UN INTENTO DE REPRESENTACIÓN CARTOGRÁFICA

Although this holistic approach to teaching medicine is advocated by the US as in the Profile of the Stellenbosch doctor and reported internationally (GMC website accessed 24/08/2007), the medical fraternity is perceived to function in, what is termed the medical model, which focuses on disease and cure there of. However medical model approaches are not limited to medical doctors (Block, Ricafrente-Biason, Russo, et al, 2005) and may be evident in other members of the health team. The medical model assumes the similarities between patients with the same diagnoses are more than the differences, thus standardised treatment protocols can be used.

This is in contrast to the social model which first emerged in the 1970’s (Tregaskis, 2002) and saw disability as a reflection of an unaccommodating society (Byron, Cockshot, Brownet, et al, 2005). This model was initially politically driven by persons marginalised by disability and focused on the role that society has in determining the presence of disability as discussed with Watermeyer, a rehabilitation expert, in July 2007. This view was posed in opposition to the reigning medical model where disability was seen to be due to a problem within the individual. In the medical model the solution to managing disability would lie in medical interventions to remove or modify the impairment whereas the social model advocated that the solution to managing disability lies solely in the accommodation of impairment by the community (Byron, Cockshot, Brownet, et el, 2005).

These models however need not be mutually exclusive and the ICF serves to integrate both models allowing medical staff to identify their role in the overall management of the person with a disability (Fielder & Marshall 1994). In the researcher’s early rehabilitation experience the term bio psychosocial model was used to incorporate both the medical and social model. The White book on Physical and Rehabilitation Medicine in Europe (Gutenbrunner, Ward & Chamberlain, 2007, pp6) claims that PM&R is “guided by a bio psychosocial approach” which “adopts the ICF”. The White book is a consensus document of PM&R specialists in Europe and concurred with opinions of PM&R specialists in the UK and North America (Tuel, Meythaler & Penrod, 1996). The White Book described the bio psychosocial model as one that considers the pathology at the level of organelles, cells, tissues and organs, through to personal functioning and family, community and societal participation and thus can be paralleled with the ICF. In addition they noted that rehabilitation is a process which “starts with the onset of illness or injury and goes on right through to the individual achieving a role in society” (Gutenbrunner, Ward & Chamberlain, 2007, pp7).

An understanding of these models helps doctors to deal with these differences of opinion in challenging situations for example when they are required to match subjective definitions of disability with objective and fair measurements, such as when assessing disability for the purposes of employment equity, access to social support and financial compensation (Carey & Hadler 1986; Edlund & Dahlgren, 2002; O’Fallon & Hillson, 2005). A contextual challenge to the practice of an ICF or bio psychosocial model is the reality of SA medical practice in both rehabilitation and medical settings. McKee a chief staff member at WCRC suggested in October 2009 that medically driven hospital management reinforces the ultimate accountability of the doctor, irrespective of treatment decisions made by team members. There is also a danger of stereotyping the medical profession as a whole into a medical model when well meaning practitioners are faced by the reality of limited resources (Scott 2006), medico legal accountability and when individual practitioners are of the opinion that functional and social components of health are not within their scope of practice (Paris 1993; Owoeye, Ologe & Akande 2007). These may be the attitudes of senior or older staff who have not experienced or adopted this comprehensive approach (Dowrick, May, Richardson & Bundred, 1996). Students interact with these clinicians who serve as role models, positive or negative and who influence the attitudes that these students develop over the course of their whole MBChB curriculum and not just in the rehabilitation training (Whitcomb, 2005).

Apart from their own viewpoints on health care delivery, doctors need to understand the patient’s values, beliefs and expectations as to how health care should be delivered (Masasa, Irwin-Curruthers & Faure, 2005). Although patient autonomy and self directed health care is encouraged as Shapiro, Mosqueda and Botros (2003) described in patients who have lived with disability for more than ten years or who are older than 50, not all patients have this frame of reference and may expect the doctor to have the last say and be able to cure all as discussed with Watermeyer, a rehabilitation expert, in July 2007 and suggested by Scott (2006). This is of particular importance when dealing with chronic impairments where self management is crucial to the prevention of tertiary complications and further disability. The preface to the Oxford Handbook of Rehabilitation Medicine (Barnes & Ward, 2005) described rehabilitation as being different from most medical specialities in that the empowerment of the patient is central to the process and that goal setting is entirely dependent on the patient’s needs with the support of family and professional teams.

Thus regarding training medical students the literature supported a balance between establishing the role of the doctor in managing the medical aspects and instilling an appreciation for the complexity of factors causing disability. Students need to be taught how to put this knowledge into practice so that they are not overwhelmed when faced with a patient who presents with bio, psycho or social concerns.

2.2.3 Health conditions and bio psycho social problems in clinical rehabilitation