The consultation for professionals

David Kinshuck

sharing decisions
treatment planning in the consultation
the patient letter
NEJM 2012
GROW coaching model
7 step change model;
Bitari's box;
NLP
Persuasion in clinical practice

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

NEJM 2013

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
Problems Proliferative diabetic retinopathy (severe diabetic eye problems with tiny blood vessels growing on the surface of the retina) Uncontrolled diabetes, slightly high blood pressure Management plan Laser has been arranged Improved diabetic control as below, aiming for HbA1c 7.5% Blood pressure less than 130 systolic You need to work with your GP/nurse intensively to help you improve your control Findings Right eye, 6/6 vision, new vessels at the optic disc Left eye 6/18 vision, maculopathy (leaky central retina reducing sight) [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 examination indicated you had diabetic maculopathy (leaks in the centre of your retina reducing your vision, a common problem in diabetes. The photos showed… 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).

The letter

Problems

Proliferative diabetic retinopathy (severe diabetic eye problems with tiny blood vessels growing on the surface of the retina)
Uncontrolled diabetes, slightly high blood pressure

Management plan

Laser has been arranged
Improved diabetic control as below, aiming for HbA1c 7.5%
Blood pressure less than 130 systolic
You need to work with your GP/nurse intensively to help you improve your control

Findings

Right eye, 6/6 vision, new vessels at the optic disc
Left eye 6/18 vision, maculopathy (leaky central retina reducing sight)

[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 examination indicated you had diabetic maculopathy (leaks in the centre of your retina reducing your vision, a common problem in diabetes. The photos showed…

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
Goal what is the goal? Reality what is happening now? Options what are the options? Will what are you going to do? what is your commitment (scale 1-10)? what support do you need? links www.mentoringforchange.co.uk

Grow model for coaching

Goal

what is the goal?

Reality

what is happening now?

Options

what are the options?

Will

what are you going to do?
what is your commitment (scale 1-10)?
what support do you need?

links

www.mentoringforchange.co.uk

7 step change model
building rapport..chat semi-open questions, e.g...what brings us here today? explore solution patterns previous attempts successful changes in other areas Miracle question..how would things be different if the problem was sorted scaling questions...where would you say you are at present? feedback, complimentary only...." I was struck by your many insights and previous ways of dealing with difficulties"; and so on. task setting link

7 step change model

building rapport..chat
semi-open questions, e.g...what brings us here today?
explore solution patterns
1. previous attempts
2. successful changes in other areas
Miracle question..how would things be different if the problem was sorted
scaling questions...where would you say you are at present?
feedback, complimentary only...." I was struck by your many insights and previous ways of dealing with difficulties"; and so on.
task setting
link

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

PDF See

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 respond differently,
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

Roadblocks

Fear
- What can you do instead
Guilt
- What amends do you need to make
Anger
- What do you need to do to respectfully sort out your boundaries
Sadness
- What will help you honour the past and move on
- How can you safely drop his façade and become more resourceful
Frustration
- What do you need to do differently to move on
Disappointment
- What refinements to your original goal are needed
Overwhelm
- What is the most important thing to focus on right now

Change frames	Persuasive phrases
I cannot stop eating when I feel down redefine...so you cannot stop putting things in your mouth when feel no good consequence...what will happen if.. prior intention..eating is the only thing that... counterexample...have you ever felt down but did something else... apply back to itself..if you are happy you will starve another outcome...real issue...it is about other choices chunking down..what specifically do you eat chunking up...if you get very depressed you will,, other criteria...when you learn some simple skill that can improve your confidence.. changing frame size...does every depressed... what did you do if you felt depressed and did not eat meta-frame.. you believe this because other people...when you sort out what's eating you... how do you know that eating makes you fell better (not the other way round) Change frames Redefine..what else could this mean Consequence What will happen.. Prior intention What is he behaviour doing for you Counterexample Have you ever done anything else Apply I back to itself Focus on another outcome Rebuild self-confidence Chunking down What examples eat/get you down Chunking up What is important here Changing frame size How could you believe this..other people	aware: perhaps you will consider time: while you are here adverb: naturally possible/need: need, can, want link: if, because means

