Academy Society Spotlight: Behavioral Sciences in Clinical Practice

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By John T. Brinkmann, MA, CPO/L, FAAOP(D)
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In 2017, Richard Thaler, PhD, an economist from the University of Chicago, won the Nobel Prize for Economic Science for his work in behavioral economics. His research challenged traditional economic theory, which assumes that individuals accurately weigh costs and benefits when making financial decisions. Contrasted with this idea, behavioral economics describes evidence that judgement errors are common and systematic, and that people tend to choose options with the most immediate appeal at the cost of long-term benefits. Thaler's book explains that people need a nudge to make financial decisions that are in their own best interests. Individuals also make choices about their own health that are not in their best interests long term. For example, many impairments that require orthotic or prosthetic intervention can be linked to chronic conditions caused or influenced by lifestyle choices. Understanding how people make healthcare decisions and how to influence them to make good ones will make us more effective as O&P practitioners.

Several different fields of study are involved in understanding the decision-making process. Sociology studies how individuals function in a broader society, while psychology is the study of the human mind and its function in a given context. Behavioral sciences focus on the decision processes and communication strategies within organisms in a social system. Behavioral sciences include relational sciences, which address relationships, interaction, communication networks, associations, and relational strategies. Clinicians function within the social system of healthcare delivery, which occurs in the context of broader family, societal, and cultural contexts. The interactions between the organisms within that delivery system (the patient, family members, caretakers, other healthcare professionals) are an important part of the care that is provided.

The social sciences are often called the soft sciences to distinguish them from the hard natural sciences due to criticism that the research methodology used in social sciences is less rigorous than in natural sciences. The controlled experimentation, greater objectivity, higher replicability, and purer application of the scientific method of the hard sciences make them more appealing to many researchers and clinicians who aim to base clinical practice on objective data. A 2005 editorial in the journal Nature titled "In praise of soft science" challenges the attitude of many researchers in the biological and physical sciences. Pointing to the limitations of a purely hard science approach to global environmental problems, public health, and medical errors, the author argues for a deeper appreciation for the social sciences. "‘Hard' scientists need to get over their disdain for their ‘soft' colleagues. The study of society can't just be left to poets and politicians. As the almost boundless complexity of physical and biological systems becomes increasingly apparent, along with the pressing need to better understand patterns of human behavior, now is as good a time as any for a rapprochement between the two wings of the scientific academy."1 Resolving the greatest challenges our patients face will require a much more robust understanding of their impairments than can be garnered through kinematic and kinetic data alone. It is more difficult to understand how and why people make the decisions they do than to measure their physical function, thus, some proponents of the social sciences distinguish between sciences that are hard and those that are difficult.

Decision Making. Foundational Content Area C.1.1 Behavioral Science: The study of fundamental psychological concepts in personality and disability in relation to healthcare, self-care and the role of relationship building in clinical decision making. Strategies include the recognition of behaviors; ability to work with individuals in distress, stages of grief and emotional adjustment; identification of problematic psychological symptoms necessitating referral to appropriate health care providers; application of motivational techniques; and care for one's own physical, mental, and emotional health. Core Curriculum Guide Master's Level

Topics and Challenges

Generally speaking, behavioral sciences can be thought of as the aspects of clinical care that are not related to technology, psychomotor skills, or physical interaction with the patient. In the early 2000s, Benbassat et al. published a paper on the barriers to teaching behavioral sciences to Israeli medical students.2 The authors identified key content areas that comprise behavioral science, including interviewing skills, medical ethics, communication, and other interpersonal skills. In the past, these aspects of care have been referred to as bedside manner, and good clinicians have always recognized this is an important part of providing effective medical care. Benbassat et al. report that medical students often fail to understand the relevance of the behavioral and social sciences for clinical practice because concepts are either so obvious that time shouldn't be spent explaining them, or they are so fanciful that they should not be taken seriously. The timing of behavioral science instruction also perpetuates the perception of irrelevance for clinical practice. For example, students who have never worked with an angry patient or one who does not follow instructions may not see the practical benefit of lectures or readings related to responding to strong emotions or adherence to a treatment plan. Other challenges include determining which non-technical aspects of care should be covered, and in what depth, and the lack of qualified instructors. Experienced clinicians may have received little or no formal instruction in the behavioral sciences, while behavioral and social scientists lack the clinical experience necessary to make their subjects relevant to students in a particular medical discipline.

Education

The National Commission on Orthotic and Prosthetic Education's (NCOPE's) Core Curriculum Guide Master's Level, includes 11 entry-level competencies for students of master's programs, four of which (A.2, A.3, A.7, and A.11) focus on tasks or skills traditionally associated with the provision of O&P care.3 The seven remaining competencies focus on skills solidly within the scope of the behavioral sciences.

Four of the 20 foundational content areas (behavioral science, communication, ethics, and models of disablement) fall within the realm of the social sciences. In addition to this explicit delineation of social science content requirements, behavioral science skills are required to demonstrate competency in almost every other aspect of O&P practice as described within the NCOPE guide. NCOPE's standards are an accurate reflection of the knowledge and skills required for effective contemporary O&P practice. Behavioral science skills are not only a complement to the technical, technological, and psychomotor skills traditionally understood as defining O&P care, they provide the context for the effective performance of all of those skills. It is difficult to imagine obtaining an accurate assessment and impression, for instance, without communicating effectively in the context of a trusting relationship.

