Diabetes is a self managed condition. You live with it 24/7 and make decisions about how to manage it during that time. If you’re lucky, you receive help, support and learning, both informal and formal, from your nearest and dearest, other people with diabetes, diabetes health services and organisations. But it’s still yours every day.
Campaigns like the recently launched ‘Taking Control’ by Diabetes UK highlight how important the education side of things is, helping people to understand more and learn the skills to make those daily decisions. ‘SD Comments’ has talked many times about the tiny numbers of people who actually receive such learning opportunities, even though they are recommended for everyone, So, we’re really pleased to see this campaign get off the ground, support it wholeheartedly, and wish it every success. There is just one thing, however…..
…and that is, the first sentence of the introduction to the campaign reads ‘..people with diabetes only spend around three hours with their doctor, nurse or consultant. For the other 8757 hours, they must manage their condition themselves’. This implies that when someone with diabetes is consulting, somehow the responsibility for their diabetes belongs to the health professional they are with.
It’s not deliberate, but this is another example of what might be called ‘unconscious paternalism’ – the idea that it’s ok for ‘patients’ to do their own thing unless they are under the jurisdiction (ie in the consulting room) of a health professional.
Apart from being at odds with the personalised care policy, the push for greater collaboration between health professionals and people with diabetes and promotion of self care, this assumption also makes the mistake of thinking that the health professional being consulted actually knows what is best for the person. They may be valued experts in diabetes, but not in living with diabetes and particularly not in an individual’s life with diabetes, not on that day, in that hour, or ever. Nor should they try or expect to be.
What’s needed is for this oft-trotted statistic to be reflected upon. Is this really what we want those numbers to mean? We suggest not. It’s perfectly valid to count the hours (or lack of them, some would say) that someone spends with a health professional, It’s also perfectly valid to consider how well these hours are used to promote and support self management and daily decision making. What’s not valid is to perpetrate the unconscious but well-rehearsed assumption, however well-meant, that really, it’s the health professional who matters most, who is somehow ‘in charge’
People with diabetes are perfectly capable of looking after their diabetes within a consultation as outside it, 8760/8760. The job of the consultation is to reflect and work together on the experiences these hours raise for the person themselves, so that they are equipped to make each one of them a success
Reference
Diabetes UK’s Taking Control Campaign
Showing posts with label consultations. Show all posts
Showing posts with label consultations. Show all posts
Tuesday, 10 November 2015
Monday, 9 December 2013
'A Straight Talk' or 'A Straight Listen'?
A health professional at a recent workshop passionately exclaimed, ‘sometimes I have to give my patients a straight talk!’ By ‘straight talk’, the health professional meant telling the person exactly where they were going wrong with their diabetes management and what the consequences would be if they did not change their ways.
I do not doubt for a moment, the health professional’s motivation of concern for the health of those on the receiving end of the ‘straight talk’, nor the desire to help achieve the diabetes recommendations which are widely published and to which such health professionals, among others, are often held responsible.
Rather, what struck me about this encounter was the idea, in our evidence-based world, that such a strategy would work to improve the situation. In fact, evidence suggests exactly the opposite, that is that a telling off (for that is what was really meant by a ‘straight talk’ in this case – I knew it because the words were accompanied by a wagging finger) is likely to make people highly disinclined to make changes and distinctly unwilling to return to the clinic or a consultation with such a health professional.
What might be a more helpful and effective strategy is one I encourage any health professional in such a situation to consider, and that is a ‘straight listen’. This consists of asking a few interested open questions and actively listening to the answers, with the aim of experiencing the world through the eyes of the person with diabetes and to help address the challenges they face. ‘A straight listen’ has many advantages, among them:
It engages the person in talking honestly about their concerns about their diabetes and their thoughts and wishes about addressing them
It is more friendly and less stressful
It creates an equal contribution and participation in the consultation
It results in increased motivation to take action outside of the consultation
It takes less time and energy and gives much more satisfaction
Sometimes, listening is thought of as a ‘soft’ skill or ‘a bit touchy feely’ as described to me by another health professional recently. However, in survey after survey of people, especially those with long-term conditions, active listening and being non-judgemental are cited as missing, and strongly wished for from health providers. A recent example is a survey published in Diabetes Update. How can it be that something so apparently simple and so desired, is so comprehensively overlooked?
In my experience, there is no shortage of health professionals expressing a desire to be better communicators or listeners, but a common reason given for not investing in actually using these skills more, is a lack of time in consultations. This is interesting, since there is evidence that consultations can be shorter where there is more listening on the part of the health professional and this also brings increased satisfaction on the part of the person with diabetes. There must be something else. I find myself wondering if part of this ‘something else’ is that being a health professional is so intrinsically linked to being an ‘expert’ and an ‘advisor’, that ‘simply listening’ means to give up these roles with the perhaps consequent loss of status or even competence? Another reason may be that, among health professionals, the skills of listening are much less practised, hence less habitual, than those of talking or telling, and so their confidence in using them is less.
