- Persuasion in clinical practice, L Walker
- Walker PDF summary
- Silverman ..communication
- Paragraphs for medisoft paste
- targets are not being met (2010); fibrates etc
The consultation for professionals
David Kinshuck
Sharing Decisions: for professionals
An extract of article JAMA,2004, Epstein et al, Communicating evidence for participatory decision making Steps for Discussing Evidence With Patients, and Examples of What Physicians Might Say
Step 1....Understand the patient's experience and expectations
"What were you hoping for in this visit today?" "I just want to make sure that I've touched on all of the important issues. " "Would you like to invite your [partner] in to discuss this together?" "Have you known anyone with [your diagnosis] ? " What was their experience like ?" [If not, then "What have you heard, or what were you expecting?"] "You have said that quality of life is more important than quantity, but in this case does that still seem to make sense?"
Step 2 ....build partnerships
"You might feel uneasy, as this can be a difficult decision. I think I understand your concerns and questions. Now I would like to help you understand the issues involved from my 'perspective so that we can make this decision together."
Step 3 .....provide evidence, including Uncertainties
"While there has been a lot of research about this question, the answer still is not entirely clear. Let me explain my view of the dilemma." "While we used to always treat ear infections with an antibiotic, research shows that in cases with fewer than 2 days of pain, the antibiotic is usually not necessary and may cause more problems than it helps. Six out of 10 ear infections resolve spontaneously within 24 hours." "Even though the evidence is divided on this issue, I think that we can still make a reasonable decision."
Step 4 ....present recommendations
"We could try a tricyclic antidepressant that may help your pain, even though the evidence is not in as to how well it works." "I think that you should hold off antibiotics for now, but you can call me if you don't get better and we can reconsider." "I'm going to suggest a medication that could help strengthen your bones but that could also worsen your heartburn if you are not careful. I think that [. ...] would be the best course of action."
Step 5......Check for Understanding and Agreement
"Does that make sense to you?" "Could you tell me how you understand the treatment choices I've presented to you for your [disease]?" "Do you see things differently?"
A Hypothetical 2-Minute Discussion That Incorporates Clinical Evidence
Physician
lt sounds like you've done well on the antidepressant but don't know whether it's worth continuing. Is that right?
Patient
Yes.
Physician
This is a difficult choice, and the answer is not quite clear. Most people do well even if they don't take an antidepressant medication. But, research shows that quite a few people will have a relapse. And, if you take the medication, you're less likely to have another episode of depression in the next 5 years.
Patient
Well, what would you do?
Physician
This is not an easy choice, so I think that different people would make different decisions. But first, let me make sure that you understand the issue.
Patient
Well, I think I understand, but how certain is it that the depression will come back? The pills are okay, but I really don't want to be on them for the rest of my life-they do they affect sex life a bit.
Physician
Do you want statistics?
Patient
Okay-let's try .
Physician
There have been several research studies, and it seems, overall, that of 10 patients with depression who stop the medicine, 4 will have a recurrence within the next year, while 6 will remain healthy. If they continued the medicine, only 2 out of the 10 would have a recurrence. Are you following me?
Patient
What's the choice then? I really don't want to feel that way again!
Physician
You've hit the nail on the head. You first said you did not want to take medication forever, and now you are telling me that you clearly don't want to have a relapse. And that is the choice we should make together.
Patient
I understand now. I guess the million-dollar question is whether I'm going to be in the healthy group or the depressed group. Is there any way to tell?
Physician
That's a good question-the problem is, we really don't know. But we know that depression runs in your family, so your risk for relapse might be some- what higher than what is reported in the research. So, a lot of physicians would suggest that you continue, and I guess that I would agree, as long as the side effects are tolerable. And, if not, there are other medications. And we can talk again in 6 to 12 months to see if it makes sense to continue.
Patient
Got it. I'll probably do it. I'm going to need to think about this for a while. Physician: Is there anything that we've discussed that you don't understand? Patient: Not really. I just need time to think.
Physician
Should we talk again next month? Maybe continue the medication until then?
Patient
Okay, sounds reasonable
Planning treatment (thanks to Jill Hill and colleagues)
When patients attend the retinopathy clinic further treatment is often needed. This can be thought of as a care or treatment plan. The plan needs to incorporate laser and any other stops to control the diabetes/blood pressure etc. So for example
- planning laser..more will be needed in smokers/patients whose HbA1c has recently droped..how many sessions/which eye?
