Behaviour change

National Botanic Garden of Wales, May 2013

I was definitely going to do some homework this evening. I brought home the folder of notes which I had been accumulating during the taught sessions of my Masters module, and brought the computer down to the dining table to make it easier to type (my bedroom doesn't have space for a chair as well as a bed, table and chest of drawers). I did the washing up, some laundry, had supper, spoke to Mr A, and then prepared to do some work.

The only thing missing was the actual case study - up to now I've been working on it at the hospital, and hadn't emailed myself a copy. Taking it back and forth on a memory stick is complicated due to NHS file security policies - they make it very difficult to take data out, so that we can't easily compromise patient confidentiality. So, no homework, and I'm blogging instead.

I didn't have a clinic today, so I went back to those carbohydrate reference tables again. It feels as though I have been working on this project forever, and in fact it has been an enormous amount of work. My colleagues came up with some suggestions and comments after I presented the first draft, and true to the adage, the last 20% has taken as much time and effort as the first 80%. It's nearly done now, and the time will soon come to compromise on perfection and go ahead with some flaws still present. For example, I would have to hold back for a few more months to get any decent carbohydrate figures for Christmas pudding.

I continue to have too few patients. I am starting to worry that unless I can fill my clinics, any extension to my contract will be at risk. Part of the problem seems to be that I keep discharging patients rather than offering them follow-up appointments. Having discussed a patient's lack of motivation to lose weight, for example, it serves no purpose to keep making them come to the hospital to have another discussion about how they haven't lost weight again. I may be repeating myself by saying that losing weight is one of the most difficult things in the world for most people to achieve, and you've got to want to do it to have any hope of succeeding.

There are a number of techniques that can be used in the complex world of behaviour change. Obviously active listening and open questioning are important to establish the topic to focus on - never assume that what's in the notes or the referrer's letter or even what you talked about last time will be what needs to be discussed this time. Circumstances change, things happen, and people move on. Last time the patient was 100% in favour of increasing the amount of exercise they wanted to do, this time they are worried about gallstones. Also important at this stage are empathy and taking care to withhold judgement.

Having established the topic, what does the patient want to do? What is the actual aim we are working towards? If it's a change towards 'healthy eating', how will we know when we have succeeded? What amount of weight loss in what period of time will bring about significant health benefit? It helps to describe the objective as fully as possible.

Then it's always worth exploring how realistic the aim is, often by questioning the importance it has to the patient, and their confidence in achieving it. At the most basic, you can use the Lickert scale, which is just a scale of 1 to 10. Anything less than 7 suggests ambivalence and is worth exploring further, and the whole thing can come apart when you really examine some of the practicalities of changing diet or lifestyle. Eating is really fundamental to who we are and how we fit into our families and wider society, and change isn't usually easy.

When it comes down to it, behaviour change is about breaking habits that aren't helpful, and developing and embedding more useful habits. Giving up smoking provides some obvious parallels - if someone always smokes with their afternoon cup of tea, then it will be important to discuss how to manage the feelings that will inevitably arise when having a cup of tea but denying oneself the cigarette. Replace 'cigarette' with 'biscuit' and there really is no difference. Setting a goal of cutting out biscuits while ignoring a lifetime of food-based habits is a recipe for failure.

We can ask questions about how a patient would feel if they achieved their objective, and what the first step will be towards that goal. What are the barriers that will interfere with success? How can they be anticipated, and overcome? Some of the barriers can be brought to light using an 'ambivalence grid', on which we record the positive and negative aspects of making a change, but also the positive and negative aspects of not making the change. It can be illuminating to examine how life would be worse if the patient lost weight (those of us who dislike shopping for clothes are well aware of one of the pitfalls). If the patient thinks that cutting out biscuits will lead to them taking up smoking again, then perhaps they should set a different goal.

These skills and techniques are among those used in Motivational Interviewing, Cognitive Behavioural Therapy, and addressing the Cycle of Change. The trouble is that I can't remember the theory or evidence base for any of these high-falutin' psychological theories, and I feel that for best practice I should know why I'm doing something as well as how best to do it. But for the moment I'm doing my best, and reflecting afterwards on whether I could have done things better, or differently, and that's how I hope to improve my practice. As well as doing my homework. Tomorrow.

Not giving advice

Budapest, October 2012

Another post is due. What to write? Work or play? Diabetes or something else?

The weather has been hot. I thought that my extra hours spent not travelling would result in lots of blog time, but today I simply overheated. The offices where I work in the hospital are not cooled, and in fact appear to be heated, since they have become hotter with every successive day of high temperatures. Luckily I have spent quite a lot of time in the clinic where patients are seen, which is air conditioned and a reasonable temperature. But although I now have my bicycle available for the commute, yesterday I had to go by car, and at the end of the day it was almost unbearably hot.

