Patient-centred assessment

We are patient-centred” is a mantra uttered by most healthcare services. How can we ensure we genuinely focus on our patient’s needs and wishes? Basing clinical thought and practice on the biopsychosocial model of illness is one way. Being patient-centred and using the biopsychosocial model of illness in clinical practice go together. You cannot avoid being patient-centred when using the biopsychosocial model of illness. You cannot use the biopsychosocial model of illness without being patient-centred. This page explores the inter-relationship and shows how to focus on the person using active listening or the ‘four habits approach’ to communication.

Introduction

Almost everyone would agree that healthcare should always be patient-centred. It is mentioned in nearly all guidelines, and it would be a brave person to disagree. However, a trial with 1546 patients investigating a patient-centred approach to patients with multimorbidity failed to find any benefit. (here) One reason for failure may have been the ‘multi-disciplinary’ intervention. It involved a doctor and a nurse, with a pharmacist at times, and it probably took a more medical approach than implied by its stated intent.

In rehabilitation, setting relevant goals requires a patient-centred approach because most interventions require the patient’s engagement and collaboration. And a patient will only be engaged for any length of time if the activity is of personal relevance or interest to them.

A systematic review in 2000 found the biopsychosocial model of illness to be the primary concept associated with patient-centred care. Other ideas were higher in 2021: ‘sharing power and responsibility,therapeutic alliance‘, and ‘the patient as a person‘. The first two are the same, and the third is strongly associated with using the biopsychosocial model of illness (see here.) Indeed, it would be challenging to be patient-centred without considering all aspects of their life because the framework provided by the biopsychosocial model requires a clinician to attend to all essential areas of a person’s life

I suggest that being patient-centred, undertaking rehabilitation, and using the biopsychosocial model are three sides of a central idea. We must see the patient as a person. We must not consider the patient as someone with a disease or a problem. We should, first and foremost, know every patient as a person who has come for advice and help in living their life.

The challenge, considered on this page, is to convert these ideas into a practical clinical approach to assessing a patient, the process of acquiring all the information needed to make a rehabilitation formulation and plan.

There are two types of information about an illness—the first concerns the disease and its direct effects. The second includes all other information, which is summarised by the word context. Acute healthcare systems have paid less and less attention to context for many years—this lack of attention matters.

Contextual errors

A failure to recognise when some non-medical factor is influencing medical treatment is sometimes known as a ‘contextual error’. Research into the importance of establishing a patient’s context when being seen about a health problem has shown that is an avoidable cause of medical harm to a patient (here) Moreover, research has demonstrated that, if the doctor attends to context, the outcome is better. (here) Last, teaching doctors about the skill needed to consider a patient’s context is also possible. (here)

Evidence shows that doctors (and almost certainly all other professions involved in rehabilitation) should consider the broader context of a patient and that the failure to do so is likely to result in harm. Conversely, doing so is associated with benefit. The skill of attending to a patient’s context can be taught.

In rehabilitation, the importance of context should be well-understood. I suspect the breadth or scope of information needed to understand a patient’s situation fully is not widely understood. Though most people try to use the biopsychosocial model, the influence of the biomedical model is so strong and pervasive that social and emotional factors receive only a little attention.

One solution would be to teach people how to collect the information needed in daily clinical practice. Within the more constrained biomedical model, the structure of an initial assessment 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 recorded is restricted to questions about smoking, alcohol and sometimes recreational drugs.

Assessing a patient within the biopsychosocial model.

One of the criticisms of the biopsychosocial model of illness is that it is difficult to collect the information. This criticism has been explored in detail here. A specific patient-centred approach to assessing a patient has been suggested as a way to “make the biopsychosocial model more scientific” (though I am uncertain how it makes it more scientific). The recommended method (here) seems sensible as a way to undertake an initial interview with a patient.

I have adapted the assessment framework a little, shown in this graphic here.

Step one Setting the scene.
This step is perhaps the most crucial part of any consultation because until the context and expectation of the assessment has been made explicit, the various parties may be communicating at cross-purposes. Never make assumptions. Introduce yourself, name and role; check who they are; check they are physically and socially comfortable; summarise how you and the patient have been brought together, and outline the process you anticipate going through (very briefly).

This step will apply whether the setting is an out-patient, on the ward, in a nursing home, at home, or on a video link. When undertaking out-patient clinics, I was frequently surprised to discover that a patient and family had no idea why they had been referred to see me or what for. On more than one occasion, I was assumed to be 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 for and concern about them.

Step three Their narrative.
Most doctors and healthcare professionals will interrupt a patient’s story before it has got off the ground, within 5-20 seconds. Allowing the patient to talk, using silence as a way to encourage continuation, will give you almost all the vital information you need. The information is not structured in the way 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. You should practice ‘active listening‘, while also observing non-verbal behaviours.

Step four Summarising/feedback.
Summarising to the patient, within a consultation, what you have heard is essential. It shows that you have been attending (and makes you listen!) It checks that you have picked up the important (to the patient) points. It allows the patient another opportunity to say, “Oh yes, there is another thing ….

Steps 5-8 the ‘traditional’ approach.
The remaining steps follow the traditional approach to a medical (and probably non-medical) consultation. Nonetheless, though the headings are similar, it is crucial to use the headings 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.

Teaching and learning this approach.

Training medical students and doctors to take a broader view of their patients has been researched. The studies below all concern, in one way or another, the steps set out in the graphic shown earlier.

A study involving 189 medical students found that four one-hour case-based discussions to illustrate the significance of contextual information and how it altered medical management was associated with students identifying more critical contextual information and proposing better management plans for patients.

An earlier study involved 26 residents (in the US), half being allocated to be given “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 through inculcating doctors with 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, and for communication and assessment, this often means when seeing a patient in a clinic. Based on the model discussed, a 12-question questionnaire has been developed to assess a clinician’s communication and assessment skills (here) This questionnaire could be used to give feedback to clinicians, especially but not only trainees.

There is also an observer rating system, which could be used by a person sitting in on a consultation, 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.

Using and recording the information

At the end of the assessment, it is my practice to start by asking the patient what they think. I say something like, “If you were in my seat, and you had heard what you told me, what would 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 or had not been told By stating your presumed facts, you are allowing the patient to correct any misunderstanding or to add the crucial missing information.

Most patients would also be very dissatisfied if you said ‘good-bye’ 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 information given by the patient will not be produced systematically, and the doctor (or other professional) 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 based within the biopsychosocial model. The exact 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 based on the biopsychosocial framework, and with added data about service use. In my experience, a 30-minute interview will give almost all the information needed to fill in almost all items within the OCCAM. (here).

Conclusion

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 will improve medical management More importantly, in the context of a rehabilitation assessment, it will also cover important matters from most if not all the domains of the biopsychosocial model of illness, and it gives some insight into what is of importance to the patient.

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