1

Evolving Models of
Health Care

• What is the World Health Organization definition of health?

• How do disease, sickness and illness differ?
• How does primary prevention differ from secondary prevention?
• What is the difference between direct and indirect risks to health?
• How have traditional medical systems influenced modern health care beliefs and practices?
• What was the significance of the Flexner Report?
• What is the biopsychosocial model?
• What is the integrated sciences model?

Health, Illness, Sickness, and Disease would be considered not only necessary, but also
sufficient, to produce health.
Sickness is different from having a disease.
What is the World Health Organization definition of An in­dividual can look and feel sick, yet have no
health? identi­fiable disease such as an infection, defec-
tive organ, or impaired physiologic functioning.
The most fundamental definition of health is Conversely, a person can have a disease for any or
“the absence of disease or disability.” The World all of these reasons but not feel or act sick. Being
Health Organization (WHO) defines health as perceived as sick by others or feeling sick oneself
a state of complete physical, social, and mental implies as­suming a sick role that is defined with-
well-being. Health is measured by the patient’s in relation­ships, families, the workplace, or the
ability to cope with everyday activities and func- community. It frees a person from the obligation
tion fully physi­cally, socially, and emotionally. At to perform the tasks of everyday living without
its optimal level, good health provides for a qual- blame (“I just feel too sick today to go to work”).
ity of life marked by spiritual serenity, zestful There are, however, certain obligations that the
activity, a sense of compe­tence, and psychological sick person must fulfill: (1) rely on experience or
well-being. seek professional assis­tance to find ways to get
better, and (2) adhere to culturally or professional-
ly prescribed regimens that will facilitate a return
How do disease, sickness and illness differ? to health reasonably quickly.
Illness represents the totality of how the patient
Disease is defined by its etiology; that is, as a pro­ behaves and feels, how the patient perceives the
cess that is caused by environmental trauma, bio­ dis­ease, and how the family and community
logic malfunction, or an identifiable agent or sub­ respond to these perceptions. Illness behavior
stance (e.g., pneumonia that is caused by a virus varies accord­ing to the person’s place within the
or bacterium). Disease may be due to a structural family or com­munity. For example, it may reflect
de­fect, such as an aortic aneurysm, or a functional the person’s at­tempts to gain attention. From the
impairment, such as an underactive thyroid gland community’s point of view, it may be seen as
(hypothyroidism). In each of these examples, retribution for past mis­deeds, as a chance occur-
medi­cal intervention aimed at the causative agent rence, a burden imposed to test will, or belief in
 The Behavioral Sciences and Health Care

