In this two-part series, we will explore the ways in which an interdisciplinary approach to health science can offer unprecedented insight into the practice of medicine.
Simply evoke the idea of interdisciplinary science in a room of researchers, and you probably will get as many differing opinions as there are disciplines. Not only is there a struggle among the scientific community to define what exactly can be considered “interdisciplinary,” but there is also a harsh discussion on whether interdisciplinary research should be seen as an overhyped fad or the future of scientific inquiry. In the field of public health, interdisciplinary initiatives are undeniably appropriate given its immense scope, but the question remains: what do these interdisciplinary approaches have to offer us that a traditional ones cannot?
Dr. William G. Powderly, Director of the Institute for Public Health (IPH) at the Washington University School of Medicine (WUSM), weighed in with perspectives gained from his work in infectious diseases, in particular, HIV:
“At the beginning, you had a situation where you had a fatal disease, where the key was to find effective treatment,” Powderly said. Over a 10 year period, extensive study into the biological and genomic structure of HIV led to the development of antiretrovirals that were very effective in controlling HIV.
The development of these antiretroviral drugs is undoubtedly a major success in the scientific arena, but Powderly said he has seen a different picture emerge after the drugs hit the market. In the United States alone, an estimated 1.2 million people are living with HIV infection. Of the nearly 80 percent of people who are aware of their infection, about 50 percent have remained in the medical care system. And of the people who have remained in care, 77 percent have demonstrated viral suppression after treatment. Yet when these results are taken together, only 28 percent of all people living with HIV in the United States are able to control the infection successfully.
In trying to explain these results, Powderly said he realized that approaching the problem of HIV from a purely biological perspective was incredibly limiting. “What you start to realize is that under the biological model, you would say you make the diagnosis, you put people on treatment, and you get a successful outcome,” he said. “If you take it in a broader context, you realize that the factors that lead to failure are actually not traditional biological models, but are more social.”
This broader context moves the initiative for treating HIV away from a disease-orientated approach, which is concerned only with combating HIV in a research environment. Under what Powderly calls the “biological model,” a number of reductionist assumptions are made: first, that all people infected with HIV present themselves to the medical system, and second, that controlling HIV only involves controlling the action of the virus in isolation from the individual.
While researchers and clinicians are working tirelessly to control the action of HIV, a large majority of people infected with HIV are falling through the cracks of our medical system. “We actually have to address why the system doesn’t work, the reason why we don’t translate the benefit of a biomedical science into a broader healthier community,” Powderly said. “And this requires going outside the discipline of biomedical science.”
To this end, Powderly cited how the insights of behavioral scientists can help investigators understand the reasons many people do not get tested for HIV and why they do not seek care. Insights from economists and political scientists can help establish and finance health care systems that work. And within the field of medicine, HIV is becoming better understood within the context of mental health and addiction, and mental health specialists are integrating their work with traditional HIV treatment to deliver a more comprehensive approach in combating the disease.
These collaborations are made possible partly from the organization of interdisciplinary programs. Powderly said he believes these programs allow for problems to be addressed in a coordinated fashion across a continuum of disciplines. “You cannot mandate top-down cooperation and collaboration, Powderly said. “But if you create a framework, if you create enough opportunities for people from different disciplines to come together around a problem, then you can use that continuum of discovery at different points to advance not only to advance what a particular lab or group is doing, but also look at it [the problem] in its totality.”
An example of such a collaborative environment is the Program of Occupational Therapy at WUSM. Its director, Dr. Carolyn Baum, stresses the importance of an interdisciplinary approach in her work. “As an occupational therapist, it is virtually impossible to study everyday life in this environment without collaborating with the teams of people who are trying to make everyday life better for people,” Baum said. In one example, Baum cited researchers and clinicians at the Siteman Cancer Center, who, in the course of managing breast cancer, also need to understand the consequences of breast cancer in cognitive impairment.
“We have interventions that improve people’s cognitive capacity to deal with their daily lives, so we study it across different disciplines,” Baum said. “The neuroscientists may be interested in whether [a drug] changes brain structure and function because it is known that the drugs are causing some brain structure and function problems,” Baum said. “We bring pieces of science to try and figure out how to improve people’s’ lives, and it’s not just a matter of improving the impairment. It may be improving the person’s capacity or maybe building a better environment in which the person can function.”
Yet novel insights often require novel interventions. At Barnes-Jewish Hospital, Baum has been a part of building an acute stroke database. For the past 16 years, every patient that is admitted to the neurology floor at Barnes-Jewish Hospital with a stroke is asked if their data can be used in the database, which now contains the data of over 18,000 patients. Reviewing this database has led to unprecedented insight that has escaped the clinical literature until now.
For instance, Baum said she has found that, contrary to what many in the medical field had thought, stroke is not solely a condition of old age. Through the acute stroke database, Baum noted that 46 percent of the cases are of people who have had a stroke under the age of 65. Some of those admitted are as young as 18. Another troubling aspect is that 52 percent of the cases involve a mild stroke that does not affect motor performance. “They can dress themselves, they can feed themselves – all the things that rehabilitation itself was built to do, they could already do,” Baum said. In these cases, the patients leave Barnes-Jewish without citing the need for additional services. “But they have executive dysfunction, where they have trouble organizing, and sequencing, and making judgement,” Baum said. This hidden obstacle can quietly hinder an individual’s ability to transition back into the workplace and lower their quality of life back home.
Since the medical system is not currently able to offer the interventions needed for these individuals to transition back into their daily work and community, Baum said she is working with investigators on a number of clinical trials that help address this issue and enable a smooth transition from hospital to home. That intervention, which was first used for patients after a stroke, is now being used for women with breast cancer who have been on chemotherapy, who may also suffer from mild cognitive impairment from the treatment process. Framing cognitive impairment not solely within the context of breast cancer or stroke has allowed the recognition that interventions originally designed for one patient population can be effective for other populations as well. This problem-orientated framework organically allows for incorporating the insights from several disciplines in promptly responding to current health crises.
In Part 2 of this series, we will understand how an interdisciplinary approach to health is crucial not only in a traditional medical setting, but also in legislation, pharmacy benefit management, and design.