Change frames

Persuasive phrases

I cannot stop eating when I feel down

redefine...so you cannot stop putting things in your mouth when feel no good
consequence...what will happen if..
prior intention..eating is the only thing that...
counterexample...have you ever felt down but did something else...
apply back to itself..if you are happy you will starve
another outcome...real issue...it is about other choices
chunking down..what specifically do you eat
chunking up...if you get very depressed you will,,
other criteria...when you learn some simple skill that can improve your confidence..
changing frame size...does every depressed...
what did you do if you felt depressed and did not eat
meta-frame.. you believe this because
other people...when you sort out what's eating you...
how do you know that eating makes you fell better (not the other way round)
Change frames
Redefine..what else could this mean
Consequence
- What will happen.. Prior intention
- What is he behaviour doing for you
Counterexample
Have you ever done anything else Apply I back to itself
Focus on another outcome
Rebuild self-confidence
Chunking down
- What examples eat/get you down
Chunking up
- What is important here Changing frame size
How could you believe this..other people

aware: perhaps you will consider
time: while you are here
adverb: naturally
possible/need: need, can, want
link: if, because
means

Phrases see Silverman, Calgary
how can I help you what have you come to see me about summarize; has anything else been bothering you summarize; did I get that right I can see that been bothering you, and we will need to look into them in a minute; are there any other areas that I might need to help with? Hello, I am...., I have had a letter..., like to start to make a list of the problems/whatever you would like help with shall we start, then move to...let's start, I would not mind also discussing.... start at the beginning, and tell me... can you tell me more about it..

Phrases see Silverman, Calgary

how can I help you
what have you come to see me about
summarize; has anything else been bothering you
summarize; did I get that right
I can see that been bothering you, and we will need to look into them in a minute; are there any other areas that I might need to help with?
Hello, I am...., I have had a letter..., like to start to make a list of the problems/whatever you would like help with
shall we start, then move to...let's start, I would not mind also discussing....
start at the beginning, and tell me...
can you tell me more about it..

Techniques	patients	Attentive listening
eye contact listen wait facilitation none-verbal cues confirm proceed sequence of events open questions sharing thought summarise then signpost	ideas, beliefs concerns (worry about symptoms) expectations effects on life feelings	encourage silence repetition paraphrase

Attentive listening, phrases Silverman
so you have been getting headaches, has anything else been bothering you so you had a headache and wondered if..... Anything else at all? So you had 1,2, and wondered, Did I get that right? Are there any other things .... ask, listen, screen, confirm, agenda shall we start with, then move on to, if that is all right. I can see that xxx been bothering you, just need to ask.... open questions, yes, go on, nod, silence repeat a phrase.. how...? repeat cues...'upset...?' 'something could be done?' interpretation...are you thinking? it sounds as though... sometimes, pains can be brought on by stress, I was wondering if you felt that may be true for you could you explain what you mean by the phrase,,, can I just see if i have got that right...internal summary ideas, beliefs, concerns (worry about symptoms), expectations, effects on life, feelings identify views, accept them, explain your understanding of the problem 'I sense that you are not quite happy?', 'am i right in thinking....?'	ideas 'tell me what you think is cuasing it? what do you think may be happening concerns what are you concerned that it might be? expectations what are hoping that we may be able to do for this? ..you have obviously given this some thought......? pick up and check verbal cues ...you said you felt.. repeat verbal cues ..I sense.... early use of feelings questions to establish interest ..ask for examples how to end..thank you for telling me ..I understand effect on life

Attentive listening, phrases Silverman

so you have been getting headaches, has anything else been bothering you
so you had a headache and wondered if..... Anything else at all?
So you had 1,2, and wondered, Did I get that right?
Are there any other things ....
ask, listen, screen, confirm, agenda
shall we start with, then move on to, if that is all right.
I can see that xxx been bothering you, just need to ask....
open questions,
yes, go on,
nod, silence
repeat a phrase.. how...? repeat cues...'upset...?' 'something could be done?'
interpretation...are you thinking?
it sounds as though...
sometimes, pains can be brought on by stress, I was wondering if you felt that may be true for you
could you explain what you mean by the phrase,,,
can I just see if i have got that right...internal summary
ideas, beliefs, concerns (worry about symptoms), expectations, effects on life, feelings
identify views, accept them, explain your understanding of the problem
'I sense that you are not quite happy?', 'am i right in thinking....?'