a higher power. The patient’s explanation of how disease, injury, sickness, and illness and the pro­
or why the illness occurred (ex­planatory model), motion of health. To achieve these goals, health
and the course the illness takes, determines how care professionals not only apply medical treat-
the patient behaves and how the larger community ments, but also seek to change patient behaviors,
will respond. beliefs, social and cultural practices, and environ-
Disease, sickness, and illness can, but do not mental conditions. To do so successfully requires
necessarily, coexist in a patient. For example, a knowledge of the ways these factors affect patient
pa­tient can have a disease, be seen as sick, and yet health and the methods by which they can be
act well. This may reflect resiliance or denial or, as effectively modified.
in the case of early asymptomatic phases of some
dis­eases, may reflect reality. A person can have a
dis­ease, not be seen as sick by others, and yet act
ill. This may reflect a need for support, or acknowl­ Health Promotion and Maintenance
edgment of some real or perceived malfunction-
ing and is often encountered in individuals who
have a “hidden” condition (e.g., spinal stenosis). How does primary prevention differ from secondary
In these instances, except for the patient’s sick prevention?
role or ill­ness behavior, the condition would not
be apparent to and, therefore, acknowledged by The health of individuals and populations is
others. A per­son also may have no identifiable main­tained by measures that promote primary
physiologic pa­thology but feel sick. This is com- and sec­ondary prevention. Primary prevention
mon in persons experiencing stress. The individual involves practices to protect, promote, and main-
may manifest the stress response by behaving ill, tain health, such as exercising regularly, maintain-
focusing upon the physical symptoms rather than ing a normal weight, and eating nutritional foods.
the sources of the stress. Indeed, in all of these dif- It also involves avoidance of activities that jeopar-
ferent cases, as­suming the sick role or displaying dize health, such as smoking or substance abuse.
illness behavior may help to rally external support Secondary preven­tion involves practices that
for the individual’s coping efforts. Thus, assum- enhance resistance to disease, such as immuniza-
ing the sick role and en­gaging in illness behavior, tion, medical surveillance, and health screening.
under certain circum­stances, can be the first step Primary prevention programs may focus on
toward health. in­dividuals or communities. Community programs
include education (e.g., about general health,
school safety, violence prevention, or safe sexual
What is the difference between direct and indirect practices); government programs include main-
risks to health? taining good sanitation or eliminating environ-
mental hazards (e.g., eradicating mosquito breed-
Action may be taken in response to direct or indi­ ing areas), and universal immunization programs.
rect risks to health. Direct risks to health are prac­
tices that endanger good health (e.g., reckless driv­
ing, excessive alcohol or caffeine consumption).
In­direct risks to health are lower risk practices Evolving Approaches to Health Care
or prevention failures (e.g., driving without a seat
belt, not exercising). Most risk factors are related Medicine likely had its earliest origins in primitive
to a person’s lifestyle and are, therefore, modifi- health care practices that began about 30,000 years
able. Some risk factors, such as age, race, gen- ago, but knowledge of the human body and theo­
der, or ge­netic makeup, cannot be modified by the ries of health care began to emerge in more system­
individual. Other risk factors, such as social class, atic form recorded by the Babylonians 6,000
religious practices, and cultural traditions, relate to years ago. The Code of Hammurabi defined surgi-
health status in complex ways and may or may not cal operations to be performed, scale of fees, and
be modi­fiable. penalties for malpractice. Five-thousand-year-old
Thus, the concept of health care has broadened Egyptian records describe symptoms of abdomi-
from the treatment of disease to the prevention of nal, eye and heart disorders, treatment of wounds,
Chapter 1: Evolving Models of Health Care 

