A lot has been said in recent years about the biopsychosocial model of healthcare and its benefits in treating patients with diagnoses ranging from acute to chronic conditions. What has not been explored as in depth is the affect of the biopsychosocial model on patient experience and engagement. This article aims to explore that relationship.
How Biopsychosocial Factors can Affect Experience
As we have written about previously here, biopsychosocial factors affect nearly every aspect of the assessment, treatment planning, and clinical outcomes for every patient. As simple as it may be to simply reduce a patient’s symptoms or dysfunction to the physiological issues like inflammation, muscle tightness, or ligament laxity, every patient has unique variables at play. These variables include not only the physical or physiological factors, but also psychological issues and/or social/environmental situations or contexts that affect the patient’s experience throughout the disease or injury process and recovery. If not taken into consideration, these factors or variables can negatively impact our patients’ experience in our clinics, hospitals, or health centers.
Physical Factors Affecting Experience
Physical Factors Like Fractures and Hardware
Rehabilitation professionals typically have a thorough understanding of physical factors affecting a patient’s condition or situation. These factors tend to be the major focus during schooling and clinical education. Factors such as acute injuries, inflammation, postural misalignment, arthrokinematic dysfunction, nerve damage, muscle tightness, and even body weight all affect a patient’s function and abilities. These factors also affect the patient’s experience of their particular condition or diagnosis.
For example, BMI has been shown to impact a person’s subjective experience during physical tasks and social engagements [1]. But can these physical factors affect a patient’s subjective experience in our clinics and health centers?
Understanding any physical factors —like diagnosis, symptoms, or common dysfunctions— affecting patients in your clinic can help guide design, modification, or adaptations that may improve overall accessibility or provide an added convenience for your patients. This leads into environmental alterations or accessibility improvements that clinic owners can implement to make their clinics not more accessible.
Psychological Factors Affecting Experience
Our brains are powerful machines, able to affect perception, physical symptoms, and our subjective experiences. As we have written about here, the brain plays a large role in patients’ experience of pain and clinical outcomes. Because most rehab clinicians are extensively trained on the physiology, biomechanics, and kinesiology of the body, most clinicians feel underprepared and less confident in addressing the multidimensional aspects of pain [2].
A patient’s understanding, perception, and belief regarding his or her diagnosis and prognosis greatly impacts everything from their subjective experience of symptoms as well as the clinic outcomes of treatment. As clinicians, we have a direct impact on our patients’ perceptions and beliefs about their situation. Our words have a long and lasting impact on our patients, either empowering them to overcome their dysfunction or injury, or causing them to react out of fear and distress [3]. Knowing this, we can see how not taking this into account could negatively impact a patient’s experience in a clinic.
Imagin a patient walks in a therapy clinic after being referred by a primary care provider (PCP) for low back pain. They have seen their PCP a few times about their back, had x-rays taken, and the PCP finally made the referral in an attempt to help the patient get some relief. The patient is greeted at the front desk, checks in, and takes a seat. A few minutes later, the therapist comes into the lobby or waiting area and brings the patient back to complete an initial interview and evaluation. When the patient gets back to the assessment area, the therapist starts off by saying, “Man, I took a look at your x-rays. You’ve got some pretty bad DJD (degenerative disc disease).” The therapist then moves right on to range of motion and strength assessments, followed by a few provocative tests. Afterwards, the therapist provides the patient some exercises to complete at home and schedules a follow-up appointment. The patient leaves the clinic, exercises in hand and an appointment scheduled for follow-up in a few days. But how has this interaction affected the patient’s experience of the clinic?
Perhaps that is exactly what that patient wanted, an assessment from a professional and some exercises to do at home. Maybe, however, that patient wanted to explain to a professional everything that was going with their back —their history of injury, what they’ve tried in the past, when the pain is exacerbated, etc. It’s likely that patient not only wanted some physical treatment, but also some validation of the pain they were feeling and reassurance that there is hope for recovery. Evidence shows that patients expect to be “handled” —or treated with manual techniques— by therapists, but they also desire reassurance from the therapist that recovery is possible [4]. By either breezing over the psychological aspects of a patient’s situation, or even using language that causes a patient to catastrophize their diagnosis or prognosis, a patient’s subjective experience of that clinic and healthcare provider can be negatively impacted. I’m sure we’ve all had patients show up in our clinic saying something like, “I tried seeing XYZ Therapy a while ago, but they didn’t do much for me. They said my ______ (shoulder, back, etc) was really messed up.” There’s a reason that that patient decided to go to a different clinic this time around. I’d say that no small part of that decision was related to their experience in the previous clinic.
