Consultation skills

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.

Learning, changing jobs and home news

National Botanic Garden of Wales, May 2013

It's one of those times when I think I've written all that I can about everything, and there's nothing left to blog about. I have an interesting and fulfilling life, it's true, but there's nothing particularly interesting to write about. Living in two places, work, badminton, family, the house and the blessed car - nothing you need to know. Mr A and I have a new boiler, the brakes on the car have been fixed, I have been on a course, that's it.

OK, so let's try harder.

I handed in my assignment for the module I'm doing for a Masters degree. It was a case study, all about a patient who was newly diagnosed with Type 1 diabetes at a relatively late stage of life, but who also is very overweight and has other health problems too. As usual, I write this on the basis that there's no reason at all to think that the patient isn't reading along with us, which makes it difficult to describe much more about the situation. I learned quite a bit about various aspects of diabetes by reading up on the evidence base, but it seemed to take an enormous amount of time. I'm not sure that doing more modules towards a Masters is how I would like to carry on with further professional development.

I have had my exit interview with my current employer - I think the administrator whose job it is to arrange these things was a bit enthusiastic, seeing as it's more than a month until I finish. It's also ironic that I haven't yet been able to complete the mandatory training associated with my induction. Anyway, I fed that back, which gave us something to talk about, along with the difficulties of having a fixed term contract working in a Diabetes department that often feels like it's in a continuous crisis situation. I would have no hesitation working with any of the Dietitians in the hospital - not just the Diabetes Dietitians - but I'm not sure I'd want to work in this Diabetes department again.

Luckily, I was allowed to continue with the training I'd been booked to do before I handed in my resignation, which took place last week. It focused on behaviour change (level 1), and covered much of the same ground as the Communication Skills module I did while at university. If done well, it can transform a difficult interview, and can help patients to achieve the results they are after. At the moment, I can see the potential and know in principle what I should be doing, but achieving it is another matter. It is something that I plan to practise as much as possible.

The new boiler was installed in my weekend home without fuss, according to Mr A who was there at the time. I played in a badminton match for the 1st ladies team of my weekday home, which is well above my standard, so losing 6-3 was a good result. I failed to get my hair cut through lack of booking ahead, mostly because I couldn't remember the name of the hairdresser. I'm busy making extravagant plans for the nearly three weeks I will have between the old and the new jobs, but will probably just sit around, as usual.

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.