The biopsychosocial model is a holistic and patient-centred approach that focuses on the complex interactions of psychological, biological, and social influences on the development and functioning of individuals.1 This model aims to achieve positive health by understanding and relieving mental distress in addition to treating illnesses.2 It is considered the Gold Standard in medical practice and views patients as a whole, rather than individuals that have deviated from their normal functioning due to health conditions.3Patient-centred care (PCC) in medicine refers to the process of engaging patients in decisions regarding their healthcare.
3 It emphasises on effective communication between doctors and patients to facilitate decision-making processes in terms of diagnosing diseases or providing treatment options. Adjusting the focus of clinical care to accommodate the needs of patients via PCC has enhanced patient experiences, decreased the duration of hospital admissions and upgraded primary health care services leading to improved health outcomes.3,4 Patients also have greater access to specialist care centres and pathological investigations.
4Health inequalities refer to the differences in health status or in the distribution of health determinants between different population groups.5,6 Some health inequalities are attributable to biological variations and others are attributable to external circumstances. The social classes of which individuals are grouped into relate closely to health inequalities according to The Black Report.5,7 Individuals are grouped into their social classes based on The Registrar-General’s Social Class (RGSC) scheme, which is a common approach that ranks five social classes in order of occupational advantage as shown in Figure 1.8 People from lower social classes experience higher morbidity and mortality rates as well as greater disability rates as opposed to individuals from higher social classes mainly due to poverty and the lack of education.9 Hence, they are less privileged in obtaining better access to nutrition, clean water supplies, improved housing and immunisation for debilitating diseases.8,10,11 The definitions of health may vary between individuals from different communities and occupational backgrounds as well as between different age groups. The majority of elderly and working-class individuals describe their health as the absence of disease, illness and injury as defined by the medical model.4,10,12,13 This model views psychological issues separately and focuses heavily on incapacity and impairment rather than an individual’s capabilities and strengths. The social model of health however describes health as the ability to function normally in communal roles, as defined by the younger generation and middle-class individuals. This model considers a person as a human being with emotions rather than just a series of bodily functions.10,14,15Health beliefs are personal convictions that influence health behaviours.16 According to the Health Belief Model (HBM), health beliefs are affected by the perceived susceptibility and severity to health threats as well as the benefits and barriers pertaining to the treatments of a perceived illness.17,18 Individuals are more likely to act in favour of their health if they believe that the benefits of the behaviour undertaken to counteract their illness outweigh the costs, side effects and other associated inconveniences.18 The HBM also encourages the principle of self-efficacy amongst individuals to encourage the exertion of control upon their health by the practice of patient self-care.17 I met a patient who presented with a severe fungal infection on his thigh. He had been applying hand sanitiser on the infection for the past three months prior to the consultation, as he believed that it was a cheaper and more effective alternative that would improve his condition. This illustrates how health beliefs relate to patient behaviour and self-care.Patients are responsible in protecting their own health, choosing appropriate and desired treatments as well as managing health conditions. This is known as patient self-care and can be carried out independently or in partnership with the healthcare system.19,20 Aside from leading a healthy lifestyle and managing minor ailments, patient self-care encompasses the management of long-term conditions such as diabetes or hypertension that have been identified in their early stages. However, slight help is still required from healthcare professionals in managing these diseases to prevent further disability or injury. Self-care is no longer sufficient once a patient experiences major trauma, which requires extensive care managed entirely by healthcare professionals. Self-care may resume once the patient begins the process of recovery.21The over-adherence to patient self-care however may cause patients to tolerate and manage their symptoms for an extended amount of time instead of immediately consulting a healthcare professional. This phenomenon is illustrated by the illness iceberg’ in Figure 2 whereby only a small proportion of symptoms are presented to healthcare services as opposed to symptoms that are not.22 Hence, supplementary factors should be present to precipitate a medical consultation which according to Zola’s triggers include the occurrence of an interpersonal crisis, the perceived interference with social and personal relations, perceived interference with vocational and physical activity, sanctioning by other individuals, and the temporalising of symptoms.23 I met a patient who had been suffering from severe migraine for the past two months, but was only prompted to finally see the doctor when it was beginning to restrict him from carrying out daily activities. This illustrates Zola’s triggers in relation to consulting behaviour.According to the GMC, a doctor must always prioritise a patient’s needs and must act immediately if a patient’s safety, dignity or comfort is compromised. Doctors must always respect and be considerate towards their patients as well as treat their patients equally regardless of race, religion or gender. The maintenance of patient and public trust is of utmost importance especially when managing a patient’s confidential records. In addition to that, a doctor has to provide good care to a patient and must always stay updated in terms of professional knowledge. Doctors are required to work together with their colleagues and their patients by acknowledging the patients’ concerns and supporting their decisions made to care for themselves.24 Doctor-patient relationships depict the amount of control that doctors have over their patients and vice versa. These relationships can be divided into four categories, which are the paternalistic, mutualistic, default and consumerist relationships.25The paternalistic relationship describes the doctor as the more dominant figure who decides on behalf of the patient’s best interests. This relationship is commonly seen in emergencies whereby patients are unconscious and hence are unable to make decisions on their own, or even under normal circumstances whereby patients have readily consented to the recommended treatment by the doctor.26,27A mutualistic relationship encourages equal partnership between a doctor and a patient, enabling both parties to be involved in a shared-decision-making (SDM) process that leads to the effective exchange of ideas while reducing decisional conflict.26 The doctor contributes medical knowledge to aid in the diagnosis and prognosis of a patient, whereas the patient contributes personal experiences and treatment preferences to a particular disease.26 Patients involved in SDM processes are able to increase their knowledge and awareness on their condition, empowering them