Beyond Engel: Why Healthcare Needs a Digital Upgrade for the AI Era
A new framework for understanding health in our hyper-connected world
When George Engel introduced his groundbreaking biopsychosocial model in the 1970s, he fundamentally changed how we think about health and illness. No longer could we view disease through the narrow lens of biology alone—we had to consider the psychological and social factors that shape human health. It was revolutionary then, and it remains influential today.
But here's the thing: Engel couldn't have anticipated the digital revolution that would reshape every aspect of human experience, including our health.
As I write this from my iPhone (with apologies for any autocorrect mishaps), I'm struck by how seamlessly technology has woven itself into the fabric of our daily lives. We wake up to smartphones tracking our sleep, consult AI chatbots about symptoms, attend virtual therapy sessions, and rely on apps to manage everything from medication reminders to mental health check-ins. Yet our foundational models of health haven't kept pace with this digital transformation.
It's time for an upgrade.
The Digital Blind Spot in Healthcare
Don't get me wrong—Engel's biopsychosocial model was brilliant and remains essential. The idea that biological factors (genetics, physiology), psychological factors (thoughts, emotions, behaviors), and social factors (relationships, community, culture) all interact to influence health was paradigm-shifting. It moved us away from the reductionist biomedical model that treated patients like broken machines needing repair.
But today, there's a fourth dimension missing from this framework: the digital realm.
Consider this: How many hours do you spend interacting with digital devices daily? How often do you seek health information online? Have you ever used telehealth services, worn a fitness tracker, or relied on an app to manage a health condition? If you're like most people, digital technology isn't just part of your life—it's fundamentally shaping your health experience.
Yet when we assess patients or design health interventions, we rarely systematically consider the digital dimension. We're missing a crucial piece of the puzzle.
Introducing the BioPsychoSocioDigital Model
I propose we evolve Engel's model to include a fourth domain: the Digital. This BioPsychoSocioDigital Model recognizes four interconnected domains that influence health:
1. Biological: Our genetics, physiology, and physical health conditions—the traditional domain of medicine.
2. Psychological: Mental health, emotions, cognitive processes, and behaviors—how our minds influence our bodies.
3. Social: Interpersonal relationships, community connections, cultural norms, and societal influences—recognizing that health is fundamentally social.
4. Digital: The impact of digital technologies, including artificial intelligence and virtual reality, on health and human experience—acknowledging that we live in a cyberphysical world.
This digital domain isn't just about using health apps or telehealth platforms. It encompasses how constant connectivity affects our stress levels, how AI algorithms influence our health decisions, how virtual reality can treat phobias or chronic pain, and how the digital divide creates new forms of health inequality.
The Four Pillars of Digital Health Impact
Within this digital domain, I see four critical attributes that healthcare professionals must understand:
Digital Interaction: We're always connected, always receiving inputs from our devices. This constant stimulation affects our sleep, attention, stress responses, and social relationships in ways we're only beginning to understand.
Virtual Healthcare: AI is diagnosing skin cancer, VR is treating PTSD, and algorithms are predicting health crises before they happen. These aren't future possibilities—they're current realities reshaping how we deliver care.
Digital Divide and Accessibility: Not everyone has equal access to digital technologies, creating new forms of health disparities. Rural communities may lack broadband for telehealth, elderly patients may struggle with health apps, and low-income families may not afford the latest health monitoring devices.
Cyberpsychology: Our brains evolved for face-to-face interaction, not for processing the constant stream of information from our devices. Understanding how digital environments affect our psychology is crucial for modern healthcare.
A New Taxonomy for Modern Medical Practice
With this expanded model, we need new categories to describe how we practice medicine in the digital age. Here's a taxonomy I propose:
1. Digital-Integrated Care: Practices that seamlessly weave digital tools into patient care—think telehealth visits, AI-assisted diagnostics, and VR therapy sessions.
2. Personalized Medicine & Genomics: Using genetic information combined with AI to create truly individualized treatment plans.
3. Preventive Digital Health: Leveraging wearables, apps, and AI to monitor health and prevent disease before it occurs.
4. Cybermental Health: A new specialty focused on mental health issues arising from our digital lives—from social media addiction to cyberbullying trauma.
5. Socio-Digital Public Health: Addressing population-level challenges in our digital age, from combating health misinformation to ensuring equitable access to digital health tools.
Why This Matters Now
You might wonder: isn't this just academic theorizing? Why do we need a new model?
Because frameworks shape practice. The models we use to understand health influence how we train healthcare providers, design interventions, conduct research, and allocate resources. If our models don't account for digital factors, we'll continue to miss crucial influences on our patients' health.
Moreover, as AI becomes more sophisticated and virtual reality more immersive, the digital dimension of health will only grow more significant. We need frameworks that help us navigate this complexity thoughtfully and ethically.
The Human-Centric Digital Future
Here's what excites me most about this BioPsychoSocioDigital approach: it doesn't abandon the human elements of healthcare for flashy technology. Instead, it provides a comprehensive framework to understand how technology can enhance human-centered care.
When we recognize that a patient's smartphone usage patterns might be contributing to their anxiety, we can address it. When we understand how their social media environment affects their body image and eating behaviors, we can intervene more effectively. When we acknowledge that their access to telehealth might determine whether they receive timely care, we can work to remove barriers.
This model ensures that as we integrate more digital tools into healthcare, we don't lose sight of the biological, psychological, and social factors that have always been central to human health. We simply add another lens through which to understand the full complexity of health in the 21st century.
What Do You Think?
As we stand at the intersection of healthcare and technology, I believe we need new frameworks to guide us forward. The BioPsychoSocioDigital Model is my attempt to provide that guidance, but it's just a starting point.
I'd love to hear your thoughts: How has digital technology influenced your own health journey? What digital health factors do you think healthcare providers should be considering? Are there aspects of the digital health experience that this model doesn't capture?
The future of healthcare will be increasingly digital, but it must remain fundamentally human. Models like this one can help us navigate that balance.
Dr. Blackford Middleton is a physician and health informatics expert passionate about the intersection of technology and human-centered care. Follow him @bfm for more insights on digital health and healthcare innovation.
Share your thoughts in the comments below, and if this resonated with you, please share it with colleagues who might benefit from this perspective. Together, we can shape a more thoughtful approach to healthcare in the digital age.