It might seem evident that assessment should be centred on the patient, but many patients feel they are objects to be dissected and quantified. As I discussed in ‘A model of person-centred rehabilitation’, the approach of the organisations providing and funding healthcare must also be person-centred, because they determine the financial and management arrangements. Personal factors are a crucial consideration in all rehabilitation. Being person-centred is a core principle of rehabilitation thinking. It is essential for rehabilitation planning because effective rehabilitation requires personalised treatments.
How can one ensure that a person-centred evaluation genuinely centres on the patient as a person rather than on their impairments and other losses? Using the biopsychosocial model of illness as your intellectual framework should support a person-centred approach. A clinician can exert reasonable control over their assessment, and this page will help keep your practice focused on the patient.
Table of Contents
Introduction
The patient’s first contact with rehabilitation will involve collecting information, usually referred to as an assessment. It is crucial to demonstrate concern for the person from the outset, not for their losses. An excellent person-centred initial assessment will provide a solid foundation for subsequent rehabilitation.
The terms patient-centred and person-centred are both used. Do they have different meanings? Most articles and other healthcare documents refer to patient-centred care. This emphasises a professional approach and makes the person’s role explicit. However, the patient’s role often implies the person is a passive recipient or an object being attended to. It specifically depersonalises the person.
I prefer person-centred care because it reminds everyone that a patient is a person and that one can only get to know them properly if one treats them as such. For example, if someone aged 60 years reports the stillbirth of a child 40 years earlier, your expressions of sorrow and sympathy demonstrate that you see them as a person, whereas simply carrying on typing into the computer shows that you see them as ‘other’.
Nonetheless, both terms should mean much the same. Observant readers will see that I use both. The vital matter is always to treat the patient as a person, an individual who is an equal and whose concerns, goals, and values must all be respected.
Rehabilitation can only succeed if it is person-centred. Almost all interventions require the patient’s engagement and collaboration. You will engage a patient for any length of time only if the activity is personally relevant or of interest to them. Personal factors have a large impact on all aspects of rehabilitation.
Being person-centred and the biopsychosocial model.
In their systematic review, Patient-centredness: a conceptual framework and review of the empirical literature, Mead and Bower (2000) identified five conceptual dimensions, the first being a biopsychosocial perspective. In 2019, Emil Longberg and colleagues brought the review up to date, emphasising the importance of the biopsychosocial model of illness.
The four themes associated with being person-centred, identified in 2019, were, in order of the number of studies contributing to the theme:
- Patient as a person, which particularly requires clinicians to explore the patient’s experience of their disease.
- Biopsychosocial approach, requiring “comprehensive care that encompasses all domains of health”.
- Doctor as person, which presumably generalises to other professions. It concerns insight into how the professional’s own experiences and values influence their clinical approach.
- Coordinated care, a new theme since Mead and Bower’s review. It considers ease of access, continuity, and cohesion in the team.
Using the biopsychosocial model as a framework should ensure that you consider and inquire about all critical areas. Acknowledging the sensitive and personal nature of the information will reassure the patient that you are concerned about them. This person-centred approach naturally leads to the other vital features of sharing power and responsibility and forming a therapeutic alliance.
Thus, one can see that being patient-centred, undertaking rehabilitation, and using the biopsychosocial model are three aspects of a central idea – the patient as a person.
The challenge is to convert these ideas into a practical clinical approach to assessing a patient and acquiring all the information needed to formulate a rehabilitation plan.
Overlooking consequences and context.
One way to view a person-centred assessment is to consider that information about an illness falls into two classes:
- Information directly relevant to diagnosis and the immediate physiological consequence. These data concern symptoms, signs, and investigations.
- All other information relating to
- The broader functional and social consequences, and
- The many contextual factors that affect the consequences
Acute healthcare systems have paid less attention to context for many years—this lack of attention matters.
In an article, Contextual Errors in Medical Decision Making: Overlooked and Understudied, Saul Weiner and Alan Schwartz emphasise the importance of establishing a patient’s context and the functional consequences of their disease. They refer to ‘contextual errors’, which “occur when clinicians overlook patient context that is essential to planning appropriate care”.
