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.

Cycling to work

On a sunny day in the middle of August, I thought I'd record my journey to work in a series of photographs. Here is my photo-story.

The trusty steed - actually, not that trusty, being a very standard sort of low cost road bike. It could do with a few more gears, only having six, of which I mostly use five.

All is quiet at this time of the morning (sometimes not so quiet at 3 a.m.) Gentle uphill slope to start the ride, no problem there.

From this angle, you can't really see the gradient, but I would like to point out that we are above the roof level of the houses at the bottom. This is the killer hill that I have to climb on the way back. It does not look as menacing in the picture as it does in real life.

A short section where I ride along the pavement alongside a busy dual carriageway without the benefit of a cycle lane. So far, I haven't met a pedestrian along this stretch.

The cycle path alongside a different dual carriageway, this one not so busy. Cyclists who can keep up with traffic tend to cycle on the road, because the pavement is badly distorted by tree roots, and pedestrians often stray into the path of cyclists due to the rather narrow lanes.

We enter the university campus, with that helpful cycle path bypassing the barrier and keeping us cyclists separated from the nasty cars.

At this point, I leave the roads and cycle paths, and head down to the lake for the prettiest part of the route.

No separation of bikes and people, but there aren't many pedestrians at this time of day. There are a few more on the return journey, but we tolerate one another pretty well.

Ooh, isn't it pretty? A little bridge over a narrow part of the lake can be glimpsed through the trees.

An alternative route would take me up past this university building, which involves a fairly long uphill and then downhill section. I prefer the slightly longer route by the lake, which takes less effort, although I'm told by Mr M (who went to university here) that in winter the lake route is closed at dusk, so I may have to do the hilly route instead.

Back on the road through the university campus, and coming up to the road works.

The narrowest section through the road works, where cyclists are asked to dismount, but we rarely do. I just change down to first gear and ride at walking pace behind pedestrians, especially those who are wearing earphones. It seems more polite than trying to attract their attention by shouting.

Destination in sight now, but the biggest and busiest dual carriageway so far is in the way. No matter, the cycle path continues on the pavement for a few meters...

...to the traffic-light controlled cycle crossing across the dual carriageway.

And onwards goes the cycle path - carrying on straight ahead would take me all the way to the city centre, alongside the canal if I want to. But I turn left at this point, into the hospital grounds.

Last stretch towards the main hospital building.

There are several of these bike cages in different locations around the hospital, accessed by swiping an authorised staff ID card both in and out, and containing rails that bikes can be locked to. They also provide a bike pump, and I think there are some basic tools in there too.

And... relax. The journey to work seems to be very slightly downhill all the way, which means I arrive without too much fuss, but the way back is therefore very slightly uphill for most of the time, with that vicious hill at the end. My legs do seem to be finding it easier each time, though.

Presents and a prize

Rented bicycle in Berlin, March 2013

It's been present-tastic at Lola Towers, partly due to my birthday and Mr A's birthday being less than a week apart, and partly because I've won another blog prize - this time, a box full of gluten-free snacks from Veronica's Snacks via The Happy Coeliac blog, and a tote bag to carry my snacks in. All I had to do was to suggest a new flavour for their crisps.

It's been a while since I gave you a social update, so in brief:

• Mr A and I have done a lot of 'gardening', which consists of pruning, hacking, bagging and dumping vast amounts of shrubbery, and in Mr A's case, sawing down and then digging out the roots of our sadly deceased ceanothus.
• We have had another posh dinner at Queans to celebrate our birthdays.
• I have had ongoing car trouble involving the brakes, ever since the service in March. The car has done over 180,000 miles and (apart from the brakes) is still in perfect working order, but will unfortunately need further attention from the garage. They are being very reasonable about it, acknowledging the fault and trying to remedy it without charge, but so far without success.
• I have a new Nexus 7 tablet, which I am still getting used to. Unfortunately, it is not quite as good as a laptop for Facebook and blogging (which is mostly what I do), and complains that it isn't compatible with BBC iPlayer or the Carbs & Cals app. It does run Skype, which my laptop has stopped doing, so that's one benefit I suppose, but I'm hoping to mend my laptop as soon as I find the MS Office CD.
• I have been out for pizza twice with work colleagues - once with the new lot and once with the ones from my previous job. I like the old lot better, and there may be a Diabetes job advertised there soon, but it is likely to be part time and temporary, and therefore not as good as the job I have now.
• I tried to do some homework on my case study, but my housemates came home and turned on the TV. My room is too small to work effectively, and at work they won't allow wireless access for personal laptops. I have put in a request for an update to the browser on the office PC, because at the moment the technology they're using is so rubbish that I can't use it properly for academic research.
• I have been cycling to work a bit, which has been a great deal easier since Dr Bike adjusted my saddle. The Trust is very supportive of cycling, and will fund half an hour for free basic servicing with Dr Bike up to once a month for staff. I also have a locker in a changing room with showers and free use of towels.

There will probably be more cycling news soon, because I have taken some photos of my route to work on a sunny day this week. I can also announce that, for the first time, I managed to cycle all the way up the steep hill to my weekday lodging. My legs subsequently turned to jelly and I felt sick, but I'm hoping it will get easier!

Prizes!

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.

Cutting out the commute

Berlin, March 2013

There's been change at Lola Towers, in as much as I'm not at Lola Towers at the moment. I have found a room in a shared house which is just three miles from work, and I'm staying here for four nights a week, travelling up on Monday morning and back on Friday afternoon.

The quest for accommodation was not without its difficulties. Rather than traditional letting agents or small ads, I used the Interwebnets option. Landlords upload vacancies, potential tenants get in touch electronically, details are confirmed, viewings take place, negotiations follow and an agreement either emerges or it doesn't. I went through the cycle just twice - I was being fairly selective, and there are a lot of shared student houses in this city with two large universities very near to the hospital where I work. I didn't want to find myself in a house sharing with teenage students who are getting up just when I'm going to bed.

On Sunday I moved into a small single room in a house shared with two young professionals who seem to spend the majority of their spare time watching TV together. I am not a natural TV watcher, although for the sake of sociability I did join them on Sunday night for one awful hour of a British magician accosting holidaymakers in Las Vegas and foisting his magic tricks on them. I don't deny that the magic tricks were good, but while I watched I had the feeling of my life trickling down some plughole. The sociability was confined to commenting on the programme - we haven't yet had a proper conversation beyond "How was your day?" - and after a while I fired up the laptop and confined my attention to my online life. It's not so much more constructive than TV, but makes me feel more like an active participant in life.

The commute time to work by car is about 20 minutes - 15 minutes on one short stretch of road between the house and the first roundabout, and about 5 minutes for the rest of the journey. You will deduce that this equates to an average of 9 miles per hour, which is not much of a rate. My plan is to resuscitate my bicycle, which has been languishing at home, and is probably in a state of decay. The hospital has a very well-publicised 'Health and Wellbeing' team including a great deal of support for cycling, so I fired off an email to enquire about cycle storage and showering options. The response was that the person responsible is on holiday until 22 July, so I'd have to cycle quite slowly until then.

I have already been in touch with three different individuals regarding playing badminton, of whom just one replied. I went along to their club on Monday, and it was busy and very hot, but friendly and a similar standard to my usual clubs, whom I have now abandoned with some sadness. During the summer they play only once a week, but starting in September it should be twice a week, which is what I'm looking for. As I want to exercise twice a week (and spend as much time out of the house as possible), I'm trying to think of alternatives for another night of the week.

The cost of the accommodation including bills is about the same as the fuel I was using to commute, and other expenses will remain about the same, so I don't expect to be worse off financially than I was before. Of course there is weekday separation from Mr A, but we have methods of communication, and I gain sleep undisturbed by snoring while he gains life undisturbed by nagging. We'll see how it works out, and in the meantime my Team Leader has mentioned that discussions will soon take place over whether my contract will be extended or not.