As I continue my musings as to the underlying causes are of the continuing need among health professionals to deliver a ‘straight talk’ against much good evidence of its ineffectiveness, I have a new offering to try and make ‘a straight listen’ more accessible and easier to learn and practice.
From today, SD’s latest download is ‘A Little Book of Listening’, a booklet with some inspiration, ideas and practical ways to use listening in consultations – and indeed in other areas of life, too. I hope that providing and spreading the word about this will go towards helping some poor souls avoid being on the receiving end of any more ‘straight talks’ next year!
Sincerely wishing you a listening 2014
Grant, P. (2013). What do Patients want from their Diabetologist?. Diabetes Update, Winter 2013
Successful Diabetes (2013). A Little Book of Listening
I do not doubt for a moment, the health professional’s motivation of concern for the health of those on the receiving end of the ‘straight talk’, nor the desire to help achieve the diabetes recommendations which are widely published and to which such health professionals, among others, are often held responsible.
Rather, what struck me about this encounter was the idea, in our evidence-based world, that such a strategy would work to improve the situation. In fact, evidence suggests exactly the opposite, that is that a telling off (for that is what was really meant by a ‘straight talk’ in this case – I knew it because the words were accompanied by a wagging finger) is likely to make people highly disinclined to make changes and distinctly unwilling to return to the clinic or a consultation with such a health professional.
What might be a more helpful and effective strategy is one I encourage any health professional in such a situation to consider, and that is a ‘straight listen’. This consists of asking a few interested open questions and actively listening to the answers, with the aim of experiencing the world through the eyes of the person with diabetes and to help address the challenges they face. ‘A straight listen’ has many advantages, among them:
It engages the person in talking honestly about their concerns about their diabetes and their thoughts and wishes about addressing them
It is more friendly and less stressful
It creates an equal contribution and participation in the consultation
It results in increased motivation to take action outside of the consultation
It takes less time and energy and gives much more satisfaction
Sometimes, listening is thought of as a ‘soft’ skill or ‘a bit touchy feely’ as described to me by another health professional recently. However, in survey after survey of people, especially those with long-term conditions, active listening and being non-judgemental are cited as missing, and strongly wished for from health providers. A recent example is a survey published in Diabetes Update. How can it be that something so apparently simple and so desired, is so comprehensively overlooked?
In my experience, there is no shortage of health professionals expressing a desire to be better communicators or listeners, but a common reason given for not investing in actually using these skills more, is a lack of time in consultations. This is interesting, since there is evidence that consultations can be shorter where there is more listening on the part of the health professional and this also brings increased satisfaction on the part of the person with diabetes. There must be something else. I find myself wondering if part of this ‘something else’ is that being a health professional is so intrinsically linked to being an ‘expert’ and an ‘advisor’, that ‘simply listening’ means to give up these roles with the perhaps consequent loss of status or even competence? Another reason may be that, among health professionals, the skills of listening are much less practised, hence less habitual, than those of talking or telling, and so their confidence in using them is less.
As I continue my musings as to the underlying causes are of the continuing need among health professionals to deliver a ‘straight talk’ against much good evidence of its ineffectiveness, I have a new offering to try and make ‘a straight listen’ more accessible and easier to learn and practice.
From today, SD’s latest download is ‘A Little Book of Listening’, a booklet with some inspiration, ideas and practical ways to use listening in consultations – and indeed in other areas of life, too. I hope that providing and spreading the word about this will go towards helping some poor souls avoid being on the receiving end of any more ‘straight talks’ next year!
Sincerely wishing you a listening 2014
Grant, P. (2013). What do Patients want from their Diabetologist?. Diabetes Update, Winter 2013
Successful Diabetes (2013). A Little Book of Listening
Friday, 8 March 2013
'Doing Diabetes' - A Very Human Mission
One of the most interesting and lively discussions that often arise during personalised care planning workshops is about behaviour change and motivation. Health professionals often raise concerns about people with diabetes not meeting recommendations for their blood glucose or HbA1c levels, weight, exercise or taking medications as prescribed. They recognise it is hard for people to do these things but also express frustration that their efforts to advise and encourage seem to fall on deaf ears. As one health professional recently put it ‘they don’t seem to realise how important it is to look after themselves. I feel like I’m wasting my time’
Indeed they might be wasting their time and also that of the person with diabetes. For although the intention is excellent and the desire to help is paramount, there is a flaw in this way of thinking about helping people change. That is the underlying assumption that ‘they’ need to do something different because they have diabetes.
The reality is that, as we have mentioned before, having diabetes – or any other long term condition for that matter – does not make you automatically more motivated or successful in your efforts to make healthy changes than anyone else, or, crucially, to heed advice however well meant, from health professionals. Nor would health professionals be more successful at it, if they developed diabetes themselves tomorrow.