- HbA1c
- find out what it is; generally target 7-7.5%
- what should the patient do to lower it
- doctors familiar with drugs can make suggestions/ideas
- refer patient to a diabetes education program DAFNE / XPERT non-insulin / XPERT insulin-users
- For all patients with poor control, generally the doctor should suggest …you need a period on intensive support and weekly/frequent contact with your GP/practice nurse to control your diabetes. Your GP/practice may be able to provide this, but if not your GP must refer you to the Community diabetes team (the arrangement in Birmingham). (A period of intensive supervision for poorly controlled patients is recommend by NICE)
- insulin users...any hypos?..if so..DAFNE
- Bp
- as with HbA1c find out what it is, generally target <130 systolic
- what should the patient do to lower it
- doctors familiar with drugs can make suggestions/ideas
- as with HbA1c BP high generally the doctor should suggest …'you need a period on intensive support and weekly/monthly contact with your GP/practice nurse to control your BP. Generally medication will be added /doses adjusted until the BP is controlled. Your GP/practice can usually this. (It seldom takes more than 10 visits) but if not your GP must refer you to BP expert, Professor Lip here in Birmingham
The Patient Letter
- This will need practice
- Letter is to the PATIENT
- Copy to doctor
- Copy to optometrist if new referral
- Explain medical terms in brackets after the term used
eg occult choroidal neovascularisation with a PED (wet age-related macular degeneration) - The letter MUST CONTAIN a management plan that includes hba1c/BP etc
The letter |
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Problems
Management plan
Findings
[Letter body]Thank you for seeing me in the eye department today. This letter summarises your “at risk eye” management plan that we agreed.
The first treatment for this is laser, and we have arranged …sessions. However, a laser is only one part of the treatment you need. Your HbA1c was 9, this is a little high….to control the retinopathy, we need an HbA1c <7.5. (The HbA1c is the long term test of your diabetes which you doctor arranges). You need a gradual drop need over the next year. This is equivalent to lowering your average sugar level from 7-9 to 5-6. You also need a blood pressure less than 130/80 and cholesterol less than 4.5 The only way to achieve this is regular visits to your GP/nurse, gradually changing the treatment etc at each visit. Therefore you really need a period on intensive support and weekly/frequent contact with your GP/nurse to control your diabetes. Your GP may be able to provide this, but if not your GP must refer you to the Community diabetes team. (A period of intensive supervision for poorly controlled patients is recommended by NICE). |
And so on. Your letter needs practice and on-going improvement; it won’t read perfectly for the first patients. My secretary objects to long letters, but if you can reuse phrases etc, have a draft letter/samples/templates in front of you when you dictate, this will make matters easier. The same phrases are very quick for secretaries to type.
Here are some phrases that may be used:
e.g. HbA1c: healthy eating, losing weight, taking diabetes tablets regularly, increasing physical activity, making an appointment with your GP for a review of their medication, getting another HbA1c repeated in 3 months time, ask your GP to be referred to the community diabetes team for support, ask your GP to be referred to a structured diabetes education programme etc
Changing behaviour
| Grow model for coaching |
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Goal
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| 7 step change model |
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Betari's box
See.
Consulting with NLP, Lewis Walker
- book
- Context reframing
- Content reframing
- Redefine
- Consequence
- Intention..need something else to help
- Counter-example
- Apply to self,,, now that’s a depressing thought
- Another outcome..what would you do with your hands instead
- Chunking down
- Chunking up
- Hierarchy of criteria
- Meta-frame...you only believe..what are the other options
- Model of the world..some people believe need...another way
- Reality strategy
- Analogy
- Metaphor
- Towards, T, away, A; Picture ;lungs damaged A, want to avoid A, stop now T, allow lungs to stay T, and play with grandchildren T
- Proactive, reactive; options and procedures; general and specific;
- Self and other
Persuasion in clinical practice, L Walker
Change
- 40% patient; 30% therapeutic alliance; expectancy/hope/placebo 15%; technique 15%
- on a scale of 1-10, how important is it for you to make the change?
- (If less than 7, change may not be likely.)