Social or Cultural Factors Affecting Experience
A major part of the biopsychosocial model is the understanding that differing factors can impact a patient’s subjective experience and outcomes. For example, social factors can impact a patient’s behavioral response to physical factors or symptoms [5]. Sociocultural factors, like the beliefs surrounding illness, pain, or treatment affect a patient’s experience by influencing their thoughts about the effectiveness of treatment or the effectiveness of the clinician.
A patient’s experience can also be affected by their family/social support system, ethnic or cultural norms, or age and sex stereotypes [5]. Early on in my clinical career I treated man, who was in his late 50s for shoulder pain. He was a veteran and retired police officer. He told me that he had injured his shoulder when he fell off of a ladder while cleaning his gutters. X-rays showed nothing abnormal, but he did test positive for subacromial impingement. He demonstrated notable limitations and pain when elevating his shoulder. Naturally, we set up a treatment plan and schedule that worked for him and we began the course of rehabbing his shoulder.
Things seemed to be going well, however, every time he came in for a follow-up appointment, he reported continued pain, limitations, and weakness. He would leave the clinic feeling better, and come back feeling painful again. After digging down a bit, he told me that he was “an old tough guy” and didn’t see the point in “wasting time” with completing his home exercises, icing, or activity modifications. He also said that he thought that therapy treatment was not working and that he would “probably stop soon”. This was a clear example of how a patient’s stereotypes and cultural norms around gender directly affected his subjective experience of the therapeutic process. If I had been aware of some of these factors at the beginning of treatment (or thought to address them with this patient), I may have been able to positively affect his feelings and beliefs about pain, injuries, and receiving treatment,
Using Biopsychosocial Factors to Improve Patient Engagement & Experience
If we understand that a patient’s experience —not only of treatment, but of the clinic or clinicians who treat them— is affected by physical, psychological, and social factors, than it makes sense that we should take those into account when trying to create a positive patient experience. Clinic owners and healthcare facilities should take a look at their physical environments, processes, and staffing/personnel to ensure they are optimized to provide the best patient experience possible.
Physical Environments
The first thing that affect our patients when they arrive at our clinic or facility is the physical environment: the parking lot, entrance, and waiting areas. This includes the cleanliness, but is not limited to it. Of course, if the clinic is nasty, dusty, and smells of trash, you’ll be starting in a hole as far as the patient experience goes, but other environmental factors can have just a large impact on a patient’s experience.
For example, I’m sure nearly every clinic or facility —in the US, anyways— is compliant with ADA (American with Disabilities Act) standards for accessibility. Let’s consider that simply the baseline: widened doorways, ramps, handrails, accessible bathrooms, etc. What about the layout of the building or clinic? Is it easy for a patient to navigate through, or are there hallways, doors, and turns that can be confusing? Consider the layout of the treatment space. When a patient comes in for treatment, can they stay in the same relative space, or do they need to be constantly shifted from area to area (mat over here, parallel bars at the far end of the clinic, assessment area in the other far corner)?
Noise level and the general atmosphere of a clinic or waiting area also impacts a patient’s experience. For example, loud radios, televisions, or other media devices in the waiting area or treatment space can impact a patient’s ability to communicate with staff and clinicians. I remember a patient at the VA who became very agitated and upset because the television from the waiting area was so loud he couldn’t hear his therapist. He wore hearing aids and couldn’t filter out the ambient noise. He ended up submitting a complaint to the department because of the poor experience. Situations like that truly have an impact not only on the patient’s experience that day in the clinic, but they can also challenge the therapeutic relationship between patient and clinician.
Processes or “Touch Points”
Even before a patient arrives at our clinic or facility, odds are they have encountered a “touch point” that can set the tone for the rest of the patient engagement. Touch points can be anything from a phone call the patient receives after the clinic receives a referral, to pre-appointment paperwork or forms that are delivered to the patient ahead of their scheduled visit (not to mention the biggest touch point of all: the front desk- more on that later). If a patient has a negative experience when trying to schedule their initial appointment, for example, they arrive at the clinic with some negative feelings or expectations about the visit. They may take a less active role in the initial assessment, be more skeptical of advice given, or be generally less willing to participate in  a prolonged plan of care.