During such a discussion, I might ask health professionals how well they manage to adhere to ‘everyday’ health recommendations around taking exercise (150minutes/week), drinking alcohol (maximum 20 or 14 units/week for men and women respectively), calorie intake (3000/2000 a day for men and women) and eating oily fish (1 or more portions/week) Often, this produces a ripple of rueful laughter, as people realise that they don’t necessarily practice what they preach and this is nothing to do with having diabetes.
Further discussion reveals that the reasons they give for not being able to meet these recommendations – typically time for exercise, having a busy lifestyle, eating what’s available, family pressures around food preferences and not making themselves and their health a priority – are much the same as those with diabetes would give, with many more diabetes related activities to perform, for example blood testing, insulin dose adjustment, hypo prevention and foot checks, not to mention clinic appointments.
So what we establish is that motivation and behaviour change are influenced because of humanity, not the condition you live with. The key drivers are not what someone else advises you to do or recommends, but how important you think an action is, how many barriers to it are in your way, whether you believe your actions will result in benefits, whether you have confidence in your ability to take whatever action it is and also what past experience of success or failure you have had – to name but a few.
The consultation that simply gives information and advice is not going to be very helpful and might well be the waste of time and cauldron of frustration mentioned by that health professional earlier. Much more useful is one that explores the human side of behaviour – what makes you do something? What stops you? How important do you think it is to deal with your diabetes? How confident do you feel about doing what is recommended? These are all questions that could use the time much more effectively and even ones that someone could reflect on in advance.
Such an approach is truly a human collaboration and makes life much less frustrating for everyone ‘doing diabetes’ in their life or work. Thankfully it is an approach firmly ingrained in the new health policy rhetoric. The challenge now is to make it a reality.
Reference
Personalised Care Planning Workshops by Successful Diabetes
Indeed they might be wasting their time and also that of the person with diabetes. For although the intention is excellent and the desire to help is paramount, there is a flaw in this way of thinking about helping people change. That is the underlying assumption that ‘they’ need to do something different because they have diabetes.
The reality is that, as we have mentioned before, having diabetes – or any other long term condition for that matter – does not make you automatically more motivated or successful in your efforts to make healthy changes than anyone else, or, crucially, to heed advice however well meant, from health professionals. Nor would health professionals be more successful at it, if they developed diabetes themselves tomorrow.
During such a discussion, I might ask health professionals how well they manage to adhere to ‘everyday’ health recommendations around taking exercise (150minutes/week), drinking alcohol (maximum 20 or 14 units/week for men and women respectively), calorie intake (3000/2000 a day for men and women) and eating oily fish (1 or more portions/week) Often, this produces a ripple of rueful laughter, as people realise that they don’t necessarily practice what they preach and this is nothing to do with having diabetes.
Further discussion reveals that the reasons they give for not being able to meet these recommendations – typically time for exercise, having a busy lifestyle, eating what’s available, family pressures around food preferences and not making themselves and their health a priority – are much the same as those with diabetes would give, with many more diabetes related activities to perform, for example blood testing, insulin dose adjustment, hypo prevention and foot checks, not to mention clinic appointments.
So what we establish is that motivation and behaviour change are influenced because of humanity, not the condition you live with. The key drivers are not what someone else advises you to do or recommends, but how important you think an action is, how many barriers to it are in your way, whether you believe your actions will result in benefits, whether you have confidence in your ability to take whatever action it is and also what past experience of success or failure you have had – to name but a few.
The consultation that simply gives information and advice is not going to be very helpful and might well be the waste of time and cauldron of frustration mentioned by that health professional earlier. Much more useful is one that explores the human side of behaviour – what makes you do something? What stops you? How important do you think it is to deal with your diabetes? How confident do you feel about doing what is recommended? These are all questions that could use the time much more effectively and even ones that someone could reflect on in advance.
Such an approach is truly a human collaboration and makes life much less frustrating for everyone ‘doing diabetes’ in their life or work. Thankfully it is an approach firmly ingrained in the new health policy rhetoric. The challenge now is to make it a reality.
Reference
Personalised Care Planning Workshops by Successful Diabetes
Tuesday, 24 July 2012
Consultations – A Meeting of Minds or an Appointment with Fear?
This week, the spotlight
has well and truly shone on consultations, in the form of several reports
released by the Health Foundation, including one entitled ‘When doctors and
patients talk: Making sense of the consultation’ (Health Foundation, 2012).