The cycle ride is pleasant and just about the right distance. There are hills but they are not too steep, there is a lake if I want to ride alongside it, and there is a stiff climb on the last leg of the way home which I cannot yet complete without dismounting - I look forward to improving my stamina. There is secure bicycle storage at the hospital, but until the cycling support officer returns, there is no locker or shower for me. And I returned to the badminton club for a second innings, which was also very hot, but enjoyable. I consumed 1.5 litres of fluid during the two hours of play.

There seems to be more to write about in the work domain, although as ever, the patients will have to remain absent from these essays. I have, however, attended half a day of training in the concept of the 'Year of Care' (with another two half-days to come). This is an approach to management of chronic disease, specifically diabetes, but applicable to most ongoing conditions. It suggests that, rather than the traditional paternal approach where the doctor manages the patient and decides what the treatment should be, more responsibility (and therefore control) should be given to the patient. After all, it is the patient who has to live with the condition day in, day out, so it makes sense that the patient should decide how the condition should be treated.

Obviously, many patients are not initially equipped to self-manage. Asking a patient "What do you think should be done next?" is pointless unless they have useful and accurate knowledge and information about their disease, any test results, the various treatment options and their consequences, and the ability to draw this information together and make a decision. But someone who has lived with diabetes (or coeliac disease, or arthritis) for many years, sometimes longer than the healthcare professional 'advising' them has been alive, is in a better position to decide what their priorities are, and which consequences of managing their condition they are prepared to put up with.

For example, one of the main markers of good blood sugar control is a biochemical test for a blood component called "HbA1c". The higher this result, the more glucose has been circulating in the bloodstream over the past 10 to 12 weeks. This generally means that blood sugar has been higher than the optimal levels for more than half of that time, and this is generally Not A Good Thing. However, there are other factors that indicate risk of future complications: blood pressure, blood lipids (like triglycerides and cholesterol), blood markers of liver and kidney function, and weight/waist circumference/Body Mass Index.

The principle of the 'Year of Care' approach is to a) provide this type of data to the patient about a week before the consultation, which demands an additional session where the data is collected/blood drawn etc (this may take place at the GP surgery rather than the hospital), b) explain or otherwise ensure that the patient understands what the results mean and the options they may have for addressing results that are sub-optimal, c) encourage the patient to express his or her own views about what the 'Care Plan' should consist of, where the Care Plan is a set of well-defined aims and objectives, and d) document the Care Plan in the medical records and for the patient to take away.

It's all very logical and sensible; I'm not sure why we need a day and a half to be taught about it. Anyway, the main things I took from the first half-day of the training were as a result of being shown a short video of a consultation conducted in the 'Year of Care' approved manner. It reminded me of how a good consultation can be done, and how easy it is to slip into bad habits. I resolved to try to address one particular habit of mine that is extremely hard to break - giving advice.

You would think that one of the key aspects of a consultation between a Dietitian and a patient would be that the patient would seek advice and the Dietitian would provide it. In fact, this is often a very unhelpful and frustrating mode of operation - imagine a patient is overweight, and comes to see the Dietitian. They talk about diet, lifestyle, activity, concomitant disease, and anything else that is relevant. "What should I do?" asks the patient. The Dietitian, who can see clearly where the problem lies, is happy to provide the answer, whether it is "Cut down on alcohol" or "Reduce portion sizes" or "Eat two slices of toast for breakfast instead of three" or whatever. The sad truth is that for a very few people this might help, but for most, it won't.

The more effective approach is to operate in a 'Year of Care' mode. The patient knows their weight/waist circumference/BMI, but may not be aware of what the specific implications are for future health, what targets for weight loss may be appropriate, how weight loss might be achieved. They will know what they have tried in the past, what has worked and what hasn't, what sort of person they are, what their immediate family and social circle is like, what barriers they face, and a hundred reasons why your advice will not work. They will also know how they are most likely to succeed, and I, as the Dietitian, do not. So my job is to turn the question round, and find out from the patient what they think will work best.

This is better in so many ways. It allows the patient to take control of what is, after all, something they will have to live with 24 hours a day. There is no doubt that for some people, being given the responsibility for deciding their own priorities is burdensome, because it is difficult to decide how to make changes that are usually unwelcome. But it also removes the option of saying "The Dietitian told me to do this, and it didn't work - it's not my fault." It also allows for the possibility of taking no action at all, which is the right choice in some circumstances. If your father has dementia and your boss is off sick and your child has just been arrested for petty theft, then trying to eat more vegetables is not going to feature on your list of priorities.

Most importantly, it reminds me that I do not have the ability to fix things, and neither is it my job to make it all better. It is my job to give the patient my undivided attention, to try and understand their situation, to provide appropriate information at the right time, and to support the patient in making the choices that are the right ones for them, and setting objectives that are specific, measurable, achievable, realistic and timed. Whoever came up with that 'SMART' acronym produced a really useful objective-setting tool.

Since the training I have seen a few patients, and have tried to remember to hold back from giving advice. It is incredibly hard, but it really worked well in at least one case, where I doubt that any other approach would have been any use at all.