fractures and dislocations, and an understanding entific study of medicine and formulating the first
that brain lesions were associated with paralysis of principles for professional conduct. Hippocratic
the opposite side of the body. medicine was the definitive standard for medi-
cal knowledge until Galen, in the second century
A.D., who began anatomical and physiological
How have traditional medicine systems influenced investigations. Based on animal dissection, many
modern health care beliefs and practices? of his findings proved to be in error, but there was
a beginning understanding of the respiratory, cir-
Major systems of traditional Chinese, Ayur­vedic, culatory, digestive, and neural systems.
and Greek medicine began to evolve be­tween Galen laid the foundations for what would
1500 and 500 B.C., and became the bases for tra- come to be called allopathic medicine by assert-
ditional health care systems currently practiced in ing that organic lesions led to dysfunctions, thereby
many parts of the world. Despite their cultural and establishing the principle that treatment of biologi-
geographic differences, there is evidence that there cal pathology was the primary concern of the phy-
was a vigorous exchange of knowledge, likely sician. Treatments were based on the law of oppo­
through trade and conquest, resulting in common sites, i.e., diseases were treated with medicines or
doctrines fundamental to all of these systems: interventions intended to create the opposite effect
1. The world is viewed as an integrated whole, of the symptom. Galenic medicine had a profound
subject to universal laws, governing all phe- impact on the development of medicine. With all
nomena including human behavior and health; its shortcomings as well as merits, it became the
2. The individual is a unified system of physical, unchallenged authority in medical dogma for 1400
mental, cultural and spiritual aspects of life; years, with the result that its dispersal worldwide
3. Health is a state of “balance” (homeostasis) influenced indigenous medical systems while sti-
between the individual and the universe and fling scientific advancement. The law of opposites
among elements, humors, and forces within the was loosely interpreted leading to the indiscrimi-
individual; nate use of enemas, bloodletting, purging, and
4. All living things are endowed with a “life other toxic and invasive procedures.
force” composed of male/female or other oppo- The resurgence of rationality, critical discourse,
sitional forces; and experimental investigation that marked the
5. Disease results from disruption of the life force Renaissance led to important advances in the devel-
or imbalance among humors, bodily functions, opment of medicine. By the 17th century, develop-
and external forces; ments in the natural sciences stimulated increasing
6. Symptoms are manifestations of the body’s research into the physical, mechanical, and chemi-
efforts to restore balance and health; cal functions of the body. By the 18th century,
7. The healer’s role is to aid the body’s efforts to challenges to Galenic or Allopathic medicine and
restore balance via treatments based on univer- treatments based on the law of opposites led to a re-
sal principles. affirmation of the physician’s role in assisting the
These early conceptualizations of disease and body’s healing efforts. This led to the development
health, rooted in indigenous cultural beliefs, con- of homeopathic, osteopathic, naturopathic, and chi-
stitute the subject matter of ethnomedicine (see ropractic approaches to medicine. (see Chapter 29,
Chapter 17, Culture and Ethnicity). While seem- Complementary and Integrative Medicine).
ingly primitive, they reflect a budding awareness
of the complex relationships among etiologic fac­
tors, the principle of homeostasis and the influ- What was the significance of the Flexner Report?
ence of stress conditions as well as insight into
the role of the healer. Thus, it is not surprising that By the end of the 19th century, medicine was
these concepts are prevalent and continue to influ- beginning to acquire a more scientific foundation
ence health care practices throughout the world and clinical techniques became more sophisticat-
today. ed and disease specific. Advances in microbiology
Modern medicine has its roots in the tradi- showed that microorganisms contributed to dis-
tions of Hippocrates (b. 460 B.C.), credited with ease and could be controlled by sterilization, anti-
establishing the first school dedicated to the sci- septics and immunization.
 The Behavioral Sciences and Health Care