Their review should alter the practice of all healthcare systems because it discusses, with evidence:
- How the failure to consider context and consequences may lead to incorrect decisions that may cause harm
- How to assess whether clinical teams are considering contextual factors
- How frequently do physicians (doctors) make these errors
- The effect of these errors on healthcare costs
- Whether paying attention to context and consequences leads to better outcomes, an observational study suggests it does.
- Can physicians be trained to consider these factors? A quasi-randomised trial suggests it may.
In summary, there is evidence that doctors, and likely other professions involved in biomedical care, should consider the broader context. Failure to do so is likely to cause harm, whereas doing so is associated with benefits. We can teach the skill of attending to a patient’s context. In rehabilitation, the importance of considering disease-related consequences and context is well understood.
Assessment within a biopsychosocial framework.
The pressing problem in rehabilitation is to obtain information efficiently while remaining comprehensive. Within the very constricted biomedical model, the diagnostic assessment process is well established: presenting complaint, history (limited to that pertaining to the complaint); review of bodily systems, and family history. In many notes, the ‘social history’ is restricted to questions about smoking, alcohol and sometimes recreational drugs.
Many people acknowledge the holistic nature of the biopsychosocial model of illness, but say that they cannot use it because it is too difficult to collect the information. This criticism has been explored in detail by Robert Smith in his article, Making the biopsychosocial model more scientific – its general and specific models.
Moreover, eight years earlier, Robert Smith and colleagues wrote An evidence-based patient-centred method to make the biopsychosocial model scientific. I am uncertain how it makes it more scientific, but the suggested method seems sensible. It provides a systematic initial interview. I have adapted the assessment framework. The MindMap below gives an overview, and a version with more detail can be opened in a new tab and saved for printing or viewing.
Step one: setting the scene
This preliminary step is the most crucial part of any consultation. Until the context and expectations of the assessment are made explicit, the various parties may be communicating at cross-purposes. Never make assumptions.
It is best to
- introduce yourself with your name and role;
- check who they are and that they are physically and socially comfortable;
- check that there is no one else they wish to join the assessment;
- summarise how you and the patient have been brought together; and
- briefly outline the structure of the meeting.
This preliminary step applies whether the setting is an outpatient clinic, a ward, a nursing home, at home, or via video link. When undertaking outpatient clinics, I was frequently surprised to discover that patients and families often had no idea why they had been referred to see me. On more than one occasion, the patient assumed I was a surgeon (I am not) and expected an operation!
Step two: the patient's agenda
Making the patient central to the consultation is not only consistent with a generally stated, but not always observed, health service mantra. It is also much more effective. A question such as “What are your main concerns?” or “What are the main things you want from this consultation?” allows the patient and, if present, a family member to tell you what you need to do to satisfy them. It also shows respect and concern for them.
Step three: their narrative.
Most doctors and healthcare professionals interrupt a patient’s story within 5-20 seconds. Inge Mulder-Vos and colleagues (2022) found a median time to interruption of 6.5 seconds, with 9 interruptions per minute. A scoping review by Amanda Coyle et al found that an uninterrupted patient statement lasted 46 seconds.
Allowing the patient to speak and using silence to encourage continuation will give you most of the critical information you need. The information is not structured as you would structure it; however, you can reorder it later. The patient will naturally and without causing you or her distress discuss emotions, relationships, expectations, attitudes, and related topics. It would be best to practise ‘active listening’ while also observing non-verbal behaviours.
Step four: summarising/feedback
Summarising what you have heard from the patient during a consultation is essential. It demonstrates that you have been listening (and ensures that you do listen!). It reduces the risk of overlooking any important points to the patient. It allows the patient to say, “Oh yes, there is another thing …”
Steps 5-8: the traditional approach
The remaining steps, shown in the overview MindMap, follow the traditional medical (and probably non-medical) consultation approach. Nonetheless, although the headings are similar, it is vital to use the stages to obtain additional valuable information. For example, asking “any family medical history?” will often elicit information about disrupted family relationships that had not previously been disclosed. Discussion of other personal or family illnesses may provide insight into attitudes toward or expectations regarding the current illness.
