Unless a rehabilitation clinician or team have a clear, complete and accurate understanding of the patient’s situation, their efforts are unlikely to be optimal; they may be wasteful and/or harmful. This section of the website concerns the way that a rehabilitation clinician should approach a patient and their problems.
The fundamental logic of the rehabilitation process is the same as used when solving any problem, and it is analogous the the medical approach to a patient. The practical application of the process is different from the medical approach, because rehabilitation takes a holistic approach, being concerned with the person, not their disease. Its goal is to optimise, usually to increase, a patient’s autonomy and social integration, This can only be achieved by understanding both the patient’s clinical state and the patient’s context in detail. The context is much more than their accommodation and family.
Taking a holistic view has consequences. The range of factors that have to be considered is much larger that when simply diagnosing and managing disease. In addition, the inter-relationships between the many factors are rarely linear, and they often influence each other. The term used for a set of inter-relationships that are multiple, non-linear, and often alter each other is complex. (click for explanation).
The number of factors that might have an influence on any single disability is too large to contemplate. The clinician needs to have a way of simplifying matters. Fortunately the biopsychosocial model offers a way. It is a framework, and it allows all factors to be categorised into one of eight categories. (See here for a brief outline.)
The framework does not give any information about whether any relationship exists between two factors for a particular patient, nor does it help identify all the factors within any particular domain that are influencing something. On the other hand, the framework does allow the clinician to group factors together.
The most important virtue of the biopsychosocial model is that it reminds the clinician to consider whether any factor within a domain might be having an impact. Looking at it another way, as information accumulates, the framework will reveal whether areas without any information remain. If so, the clinician can ask a pertinent question.
The challenge facing any rehabilitation clinician is to collect information from all domains in an efficient way. The ‘traditional approach’, used in many medical spheres, is to ask a series of directed questions covering the important domains. When I trained as a medical student, we were taught a series of questions for eliciting whether there were problems with the cardiovascular system, the respiratory system, the gastrointestinal system and so on through all the organ systems.
This systematic approach to making a medical, disease-based diagnosis ensures that nothing important is missed, and it is appropriate especially when someone is acutely unwell. Most doctors can cover all relevant systems in a few minutes at most, and there are a limited number of questions. Even so, this ‘review of systems’ is less satisfactory for people with long-term conditions, and for people with multiple pathology, because many symptoms may arise from more than one disease.
A similar systematic approach is less easy in rehabilitation, because the number of relevant items is much larger. More practically and importantly, to the best of my knowledge, no relatively limited list of questions has been devised. Also, again in practical terms, there is a difference. In a medical context, the question simply establishes whether or not a symptom is present. The answer is usually short, and unambiguous.
In rehabilitation, the question usually concerns details about something which is always present. For example, most people (but not all people) live in a house or other accommodation, and the issue that needs exploring concerns the suitability of the accommodation for that person, which is turn depends upon the problems they have. Therefore one can construct a list of domains to ask about, but the actual questions needed will vary from patient to patient. It is rarely a quick matter.
One approach is to let the patient tell you, rather than asking them. This refers to the use of ‘active listening‘, where you let the patient tell you, not in a structured way, but often in an efficient way. The secret is simply to keep quiet, avoiding asking any questions as far as possible and allowing the person and, if present, family members to tell you. (Also see here for a second reference.) During this process, or more commonly, after the process, information should be placed into the various domains within the biopsychosocial famework.
With practice and experience, information can be structured roughly on paper. Information can be used to develop a more formal record, using the OCCAM, the Oxford Case Complexity Assessment Measure. This gives a structured record of important information in different domains. It gives a measure of case complexity. It is explicitly based on the biopsychosocial model of illness, and is derived from another measure, the INTERMED.
The OCCAM should not be used to structure the clinical history or examination, as that would disrupt the flow and reduce the information given. Specific questions used after most information has emerged, to clarify points ad to fill lacunae. It is purely a structured way to record and quantify complexity, and it inevitably ensures that each important domain of the model has been considered.
In principle, and when starting to learn, it is normal to collect information first, and then to use it to analyse what is happening. However, in practice a clinician is much more likely to have a hypothesis about what the situation is and to particularly seek out or listen for information that confirms (or refutes) a hypothesis. The risk of this approach, in rehabilitation, is that it is too easy to confirm a hypothesis. Therefore it is important, always, to ensure that each domain is at least considered to avoid missing an important factor.
In summary, the biopsychosocial model’s framework can be used both to organise information, and as a basic checklist to ensure that each domain is actively considered. The remainder of this part gives more information on how to undertake the analysis, and illustrations of the types of information and factors that may emerge, click here.