The Subjective Assessment 

Another topic which came up during my discussions would be the sense that the clinician felt that they were going into the appointment and just ‘winging it’. They would go in without a plan of what they were going to do. They would have no preconception about what was going to happen and how they were going to carry out the appointment. I interpret this as the repeated experience of having such varied assessments and never knowing where they were going to go. Once you have experienced this over and over again, going in with a intended structure is an unnecessary baggage and a hinderance that it gets shed. I remember watching a student perform an assessment on a patient as a viva. They had practiced and prepared to do the perfect neck assessment. Only to be presented with a patient who had a history of trauma and strangulation. The assessment was going fine until he wanted to palpate the front of her neck and walked towards her with his hands outstretched and directed straight at her neck. She clearly panicked and he went into a form of conflict. His brain was telling him to continue with his assessment because this is what he practiced but his conscious was a tiny voice screaming at him that something was wrong here. I watched him step forwards and back for a few seconds playing out this internal dialogue with his feet, knowing that if her was to touch her I’d have to step in and he’d fail his viva. Thankfully he made the right choice and that tiny voice in his head got his attention. This is an extreme example and something I’d hope that all competent physios would get right. She was so clearly distressed at what he was doing even in his focus structure orientated state he was able to adapt. Imagine this on a tiny scale happening every minute. With adaptation after adaptation occurring making each assessment and appointment different to the last. While each one done by a general physio will be different, the guiding factors will be dominated by the logic process of the physio or the need to work out what is the best treatment option. The absolute dominance on the focus of patient comfort will not be the dominant guiding factor and therefore the individual session which is created will look very different.

 

From the perspective of the MH physio, after a while this lack of structure starts to feel like ‘I’m never going in and doing the same thing’ and nothing is run of the mill. You will so often you experience things that you have never seen before so the need to create while going along becomes an important skill. This is entering the appointment in an adaptive mindset. If the person is in an adaptive mindset before they go in, they give themselves the greatest likelihood of rapidly changing how they were running the session. Being able to adapt quickly to however the patient is presenting on that given day. Entering in a fixed mindset will lead to ploughing on forward using the same strategy. What if today is the day that that strategy is not the correct one? How long into that appointment will it take the clinician to realise and begin to change their approach? Hopefully not too late to ruin the appointment, or potentially an even greater degree of damage.

 

If you enter in an adaptive mindset, you are more likely to be able to rapidly adapt to the needs of the patient. It may be necessary to first spend some time allowing the patient to off load regarding something frustrating that happened that morning or earlier during the week. It may be that the patient is feeling particularly low that day, and you need to adapt your manner to place your energy more aligned with how the patient feels that day. You may need to adapt your presentation of self, the intended topic of the appointment, the order of the appointment, the length, the venue, the way you’re sitting. I believe that the speed at which this need is recognised, and the effectiveness of the adaption are what will make the difference between an effective clinician and one that struggles with this patient group. The more consistent experience the clinician has with working with this situation the more likely it is that they will develop these skills. Some it will come naturally to, some it will take more time and a conscious effort.

 

It is my belief that a casual first assessment which feels like a conversation between two peers is important for achieving the best clinical outcomes. If patients feel comfortable and relaxed in your presence, then they will be able to provide you with the best quality answers to your questions. It must feel like there is no right or wrong way for the person to behave.

 

Consider who you need to be to be a peer of your patient, the assessment needs to feel like a conversation, not an interview if you wish to get the most out of the appointment.

 

The questions which we ask in the subjective assessment are not always what people are expecting.  I'm sure you've experienced asking a patient a simple question about the history of their problem, and instead they decide to answer their own question. They give you their own history or explanation of what happened disregarding the question you asked. If you just accept this you are likely to find your thought processes and therefore clinical reasoning process is disrupted or derailed.

 

There is a set of patients that will practice what they are going to say before they come to you. They may do this as an anxiety management strategy; they may do this because they are a ruminator and spend too much time thinking about their symptoms. Obviously, you see this outside the world of mental health as well. It is just more prevalent in MH so we need to be better at working with it, and you may need to be more skilful with your response as just stopping someone and politely asking for them to answer the question in the way you have asked may have unseen consequences. The person may inside feel that they have offended you, no matter how polite and gentle you were. My advice would be to accept the person’s answer, validate it by working with it and then move on. Then engineer the conversation to go back around to what you wanted later.

 

Some patients who practice what are they going to say before they come to see you will do so using their own logic process to work out what they think is wrong. I doubt this is a need to practice what they're going to say in expectation of saying it to the physio, but rather the consequence of their own attempt to understand their own problem through their process. They've thought about their problem, they've created a narrative, and they find it easier to give that to you, instead of answering your question. Some patients on the other hand will not have thought about their problem beyond, that it hurts or exists, and so when we start asking what appear to be rather abstract questions, the answers do not come easily when we are in a high stress situation. I'm sure you've experienced the situation on a job interview when you get asked what would be a simple question if you weren't in a stressed state, but your mind clams up and you can't answer anything more than the simplest question. If the subjective assessment feels like a job interview, then you're not going to get the best out of your patient. It can be very difficult to prevent an initial assessment, from the patient’s perspective, having the same atmosphere and creating the same physiological and neurological response as a job interview. This is why I believe it is very important to control as many aspects as possible and make every attempt to create a relaxed and friendly environment.

