Training principle of the month 5: A biopsychosocial approach is applied at all times

This month we explore the social and psychological factors that may impact a patient's clinical presentation.

We have an interview with paediatric consultant Dr Lil Breen who shares her insights on how to apply a biopsychosocial approach and why it is crucial for good care. And, trainees Dr Tom Leyland and Dr Sunitha Vimalesvaran have put together case studies, an interview with a patient and a learning presentation slideset.
RCPCH Progress+ Training principle of the month
Last modified
18 February 2022

From children and young people

Living with a long-term condition or having other things like being in foster care can mean that we need more help. We have been talking about this and we really want people to think about all of our lives, not just the bit that needs help from a doctor.

Being me was a project for children and young people aged 8-14 who were living in care. This group said:

Doctors need to remember that sometimes children’s hearts are broken. We need to know how to sleep more, how to stay calm, how to eat well and to be more active to stay well. We need someone to talk to about our sad feelings

Being Me poster: "Here are some feelings you might like to share. You can write or draw on the other side and add your own." Children's drawings of emotions such as 'Happiness', 'Anger' and 'Isolated'
Feelings posters produce by the Being me group

Being me set out to to help children tell their doctors what was going on for them, to support their health needs, feelings or things at home. They created health and wellbeing passports, including for children and young people in care, tips for doctors, a 'feelings teller' game and a poster (pictured right). You can download these resources on our Being me page.

It’s also been hard having a long-term condition during the pandemic. We have felt more worried about having to shield then having to go back out and mix with others, our mental health has been worse, and it’s been hard to get the help with we need with changes to our homes or support at school or college because everything is a bit slower because of the pandemic.  It is so important to always think about the whole child or young person every time you speak to them and help by linking people together, not just the bit you are responsible for.

You can read more about what young people have experienced over the pandemic on our COVID-19 &Us page.

Engaging and supporting the patient as a whole

So much of our paediatric practice is influenced by psychological and social aspects of children's lives, if we neglect these it is very difficult to provide patients with a good level of care

In this video, Dr Breen gives us her insight on how to embed a biopsychosocial approach into patient encounters.

Trainee led exploration of biopsychosocial challenges - case study

Training level:  All levels

Setting: Inpatients

What prompted the change? A teenaged patient with a long term condition which had been well controlled on medication had recurrent admissions for relapses. It was suspected that they were not taking their medication but this was denied by the patient. 

What happened? Following a ward round, in which the patient had stated they always took their medications unless they occasionally forgot, a trainee attended the patient for a discussion. Following a chat about likes, dislikes, school and home life, the patient disclosed that they had not been taking their medication. They expressed that they liked the hospital admissions as they had their own room instead of sharing with siblings and they could stay in bed all day. Following this, with their consent, the trainee discussed the patient with the psychologist and pharmacist as well as at the weekly speciality multi-disciplinary team meeting. Following this, the responsible consultant had a further discussion and completed case based discussion assessment. 

How did this support training and trainees? The trainee was empowered to have discussions with patients about their conditions but also their lives. Sometimes context is important and a friendly chat away from the pressure of a ward round situation (with multiple professionals and time pressures) can allow a patient to feel more relaxed. After these discussions, they were able to evidence this with a case based discussion.

Any practical tips? Take time to be friendly to patients, a little effort to build rapport can really help. This can be playing 'round and round the garden', acting like a cartoon character or asking them about their friends or computer games depending on their age. If you are speaking to a patient on your own, make sure you maintain physical distance or consider a chaperone to avoid any feelings or accusations of inappropriate behaviour.  Once you have explored the biopsychosocial factors in a case, make sure you discuss these with the relevant people (maintain the trust of the patient by explaining that you need to do this and why). Use the opportunity to evidence your learning by completing a reflection or case based discussion around the case.

Trainee engagement in strategy discussions - case study

Training level:  All levels

Setting: Community paediatrics

What prompted the change? Paediatric trainees were often not involved in safeguarding meetings but this was felt to be a valuable learning opportunity.

What happened? Trainees were encouraged to attend safeguarding meetings, either as observers or to present the views of the medical team.

How did this support training and trainees? This change towards encouraging and facilitating trainees to attend meetings with other professionals gave them new experiences. Trainees were able to hear about the challenges facing their patients and families from those who had knowledge of this - the teachers, social workers, parole officers etc. This awareness was really helpful for trainees to allow them to better understand the lives and challenges of their patients. It allowed them to appreciate the factors which could contribute to their health problems or overshadow them. Many roles as paediatric consultants are challenging. Exposure to and experience of these as trainees helps to build understanding.

Any practical tips? If there is an opportunity for a trainee to attend a meeting or have a discussion with members of a multidisciplinary team, take it. Make time for trainees to broaden the scope of their practice - they may not have the same opportunity before they are a consultant. 

A patient's perspective - interview

Dr Vimalesvaran interviewed a 15-year-old girl who recently received a liver transplant and was recovering in hospital. This interview demonstrates the importance of understanding the wider implications of a young person undergoing hospital treatment and how the MDT can help them.

Dr Vimalesvaran: Thank you for sitting down with us today. We want to explore your thoughts about the biopsychosocial approach in the care you have received. We want to know how your illness has had an impact on your physical, psychological and social wellbeing. Shall we start with the impact on your social life?

Patient: It has been hard. I haven’t spent much time with my friends but I am trying my best to keep in touch with them through video calls. I also think it’ll be harder to go out with friends when I go home because of my transplant, so I will have to put in extra effort to form friendships. 

Dr Vimalesvaran: That must be hard. Has it had an impact on your family life too?

Patient: Yes it has.I have had the chance to spend more time with them throughout which is the opposite to before! Whilst it has been nice, it does feel like my independence has been taken away a little. But I must say I have really enjoyed spending time with them whilst I have been recovering.

Dr Vimalesvaran: Having a transplant has been pretty life-changing I’m sure! What has been the impact on your psychological and mental health?

Patient: Well I think I used to be more independent and have more control over my life. So I have definitely found that frustrating. But I am slowly trying to take more charge of my life by for example taking my own medications and doing things on my own so I am gaining that independence again.

Dr Vimalesvaran: What can we do differently to make things better for you?

Patient: Not much, really! I have found having a psychologist to be really useful. They have reviewed me on multiple occasions and I have found it helpful to talk about my feelings. I also find the physiotherapist to be very helpful in terms of getting me back on my feet!

Dr Vimalesvaran: What is the one thing you felt that was most important throughout this journey?

Patient: Being a part of the decision-making process made all the difference. Every step of the way, I felt like I was being listened to and my views were taken on board. I also really appreciate the fact that things were explained to me in a simple, non-complicated way so I could understand what was happening to my body. For me, this gave me a sense of control over my health.

Dr Thomas Leyland is an ST5 at Arrowe Park Hospital and is a regional rep for Mersey on the RCPCH Trainee Network. Dr Sunitha Vimalesvaran is an ST6 PGHAN trainee at Kind College Hospital, London and is an exam rep for the RCPCH Trainee Network.

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