Communication. Since the prosthetist-orthotist creates a product to be worn by a human being, success or failure will be influenced by the opinions, attitudes, feelings, likes and dislikes of that human being. The experienced prosthetist-orthotist knows that in many instances the critical problem in the successful fitting of a prosthesis or an orthosis lies with the psychology of the wearer rather than in any physical or biological problem. The prosthetist-orthotist must, therefore, be capable of understanding and relating to his patients so that he can work constructively with the individual's psychological attributes rather than at crosspurposes. Patients, peers, professional colleagues, and prosthetist-orthotists themselves must be viewed in psychological terms and dealt with in a similar manner.4

The emphasis within NCOPE's guide echoes the perspective of Sydney Fishman, PhD, a pioneering O&P educator, who authored the article "Education in Prosthetics and Orthotics" in the inaugural issue of Prosthetics and Orthotics International.4 (See sidebar.) In 2002, a group of researchers reviewed articles published in Prosthetics and Orthotics International during the preceding 25-year period and analyzed them for content related to psychology.5 They concluded that "despite Fishman's…paper...identifying the psychological sciences as one of six areas of importance for prosthetics and orthotics, psychological issues have largely been overshadowed by physical aspects of the subject." These authors go on to identify "key concerns" related to psychological aspects of O&P practice and suggest ways that these topics can be integrated into O&P practice, including psychological assessment, promoting positive coping and adjustment, implications of developmental stage and age, and body image and one's sense of self.5 In the 15 years since the publication of that review, much has been done to remedy this situation. One of the challenges to addressing the ongoing need for behavioral science research within O&P is likely that those topics continue to be viewed as an adjunct to, rather than an integral part of O&P practice. However, while the provision of a mechanical device could be considered an essential element of O&P practice, practitioners in contemporary practice are increasingly required to be proficient in behavioral sciences skills. To be effective, practitioners must be skilled in handling the common and unique characteristics of both the physical and psychosocial presentation of each patient.

Research Methods

Research in the hard sciences typically involves controlled experiments in a laboratory setting and relies on data derived from measurement for its conclusions. Tightly controlled experiments that must limit variables often do not match the real-life settings in which our patients function, and deeper exploration of their experiences requires a broader approach. A social science researcher obtains data by observing and interacting with individuals and attempts to understand "social and human phenomena in their natural settings, attempting to make sense of or interpret these phenomena in terms of the meanings participants bring to them."6 An increased familiarity with social science research methods may result in a greater appreciation for that research. More importantly, having a better understanding of many areas of practice related to behavioral science could improve the care we provide: Why do patients prefer specific components or designs, what influences adherence to treatment recommendations, what type of education best prepares students and residents to practice independently, and how can we effectively manage encounters with challenging personalities? These are just a few examples of research questions whose answers require a social science approach and qualitative methods. Expertise in qualitative methods will allow us to explore these and many other questions and develop clinical approaches that more effectively meet the needs of our patients. (See sidebar.) During the past decade, O&P researchers using these methods have made significant contributions to our clinical understanding, often by integrating this research into quantitative, laboratory-based studies. This mixed-methods approach will give us a more holistic understanding of how patients make decisions, and how we can effectively partner with them to make healthcare decisions in their own long-term best interests. Our patients often need a nudge in the right direction, and providing this nudge is part of our professional responsibility.

Common Qualitative Methodologies
1. Grounded theory: explores social processes to produce explanatory theory. 2. Phenomenology: deeply probes individual experiences of selected phenomenon. 3. Ethnography: studies culture to describe the nature and meanings of routines and rituals. 4. Case study: analyses one (or more) instances of a problem, to inform understanding Adapted from Cristancho, et al. 2018.6

Resources

A purely rational analysis of the cost and benefit related to developing behavioral science skills should cause us to pursue training in those areas.7 However, O&P practitioners, like the patients we serve, often make decisions without considering the long-term consequences. We may find it difficult to devote the time, energy, and money to this aspect of our practice and focus instead on device design, component selection, and other tangible clinical skills. Recognizing that practitioners also need a nudge, the American Academy of Orthotists and Prosthetists (the Academy) offers education and resources intended to increase our effectiveness in the non-technical aspects of our practice. For example, the Academy Behavioral Sciences Society will be offering training on motivational interviewing and other behavioral science content at the 2019 Academy Annual Meeting & Scientific Symposium. Taking advantage of these and other opportunities will nudge us in the right direction and help us make decisions that most effectively support our patients.

 John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center and Chair of the Academy Behavior Sciences Society. He has more than 20 years of experience treating a  variety of patients.

 Academy Society Spotlight is a presentation of clinical content by the Societies of the Academy in partnership with  The O&P EDGE.

 References

1.  Nature 435, 1003 (23 June 2005) https://www.nature.com/articles/4351003a

2.  Benbassat, J, R. Baumal, J. M. Borkan, and R. Ber. 2003. Overcoming barriers to teaching the behavioral and social sciences to medical students. Academic Medicine 78(4):372-80.

3.  http://www.ncope.org/view/?file=core_guide_for_OP

4.  Fishman, S. 1977. Education in prosthetics and orthotics. Prosthetics and Orthotics International 1(1):52-5.

5.  Desmond, D., and M. MacLachlan. 2002. Psychological issues in prosthetic and orthotic practice: A 25-year review of psychology in Prosthetics and Orthotics International. Prosthetics and Orthotics International (3):182-8.

6.  Cristancho, S. M., M. Goldszmidt, L. Lingard, and C. Watling. 2018. Qualitative research essentials for medical education. Singapore Medical Journal.

7.  Sherwood, A., J. Brinkmann, and S. Fatone. 2018. Review of benefits to practitioners of using good patient-practitioner communication. JPO: Journal of Prosthetics and Orthotics 30(1):5-12.