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CAUSE of the CAUSE – Dr Graeme Wilkes

16 November 2018

Biopsychosocial courses and practice in Physiotherapy / MSK practice – just a tick box exercise?

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So here I am in the twilight of my career stretching back 34 years.

  • From hospital doctor to GP, to Community Sports & Exercise medicine Consultant and Medical Director with Connect Health
  • From NHS hospital to Independent sector NHS GP to Independent sector community NHS provider

I have experienced a great deal. I might be forgiven for thinking you can’t teach an old dog new tricks. However. that’s not me and the fact is healthcare is ever changing and that’s the great thing about working in health. As I say to enthusiastic young guns – “don’t be dogmatic about new things you become passionate about. You will probably be laughing that you “thought that” or “did that” in a few years’ time”. You may be thinking “Did we really do that” or “really not do that”!

So, my recent revelation has been fuelled by two things running in parallel:

  1. Firstly, I have been doing some work with the very knowledgeable David Julian from First Contact Clinicalon Social Prescribing and causes of poor outcomes in chronic diseases (such as MSK)
  2. Secondly, I have been privileged to attend the recent #TheBigRs conference (see reform.physio), join in the debate and specifically hear Jo Gibson, @ShoulderGeek1, talk about (the limitations of) Biopsychosocial assessment in physiotherapy practice.

Both the above also have provoked even more thought on my part on the mad rush of First Contact Practitioners (physiotherapists) into General Practice – more of that later.

So where to start? For 13 years I worked as a GP partner in inner-city Newcastle upon Tyne. My GP training was varied but included many hours of studying “Consultation Theory” – reading several books on consultation theory, scientific papers and having my consultations “videoed”. Very un-nerving but I learnt a lot about my deficiencies including to “STOP TYPING – YOU ARE MISSING HUGE VISUAL CLUES”! At the end of all that and indeed 13 years of GP practice, followed by 12 years doing GP Out-Of-Hours alongside my new MSK practice, I thought I knew how to consider patients biopsychosocially and really get to the bottom of problems. And I did, or did I really?

David Julien, a GP turned Addictions/Change Management/Social Prescribing specialist has just opened a door or more accurately a stairway down to a new level of enquiry. This is based on many pieces of work and theory but summed up in the Public Health England document: Local wellbeing, local growth(1) :

Reducing health inequalities: system, scale and sustainability (1)

 

All the illustrated “determinants of health” play important parts in ill-health and chronic disease including musculoskeletal disease and how patients react to this. This isn’t new – we all know this. It’s largely the “S” of “biopsychosocial”. How many times do we actually know or ask about any of these things………. rarely I suggest …. not equipped , not interested or just don’t have the time……..? Does it matter ?

The mind-blowing bit for me is the following:

Figure 2 (based on Labonte 2) sets out the ways that risk conditions, psycho-social risks and behavioural risk factors, interconnect to affect changes in the body that lead to illness or health:

So simplistically, what this is saying is when you have a problem – let’s say COPD (“bad chest”), then being a smoker is a cause – the first layer down. So, what we all do (“Make every contact count”) is say “Mrs Smith – you have COPD and you smoke – you really have to stop, I will signpost you to the smoking cessation service”. The cause of Mrs Smith’s bad chest is her continual smoking – easy – stop her smoking and things will improve … probably! Simple!! Job done, tick the box, get the incentive pay. No!!!!!!!

The real issue is the layer down: the “cause of the cause”. Mrs Smith has one or all of – an abusive husband, financial problems, a disabled son and poor social networks. She isn’t going to stop smoking whilst all that is unresolved. So, she keeps smoking and her chest gets worse. When she is admitted to hospital with her infective exacerbation all the nurses and junior doctors say: “you really should stop smoking”. She doesn’t. So, it goes on. “Well at least we tried” – tried what! Best of all, we get paid (GP) or congratulated (community KPI) for asking………

The Cause of the Cause

This is the key. Did I know this as a GP – well sort of. Was I effective in resolving these things …. 10 minute appointments, visits to do, poor support structure out there ….. social workers unproductive (not their fault), public health undervalued etc etc … so no probably not.

Jo Gibson at #TheBigRs left her renowned shoulder expertise behind and challenged the audience of largely physiotherapists that the Biopsychosocial teaching and subsequent actions really doesn’t equip or teach anyone anything effective. The biological model rules. In the MSK pathway we still:

  • Heat
  • Move structures back and forth
  • Inject
  • Stroke and prick
  • Worst of all – operate on…..

people who may be harbouring a variety of causes of their causes. Causes of why they don’t do their exercises, of why they ignore advice and why they succumb to passive treatments that don’t work because no-one knows how to activate them psychologically and socially, help them solve the cause of the cause, understand them, make a difference.

Jo stimulated me to think about myself and those around me during my many years in Health care in terms of BioPsychoSocial application in our practices so here it is with portions represented by their size:

Myself as a GP:                             B p S

Myself as an MSK physician:    B P s

Community Physiotherapists:  B p s

APP/ FCP:                                     B p s

Rheumatology:                            B

Orthopaedics:                             B

Pain Consultant:                        B (p) ?

Happy to be shot down on these and there will of course be exceptions and debate but that’s how I believe it looks.

So here it is: Public Health has been drummed out of the NHS. The B rules still. We waste funding every day on treating what we see and trying to advise on the causes (posture, weakness, proprioception, myofascial tightness, core stability, pain inhibition etc etc). It’s time to put some S back in and it requires some P.

The evidence base for subacromial decompression is poor, the expense is huge. How about heating homes, improving social support, providing health coaching and all the other measures too with the diverted funding. Then when patients are ready let’s apply the science and load and condition their tissues.

Summary:

  1. Screen for Cause of Causes
  2. Assess patient activation
  3. Correct the above before you tackle the B

These are the basic tools we need before any other. As stated at #BigRs – we need to stop and listen and let patients tell their story and understand their true needs.

Perhaps we could spend the money saved from un-evidenced and pointless injections and surgery in many people to fund more time with patients and ask them “tell me about yourself and your life” before we ask “where does it hurt”.

  1. Public Health England. Local wellbeing, local growth: adopting health in all policies 2016 [Available from: https://www.gov.uk/government/publications/local-wellbeing-local-growthadopting-health-in-all-policies.
  2. Labonte R. Health promotion and empowerment practice frameworks. 1993. 15
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