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.

Ramblings

Munich Stadtmuseum, March 2013

It's been a while, peeps. It feels like I'm always starting with the same line: "It's been busy... I haven't had time..." like Garrison Keillor does when he says "It's been a quiet week in Lake Wobegon, Minnesota, my home town" and you know you'll be listening to something ordinary for a few minutes, in the mellow marshmallow voice that could make a shopping list sound interesting.

Anyway, it's been busy, and I haven't had time. Work, more work, and my MSc module is taking up a lot of spare time. Badminton is available two evenings a week now, which is good for my health and should be good for my waistline. Cycling was going well (three days a week and getting up that hill regularly one time out of three) except this week the garage door has broken, so I can't get the bike out at all.

Yesterday I had a flat tyre, which loomed over me all day alongside dark hatred of car mechanics. But in the end there were silver linings to this black cloud: firstly RSB showed considerable enthusiasm in the idea of helping me change the wheel, which turned out to be because he hadn't ever done it before, leading to the second silver lining - he did all the work while I just stood and directed operations. And the third benefit - when I mentioned my predicament, one of the doctors recommended a garage where there were friendly and helpful people, who I hope will not do as much damage to the old and venerable car as the last garage did. (She's still not right even after all the messing around with the brakes.) I left the wheel there and arranged to pick it up today.

When I went back to the garage today, it was the work of a few moments to replace the repaired wheel. It occurred to me that one of the other tyres looked a bit soft, and behold! when they checked it, it was in much the same state as the one that had just been fixed. So the spare wheel is now on a different corner of the car, and I will return to the garage again tomorrow, and with luck that will be all the garage visits for a while. Except that the car's really not right yet, so maybe there will be more.

So that's where some of the time went. Of course much of my time is spent actually doing work, and I had a more than usually successful clinic recently. I managed to work out why one patient had recently started having daily hypos (she was on a reducing dose of steroids) and I was very pleased with that, because it's something I might once have missed. I have also taken over the ante-natal clinic from RSB, so now I see a few women with Type 1 and Type 2 Diabetes as well as all those with Gestational Diabetes.

Since attending the third and last training session on Care Planning I have been trying hard to follow through with my resolution to try not to give advice. It seemed to work very well indeed for a patient who wants to lose weight. In the 'not giving advice' endeavour I am inspired by Lola II who does a job in which it is absolutely forbidden to give advice no matter how much you want to, even if you know exactly what everyone should do. I think that would kill me.

Not all my consultations have gone so well. I had to deal with a couple who had been having an immense row immediately before I entered the room, and I'm not sure whether I handled it well or not. Sometimes I feel at the end of a consultation that I haven't contributed anything positive to a person's situation. And the DNAs keep (not) coming, and now that I am more established, I wonder if it was something I said.

I have nearly finished my induction - a recent mandatory training session on CPR was more enjoyable than I expected; I passed the online assessment for Consent procedures, and there's only Manual Handling left to do. I was asked to feed back my thoughts on induction, and I welcomed the opportunity to let off a bit of steam. When the induction process is completed just two weeks from the end of the original nine-month contract, it cannot be considered fit for purpose.

Outside work I am also struggling with time, as I am very behind with home admin because of being away all week. When I get back, Friday night is very much a rest night with Mr A, and then it's usually a trip to the famous veg shop on Saturday, sometimes a supermarket trip as well, house cleaning, laundry, and anything else that's going on. Two weeks ago there was the first Warwickshire Pride festival in the Pump Room Gardens; last weekend Lola II and Mr M visited so we could all go to the Leamington Food and Drink Festival. And I've submitted a job application.

Yes, after more than six months without any sort of vacancies for adult diabetes dietitians (there have been loads of paediatric diabetes vacancies due to a quirk of NHS funding), a job has been advertised, in the same Trust where I worked before but a different site. It is a permanent post - hooray - but only 20 hours a week. After a good deal of vacillation and discussion with Mr A and with previous, current and potential future employers, I decided to apply. And you know how much time that takes (perhaps you don't? It is A Lot Of Time). And there are two other part-time opportunities on the horizon, although they are both in the region where I work now, far from home.

There was also a night out with the Dietitians. Not a big one - we all meet after work, have a very early dinner and then it's all over by about 7pm, which suits me perfectly because I'm starting to feel the pressure of not enough silent time on my own. [Silent time on my own is all that keeps me sane.] I'm having some silent time on my own tonight, because today I have decided that it is more necessary than badminton. This is rare and unusual, but it is the right decision. I maintain my sanity, and you get a long and rambling blog post. We are all winners.

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.