Assessment and ..

Assessment, coupled with formulation, is the crucial first stage in rehabilitation. In a complex case, this always requires input from all members of the team, including the doctor, because if the initial analysis is wrong then harm may be caused. The potential for harm includes not treating a treatable problem, giving a treatment that causes harm with no likelihood of benefit, wasting the person’s time and energy, and, possibly, raising unachievable expectations.

I emphasise the importance of medical input from a specialist doctor, because it is a common belief that the doctor’s role is minor at this stage and that the given disease diagnosis is correct. Diagnoses, even from specialist services, can be wrong. While I do not know the frequency, over the years of my practice it happened most weeks. Moreover patients develop new symptoms or other problems which other doctors may attribute, incorrectly, to the disabling disease and so miss the opportunity to give effective treatment.

On the other hand, many patients presenting to a rehabilitation professional may have a relatively straightforward problem, not warranting a full review by every team member. It is reasonable for one team member to assess and formulate a case but, unfortunately, there may be “unknown unknowns”; the clinician may not realise that there are matters requiring other expertise. Discussion with other team members reduces the risk of missing something, even if the patient is not seen by them.

Moreover, anyone specialised in the practice of rehabilitation should have enough general clinical knowledge to recognise when other expertise is needed; it is a normal skill within a true multidisciplinary team. No rehabilitation professional should work outside the context of a team, and all professionals should have easy, quick access to other professions to discuss any doubts or concerns. Third, most professionals working in rehabilitation should know or learn some simple methods for screening for commonly missed problems.

It is also important to understand that assessment is not a process that occurs in complete isolation from all other processes, nor is it a process that occurs instantaneously; it is not a photograph or a blood test. Rather it is itself an incremental and reiterative problem-solving process. The patient presents with a problem and, among other things, the clinician or clinical team start to collect data to confirm or rule out hypotheses concerning the nature and aetiology of the problem. Moreover, trials of treatment may well be a part of the assessment, investigating whether a treatment appears to help which may give a clue about cause and/or prognosis.

More details about the assessment phase are shown in this graphic.

… and formulation

Formulation, a term often used in psychiatry where almost every problem is complex, is the end result of assessment and analysis. It can be considers as drawing a diagram which shows all the problems, and all the factors from different domains of the biopsychosocial model that influence the problems, and all the interactions and, in addition, shows potential interventions and how each would change the future. Such a diagram cannot be drawn! However an image can show the outline components of any formulation.

In inpatient practice, the planning meeting (often termed ‘goal setting meeting’) may be taken up with discussing the situation, but (in my experience) there is rarely any actual, well-thought-out formal articulation of the situation. Formulations are rarely written down or recorded. Yet the implicit formulation underlies all the decisions made at the planning meetings. In practice most time is spent on reporting on assessment, largely in a descriptive way using formal, structured tools but interpretation of the assessment is much less commonly discussed.

So, here, I will suggest that, in complex cases (all inpatients, and a significant number of out-patients) the team should set aside ten minutes to undertake a formal analysis and formulation of the situation shortly after the patient is first seen. Indeed, I suspect that if formualtion became an integral stage of every patient’s rehabilitation, then patient outcome would be improved and less mistakes made. (There is a research project for someone!)

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