In which very little indeed happens

Pharmacy museum, Krakow

A bonus early blog post today, because I know the weekend's going to be full of stuff so I'd better do this now. However, there is nothing of any particular note to report, just the usual saxophone and clarinet choir on the first Saturday of the month, more slogging in the garden to tame the wisteria, meditation on Tuesdays, Thursday night badminton starting again after the summer, and what is turning into a near-regular Wednesday night pub quiz. And the Great British Bake Off for a few more weeks.

There's been a bit of excitement with postal services - I've agreed to make Lola II another dress and the fabric failed to arrive for ages despite much chasing. I ordered a hard case and a stand for the new baritone saxophone, and there were some difficulties with delivering both of those as well. Luckily I've got helpful neighbours who will accept stupidly large packages, although I had to haul one of the neighbours out in his slippers to move his car from in front of my garage - yes, the car is still going into the garage and I haven't stopped being just a little bit excited every time.

Slightly more interesting were the visit from the architect to draw up plans for the house preparatory to designing the new kitchen, and a Barn Dance. I can't remember having been to a Barn Dance before, but I was almost too tired to enjoy it. It was in a marquee in a field with a fish and chip supper included, and six of us Stripped the Willow and Gay Gordoned along with the natives of Old Milverton until a very late hour.

I've finally started the big Ebay project, which is intended to monetise dad's eclectic collection of postal mechanisation ephemera. Contrarily, I have started with some other random items from the loft so that I get the hang of how it all works and get into the groove of putting things up for auction on a pretty regular basis. It's a project that will probably run for a year at least, so you can expect occasional updates.

At work I have had a slight disagreement with a colleague about what exactly my priorities should be - I was asked to cover a clinic for a colleague at very short notice, which meant I wasn't available for the regular clinic also taking place. The benefit of this contretemps is that there's a chance that my priorities will be assigned formally at last, rather than me having to make my own choices based on nothing more than what I think is the right thing to do.

It's not entirely surprising that my blog audience is not growing given this poor quality of content, although strangely the day after I wrote this my blog audience did indeed increase by one individual - welcome to medusarog! And today there may be another - Parkrun Simon! I like to name check each known reader - I think everyone's had a mention now. If you're reading and I don't know about you (or have forgotten), I'd be delighted to say hello. Welcome to the place where, really, nothing much happens at all, and join the few regular readers in my small circle of family and friends.

Pharmacy museum, Krakow

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.

Feeds, food tasting and hand-washing

On the M40, May 2012. No, I have no idea.

Back at work to a three day week after a ten day holiday was challenging last week, and demanded all the prioritisation skills I have. My colleagues dealt with the urgent referrals on my wards while I was away, but there were plenty of non-urgent cases, and other colleagues were away when I was back at work, and I had to reciprocate and cover their urgent referrals. Added to that, I had a food tasting session, a department meeting and compulsory training on hand-washing to squeeze into those three days.

So I prioritised the tube-fed people - those who can manage to eat just had to get along somehow until I could get round to them. And, of course, they were all slightly 'interesting' cases that needed extra time and attention, rather than the quick, straightforward, 'just calculate the total requirement and divide by the number of hours the feed is delivered' cases.

There was one whose feed rate had been reduced to a bare minimum because of unpleasant side effects, so I had to try and consider how to tweak the feed schedule to meet the patient's nutritional requirements. Another was a patient who was frail and elderly, and one of the reasons for admission was because he'd stopped eating - in this case, the purpose of artificial nutrition has to be clarified, because the patient was not suitable for a permanent PEG tube but wouldn't be able to go back to the nursing home with an NG tube. This is one of the worst possible situations - do we allow the patient to remain on the ward indefinitely just so that he can be fed? If not, what is the alternative? Ultimately it's the doctor's decision, but my job to raise the issue to try to ensure that a decision is made.

Another patient had received a trauma injury and had come from Intensive Care where they had placed an oro-gastric tube, which is an alternative when the naso-gastric route is not appropriate - but the tube had come out and nobody on the ward quite knew whether another oro-gastric tube was needed (which would have to be put in place by a doctor) or whether an NG tube would do (which could be placed by a suitably-qualified nurse). Then just as I thought it was all over, there seemed to be another new NG feed schedule needed, except when I got to the ward there was no NG tube in place and some confusion about whether one was needed or not. I didn't hang around to find out - if they'd decided to go ahead there were options they could implement for the weekend and I could re-visit the patient on Monday.