to make informed decisions of their own. SDM processes also allow doctors to elicit specific information regarding a patient’s preferences to provide the most suitable treatment options, leading to increased patient satisfaction.28,29Next, a default relationship arises when patients are timid in conveying their opinions during a medical consultation despite the doctor having reduced some control to focus on a patient-centred approach.26,27 This causes the consultation to lack direction as both parties exhibit a passive role.26 Patients in a consumerist relationship however exhibit the more dominant role compared to doctors as they have a greater autonomy through their payment to doctors who in turn aim to earn profit.26 Consumerist relationships are often presented in aesthetic medicine or when healthy patients intend to illegally obtain a sick note from doctors. A summary of these relationships are as depicted in Figure 3. The Calgary-Cambridge framework as depicted in Figure 4 outlines the flow of events that occur in a medical consultation. This framework is fully patient-centred and addresses the patient’s perspectives besides obtaining sufficient information to diagnose a patient’s condition.30 This framework states that a medical consultation is initiated when the physician establishes an initial rapport with the patient and explains the contents of the consultation. The physician then gathers information on the patient’s past medical history, family and social history via active listening and observation of the patient’s verbal and non-verbal cues. The patient’s perspective in terms of ideas, concerns and expectations are deeply looked into as well. A physical examination is then conducted followed by further explanation and planning. The physician is required to aid the patient in the recalling and understanding of information by avoiding medical jargons, but by using signposting, repetition and summarisation. The session ends when the physician decides upon an appropriate point of closure after a certain measure of forward planning.31 Evidence-based practice (EBP) according to Dr. David Sackett is defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.’33 EBP is important because physicians need to constantly stay updated with the latest information on diseases to ensure the consistency of treatment options worldwide.34 EBP also increases the accountability to decisions made as they are based on valid information and hence are able to withstand any form of criticism or judgement.35 A physician’s clinical judgement and reasoning relies strongly on EBP as the strength and effectiveness of the evidence at hand is combined with the physician’s pre-existing medical knowledge and individual expertise to effectively treat a patient.36 The repeated exposure to real health-related cases enhances a physician’s clinical reasoning and problem-solving skills as the physician is able to continue developing memory schemes for long-term storage.37,38 However, physicians are often placed in situations whereby a well-defined answer to a patient’s problem does not exist despite having years of clinical experience. This dilemma is referred to as clinical uncertainty and is inherent in medical practice.39 Clinical uncertainties may arise from the patient’s inability to provide a complete recollection of events due to varying preferences of information, or the physician’s inability to provide clear explanations of the disease process to patients who are not medically trained. Physicians who are unable to stay updated with the latest clinical insights may also contribute to clinical uncertainties due to informational deficits. 40 Hence, EBP should be made available during medical consultations to overcome clinical uncertainties and to provide an accurate diagnosis. Health promotion is the process of encouraging people to increase control over and to improve their health by utilising a range of social and environmental interventions whereas disease prevention is based on specific efforts aimed at reducing the development and severity of chronic diseases.41,42 Health promotion and disease prevention programmes complement one another in addressing the social determinants of health, which influence modifiable risk behaviours that may contribute to the development of illnesses.42 Disease prevention can be divided into three stages, which are the primary, secondary and tertiary stages of prevention. The purpose of primary prevention is to prevent the occurrence of a disease or injury by preventing, altering or increasing resistance towards health hazards.26,43 This is carried out via immunisation or the encouragement of healthy lifestyles via campaigns.26,33 Secondary prevention involves detecting and treating the early onset of diseases, allowing individuals to return to their original state of health and preventing long-term health issues.26,43 Regular screening procedures are conducted by physicians and clinicians alike to diminish the development of diseases.26 Lastly, tertiary prevention aims to limit the incapacity of an ongoing illness or injury to improve a patient’s functional abilities, quality of life and life expectancy as seen in palliative care centres.26,43 The patient pathway refers to the route taken by patients from initial contact with a healthcare professional to when they are discharged after the completion of their treatment.44 Patients have a range of alternatives in determining the course of their treatment, from dealing with the symptoms themselves to obtaining professional help.44 Primary care is the first stage of professional care that patients come into contact with.45 The primary care team consists mainly of general practitioners (GPs), which are doctors that work together with other healthcare professionals such as practice nurses and pharmacists in resolving non-urgent cases locally.46 The GPs in the primary healthcare system deal with a variety of patients presenting from a range of mild and common symptoms to chronic illnesses requiring weekly management through medication and tests or behavioural modifications. These GPs are responsible in managing health issues within their expertise, and behave as gatekeepers in referring patients to specialists in the secondary care.45 These specialists conduct surgeries and provide rehabilitation services such as physiotherapy in hospitals or in community-based environments.47 Tertiary care services however are dominated by consultants, which are doctors that have a wider knowledge base and more access to complex and specialised equipment.46,47 I met a patient who had been suffering from severe neck pain for the past month. The doctor detected a few abnormalities with the patient’s cervical vertebrae after an X-ray was conducted, but was unsure of the diagnosis as it was beyond her area of expertise. Hence, she immediately referred the patient to an orthopaedic specialist who would be able to provide a second opinion and conduct further tests. This situation illustrates the patient pathway from primary to secondary care.All healthcare professionals involved in the patient pathway work together in evaluating and planning patient care through the multi-disciplinary teamworking (MDT) approach.48 MDT emphasises on solid communication amongst healthcare professionals and patients, which has proven to be beneficial in numerous ways. Aside from ensuring the smooth transition of patients into different levels of healthcare, effective communication amongst healthcare professionals has proven to be essential in reducing the number of patient errors and promoting patient safety.49 Patients feel acknowledged when both their verbal and non-verbal cues are taken into consideration, hence increasing compliance towards treatments.50