This is welcome news to
us, as consultations and how they are conducted, and helping health
professionals develop more person centred skills, has long been a central theme
of our work. This is because we know that people with diabetes have mixed and
often unpredictable experiences with their health professionals, and frequently
spend days and even weeks before their meetings feeling anxious and concerned
about what might happen, particularly about whether they might hear bad news
about their health. Not least of their worries is being judged for not
achieving better control of their blood glucose, without the chance to explain
the complexity of managing diabetes day by day in the face of other pressures
and demands. As one person memorably put it ‘consultations for me are about
attending to receive my ritual telling off’ (although in reality the words
‘telling off’ were said in rather more colourful language!). Another lady put
it like this – with tears in her eyes -
‘I feel like I’ve failed an exam every time I go to the clinic’.
The Health Foundation
review, which is based on extensive interviews and workshops with a range of
doctors and patients, not only completely validates this aspect and discusses
fear of patients as a key influencer of their participation in a consultation,
but also suggests that the fear of doctors is a factor too. Their fear centres
on making the wrong diagnosis or on potentially being regarded as less
professional if they alter the way they work. With the power in healthcare
still largely residing with the health professional, the consultation is often
structured to allay the fears of the doctor rather than the patient, giving
rise to the experience of many of being talked at rather than with and being
unable to fully express their thoughts, feelings and wishes.
It’s not all bad news for
consultations of course - many go very well, and the bond between health
professionals and the people they see is often close and productive. Diabetes
UK’s magazine ‘Balance’ runs a regular column ‘I couldn’t do without…’ in which
people describe where their best support comes from. This very often features a
nurse, doctor or other health worker. What we need is more of these obviously successful
encounters and less of the ones that are, frankly, a waste of time and effort,
not to mention money, for all concerned.
But the good news is, a
knight in shining armour may be coming to the rescue. A new way of working is
hovering on the edge of diabetes care, looking for ways into the mainstream.
This is personalised care planning, which features shared decision making at
its core and has been shown to be successful in transforming the routine,
health professional-based consultation to one that is truly collaborative, to
the satisfaction, and in many cases delight, of both health professionals and
people with diabetes.
With personalised care
planning, people with diabetes are able to have a much greater say, literally,
in the consultation, and no longer have to wait in trepidation for their own
test results (blood, eyes, feet and so on) to be given - or often partially
supplied - to them by their health professional. Personalised care planning
means they receive a comprehensive set of results and have time to reflect on
them well before their consultation. They can then make decisions in the
comfort of their own home before meeting up with the health professional to
talk about what aspects of their diabetes, if anything, they wish to work on as
a priority. Quite often, they attend having already made a decision about
changing something, and have got started on it, so saving a lot of time which
can then be used to discuss other aspects of their health or make for a shorter
consultation.
Health professionals are
naturally sceptical and need convincing about new practices, an aspect
highlighted by another of the recent Health Foundation reviews on the evidence
for shared decision making in consultations (de Silva, 2012). This review
describes principles that are known to promote shared decision making, which
happily including many that feature in personalised care planning, such as:
goal setting and review; making care plans in partnership together; emphasising
options; problem solving; and preparation for the consultation in advance.
However, even though this evidence is available, health professionals are also
as vulnerable to the difficulties of changing their practice and behaviour as
anyone else, and for these reasons, personalised care planning has not yet been
widely implemented.
Fortunately, the body of
evidence for personalised care planning is increasing all the time, and we are
proud to be contributors to this in a number of ways:
·
Our website
resources, including workshops (Successful Diabetes, 2012)
·
2 recently published
papers (Walker et al, 2012; Walker and Rodgers, 2012)
·
Our book explaining
the nuts and bolts of how to set up personalised care planning (Walker and
Rodgers, 2011).
Now, with the Health
Foundation’s timely reviews, we sincerely hope that services will be able to
stop saying ‘why should we?’ and see that ‘how can we?' is the only question
they need to ask!
Does anything in this blog
ring true for you? Do you have experiences of consultations or personalised
care planning... or the opposite? Post your thoughts and comments and share them with us here…
References
de Silva, D. (2012).
Helping people share decision making: a review of the evidence considering
whether shared decision making is worthwhile. Health Foundation. http://www.health.org.uk/publications/helping-people-share-decision-making/
Fischer, M., Ereaut, G.
(2012). When doctors and patients talk: making sense of the consultation.
Health Foundation. http://www.health.org.uk/publications/when-doctors-and-patients-talk-making-sense-of-the-consultation/
Successful Diabetes
Workshops http://www.successfuldiabetes.com/workshops
Walker, R., Rodgers, J.
(2011). Implementing Personalised Care Planning in Long Term Conditions. SD
Publications. www.successfuldiabetes.com/books
Walker, R. et al (2012).
Introducing personalised care planning to Newham: outcomes of a pilot project.
Diabetic Medicine, 29, 8, 1074-1078. Abstract can be viewed at
Walker, R., Rodgers, J.
(2012). Personalised care planning for long-term conditions. Diabetes and
Primary Care, 14, 3, 177- 181. Online at
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