ideas

'tell me what you think is cuasing it? what do you think may be happening

concerns

what are you concerned that it might be?

expectations

what are hoping that we may be able to do for this? ..you have obviously given this some thought......?

pick up and check verbal cues

...you said you felt..

repeat verbal cues

..I sense....

early use of feelings questions to establish interest

..ask for examples

how to end..thank you for telling me

..I understand

effect on life

4 Rs See
Reluctant How much worse.. Rebellious Fearful of change You are right, you are probably not the kind of person who could easily stop Resigned One small step Rationalise..have all he answers What are he positive benefits of (smoking)

Skills for building relationship	acceptance is not agreement
nvc, pick up cues, eye, etc, rapport accept, empathy, support, sensitivity involve patient share thought. provide rationale (how many pillows), examination explain sometimes it is difficult to work out.....due to physical illness, or related to stress....pause	understand feelings I can see that... so you are worried....pause patient.... I can understand, we will check carefully, tell me more then i will examine you partnership we will have to work together	acknowledge efforts ....... sensitive ........ support I am concerned.. understand I understand. offer help is there anything

Skills for building relationship

acceptance is not agreement

nvc, pick up cues, eye, etc,
rapport
- accept, empathy, support, sensitivity
involve patient
- share thought. provide rationale (how many pillows), examination explain
- sometimes it is difficult to work out.....due to physical illness, or related to stress....pause

understand feelings

I can see that...

so you are worried....pause
patient....
I can understand, we will check carefully, tell me more then i will examine you

partnership

we will have to work together

acknowledge efforts

.......

sensitive

........

support

I am concerned..

understand

I understand.

offer help

is there anything

Explanation and planning	skills	shared decision making
diff diagnosis physicians plan explain negotiate plan	chunks and checks assess patients knowledge what other information would be helpful explain at appropriate times organise explanation signpost repeat summarise diagrams, notes. check understanding explain and relate to patients framework encourage patients to contribute pick up cues, ask beliefs	shares thoughts, options, involves pt how much would patient like to be involved in decision negotiates checks with patient

Conflict	Influence	Managing difficult conversations
why you feel that anxiety,,,fixation stress ... >>not rational, need to understand the pressures feedback...don't comment on their personality intention-behaviour-effect... i notice when you said this...it had xxx effect joint meeting off site (sort of) different expectations listen, keep cool, letting go,delayed response..email reply open, consensual style..approach>situation	make others want persuasion>get into the head of other person prepare objective, bottom line shared view team role to keep an eye on negotiation rescue if problem compromise...over what, don't react --- knowing what sets you off self aware disarm them..... agree to minor thing change the game, make it easy to say yes, think who is behind, mutual benefit silence as a tool, listen, patience, takes time to take things in under stress lead up to controversial issues, involve right people early on	prepare be clear on aim understand v understood build on hat you have in common keep your head speak clearly, confident share views/feelings flexible, time move to problem solving know when to end

Conflict

Influence

Managing difficult conversations

why you feel that
anxiety,,,fixation
stress ... >>not rational,
need to understand the pressures
feedback...don't comment on their personality
intention-behaviour-effect... i notice when you said this...it had xxx effect
joint meeting off site (sort of)
different expectations
listen, keep cool, letting go,delayed response..email reply
open, consensual style..approach>situation

make others want
persuasion>get into the head of other person
prepare
objective, bottom line
shared view
team role to keep an eye on negotiation
rescue if problem
compromise...over what,
don't react ---
knowing what sets you off
self aware
disarm them..... agree to minor thing
change the game, make it easy to say yes,
think who is behind, mutual benefit
silence as a tool, listen, patience,
takes time to take things in under stress
lead up to controversial issues,
involve right people early on

prepare
be clear on aim
understand v understood
build on hat you have in common
keep your head
speak clearly, confident
share views/feelings
flexible, time
move to problem solving
know when to end

