Assessments Contract to Fit the Time Allocated.
Recently, a physiotherapist friend did two opposing things in reasonably quick succession.
In the first they complained of not having a good first session with a patient as they couldn’t get to where they wanted to in the time.
In the second their initial assessment with a patient lasted two and a half hours.
We discussed the idea that pushing to achieve a particular goal in the first assessment might have stifled where the session should naturally go.
And as for the second assessment, initially they seemed to think it was OK. But in the next session the patient did say “it was a bit long”.
How Long is an Assessment?
That led me to think how long an assessment should last. Or any session for that matter. And should you have a specific goal, a number of things to cover, a load of boxes to be ticked?
Who should set the agenda for an assessment? Should it be a dry collection of the facts of the case or a freewheeling conversation about whatever comes up?
As a physiotherapist, am I an expert questioner teasing out the salient points, a data collector, a coach, a guide or a supportive ‘friend’?
Having a Goal
Without a goal when we approach an assessment we won’t achieve anything, but how set out, how rigid should that be? When we are starting out we need a more controlled structure to work with, and as we become more experienced we can take a quicker route to our goal.
If we achieve mastery of the process, we should have answered all these questions and come to an expert assessment, clearly seeing the problems and able to move the patient towards a solution.
But how many of us progress beyond the stage of collecting what we see as the facts, going through the list on the assessment form and then emerge as great interviewers?
In his first session, my physio friend had the goal of getting to a conclusion and when they didn’t they felt frustration. The goal was blocking them from allowing the assessment to take the shape it was forming.
The Shape of Assessments
Assessments have a life of their own, and we don’t know where they’re going to take us. At least that’s how I think they should be. When you sit down to assess a patient, if you have only a limited idea where you’re going to be in 30 or 60 minutes this can allow the patient’s narrative to prevail.
The clinician’s skill is to respond to how the assessment is unfolding and help the patient get across all the aspects of their issues. If you let them, the patient will take you on a journey through their life and show you how to help them get better. The assessment forms its own shape and we need to avoid getting in the way.
Cramming Stuff In
The initial assessment often includes the subjective examination, the objective examination, problem identification and a treatment plan.
Mostly this fits into a time allotted. With 15 or 20 minute sessions we will have to direct the patient and get their answers to defined questions or we’ll never get through our list.
Like Parkinson’s Law in reverse, the work is compressed into the time available for it. Having to reach a goal forces us to be rigid in the execution of the interview, and to get to the end at the end.
Targets and Capacity
Demand for appointments, the capacity of the services and the targets set for them all conspire to provide a service which could be so much better. Time is constrained, gradually more and more, to allow more throughput.
Reducing the time for initial assessments could start at 45 minutes, then it seems sensible to reduce it to 30 minutes and then to 20 minutes to get through the numbers.
Without outcomes to tell us how our patients are doing over the longer term, any consultation is of limited worth. We get through the numbers, reduce the list and reduce the waiting times. These things are easy to measure but we are not measuring the things that are important.
I don’t know how long as assessment should be, just that it takes the time it takes to get to a place where the patient feels understood and we feel we know what’s going on. And that should be the goal.