At the same time, the quality of medical train- and a proliferation of psy­chologic and sociocul-
ing was being scrutinized. The Flexner Report, tural models of health care as alternatives to pure
published in 1910, called for the establish­ment of biomedicine. But these models were flawed in the
higher standards for U.S. medical educa­tion and same way as biomedicine – too narrowly psycho-
defined biomedicine as firmly grounded in the logical or too narrowly sociocultural, emphasizing
basic biologic sciences and scientific method­ology. the importance of their specific fac­tors but failing
Public support for research and training in­creased, to take into account how these fac­tors interacted
leading to the provision of enormous fi­nancial and with biologic factors. By the mid 1970s there was
technological resources. However, by defining increasing recognition that a more comprehensive
scientific medicine as solely biological and ignor- approach to health care was needed.
ing the contributions of other sciences, the broad-
er context of health care became obscure in post
Flexnerian medical education and practice. What is the biopsychosocial model?
The limitations of biomedicine became evi-
dent during WW II when the treatment of injured In 1977, an internist at the University of Rochester,
sol­diers suffering “shell shock” (posttraumatic George Engel, published an article in Science,
stress disorder) raised awareness of the influ- which proclaimed “The Need for a New Medical
ence of psychosocial factors on a patient’s ill- Model: A Challenge for Biomedicine.” Engel
ness and treatment outcome. This awareness led asserted that in this new biopsychosocial model
to the development of psychosomatic medicine (1) there are multiple determinants in the develop-
ment of dis­ease and the resultant illness process;
and (2) there is a hierarchical organization of bio-
Clinical Application of the Biopsychosocial Model logic and social systems that contribute to the dis-
ease and illness experience. Each system is a com-
A person can function normally physiologically with ponent of a higher, more abstract system, and any
only one kidney. Therefore, after recovery, an individu­ changes in one sys­tem will change other systems,
al who has served as a kidney donor can have normal especially those most closely linked to it within
renal func­tioning. In the biomedical model, this person the hierarchy (see Figure 1.1.). It follows that (3)
has returned to a fully healthy state. However, in the the psychologic and social sciences are equally as
biopsychosocial model, attention would be paid to the important as the natural sci­ences in understanding
psychosocial pa­rameters of the patient’s condition as the determinants of illness.
well as the bio­logic state of health. Recovery may be During the early 1970’s, behavioral research
facilitated if the donor knows the recipient was helped was already generating convincing data support-
by the donation, the community applauds the donor for ing what was to become known as the biopsy-
the gift, and the donor believes that full and rapid recov­ chosocial model, including the importance of
ery is ex­pected. On the other hand, the donor may feel cogni­tion, learning, society, culture and the envi-
dam­aged or otherwise impaired, or may feel that insuffi­ ronment, as well as biology, in determining health
cient gratitude was expressed. These latter perceptions and ill­ness. The Canadian government’s Lalonde
may slow or prohibit full functional recovery (i.e., a Report of 1974 and the U.S. Surgeon General’s
re­turn to life as it was experienced preoperatively). Report of 1979 concluded that most major health
In the case of the kidney donor, no biologic inter­vention problems confronting North Americans had their
beyond appropriate postoperative care is re­quired. origins in individual behavior. The field of behav­
However, the biopsychosocial model recognizes that ioral medi­cine emerged as an interdisciplinary
education about the physiology of renal function­ing research effort to define the empirical linkages
is essential to reassure the patient of his/her biologic between the behav­ioral and biomedical sciences.
integrity; information about the benefits to the recipi­ What was needed was a blueprint, a theoretical/
ent will reinforce the donor’s sense of self worth by conceptual framework, to guide this interdisciplin-
ac­knowledging his/her altruism; the support of family ary effort. The biopsychosocial model needed to
and the community can be useful in permitting a peri­ be moved beyond the no­tion of an amalgamation
od of recovery followed by graded reintegration to full of distinct sciences to the notion that medicine is
activity. really the product of the in­tegration of these dis-
tinct sciences.
Chapter 1: Evolving Models of Health Care 

Figure 1.1. Biopsychosocial model grated system of many interacting variables that
can be organized under five domains: biological,
behavioral, cognitive, sociocultural, and envi­
Systems Hierarchy
ronmental (see Figure 1.2.). Each domain repre-
(Levels of Organization)
sents a category of information that is critical to
the evaluation of the patient. The variables within
Biosphere
each domain are constantly interacting with vari­
↕
ables in all the other domains such that any change
Society-Nation
in one effects a change in all the others. Like all
↕
systems in all sciences, the human system strives
Culture-Subculture
to maintain an optimal balance, not only within
↕
each of the domains but between them. Hence, the
Community
con­cept of homeostasis applies to psychosocial as
↕
well as biologic phenomena and defines one of the
Family
uni­versal integrating principles.
↕
Any challenge to homeostasis is regarded as
Two-Person
stress. This is not the popular, narrow notion of
↕
situational stress but rather the universal prin-
Person ciple that describes any “system under strain.” Of
(experience & behavior) course, stress or challenge is not the problem, per