Learning to assess.
Several studies have investigated training medical students and physicians to be more holistic, considering the disease’s consequences and context.
In an early study, Robert Smith et al (1995) randomly allocated half of 26 residents (in the US) to receive “intensive training in psychosocial medicine”. Patients treated by the trained residents reported greater satisfaction and confidence in them when compared to the untrained physicians.
In 2010, Alan Schwartz et al. conducted a quasi-randomised study recruiting 124 medical students (of 189 eligible), of whom 65 received four one-hour case-based discussions that illustrated the significance of contextual information and its effects on medical management. Students educated in this way identified more critical contextual information and proposed better management plans for patients.
A third study by Bōrd Jensen et al (2011) reported on the Effectiveness of a short course in clinical communication skills for hospital doctors: Results of a crossover randomized controlled trial. They were studying the effect of training doctors in the four habits associated with better communication with patients:
- Invest in the Beginning;
- Elicit the Patient’s Perspective;
- Demonstrate Empathy;
- Invest in the End.
The intervention was an intensive two-day programme delivered to the equivalent of consultant-level specialists. The standard of communication improved, and consultations were no longer in the trained group.
Learning is most effective when it occurs as part of the activity in the appropriate context, which, for communication and assessment, often means seeing a patient in a clinic. Based on the model discussed above, Grayson-Sneed et al. (2016) developed a 12-question questionnaire to assess a clinician’s communication and assessment skills. This is completed by the patient, and the results can be used as feedback for clinicians to inform learning and improvement.
Grayson-Sneed et al. (2017) also developed an observer-rating system. The observer can be a non-professional, and the results could also be used to provide feedback to the clinician.
I have also discussed assessment competency on one of the 40 pages devoted to rehabilitation competencies in the rehabilitation training syllabus.
In summary:
- Assessment, the collection of information, depends on good communication
- communication can be improved through training in a method that also increases the acquisition of information not directly relating to disease,
- valid measures of communication skills are available to help doctors (and others) to learn through feedback on performance.
Recording and using the information
At the end of the assessment, I start by asking the patient what they think. I say, “If you were in my seat and had heard what you told me, what would you be thinking about your problem?” or “Before I say what I think is going on, why don’t you tell me what you think?”
However you do it, you need to provide an immediate formulation before you and the patient part company. The most important reason is that talking to the patient through your formulation will reveal what you had not considered and what the patient has not disclosed. By stating your presumed facts, you allow the patient to correct any misunderstandings or to add further, often vital, information that was previously missing.
Most patients would also be very dissatisfied if you said ‘goodbye’ without giving an opinion, however provisional. When faced with any complex problem, the risk is that a person prevaricates and never reaches a conclusion. Committing to a provisional formulation requires you to make decisions and commit to them. You are inviting someone to prove you wrong, and this will either improve the patient’s outcome by approaching the truth more closely or bolster the strength of your case.
The information will initially be recorded as notes taken during the consultation. The patient will not present information in a structured or systematic manner. The doctor (or other professionals) must not try to impose any order on the patient, however gently it is done.
When the assessment and consultation are complete, the doctor will need to transform the patient’s narrative, which has jumped all over the biopsychosocial framework, into a coherent account within that framework. The detailed presentation will be at the personal or team’s preference.
It is also possible to use the information garnered to measure the complexity of a particular patient’s problem. The Oxford Case Complexity Assessment Measure (OCCAM) is based entirely on the biopsychosocial framework, with additional data on service use. A 30-minute interview will enable me to complete the OCCAM.
Conclusion
Assessment, the goal-focused collection of information to facilitate formulation and rehabilitation, requires good person-centred communication. It should be an activity shared with the patients and, if appropriate, family and possibly others. It must be flexible, tailored to the situation. It should not be undertaken as a protocolised, form-filling activity collecting data because the system or guidance requires it.