Sunday, 16 March 2014

Consultation skills

Leaves of a Swiss cheese plant in front of a window
National Botanic Garden of Wales, May 2013
It's been a good couple of weeks in the office and out of it. As highlighted previously, I have started the 'Couch to 5k' running plan and haven't yet missed a session. I didn't think I liked it much, except that I find myself almost looking forward to the sessions, and I can't work out what's going on. Lola II suggested it might be the dolphins (or 'endorphins' as they are more widely known). I have no idea. Anyway, I am now able to run, very slowly, for 90 seconds at a time. It is early days.

Patients come and go, and I have been enjoying hearing their stories and trying to encourage, guide and motivate them to achieve their goals. This idea of the patient owning and managing their chronic condition is not new or novel, but not often expressed. Because we often have lunch together, the team tends to share experiences of clinical situations quite a bit, and the underlying principle is often of the clinician 'treating' or 'managing' the patient, or generally telling or advising them what to do. I am making every effort, and getting increasingly more skilled at the opposite approach: not telling or advising them what to do. This takes an enormous amount of self-restraint on my part, but I think I am getting better at it.

For example, many of the patients I see have other conditions as well as diabetes. There are many different avenues I can follow in my dietary advice: a) general healthier eating (more veg, less saturated fat, lots of fluid, eating breakfast, less salt, oily fish twice a week etc), b) diet to influence blood glucose, c) dietary management of other conditions such as high cholesterol, high blood pressure, kidney failure, low calcium, anaemia and so on, and d) weight management - usually weight reduction, but not always. Looking at the patient's medical history and biochemical test results usually gives me an idea about what might ultimately have the greatest benefit on health.

But it is fruitless for me to decide what should be done and then do it. Diabetes is not like a broken bone - once diagnosed, it is not possible for a simple plan for treatment and review to be devised, implemented and followed up. It is a lifelong diagnosis where the majority of management and treatment takes place in the absence of any health professionals, done entirely by the patient. I even wince each time I write 'patient', because I spent a considerable amount of my career insisting that people are people and are not defined by their condition - they are not diabetics, they are people who have diabetes. Someone with diabetes is not ill, and is only defined as a patient when they turn up at the clinic. The rest of the time, they are in charge of their 'illness'. I don't have a better word yet, and would be viewed most oddly if I started to use the words 'client' or 'service user' in the NHS setting. But I digress.

The way it works is this. I invite the person into my room, introduce myself, and then ask either how it's gone since last time, or what's brought them to the clinic on this occasion? The idea is that they choose what we're going to talk about first. Obviously I might have issues that I'd like to raise, but my agenda is secondary.

For example, many people who see me are overweight, obese or morbidly obese. This may be the main 'problem' and if addressed, the majority of their other health conditions might be improved. But many people are happy with what they weigh and how they look, even though they are aware of the health implications. Many more are not happy but have tried many times to change and failed, or had succeeded, lost loads of weight and then put it all back on and more. Many are defeated. There is no point in me listening to their story and then telling them what to do. Nobody wants to be told what to do, especially by someone who only met you ten minutes ago and knows nothing about your life. They've tried over and over again, it didn't work, end of story.

Last week I felt my practising had paid off. An overweight lady was brought to me: "she needs to lose weight." This is often the first barrier - very few choose willingly to see a Dietitian, because they expect to be 'told off'. They know they have a problem, and they know the answer, everybody's told them they need to lose weight, they know they should lose weight but they've tried and failed and they don't see the point in having their noses rubbed in it, or exposing their weakness to a stranger. It's personal, uncomfortable, and emotionally painful.

The lady was happy to talk about her diet, but she didn't see what she could change. She told me about coming from a culture where being overweight is not a problem.

"So, you're happy with the way you are. That's good," I said.

Instead of agreeing with me, she continued to tell me about her diet, what she eats, how much she likes food.

"I get the impression that you don't really want to change anything at the moment. Is that right?" I asked.

Still no agreement. More information about her lifestyle. I must say, her cooking sounded amazing. A bit carb-heavy, but tasty.

"So, you don't feel that your weight is a problem. Would you like to talk about anything else? Do you have any other concerns about your diabetes?"

Again, she didn't really address the question I'd asked, but carried on chatting about her meals and her cooking. I felt like Jeremy Paxman that time he asked the prison chap the same question fourteen times. I just wanted her to agree that we could leave the weight thing alone, and then she could go.

But instead, she suddenly suggested a couple of things she might be able to cut out of her diet. I was genuinely amazed. I've always believed in this approach to consultations, where you get the patient to make the suggestions, but so often they hold back and hold back and eventually I give in. This time I think I was determined not to be directive, and for the first time, it really worked. We agreed on one or two goals, and arranged a follow up.

Whether she returns will perhaps be a test of success, and it's quite possible that she may not actually make the changes she suggested, or achieve the results she hopes for. But I would have suggested different changes, and she definitely wouldn't have taken those on board, and I definitely would never have seen her again. So we'll see.