se. First, the degree of stress determines, in part,
↕
the nature and intensity of the response. Ev­ery
Nervous System
college student is familiar with the “inverted U”
↕
shaped curve describing the relationship between
Organs/Organ Systems
stress and productivity. Too little chal­lenge (stress)
↕
is poorly motivating, hence poor performance. Too
Tissues
much challenge (stress) can impair perfor­mance.
↕
Moderate challenge (stress) appears to be optimal,
Cells
i.e., enough to motivate and inspire, but not over-
↕
whelming.
Organelles
Second, it is the stress response, or more spe-
↕
cifically, its failure in enabling the individual to
Molecules
successfully cope with, adapt to, and resolve the
↕
stressful condition, that defines the individual’s
Atoms
health vs. illness. It is the breakdown or dysfunc-
↕
tion of the stress response that constitutes disease
Subatomic Particles
or disorder. Ironically, it is also the successful
functioning of the stress response that can some-
times contribute to disease and disorder, as in auto-
immune diseases where an “overzealous” immune
The Integrated Sciences Model of system begins to attack its own host body.
Health Care The stress response is composed of biologi-
cal reactivity (physical symptoms), as well as
behavioral, cognitive, and sociocultural reactivity,
What is the Integrated Sciences Model? each domain influenced by genetic determinates,
learning processes and past experience. Biological
In the Integrated Sciences Model (ISM), psy- reactivity reflects the complex interplay of the
chosocial phenomena are functionally connected body’s “life support” systems and their genetically
to bio­logical phenomena in accord with common predetermined response to homeostatic challenge,
univer­sal principles such as homeostasis, stress manifested as the physical “symptoms” commonly
adaptation, learning and development. According associated with the stress response (see Chapter 7,
to this model, each pa­tient is a complex but inte- Stress, Adaptation, and Illness).
10 The Behavioral Sciences and Health Care

Figure 1.2. Integrated Sciences Model

Biology
Genetics
Bio System Response

Behavior Environment
Coping Life Events
Illness Reinforcers

Cognitive Sociocultural
Appraisal Social Support
Meaning Customs, Values
“Explanatory Models” Sanctions

In every individual, any challenge (stress) to adulthood, setting the stage for potential ma­jor
any domain destabilizes the entire interdepen- health care problems later in life. As another
dent system and results in a multivariate response ex­ample, healthy diet (e.g., low fat, low salt, low
throughout all domains. This destabilization is not cho­lesterol), no use of tobacco, illegal substances
necessarily problematic since the patient may be or alcohol, and healthy physical activity, as well
able to cope, i.e. adapt quite well in all domains. as healthy stress response patterns (e.g., reducing
For example, biological challenge (disease) can the Type A re­sponse) aid in preventing high blood
necessitate behav­ioral adaptation (take medicine), pressure, coro­nary heart disease, diabetes and cer-
cognitive adapta­tion (“I can’t work and need some- tain cancers in adults. Thus, establishing and main-
one to cover for me”), sociocultural change (let taining healthy lifestyle patterns early in life are
mom take care of me) and environmental change essential for con­tinued good health in later years.
(move to a healthier climate). How variables in the five domains interact over
The system is evolutionary, that is, con­tinually the life span of the individual is a product of adap­
subject to adaptive change. As a person en­counters tive experience. The basic process underlying this
new experiences, stressful challenges or changes adaptive experience is learning in all its forms,
in one domain, responses in other domains are from the most fundamental reflexive act to the
induced. This complex interaction of domains most complex abstract conceptual formulation. No
contributes to the health condition of the patient other process is sufficient to account for the myr-
at all ages and developmental levels from “womb iad connections that have been demonstrated to
to tomb.” For example, caught up in change and exist among variables in the domains. The lines of
ex­perimentation, adolescents engage in behaviors the pentagram in Figure 1.2. represent the acquired
that may become health threatening. Atti­tudes and or learned connections be­tween these variables. It
patterns related to diet, physical activity, tobacco, is understanding the mechanisms underlying these
alcohol and substance abuse, safety and sexual interactions that is the focus of behavioral medi-
behavior may persist from adolescence into young cine research.
Chapter 1: Evolving Models of Health Care 11

Diagnostic Assessment stop ciga­rette advertisements) are likely to fail.

