It might seem evident that assessment should be centred on the patient, but many patients feel they are objects to be dissected and quantified. How can one ensure a person-centred evaluation is genuinely centred 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 enforce a person-centred approach. As I have discussed here, many forces are acting against a person-centred approach across all rehabilitation. Nonetheless, a clinician can exert reasonable control over their assessment, and this page will help keep your practice focused on the patient.
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Rehabilitation can only succeed if it is person-centred. Almost all interventions require the patient’s engagement and collaboration. And you will only engage a patient for any length of time if the activity is of personal relevance or interest to them. The patient’s first contact with rehabilitation is an assessment, and it is crucial to demonstrate a concern for the person from the outset, not the losses the person has. An excellent initial person-centred assessment will form a good foundation for all subsequent rehabilitation.
The biopsychosocial model of illness is closely associated with patient-centred care. Mead and Bower found this in their systematic review in 2000. (here) A later study in 2019 found that other constructs overlap with the use of the biopsychosocial model, such as ‘sharing power and responsibility’, ‘therapeutic alliance’ (both much the same), and ‘the patient as a person‘ were also associated with patient-centred care. (see here.)
The alert reader will have noticed I move between patient-centred and person-centred, seemingly at random. Most articles refer to patient-centred care, retaining a professional approach. Still, I prefer person-centred because it reminds everyone that a patient is a person, and one can only get to know the patient properly if one treats them as a person. For example, if someone aged 60 years reports the stillbirth of a child 40 years earlier, expressing sorrow and sympathy demonstrates that you see them as a person but simply carrying on shows you see them as an ‘other’.
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 on this page 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.
One way to view a person-centred assessment is to consider that information about an illness falls into two classes: directly related to the disease and its direct effects upon the person, and all other information, summarised by the word context. Acute healthcare systems have paid less and less attention to context for many years—this lack of attention matters.
The importance of establishing a patient’s context has been researched in a medical setting. It has been shown that ‘contextual errors’, a failure to recognise when some non-medical factor influences medical treatment, are an avoidable cause of medical harm to a patient. (here) Moreover, if the doctor attends to context, the outcome is better. (here) Third, teaching the skill of paying attention to the context within medical care is possible. (here)
In summary, there is evidence that doctors (and almost certainly all other professions involved in rehabilitation) should consider the broader context. The failure to do so is likely to result in harm, whereas doing so is associated with benefit. And we can teach the skill of paying attention to a patient’s context.
In rehabilitation, the importance of context is or should be well-understood. I am less confident that the breadth or scope of the context that needs exploring and taking into account is so widely understood or agreed upon.
Assessment within a biopsychosocial framework.
The pressing problem is obtaining contextual information in a way that efficiently acquires enough data over a wide enough field. Within the very constricted biomedical model, the diagnostic assessment process is well established: presenting complaint, history (limited to that appertaining 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 here. Moreover, a specific patient-centred approach to assessment has been put forward to “make the biopsychosocial model more scientific” (though I am uncertain how it makes it more scientific).
The suggested method (here) seems sensible as a way to undertake an initial interview with a patient, and I have adapted the assessment framework a little. I have illustrated it in a graphic here.
Step one: setting the scene
This preliminary step is the most crucial part of any consultation. Until the context and expectation of the assessment have been made explicit, the various parties may be communicating at cross-purposes. Never make assumptions. It would be best to introduce yourself with your name and role; check who they are and are physically and socially comfortable; summarise how you and the patient have been brought together; and outline the process you anticipate going through (briefly).
This preliminary step applies whether the setting is an out-patient, on a ward, in a nursing home, at home, or on a 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 or what for. On more than one occasion, the patient assumed I was a surgeon (I am not) and they were expecting an operation!
Step two: the patient's agenda
Making the patient central to the consultation is not only going along with a generally stated, but not always observed, health service mantra. It is also much more effective. A question like “What are your main concerns?” or “What are the main things you want from this consultation?” allows the patient and family member, if present, 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 before it gets off the ground within 5-20 seconds. Allowing the patient to talk, and using silence to encourage continuation, will give you almost all the critical information you need. The information is not structured as you would structure it, but you can re-order it later. The patient will, naturally and without causing you or her distress, talk about emotions, relationships, expectations, attitudes etc. It would be best to practice ‘active listening‘, while also observing non-verbal behaviours.
Step four: summarising/feedback
Summarising what you have heard from the patient within a consultation is essential. It shows that you have been attending (and it makes you listen!). It checks that you have picked up the important (to the patient) points. It allows the patient to say, “Oh yes, there is another thing ….“
Steps 5-8: the traditional approach
The remaining steps follow the traditional medical (and probably non-medical) consultation approach. Nonetheless, though the headings are similar, it is vital to use the stages to gain more invaluable information. For example, asking about “any family medical history?” will often disclose disrupted family relationships hitherto not disclosed. Discussion of other personal or family illnesses may give insight into the attitudes towards or expectations of the current illness.
Training medical students and doctors to take a broader view of their patients has been researched. In one way or another, the studies below all concern the steps in the earlier graphic.
In a study involving 189 medical students, Schwartz et al. gave some students four one-hour case-based discussions that illustrated the significance of contextual information and how it altered medical management. Students educated in this way identified more critical contextual information and proposed better management plans for patients.
An earlier study involved 26 residents (in the US), of whom half received “intensive training in psychosocial medicine”. Patients treated by the trained residents expressed greater satisfaction with and confidence in the trained residents.
A third study focused on improving communication by inculcating doctors four habits when communicating with patients: Invest in the Beginning; Elicit the Patient’s Perspective; Demonstrate Empathy; Invest in the End. The intervention was an intense two-day programme delivered to the equivalent of consultant specialist doctors. The standard of communication improved, and consultations were no longer.
Learning is most effective if it occurs as part of the activity in the appropriate context, which, for communication and assessment, often means when seeing a patient in a clinic. Based on the model discussed, Grayson-Sneed et al. developed a 12-question questionnaire to assess a clinician’s communication and assessment skills (here). One could use this questionnaire to give feedback to all clinicians, not only trainees.
There is also an observer rating system, which c a person sitting in on a consultation could use, and this person could then give feedback (here).
These and other studies suggest (a) communication can be improved through training in a method that also increases the acquisition of information not directly relating to disease, and (b) valid measures are available to help doctors (and others) to learn through feedback on performance.
Recording and using the information
At the end of the assessment, it is my practice to start by asking the patient what they think. I say, “If you were in my seat, and you 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 the patient through your formulation will reveal what you had not thought of and what the patient has not told you. By stating your presumed facts, you allow the patient to correct any misunderstanding or add further, often vital, information previously missing.
Most patients would also be very dissatisfied if you said ‘goodbye’ without giving an opinion, however provisional. It forces you to make some decisions to commit yourself. When faced with any complex problem, the risk is that a person prevaricates and never reaches a conclusion. By stating a conclusion, 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 be recorded initially as notes made 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 over, the doctor will need to transform the patient’s narrative, which will have jumped all over the framework, into a coherent account structure within the biopsychosocial framework. The detailed presentation will be a personal or team 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 entirely based on the biopsychosocial framework, with added data about service use. A 30-minute interview will enable me to complete the OCCAM (here).
The conclusion, which is argued in much more detail here, is that a clinician who communicates with the patient in the manner set out in the graphic will generally obtain information that covers all aspects of the biopsychosocial model of illness. This outcome will improve medical management. More importantly, in the context of a rehabilitation assessment, it will also cover essential matters from most, if not all, of the biopsychosocial model of illness domains. It gives some insight into what is of importance to the patient.