 

What is really important to express here is that it may be important for the appointment not to feel like an interview at all. Not a single bit, nothing. No pieces of the assessment that have any resemblance to an interview at all. The level of sensitivity that we can be working with is out of the norms of the regular patient population. The level of ‘feeling like an interview’ that a regular patient can easily tolerate. Please don’t imagine an actual job interview and because the assessment you provide isn’t like this in your opinion then you are already doing this. What we are dealing with always in mental health physio is the perception of reality which the patient is experiencing. We must always remember that the perception of reality is what we are working with, and we need to work with that. This is a theme which will be prevalent throughout. It is not the reality of your assessment which is important, it is the person’s perception of your appointment which is key. Think of it like marketing a product. It is not the reality of whether a Dyson vacuum cleaner sucks up more than another hoover. It is whether the consumer believes it does which makes them happy with the product. The Dyson being clear allows people the satisfaction of seeing what is sucked up and that all the validation of their belief from spending so much money that the person needs. It is very likely that the person may well be coming to your appointment with the belief that it is going to be stressful. It will only take tiny factors to confirm this belief and now your appointment has become as stressful as an interview. The reality of your appointment may be a lovely process, the experience of the person going through it may be that it was an interview because that is the belief that they came to see you with. If the appointment is offered in a skilled way then everything that is done in advance of the appointment will go towards decreasing this expectation. You then have much more chance that the appointment will be successful. Market your appointment well as though it will not be stressful and the person is less likely to find it so. Providing an assessment with as few factors at all to trigger the experience of an interview will give the best chance of the person not perceiving that it was that way. If you have marketed your appointment well in advance the expectation will not be so strong that the experience will be stressful and you will have more leeway to ask questions that have the sense of an interview. If the assessment is not marketed well, the person is coming in with the belief that it is going to be stressful, if the controllable factors which immediately precede the appointment have not been controlled to decrease flight or fight stimulation then the clinician will need the skills of the world’s greatest psychologist to have a successful appointment. And even that may not be enough.

 

I prefer my subjective assessment to take place as a long form conversation instead of a series of questions with answers. Clearly there will always have to be questions, however, I want the questions to neatly flow from whatever is the current topic of conversation to the next. I will start with a very open-ended question such as ‘So, tell me all about it’ ‘So it's your knee, tell me all about it’. I picked that phrase deliberately because I want the sense of ‘tell me everything, I'm here to listen’. I want to know everything no matter how insignificant you might think it is, it is important to me. From here it depends where the patient goes. I need all the standard information a physio would be interested in such as how did it start? when did it start? What are the aggravating factors etc. These questions would be woven into the conversation as much as possible they're not in a strict order. The manner in which they are asked is as though the questions has been triggered by what has just been said and the language is deliberately basic and somewhat clumsy. Avoiding it looking rehearsed, if mistakes are made in how you articulate something then it feels more like you are developing the sentence in the moment and are in the moment with the person and really listening. It is fine to begin articulating something, make a mistake and then correct yourself. There will be a sweet spot for this where you go too inarticulate and you sound incompetent, or make too many mistakes and you appear like you’ve never done this before. It’s important to show you are in the moment in conversation, what you are saying is not a rehearsed routine that the patient is not just the next person along your conveyor belt.

 

The conversation won’t just be me asking questions. We will be sharing information with each other.

I will take opportunity to say interesting things, explain what I'm looking for, explain what it might be

and the conversation is unstructured and free-flowing.

 

The writers of South Park have advice for budding writers where they explain that everything that  

happens next should follow ‘therefore’. And therefore, this happens and therefore this happens and so on and so on. If the story is established through, ‘and then this happens, and then this happens’ then we feel like everything is disjointed and nothing flows. If you want to weave in a difficult question then the question mustn’t stand out from the rest. The person must be in the flow and then they answer the next question seamlessly.

If you want to achieve this form of assessment the words to keep in your head are ‘therefore’, ‘but’ and ‘so’. If everything you say could follow on from one of those words then things will be pretty good. You don’t have to say the actual word 

 

A difficulty which requires a degree of skill is to keep navigating the conversation in the way that you

wanted to go in the way to provide you with the information that you actually need.

 

Use the subjective as a long form conversation to use strategies to establish competency.

Establish values, establish your identity, establish your integrity.

 

What needs to be established and then how to use the subjective to do this.

 

Use it to show that you have listened to the person.

 

You can weave in the question of what do you think it is what do you think should be done

 

But only after you have established that you are competent

 

Use it to be able to ask difficult questions in a way that appears gentle and spontaneous and doesn’t feel important. If the person feels that you are making something into a big thing then it must be a big thing.