Health be­haviors are complexly determined and
The accurate assessment of the differential and the probabil­ity of change is maximized only if
interactive con­tributions of biological, behavioral, treatments ad­dress all of the contributing factors.
cognitive, cul­tural and environmental risk factors Thus, the ISM demonstrates that optimal treatment
and etiologic agents is essential to determining the must be multimodal. In our example, a multimod­
most effica­cious treatment interventions or strat- al approach might involve the following:
egies. Thus, com­prehensive evaluation of every • Biological: Nicotine patches to counter nico-
patient should in­volve a detailed exploration of the tine dependence
variables within each of the five domains. By so • Behavioral: alternative work breaks such as
doing, the physi­cian determines the nature of the ex­ercise; social gatherings in nonsmoking ven-
problem, identi­fied not only in terms of biologic ues; stress management training
symptoms and etiology, but also where it occurs • Cognitive: require patient to explain to others
(environment), what the patient was doing at the (e.g., young people) how smoking is harmful;
time (behavior), what the patient was thinking, ex­pose to high-profile, high-status nonsmokers
saying, interpreting (cog­nition) in what setting, as models
with whom, under what cir­cumstances, and with • Cultural: encourage family to reinforce not
what consequences (sociocul­tural). Having this smoking; limit smoking to inconvenient and
comprehensive information in­forms the physician uncom­fortable places; encourage patient to
about the complex biobehavioral interactions that join a “smok­ers anonymous” group
contribute to the particular disor­der and so pro- • Environmental: make smoking materials less
vides the information required to design an effec- accessible, e.g., raise taxes, restrict access; pro-
tive treatment plan. mote nonsmoking social and recreational areas
The model illustrates the complexity of fac- (note link with Culture)
tors contributing to this major health risk, and why Not all interventions will be feasible but a
treat­ments that focus only on one domain (e.g., multimodal approach is more likely to be suc-
change smokers’ cognitions) or one variable (e.g., cessful than a single intervention that targets a
non-responsive variable. Extrapolating beyond
the individual pa­tient, the same principles apply
Clinical Application of the Integrated Sciences Model to community, re­gional, and global health pro­
grams. For example, by identifying the treatment
A patient has been advised by his doctor to give up goal of a public health initiative, e.g., reduced
smok­ing because of chronic obstructive pulmonary dis­ incidence of dengue fever (biological domain),
ease (COPD). Reduced smoking behavior is the treat­ a health care researcher can identify factors that
ment goal. We review the domains in Fig. 1-2 and the contribute to the prob­lem: (1) behavioral factors
variables that influence smoking using (-) after a vari­ – no one takes responsi­bility for draining or treat-
able if it discour­ages smoking, and (+) if it encourages ing standing water; (2) cognitive factors – no pub-
smoking: lic awareness about how to treat the problem; (3)
Biological: COPD (-), nicotine dependence (+), cultural factors – lack of community coordina­tion
ge­netic factors (+/-) of efforts (house construc­tion, social and personal
Behavioral: peers smoke (+), social gatherings (+), habits contributing to infection risk); and (4) envi-
social censure (-), stress reduction (+), ronmental variables – poor drainage is a known
“cool” image (+). problem in swampy land. Thus, any effort, regard-
Cognitive: knowledge of smoking risks (-), belief less of magnitude, that targets a single variable
“I’m invulnerable, and can quit any­ will be less suc­cessful than a multimodal approach
time” (+), targeting multiple variables.
Cultural: value systems (+/-), gender models Even though a specific biobehavioral fac-
(+), social sanctions (+), roles in inter­ tor is important in the etiology of a condition, it
action (+/-) does not always play an equally important role
Environmental: accessible (+), relatively inexpen­sive in treatment (i.e., biologic causes do not always
(+), reinforcing advertisements (+) require biologic treatments). For example, in
cases of CNS damage, behavioral rehabilitation
12 The Behavioral Sciences and Health Care