The food-tasting happens about four times a year, and had been scheduled by the hospital Catering department before the Bank Holiday had been moved. This is probably why it had ended up in a three-day week, and that was why only three of us turned up: me, the manager of the Dietetic service, and a member of the lay panel that represents the interests of patients. We were outnumbered by the catering staff hosting the tasting session.

There being no such thing as a free lunch, our job was to rate all the available foodstuffs by appearance, smell, texture, taste, temperature, and anything else we could think of. All the day's standard main course menu items were there, plus a few extras: a 'fork-mashable' option, two from the 'ethnic' menu, one of the 'Lite bites' that are available outside regular mealtimes, plus a couple of puddings. Served at the perfect temperature in this calm, controlled setting, all the meals were pretty good, with a couple of really outstanding options and a couple that were just OK. Served in the normal overworked ward environment, where they may have been heated up for too long or not long enough, and may take a little while to actually reach the patient, I imagine some options may in reality be less attractive.

The compulsory hand-washing training was fairly straightforward, except that I refused to have the UV-fluorescent liquid applied thanks to its paraben content. So the infection control nurse just watched me washing my hands. And he was delighted when it turned out that we had their missing UV light box, which had been loaned to our department and then forgotten about to the extent that they'd given it up as lost.

With my holiday just a dim and distant memory, so the week ended. Some time has passed without me managing to get this blog updated, and much has happened - Sister D celebrated her silver wedding anniversary, Mr A is spending three weeks on 'work experience' in Manchester, and all my wards were swapped for different ones. More to come as soon as I can manage it.

Prioritisation

Jephson Gardens, Feb 2012

My main weakness over the first weeks of my first dietetic job has been the tendency to accept referrals and agree to review patients that a more experienced Dietitian would discharge from their care. Without the experience to be certain that my practice is safe and correct, I have tended to want to review patients to make sure that all is well, and to find out whether my recommendations worked. This is commonly found with new Dietitians, and a sign of increasing confidence is to reject a referral or discharge a patient from dietetic care.

What this has meant is that my caseload is rather too big, and I wasn't able to review all my patients last week. This is fine, because if there had been any cause for concern, the ward staff would have bleeped me or called the office, which they actually did once or twice. New referrals kept coming in, and those patients have to come first.

When you are interviewed for a job as a Dietitian, invariably there is a question about prioritisation, which goes like this:

"It is Friday afternoon and four referrals have been received in the dietetic office. What do you do?"

Then they describe the four different patients, who usually are as follows: one overweight patient on a ward wanting healthy eating advice, one person with newly-diagnosed diabetes about to be discharged home, one malnourished in-patient with poor appetite, and someone who has just had a nasogastric (NG) tube placed and needs a regimen for feeding through the tube. What you do is offer the overweight patient an outpatient appointment, go and see the person with diabetes before they go, tell the ward staff to give the malnourished patient food, snacks and supplements and re-refer if things don't improve, and tell them to use the emergency regimen for NG tube feeding that has been drawn up for just such contingencies, until you can see the patient on Monday.

Up until last Friday I had thought it was a useful exercise to ensure that candidates can make the right choices when demand for dietetic input exceeds the number of hours in the working week. Last Friday I discovered that it is actually a very accurate description of real life. I had new referrals for a patient with type 1 diabetes, another who was obese, a third with Crohn's disease, another with a reported BMI of 15 kg/m² (which is seriously underweight), and I was on a ward reviewing a patient receiving an NG feed. And it was 2 o'clock on Friday afternoon.

It all went to pieces through an unprecedented chain of events that meant I had to spend a long time on the ward sorting out a potentially harmful situation, and then reporting a 'Clinical Adverse Event'. It's interesting to find that as the end of the working week approaches, priorities sort themselves out - three of the referrals ended up being somehow much less important than I had originally imagined, and, for the first time, I rejected a referral. It felt good.