing ways that doctors might improve their skills in eliciting such.10 Paradoxically, its exclusion from medicine by medicine’s science notwithstanding, few clinicians would seriously argue that what patients tell us can therefore simply be disregarded. Rather, the issue hinges on what has become a cultural imperative of western society, namely, that the canons of science as defined in the 17th century continue to apply. The possibility that the premise itself is a fallacy is simply ignored. This is what we now examine.

What we observe is not nature itself but nature exposed to our method of questioning.

W. Heisenberg11

Physicist Heisenberg’s dictum exemplifies a fundamental distinction between 17th- and 20th-century scientific thinking, the latter of which is derived from such conceptual developments as evolution, relativity, quantum mechanics, general systems theory, far-from-equilibrium thermodynamics, and, more recently, chaos and complexity theory. Loosely speaking, we are applying biomedical and biopsychosocial as labels to contrast the two positions.8

Actually, what Heisenberg enunciates is what clinicians have known from time immemorial—namely, that the answers you get from a patient depend on the questions you pose and how you do so. More broadly, it exposes the fallacy of the 17th-century natural science position that what scientists discover exists entirely external to and independent of themselves. In fact, rather than simply examining or observing something “out there,” scientists devise mental constructs of their experiences with the observed as a means of characterizing their understanding of its properties and behavior. This change in perspective began in physics with relativity theory, which required acknowledgment that the location of the observer cannot be ignored relative to what is being observed. The rediscovery of the obvious occurred in that transformation—namely, that science itself is a human activity. The lesson is that humanness and human phenomena cannot be excluded from science. Medicine’s long history of successful utilization of what patients have to say about their experience of illness itself surely suffices to justify reviving earlier efforts at developing more systematic (ie, scientific) approaches to so doing.

It is important to ask questions of patients because with the help of these questions one will know more exactly some of the things that concern disease and one will treat the disease better.

Rufus of Ephesus, 1,000 a.d.10

The first formal document solely about the value of the information patients can provide is credited to Rufus of Ephesus. Surely, his words “will know more exactly” eloquently reveal his advocacy of an approach more scientific than those solely dependent on chance, fate, magic, or mysticism that were so commonplace in those days and that are still evident today in some instances of so-called alternative medicine. Rufus thereby revealed his intuitive awareness that the very universality of sickness and death as human experiences rendered the patient a logical source of primary data.

The sick person’s appeals for help and the helping responses evoked thereby already reflect a biologic social interdependency with a long evolutionary history, which, in humans, was evident early in the response to the crying of an infant. In that biologic constellation are already suggested the origins not just of sick role behavior but also of the profession’s and institution’s responses thereto. What originated in infancy as nonspecific cries of distress are eventually differentiated to include personal and social awareness of being sick as a distinctive category of distress. Similarly, what may have begun merely as helping responses comes to oblige the helper to differentiate sickness from other types of distress. The mother’s inquiry of her child as “What’s wrong?” or “Are you feeling all right?” can hardly result from anything other than learning by living and experiencing; she has already gone through the same steps in growing up, as have most of us.

Intuitively, doctors tend to take such lay opinions seriously if for no other reason than that they often do prove to be correct. But such judgments by physicians are still mainly extensions of natural reactions with which we all have grown up. They are not yet scientifically based. Biopsychosocial thinking aims to provide a conceptual framework suitable for developing a scientific approach to what patients have to tell us about their illness experiences. But to accommodate the human domain, science and being scientific must be redefined.

The object of science is to render as reliable as possible whatever claims to knowledge we make…[and is achieved] by reasoned efforts that ultimately depend on evidence that can be consensually validated.

Charles E. Odegaard, 198612

Historian Odegaard’s succinct statement may be viewed as an effort to provide a more generic definition of science and being scientific, one that is independent of domain or method. With respect to the patient’s verbal report of an illness experience and the doctor’s version thereof, both constitute claims to knowledge about what each believes he or she knows about what has happened and about what the patient’s experiences were like. These constitute the data on which the doctor depends for further study and decision making. Doing so scientifically requires the discipline to enhance the reliability of the very process of data acquisition itself.

To explore scientific acquisition of verbal data, we can exploit the fact that every reader has surely experienced falling ill. I propose that readers pause and mentally reconstruct a recent occurrence of not feeling well, no matter how trivial, just as one might in anticipation of seeing her or his physician. I will do the same; but please do not look at my account until you are satisfied that what you have put together really represents what you think you would want to share with your own doctor. Our respective offerings may then be examined to see how useful Odegaard’s generic definition may be for the scientific handling of what patients tell us about feeling ill. You might find it worthwhile to put your thoughts in writing as I do now.

I had another of those unpleasant episodes last night. I awakened early, about 5 a.m., feeling vaguely uncomfortable. Then gradually I became aware of a steady, annoying sensation in my throat, a familiar recurring experience awakening me from sleep. The sensation is hard to describe—it is clearly located at the level of the suprasternal notch, I can indicate it with my fingers, as a “full” feeling, as though somehow being stretched; slightly achy, steady; a little lump, a little sore in the throat.