is the best approach to re­establishing lost func- course of a disease, and the patient’s responses to
tion by programming other ar­eas of the brain to both the disease and its treatment. Specific genet-
perform that function. Although new drugs have ic, neuroendocrine, biologic, behavioral, cogni-
significantly improved the survival statistics for tive, sociocultural, or environmental models have
HIV and AIDS patients, behavioral management been proposed to explain specific disease states
of the psychological and social con­sequences of or health conditions. While highly circumscribed,
the disease and its spread is still a ma­jor focus of these models should not be dismissed but rather
disease management. Insulin-dependent diabetes should be included within the broader context of
also reflects the complex interaction of bio­logic the ISM.
(administering insulin) with behavioral fac­tors
(diet, exercise, monitoring). Dysmenorrhea and
premenstrual tension are clinical phenomena that
derive from a biologic basis but may be precipi- Recommended Reading
tated by and manifested as complex, multidimen-
sional biobehav­ioral conditions. Thus, optimally Carr JE. Proposal for an Integrated Sciences Cur­riculum
effective treatment will often involve combina­ in Medical Education. Teaching and Learning in
tions of biological/pharmacological and behav- Medicine 1999; 10:3–7.
ioral approaches. Cuff PA, Vanselow NA (Eds.). Improving Medical
As the name implies, the Integrated Sciences Education: Enhancing the Behavioral and Social
Model attempts to account for all the possible vari­ Science Content of Medical School Curricula,
ables and processes that determine the etiology and Washington, DC: National Academies Press; 2004.
Engel GL. The need for a new medical model: a chal-
lenge for biomedicine. Science 1977; 196:129–36.
Integrated Sciences Model Kandel ER. In Search of Memory: The Emergence of a
New Science of Mind. New York: Norton, 2006.
(1) Stress in the form of challenges or change (dis­rup­ Porter R. The Greatest Benefit to Mankind: A Medical
tion of homeostasis) in the biological, behavioral, History of Humanity. New York: Norton; 1997.
cognitive, sociocultural and/or environmental World Health Organization. The World Health Re­port
condition of the patient initiates responses in all 1997: Conquering suffering, enriching hu­manity.
domains (to restore homeostasis). Geneva, Switzerland: World Health Or­ganization;
(2) The system is constantly evolving. Challenges to 1997.
the organism are ongoing and the system is con­
tinuously adapting to the stresses of everyday life
and experiences.
(3) Disease is a byproduct of the individual’s efforts to Review Questions
adapt to biological, behavioral, cognitive, cultural
and environmental stressors. Therefore, accurate­ 1. A process that is caused by environmental
ly assessing the differential role of each of these trauma, biologic malfunction, or an identifi-
risk factor domains is essential to determining the able agent or substance is defined by which of
best treatment strategy. Treatment strategies may the following concepts?
address an etiologic factor directly or indirectly A. Disease
(i.e., biologic causes do not always require biologic B. Illness
treatments). C. Injury
(4) The treatment, itself, will have direct biological, D. Sick Role
behavioral and cognitive effects on the patient, as E. Sickness
well as cultural and environmental impacts (side
effects). 2. Scientific standards for modern biomedicine
(5) Thus, the treatment response may require addi­ and educational standards for modern medical
tional intervention in any or all of the domains education are associated with which of the fol­
(e.g., combined biologic and behavioral therapies lowing?
for stroke patients). A. The Biopsychosocial Model
B. The Explanatory Model
Chapter 1: Evolving Models of Health Care 13

C. The Integrated Sciences Model

D. The 1910 Flexner Report
E. The 1979 Surgeon General’s Report

3. Defining all the variables and processes that

contribute to health, disease, sickness and
ill­ness, and the complexity of biobehavioral
mechanisms by which they interact and are
inter­dependent defines which of the following
mod­els?
A. Behavioral Model
B. Biomedical Model
C. Biopsychosocial Model
D. Integrated Sciences Model
E. Sociocultural Model

Key to review questions: p. n