Assertive	Active listening	Influencing at a meeting
be direct be appropriate take responsibility tackle the problem be clear stay on track confident delivery inflection body language/facial expression, eye contact, proximity ..not too close listen actively be organised remain calm Delegate identify skills in team risk assessment, support, remain accountable, people development,	body language tone of voice checking understanding questioning. closed. open probing mirroring, linking, prompting building on ideas checking back and summarising Criteria for resolution mutual definition and understanding of problems all parties accept part of problems some way to hold party to agreements reached must get something out of resolving conflict listen, low defensiveness, stay in problem solving mode	under stress 7% message, body language eye contact..rude in Jamaican/Indian children>adult organise paper work so can find under pressure making reasons, saying no, disagree, being 'straight forward' don't be over apologetic respect their right to say know keep it short give reason if think it will help don't play on good nature don't take no personally give real reason for refusal tone of voice, be concise state disagreement clearly don't put yourself or others down be constructive be open if change mind quiet and deadly..you have a choice listen,evidence, calm, prepare assertiveness, have solution

Assertive

Active listening

Influencing at a meeting

be direct
be appropriate
take responsibility
tackle the problem
be clear
stay on track
confident delivery
inflection
body language/facial expression,
eye contact, proximity ..not too close
listen actively
be organised
remain calm

Delegate

identify skills in team
risk assessment,
support,
remain accountable,
people development,

body language
tone of voice
checking understanding
questioning.
closed. open probing
mirroring, linking, prompting
building on ideas
checking back and summarising

Criteria for resolution

mutual definition and understanding of problems
all parties accept part of problems
some way to hold party to agreements reached
must get something out of resolving conflict
listen, low defensiveness, stay in problem solving mode

under stress 7% message, body language
eye contact..rude in Jamaican/Indian children>adult
organise paper work so can find under pressure
making reasons, saying no, disagree,
being 'straight forward'
don't be over apologetic
respect their right to say know
keep it short
give reason if think it will help
don't play on good nature
don't take no personally
give real reason for refusal
tone of voice, be concise
state disagreement clearly
don't put yourself or others down
be constructive
be open if change mind
quiet and deadly..you have a choice
listen,evidence, calm,
prepare
assertiveness,
have solution

Asking assertively (MIAD)	Saying no assertively	Feedback
listen state information you have.. I know, I feel, I would like ask what action would lie I want I need I would like ask for commitment... will you do that for me	consider consequences of saying no consequences of further actions consequences of letting then continue to act listen..show person understand what they want refuse I don't want to, would rather not i would find that difficult Tell I know I believe I feel repeat 'tell' as necessary ? compromise	specific positive feedback, what went well and the reason i say that feedback on observed behaviors, not attitude/impressions offer description of what you saw & felt, not judgement focus on behaviour which can be changed ask questions rather than make statements set ground rules in advance comment on things done well as well as areas for improvement observe personal limits consider value to receiver before offering

Asking assertively (MIAD)

Saying no assertively

Feedback

listen
state information you have..

I know,
I feel,
I would like

ask what action would lie

I want
I need
I would like

ask for commitment...

will you do that for me

consider

consequences of saying no
consequences of further actions
consequences of letting then continue to act

listen..show person understand what they want
refuse

I don't want to,
would rather not
i would find that difficult

Tell

I know
I believe
I feel

repeat 'tell' as necessary
? compromise

specific positive feedback, what went well and the reason i say that
feedback on observed behaviors, not attitude/impressions
offer description of what you saw & felt, not judgement
focus on behaviour which can be changed
ask questions rather than make statements
set ground rules in advance
comment on things done well as well as areas for improvement
observe personal limits
consider value to receiver before offering

Sources of conflict	how do you respond to conflict	questions to resolve conflict
interdependence multiple roles different expectations scarce resources differing needs, values different information perceptual differences different time perspectives personal traits and skills	competing power seeking avoid deny compromise/negotiate collaborate or integrate	what is the problem as you see it what are others doing to contribute to problems what are you doing to contribute to the problem what do you need/want form others to resolve first steps?