Friday, 7 March 2014

What I've been reading

Image of the book cover

The Magical Maze: seeing the world through mathematical eyes
by Ian Stewart
"Enter the magical maze of mathematics and explore the surprising passageways of a fantastical world where logic and imagination converge. For mathematics is a maze - a maze in your head - a maze of ideas, a maze of logic."
This book is the basis for the Royal Institution Christmas Lectures of 1997 presented by the author. It has mostly familiar content (familiar to me, anyway) like the Monty Hall problem in the chapter about probability, and stuff about chaos and fractals. Some was new, particularly a chapter about why different four-legged animals have different gait, i.e. move their four limbs in a different order when walking/running. Despite the slightly weird story-like interludes between chapters, it is science that is well-explained without being patronising.

Image of the book cover

Bad Angels
by Rebecca Chance
"Step into Limehouse Wharf, the new, uber-luxury apartment building where Melody Down, an actress whose career is in tatters after too much plastic surgery has holed up to get her body and her boyfriend back. Aniela Jasicki, the nurse in residence, finds herself falling for the unlikely Jon Jordan, an assassin for hire who is also convalescing there."
Eleventh of my 12 Books of Christmas, and even the author describes it as a bonkbuster, so my expectations were low - but they were exceeded, as the writing was good and I can't complain that there was too much sex in it, given the genre. Obviously I won't be reading any more of her work if I can help it, but if you like that sort of thing, it's better than any of the others I've been subjected to since winning these 12 books. At the time I was pleased to have won, but my life has not been enhanced by the experience. Only one more to go, and it's a hardback, although I don't quite know what difference that will make.

Image of the book cover

Salvation of a Saint
by Keigo Higashino
"When a man is discovered dead by poisoning in his empty home his beautiful wife, Ayane, immediately falls under suspicion. All clues point to Ayane being the logical suspect, but how could she have committed the crime when she was hundreds of miles away?"
I read this one in just a day, mainly because I knew the truth would only be revealed at the end, and I couldn't bear to wait. It isn't as good as the first one (The Devotion of Suspect X) but still head and shoulders above other modern crime thrillers that I've read.

Image of the book cover

Dr Bradley Remembers
by Francis Brett Young
"John Bradley, aged seventy-five in 1937, reflects on fifty years as a general practitioner in Sedgebury in the Black Country, after being trained at North Bromwich Medical School. In the days before the National Health Service, he reveals how precarious the rewards of a practice could be and the parts played by chance and determination."
Based on a medical practice in a Black Country town from the 19th to early 20th century, the story covers the doctor's life including his marriage and the raising of his son, the growth of coal mining and the expansion of the small town into an industrial centre. It was easy to read, and quite an interesting historical account of 'medicine' as practised in rural England. The copy I have was given to my father as a prize at school - I don't know if he remembers reading it, perhaps he will comment?

Sunday, 2 March 2014

Running into the future

Lttle pink flowers
National Botanic Garden of Wales, May 2013
Looking back over the last couple of weeks, my diary is a desert; looking forward, it's a bit more interesting. I didn't have much to write about last time, and there's not much more this time, although I have been away on a two-day course intended to help me deliver the Structured Education for people with Type 1 Diabetes that we offer.

It was a good course, and I learned a few things, practised a few techniques, and gained confidence from the fact that I knew as much as anyone else about the subject. We were all Diabetes Specialist Dietitians and Nurses, as were the course facilitators. We all went out to dinner between the two days, and they managed to make it a learning experience by highlighting the difficulties of carbohydrate counting and insulin dosage and timing to those who'd never thought about it previously.

The team back home seem very easy-going about incorporating change into our course, and said before I went that they are looking forward to hearing about anything I think can improve our offering. I haven't yet observed our course so I don't know exactly what's in it and how things are done, but I'm looking forward to it now.

On the way I stopped off in London to surprise Lola II on her birthday, in collusion with Mr M. It is the first time that I have ever managed to avoid giving away a surprise; even Mr A managed not to spill the beans, so Lola II didn't suspect anything at all. When I tapped her on the shoulder she was so surprised that she said she couldn't quite understand what she was seeing - someone who looked a lot like me, but couldn't possibly be, because we were on the third floor of the Science Museum in London.

The Science Museum occasionally opens late in the evening with all sorts of activities - for adults rather than families on this occasion, and it was amazing to see throngs of people swarming around swigging from bottles of cider, taking part in a variety of science-related fun. The event that intrigued me the most was the advertised 'Silent Disco', where the music is conveyed via headphones. It wasn't quite as strange as I was expecting, because it was in a roped-off area in one of the main halls so there was quite a lot of ambient noise as well as the noise made by the dancers singing along. We didn't try it ourselves - there was a long queue for the headphones.

Disco moves with lights and headphones

That's about it for past activities; I try to avoid relating what is in the future, in case it doesn't happen after all, and in case it isn't worth writing about. But this is my 50th year, and this milestone has prompted me to make more plans than usual for things I both have and haven't tried before.

Many of my contemporaries are obviously reaching the same milestone, and it is interesting to see what some of them are doing, from a parachute jump to a trip to New York to a tea party to a first ski trip in Lapland. On my actual birthday I will be at home, but Mr A and I should be going to Cambridge Folk Festival shortly afterwards. In the meantime, I am planning to work up to running 5 kilometres using a set of 'Couch to 5k' podcasts from the NHS Choices website. I have also booked a ski trip for the end of March, which is making me unfeasibly excited. It is a trip for lone travellers (Mr A is not coming) and intended to help intermediate level skiers improve, and I'm looking forward to it a great deal.

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