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.

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