Sources of conflict

how do you respond to conflict

questions to resolve conflict

interdependence
multiple roles
different expectations
scarce resources
differing needs, values
different information
perceptual differences
different time perspectives
personal traits and skills

competing
power seeking
avoid
deny
compromise/negotiate
collaborate or integrate

what is the problem as you see it
what are others doing to contribute to problems
what are you doing to contribute to the problem
what do you need/want form others to resolve
first steps?

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

here

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

Shared decision making DDDDDD

Develop trust
Discover patient’s views
Discuss option etc
Double check understanding
Decide
Document

Mastering adverse outcomes ASSIST

acknowledge
sorry
story
inquire
solution
travel..will look after you
https://www.hse.ie/eng/about/who/qid/other-quality-improvement-programmes/opendisclosure/opendiscfiles/managing-complaints-using-the-mps-assist-model-of-communicationpdf.pdf

Mastering risk CLEAR..clear communication

CLEAR
Connect listen empathise ask review
Ask: ice (diseases concerns, expectations, specific questions/issues for that patient, ask permission, review..checking during consultation

Consultation gone wrong

Apologise, got on wrong foot, can we start again/ could we explore our discussion today

Mastering professional interactions

Handing over
MPSC Message. (Code, mode), People , , setting , Check
SBAR Situation, background, assessment, recommendation
HALT hungry angry late tired...patient colleagues

Could you give me a summary of what i have said so i can be sure i have been clear
Methodical structured conversation saves time later

Peters the chimp paradox 2012
? Hot button https://www.conflictdynamics.org/what-are-your-hot-buttons/

Diagnosis of interactional difficulty

What where is the difficulty , patient view
Support skill
Active listening
Empathy
Summarise and reflect back events and emotions

Address

Reframing ...doctor from negative to sympathetic
Challenge negative view
Tension skills
Agreeing on disagreement, you want a scan, i don't believe necessary, i believe this is causing tension between us.
Stating boundaries

SOLVE Summarise options list verify enable

Summarise and reflect back events and emotions
Solution focused
Avoid evaluations of options at this stage

Assist patient to generate solutions
Being led by patients needs and ideas
Give patient ownership
Language ....Dont use

but why with respect
Swearing a sign of distress

After this

Would it be helpful for me to list some options i can think of
Like to find an option we can agree to
Pick up on cues
What matters most to you
Don’t take over option generation from patient
Be specific in summary
Not reaching a mutually agreeable solution, what do you think we should do,
Extremely difficult time, lots of problems, sorry you are suffering so much

mastering adverse outcomes
ASSIST acknowledge sorry story inquire solution travellinkf

Clear communication
CLEAR Connect listen empathise ask review
ice, specific, ask permission,
review..checking during consultation
ice= ideas concerns expectations

decision making DDDDDD

Develop trust
Discover patient’s views
Discuss option etc
Double check understanding
Decide
Document

Apologies 2018

Read referral, correct patient, look at patient, not screen, Listen 2 minutes uninterrupted talking time, don't criticise (anyone) in front of others
Apologies
- early if results not arrived
- Prompt apology
- Correct cause
Formal complaint, Pals, Complaint management pathway
- Get first response letter write
- Clear apology
- Accurate timeline
- Clinical outcome
- Go through specific questions asked
- Dr talk through with pals
- Offer second opinion
- Address unanswered points
- if you meet., may need to listen for 1 hour
- emotions

Rollnick Miller

Motivational interviewing power point managing discord

Traps
Question answer
Premature focus
Righting reflex

Rule
Righting
Listening
understand
empower

darn
desire
ability
reasons
need

desire..what do you want
ability what is possible
why would you make this change
needs how important

NOT why cant, don’t, haven’t, do you need to

What are the good thngs about….
What are the not so good things
Where does that leave you know

Ask permission to inform

For professionals

the '5 A's

From here the 5 As in diabetes education

Advice has to list to patients problems, and tailor the goals accordingly. There are many strategies, (p115) , including the Care Ambassador program & here. Such strategies should be used. (P126) as below, describes an office based intervention.