- How confident are you that you could change if you wanted? etc, see below
Prochaska
- Raise awareness
- Resolve ambivalence...not sure want to change
- Prepare to make changes
- Taking action
- Staying on track
- in See
Motivational interviewing
- see
- express empathy...reflective listening
- develop discrepancy.... in the direction of making changes needed, help patients persuade themselves to change
- roll with resistance...avoid confrontation, reframe, agree; if there is resistance, need to reframe
- support self efficacy..patient can do it, 'I can help'.
Positive psychology
- see Authentic Happiness (book) Learned Helplessness
- find particular strengths and traits that will help patient change
An Overall Strategy
- See
- doctor needs right state of mind
- have you the rapport with patient?
- what stage is patient?
- how can you move patient one stage forward?
- how do you keep them on the right track?
Styles of change
- See
- how does patient normally change...quickly? start new things, stop old things, small/large
- how did you change previously, what did you focus on, what did it feel like, what helped you, how did you know what to do?
- how do they motivate themselves...away from something, towards something new?
- what is the worst that can happen, and how can i avoid it?
- what is the best that can happen, and how can i make this even better?
- make change comfortable and safe.
- people are always motivated...but what for?
Conflicts
- are a type of ambivalence
Language
- 'should'..obligation, ambivalence
- 'why bother'...?depressed, or 'learned helplessness'
- 'fuck you' = resistance
Look at the problem structure rather that the content
- the content...is what they believe about the situation
- away from..thinking what is wrong
- reactive...wishful
- external locus..things happen to them
- chunk up..everything is wrong is overwhelming
- know what to do but cannot, don't know how to
Structuring solutions
- towards..what want to happen
- proactive...analyse
- internal locus....you have choices, create own solutions, don't wait to be rescued
- chunk down, a bit at a time
- procedures...follow a plan, commit to learning new skills, look for hidden resources
Problems to solutions
- listen....how do you know this is a problems....what lets you know...how is this affecting you right now?
- if this was to become a problem, how would you know
Solution strategy
- if the problem were solved how would you know, what would be different about you/situation, how will you be as a person
Need to know if have skills and confidence to make change
- need to unearth abilities and talents
Is the problem what you think?
- drug of choice for negative emotions OR/AND low self-esteem
Identify process behind problem
- raise awareness: what's really going on, what thoughts, triggers, what choices will change directions, where can I intervene effectively
Going where problem isn't
- don't stay with negative feelings
- solution spaces...where can you forget about the problem
- counterexamples.....think of times you should have had the problem but didn't
- where were you, what were u thinking/feeling/ doing then
- think of signature strengths
Assess importance, confidence, readiness to change
- score: On a scale of 1-10, how important is it for you to make the change? How confident are you that you could change if you wanted? (Doctor think..how ready is patient ready to change?) (If less than 7, change may not be likely.)
- raising the scaling numbers: you are a 3 that is great, why is it a 3 not a 1
- so, what would 4 look like
- don't take any steps until you are absolutely ready
Listening
- Being 100% present: listen carefully, empathic
- be curious..I wonder what they like, motivate, passionate, what are they thinking, sporty, values?
- congruence..doctors and patient, are you puzzled:
- yes i will try but...
- on the one hand..
- I think I can do that (sight)
- I will try
- I know what I need..does not seem right
- these represent ambivalence/conflict that can delay change
- listen...sit at 45 degree, same eye level, mirror speech rate etc, open posture, nod, note direction of gaze eg talking about problems, minimal encouragers...ahs., open questions
- reflective listening
Roadblocks
Don't
- recommend solutions
- judge
- ignoring
- cross examine
Do
| Change frames | Persuasive phrases |
I cannot stop eating when I feel down
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| Phrases see Silverman, Calgary |
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| Techniques | patients | Attentive listening |
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| Attentive listening, phrases Silverman | |
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ideas
concerns
expectations
pick up and check verbal cues
repeat verbal cues
early use of feelings questions to establish interest
how to end..thank you for telling me
effect on life |
| Skills for building relationship | acceptance is not agreement | |
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understand feelings
partnershipwe will have to work together |
acknowledge efforts
sensitive
support
understand
offer help
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| Explanation and planning | skills | shared decision making |
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| Conflict | Influence | Managing difficult conversations |
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| Assertive | Active listening | Influencing at a meeting |
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Delegate
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Criteria for resolution
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| Asking assertively (MIAD) | Saying no assertively | Feedback |
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| Sources of conflict | how do you respond to conflict | questions to resolve conflict |
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Consultation and the doctor..for professionals
This paper notes
- The level of satisfaction after initial photocoagulation treatment was high; 46.4% of patients with proliferative retinopathy and 53.1% with maculopathy scored 31 or higher.
