In the preceding paragraphs many theoretical models were put forward, but it is now desirable to introduce a holistic model of causation, one that is more naturalistic than the simple linear reductionist models (Borrell-Carrió et al., 2004). A comprehensive literature search showed that the most common and widely accepted holistic framework for treatment and rehabilitation is the biopsychosocial model. The popularity of this model can be seen by the frequency of its occurrence in online sources. A preliminary assessment of the biopsychosocial model was conducted using the Medline database, using the term ‘biopsychosocial’ in the topics field. It is well recognised that use of the term ‘biopsychosocial’ does not necessarily indicate an adoption of the biopsychosocial model, but at a minimum, it does reflect a recognition of the perspective (Suls & Rothman, 2004).

Figure 1.5: Frequency of citation of the term ‘biopsychosocial’ using the Medline database.

4.1 The Biopsychosocial Model

One of the famous landmarks articles, published almost thirty years ago by Engle (1977), questioned the biomedical interventions used in both psychiatry and medicine, and warned of a crisis in the biomedical paradigm (Alonso, 2004). Engle (1977) argued that a true medical approach should consider: (1) the patient; (2) the healthcare system; (3) the social context of the patient’s life; and (4) the psychological context (Mrdjenovich et al., 2004; Pereira & Smith, 2005). The main proposition of the biopsychosocial model is that treatment interventions should be an interlinked system covering multiple dimensions (i.e. diagnostic and causative variables), taking into account biological, social, psychological and macro (e.g. socioeconomic status, cultural, ethnic) issues (Figure 1.6) (Burton et al., 2008). Any defect in one part of the system will affect another part of the system (Keefe et al., 2002). For instance, deterioration of a patient condition (biological effect) can negatively affect patients` emotional states increasing stress and anxiety level (psychological effect) affecting his/ her ability to work or perform his/her daily routine activities (social effect), which will then, subsequently, increase pain and/or disability levels (Keefe et al., 2002).

Figure 1.6: A pictorial illustration of the biopsychosocial model. Adapted from Finlay (2009).

The biopsychosocial model accentuate the importance of interacting and understanding the patient as a unique individual taking onto consideration their belief system in a moderate way that neither concentrate on the biomedical aspects or psychosocial aspects but rather illustrate their relationship together (Jones et al., 2002). In comparison between the biopsychosocial model and the earlier discussed models, it can be seen that the biopsychosocial model posits a much complex, multidimensional and broader approach of clinical care (Hadjistavropoulos & Craig, 2004).

Engle’s new paradigm has often been seen as “a radical departure for medicine” (Salmon & Hall, 2003, p.1972). However, Lambert et al. (1997) stated that although the biopsychosocial model is a new approach, it is still conservative. This assessment was based on several perspectives proposed by the model. First, by underlying the need for good clinical decisions to respond to the eccentricities of each individual patient, it re-affirms the patient’s role, self identity and professional independence (Armstrong, 2002; Salmon & Hall, 2003). Secondly, the model extends the responsibility of medical care to go beyond biological complications and encompass non-medical treatments as well (Baer, 1989). Physicians are required to connect with their patients in a relationship that involves not only the patients’ complaints and symptoms, but also their personalities and psychosocial lives (Salmon & Hall, 2003). Conversely, patients are expected to be prepared to respond to the physicians and bring about the required changes in their lives to prevent and/or manage their illness (Salmon & Hall, 2003).

However, one of the issues that has been discussed in the literature is whether the concepts of the doctor-patient relationship and patient-centredness can affect and threaten the doctor’s authority. However, if the requirements for patient-centredness and a doctor-patient relationship are applied in a moderate and professional way, they do not threaten either the doctor’s authority or their responsibility, especially since physicians maintain their authority by virtue of their specialist knowledge and their responsibility for an accurate diagnosis and appropriate treatment (Salmon & Hall, 2003).

Taking on the considerations mentioned in this section lead to a perceived need for a study to determine the current methods followed in managing lower limb injuries (either in elective or emergency cases) and whether the biopsychosocial model is a better approach of treatment.