The biggest, and most frequently encountered, touch point is the front desk. Often, front desk staff and business managers in therapy clinics interact well with patients and their families. They are helpful, kind, and courteous. But what about front desk procedures like sign-in, scheduling, or payment processes? Sometimes, seemingly small nuances or procedures can negatively impact a patient’s experience. In instances involving minor procedural pinch-points, it helps if everyone staffing the front desk has a higher purpose in mind. We all went into rehab and therapy because we want to help people get better, whether it be by relieving their pain or helping them meet developmental milestones. Sometimes for staff however, it can easily become just a job and procedures that could be set aside to make the patient’s experience more convenient or pleasurable become iron-clad laws that cannot be broken. When staff and clinicians buy in to a higher purpose, or mission, of the clinic or organization, procedures and rules can be bent, bypassed, or changed to make the patient’s experience the best it can be.
Social And Interpersonal Interactions
As mentioned up above, staff interactions with patients provide the biggest opportunity to positively impact the patient experience. They also have the ability to do the opposite. The way staff communicates with patients signals to them —either consciously or subconsciously— how to perceive the forthcoming experience in a clinic. When a patient checks in for their first appointment, are they seemingly shuffled along the “check-in” process, filling out paperwork, handing over their insurance card, etc.? Obviously, we need to check patients in and verify identity and coverage, but how do we go about it? A disinterested receptionist shuffling patients through what feels like a conveyor belt check-in process gives patients the subtle sign that they are just a number in the system. It prompts them to expect nothing more than impersonalized, generic care even if that’s not the case. A patient with this perception may feel like they are getting run through a canned exercise program in the clinic, even if the therapist has individualized it and is monitoring and progressing the patient on an individual bases.
Another example involves how our clinic staff address patients. Something as simple as calling a patient by their name, or remembering their name when they call back or return to the clinic, greatly improves the patient’s perception of their experience. Patients want to feel valued, heard, and listened to. Recent studies suggest that patients want to be involved in decision making and  involvement in decision making and act as partners in both the quality and improvement of the healthcare services they receive [6]. That all starts with being identified as a unique individual receiving care in this clinic or facility.
Personalization is one of the most effective ways of making a patient feel valued and heard. An opportunity to improve personalization occurs with patient education. As we have discussed here, especially when treating patients in pain or with chronic conditions, patient education takes a central roll in the treatment process. Therapists and clinics that understand the biopsychosocial factors that may be at play in a particular patient’s situation are able to tailor the education and information they provide the patient. This makes the information more relevant to the patient and also gives the patient the sense that this clinic or clinician truly cares about them and their situation.
Summary
In the end, improving patient experience and engagement in our clinics and facilities requires a comprehensive review of everything from our physical environments to staff training and interaction. We need to understand that patients want to be listened to and valued as partners in their healthcare. We should try and implement procedures and processes to foster this partnership with our patients. Understanding how biopsychosocial factors can affect the patient experience helps us to modify and change as needed to deliver care that is truly focused on each individual patient that comes into our clinics. Because at the end of the day, that is what healthcare and rehabilitation are all about: the patient.
Have you tried implementing some of the principles of the biopsychosocial model to improve patient engagement in your clinic or organization? Share any additional resources that you found helpful in the comments below!
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References
[1] de Filippis LG, Gulli S, Caliri A, D’Avola G, Lo Gullo R, Morgante S. et al. Factors influencing pain, physical function and social functioning in patients with osteoarthritis in southern Italy. Int J Clin Pharmacol Res. 2004;24(4):103–109. Available at: https://www.ncbi.nlm.nih.gov/pubmed/15754914
[2] Synnott, A., O’Keeffe, M., Bunzli, S., Dankaerts, W., Osullivan, P., & Osullivan, K. (2015). Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: A systematic review. Journal of Physiotherapy, 61(2), 68-76. Retrieved from https://doi.org/10.1016/j.jphys.2015.02.016.
[3]Â Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The Enduring Impact of What Clinicians Say to People With Low Back Pain. Annals of Family Medicine. 2013;11(6):527-534. doi:10.1370/afm.1518.
[4] Nijs, J., Roussel, N., Wilgen, C. P., Köke, A., & Smeets, R. (2013). Thinking beyond muscles and joints: Therapists and patients attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment. Manual Therapy, 18(2), 96-102. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/23273516.
[5]Â Turk, D. C., & Gatchel, R. J. (2018). Psychological approaches to pain management: A practitioners handbook. New York: The Guilford Press. Available in part from:Â https://books.google.com/books?hl=en&lr=&id=ngBPAgAAQBAJ&oi=fnd&pg=PA3&dq=social+factors+in+the+biopsychosocial+model+of+pain&ots=zY1XoWz6h4&sig=iyo8RZ51CH97Zg8-sHvvQzvH1H0#v=onepage&q=social%20factors%20in%20the%20biopsychosocial%20model%20of%20pain&f=false
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