A Primary care plan (p126)

prior to visit
mailed reminder
goals, self-monitoring records, blood tests

waiting room
patient completes self management form
surrounded by diabetes information.. pamphlets, leaflets, posters

examination room
nurse gives feedback on changes
nurse checks self management form and finds areas of most concern

doctor examination
check self-management form and discuss areas of most concern TO PATIENT
reinforce willingness to change behaviour, refer to nurse for specific plan

nurse follow-up
review and clarify goals in one area of self-care
develop a realistic specific & measurable plan
have patient identify barriers & assist problem solving
plan continues support...diabetes support group, education, community, phone call between visits
record goal and plan for follow-up at next visits

Stopping treatment, ask and listen 60%

understanding of current problems
what outcome dont you want
fears and worries

Evoking change talk, after Pip Mason and others

Desire: Questions usually include words such as want, wish, and like.
Example questions:

How would you like for things to change?
How do you want your life to be different a year from now?
What do you wish for in your relationship?

Ability: Questions usually include what a client can do, is able to do, or could do.
Example questions:

If you did really decide you want to lose weight, how could you do it?
What do you think you might be able to change?
Of the various options you’ve considered, what seems most possible?

Reasons: Questions usually ask about specific reasons why a client may consider making a change.
Example questions:

Why would you want to get more exercise?
What’s the downside of how things are now?
What might be the good things about quitting drinking?

Need: Questions usually ask about an urgency for change to happen.
Example questions:

What needs to happen?
How serious or urgent does this feel to you?
What do you think has to change?

By asking these types of questions, you may be surprised by how much change talk you will hear. And a good rule of thumb is to think about the response you would like to hear since the ratio of change talk to sustain talk is a predictor of change actually occurring.

Open questions

What are the good things about status quo, not so good things
- Tell me more…
- What does that look like…
- When was the lsat time that happended,
  Give me an example
What was life like previously
If you wre successful..what would life be like
What are the worst if you don’t
What are the best if you make this change
On a scale 1-10 where are yoyu ,,,
- and why are you not [lower]
- What could move you up to …
- What migh happen that could move you from x to x +1
- How much do you want this
- How confident are you
- How committed
Values..what do you want, what is important for you
Come along side
" perhaps………is so important to you that you wont give it up, no matter what the cost "
i'd really like you to tell me what you think about this

going in circles: not enough complex reflections or challenging
situation challenging for patient, 'difficult to do one thing and not the other'
if you are struggling or they are entrenched, patients has the autonomy as a strength
empathic find out about patient/client;
discord, not feeling heard/problem with relationships, bumpy bits of motorway, lack of partnership
sustain talk
what do you achieve this for, summarise as reflection and listening, reflect feelings
soften sustain talk:.person giving you good reasons, reflect back in a softer way, e.g. would take bit of adjustment,
reflect feelings, challenging
pros and cons of changing, start with where patient is at, so if not doing something, start with what dont like..empathise with these and reflect the difficulties
facing up to and patient verbalising conflict
confrontation creates denial and resisitance
powerful: here are the options you have 'choice includes carry on smoking wishing they weren't '

plan^^

evoke importance ^^

focus^^

engage and establish^^ (dont argue ..empathise 'roll with resisitance'; )

A lots of patients find it useful

to discuss ..opportunistic: do you have any thoughts about what may help your eyes, if its ok with you my patients find it very useful if .., would it be ok if we discuss this, how do feel about smoking,

How do you feel about smoking?

I love smoking..what do you like about it

POT

this is a real nuisance, i could spend a little time talking about what might ...pots permission opinon thoughts

Books

miller and rollnick 2012,

health behaviour change Mason

How do assess MI

problem issue but you might not want to tell me now

Comfort eating

Stress

Stuffing emotions. Eating can be a way to temporarily silence or “stuff down” uncomfortable emotions, including anger, fear, sadness, anxiety, loneliness, resentment, and shame. While you’re numbing yourself with food, you can avoid the difficult emotions you’d rather not feel.

Boredom or feelings of emptiness.

Childhood habits. Think back to your childhood memories of food. Did your parents reward good behavior with ice cream, take you out for pizza when you got a good report card, or serve you sweets when you were feeling sad? These habits can often carry over into adulthood. Or your eating may be driven by nostalgia—for cherished memories of grilling burgers in the backyard with your dad or baking and eating cookies with your mom.

Social influences.