4.1.1 To what extent have the medical establishment and different research fields adopted the biopsychosocial model?

The biopsychosocial model has been widely adopted and promoted in different domains, including medical schools, major medical organisations, social work departments, public health, counselling, and some fields of psychology (Kaplan & Coogan, 2005). For example, the WHO’s International Classification of Functioning, Disability and Health (ICF), which is a global framework of disability and rehabilitation, is based on the biopsychosocial model (WHO, 2001).

Dowrick et al. (1996) conducted a study to explore whether the biopsychosocial model is based on rhetoric or reality. A semi-structured postal questionnaire was sent to 494 principal general practitioners. The questionnaire sought the practitioners’ views about what they believed to be relevant and appropriate to a practitioner’s skills and knowledge in general medical practice, and investigated whether these views are consistent with the biopsychosocial model. Only 41% (207) of the sample responded to the questionnaire, which is considered to be a low response rate (Church et al., 2001). The results showed that general practitioners embrace the view that physicians should incorporate a biopsychological model, rather than a biopsychosocial model, in their general medical practice. However, the results cannot be generalised because the study was conducted exclusively on members of a specific organisation. Therefore, the results can only be only applied to the specific population described in the study.

Similarly, Alonso (2004) also investigated the extent to which the biopsychosocial concept has been adopted by medical researchers. Using the Medline database, Alonso examined published articles in the period 1978-1982 (period a) and the period 1996-2000 (period b). Period a was selected because it covers the first five years since Engel’s conceptualised his new model, and the second period (period b) was determined by the date of Alonso’s study (covering the five years before the study). The findings of the previous study showed that the conceptualisation of health in medical research, as characterised in articles written within the past two decades, has not changed. In other words, physicians are still reluctant to incorporate the biopsychosocial model, and often focus solely on traditional methods of treatment. Other studies (Dowrick et al., 1996; Cohen et al., 2000; Alonso, 2004; Kaplan & Coogan, 2005) also concur with the findings of Alonso’s original study, and conclude that the biopsychosocial model has not been fully integrated into actual medical practice.

Conversely, in an evaluation of published articles between the years 1977-1987 and 1988-1998, Hwu et al. (2001) found a considerable spread of medical research articles that did include social and psychological aspects in their definitions of health and medical care. In addition, a literature search also shows that several behavioural, medical and psychological phenomena have adopted the biopsychosocial concept (Kaplan & Coogan, 2005), in areas such as schizophrenia (Kotsiubinskii, 2002; Schwartz, 2000), chronic fatigue (Johnson, 1998), antisocial behaviour (Dodge & Petit, 2003), gastrointestinal illness (Drossman,1998), spinal cord injury (Mathew et al., 2001), and pain management (Truchon, 2001; Covic et al., 2003). Clearly, there are conflicting findings in the existing literature regarding the extent to which the biopsychosocial model has been integrated into the medical domain, indicating a need for future research.

4.1.2 Application of the biopsychosocial model in rehabilitation

Several authors have argued that there is a considerable gap between the introduction of a new or revised model and the application of the proposed model in clinical practice (Linton, 1998; Muncey, 2000; Jones et al., 2002). The challenging factors surrounding changes in clinical practice have been reviewed by Muncey (2000), two of which are associated with physicians’ decision-making skills and knowledge. In addition, physicians’ reluctance, in some cases, to integrate new models into their clinical practice should also be taken into consideration (Silagy, 1998; Jones et al., 2002).

Furthermore, because the current medical literature is often introduced at a basic scientific level, it is complicated for non-researchers to understand and transfer new models and theories to clinical settings (Jones et al., 2002).

Jones et al. (2002) stated that in order to achieve successful application of a new pattern of behaviour and practice thinking, two elements are required. These are reflective, critical clinical reasoning (i.e. the decision-making process), and a suitable organization of knowledge in which the new model can be implemented.

The significance of the biopsychosocial model is based on its capability to show the multitude of interactions between its elements (Jones et al., 2002). in addition, every individual element can then be further explored. However, this means that physicians need to further develop their clinical practice skills in terms of patient assessment and management, either physically or in terms of other factors that contribute to their patient`s illness (Jones et al., 2002).