- Although 69.5% of all patients reported that their expectations of treatment corresponded to their final 9-month visual results, only 8.7% of these patients reported an improvement in visual acuity after 9 months.
- The number of unwanted actions performed by the patients during treatment were significantly related to the number of unclear instructions given by the physician
- [By using these improved consultation techniques], a high level of satisfaction was observed, despite the minimal improvements in visual acuity. Attempts to further improve patient satisfaction might focus on improved education of patients on the possible benefits of laser treatment, greater care in communicating information during treatment, additional nursing support, and additional clerical time to communicate with patients before each appointment.
- decisions should be shared with patients
Paragraphs for medisoft paste
It was a pleasure to meet ....... today. We discussed the retinopathy and diabetic control.
Concerning the retinopathy, this was early.
However, my impression was the diabetic control/BP was not meeting NICE guidelines (.........).
With high glucose levels and blood pressure the eyes and sight will become a severe problem, and the only way to prevent this is to achieve good control.
We really need an HbA1c below 58mmol/l, 7.5%. The HbA1c on the system that I found was.....
I would therefore be grateful if you could advise. I wondered if the
XPERT program, as recommended by NICE would be helpful and appreciate your help arranging this
DAFNE program, as recommended by NICE would be helpful and appreciate your help arranging this
A referral to a psychologist, in view of all the problems , as recommended by NICE, would be helpful and appreciate your help arranging this
A referral to n obesity program, in view of all the problems, as recommended by NICE , would be helpful and appreciate your help arranging this
Most patients, with weekly review of glucose levels, 2 weekly review of blood pressure and weight, in primary care, and adjustment of treatment as required make a great deal of progress over 3-6 months, and this is now standard practice, and so I would be grateful if you would consider this.
With good control the retinopathy may get a little worse but will eventually stabilise.
Process skills for explanation and planning
Amount and types of information
Chunks and checks
- patient's response a guide
Assesses patient
- prior knowledge early on when giving information
- wish for information
Asks patients what other information would be helpful
- aetiology, prognosis
explain at appropriate times
- avoid giving advice, information or reassurance prematurely
Aiding accurate recall and understanding
Organizes explanation
- discrete sections/ logical sequence
Uses explicit categorization or signposting
- (e.g. There are three important things that I would like to discuss. First ..Now, shall we move on to ..)
- Uses repetition and summarizing to reinforce information
- Language: uses concise, easily understood statements; avoids or explains jargon
- visual methods of conveying information: diagrams, models, written information and instructions
- Checks patient's understanding of information given (or plans made), e.g. by asking patient to restate in own words; clarifies as necessary
- 80% of patients want more information, ask if want more information...chunk, check ,number, signpost
- it would be helpful if you could ..what we have agreed so far so I can ensure we are on the right track
Achieving a shared understanding: incorporating the patient's perspective
- Relates explanations to patient's illness framework: to previously elicited ideas, concerns and expectations
- Give opportunities / encourages patient to contribute: to ask questions, seek clarification or express doubts; responds appropriately
- Picks up verbal and none-verbal cues, eg patient's need to contribute information or ask questions; information overload; distress
- Elicits patient's beliefs, reactions and feelings re information given, terms used; acknowledges and addresses where necessary
Planning: shared decision making
- Shares own thinking: ideas, thought processes, dilemmas
- Involves patient by making suggestions rather than directives
- Encourages patient to contribute thoughts: ideas, suggestions and preferences
- Negotiates a mutually acceptable plan
- Offers choices: encourages patient to make choices and decisions to the level that they wish
- Checks with patient: if plans accepted; if concerns have been addressed
- discuss options, information, steps involved, benefits, disadvantages,
- elicit patient's views and accepts
- assess reactions, concerns, consider lifestyle