One of the elements that should be considered in the application of the biopsychosocial model is diagnostic reasoning, which mainly depends on the application of the scientific paradigm (or the empirico-analytical model) for decision-making and validation. This form of reasoning attempts to identify and test hypotheses relating to the nature of psychological and physical impairments and their functional disabilities (Jones et al., 2002). Narrative reasoning is another form of reasoning which is used to understand the patient’s own experience with their pain and illness (Mattingly, 1994; Jones et al., 2002). However, although this sounds like a simple method, in fact it is far more challenging than simply listening to patients’ own stories (Jones et al., 2002).

Finally, it is essential to highlight the fact that the biopsychosocial approach is not only concerned with curing pathological defects, but also with helping people to regain their normal life activities (Burton et al., 2008). In addition, it is acknowledged that there may be a certain amount of reluctance regarding the adoption of the biopsychosocial model because of the hurdles in the way of its clinical application (Burton et al., 2008). Changing the way in which injuries are managed in clinical settings will require further investigation, since little attention has been paid towards identifying the current methods that are used to manage lower limb injuries (either in emergency or elective settings) and whether the biopsychosocial model is a better approach in managing such injuries.

From the findings and the studies presented in this literature review, it can be concluded and hypothesised that enough clinical evidence exists to show that the biopsychosocial model is a better approach to managing lower limb injuries. On the other hand, the literature does not answer the basic question to whether the surgery is elective or emergency make a difference to the patient experience after injury, which necessitate the need for further investigate.

5.0 Conclusion

Little attention has been given to the patient’s experience after lower limb surgery – for example, comparing and contrasting the experiences of patients who have had elective or emergency surgeries, exploring physical, social and psychological aspects, and looking at whether methods of treatment and follow-ups are applied differently between elective and emergency surgeries.

In addition, although various studies had focused on how the physical, social and psychological factors interlink together, no previous study has investigated the outcome of the application of the biopsychosocial model in managing patients after lower limb surgery as a result of injury, compared to those who were treated using other treatment approaches.

Therefore, to address these issues, this study aims to explore and report the patient’s experience of clinical care of lower limb injury after surgery, comparing and contrasting the experiences of patients who have had elective or emergency surgeries, and investigating whether the biopsychosocial model is a better treatment approach for the management of lower limb injuries than other approaches. Thus, the current study is based on the following research questions:

6.0 Research question

Primary research question:

What are the differences between patients’ experiences and clinical approaches after elective lower limb surgery as a result of injury, compared with patients’ experiences after emergency lower limb surgery as a result of injury?

Secondary research question:

If a difference exists among patients’ experiences and clinical approaches between elective and emergency lower limb surgeries as a result of injury, how does this difference related to the current care pathway including the biopsychosocial model?

6.1 Aims and objectives

The aim of this study is to develop a better understanding of patient’s experiences after a lower limb injury that is severe enough to necessitate surgery, and to compare medical services (after lower limb surgery) provided in emergency settings vs. elective settings. In addition, the study aims to investigate the efficiency of current methods of treatment and compare them with treatment methods derived from a biopsychosocial approach.

Understanding the experience of lower limb injury from the patient’s perspective is essential for providing guidelines for appropriate and efficient medical services, and in the prevention of future complications for the patient. In addition, such an understanding will form a reference for future research studies.

The objectives of this study are to explore and report:

The difference in patients’ experiences of medical services for lower limb surgery provided in emergency settings and elective settings.

Whether the current biomedical approach to managing lower limb injuries is efficient enough from the patient’s perspective.

The importance of psychosocial factors for a patient with lower limb injury.

The importance of implementing treatment methods derived from a biopsychosocial model approach.

6.2 Statement of null hypotheses

The research is based on three null hypotheses:

The primary null hypothesis states that there will be no difference in patients’ experiences in emergency and elective surgery settings for patients with lower limb injuries.

The secondary null hypothesis states that there will be no difference between elective and emergency lower limb surgeries as a result of injury, and hence it does not relate to the current care pathway including the biopsychosocial model.