Bradford VTS Online Resources:

CSA

Dealing with a long-case e.g. diabetes

TYPES OF CASES

New Diagnosis Explanation PLUS Lifestyle Discussion in

  • Diabetes
  • Asthma/COPD
  • Heart Attacks/Angina
  • Strokes

Let's go through a case - John

Here’s a typical CSA case.

John is a 45 year old gentleman.   His HBA1c has been in the prediabetic range for the last few years.   However, the latest two readings  show readings of 55.   He has a BMI of 31 and smokes 10 cigarettes a day. He works as a fork-lift driver.    As far as he is aware, he has just come for the result.  How would you proceed?

From further data gathering, you obtain:

  • He knew he had prediabetes but didn’t really know what this meant.
  • He has an aunt and a friend with diabetes but says he knows very little about diabetes.
  • He has not weight loss, polydipsia or polyuria.  He is always tired when he gets home from work (nothing new for the last 10 years!).
  • He works as a fork-lift driver.   Lives with his husband.

What would you do now in TODAY'S consultation?

Most GP trainees who attempt this case are fully conscious of the amount of work they have to do.  Look at some of the things the average GP trainee will want to go through methodically and will want to somehow cover in today’s consultation.  

  • Diabetes explanation
      • What it is
      • Insulin and sugar and how it all works
      • Why we worry – the long term effects
      • Management
  • Losing weight
      • Can potentially reverse diabetes
  • Diet
      • Cutting out the Cs – chocolate, crisps, cake, candy (sweets) and cookies (biscuits)
      • Low carb foods, higher protein diet
      • The Eat Well plate
      • Fruit and veg
      • Structured diabetic education programme
  • Exercise
      • 30mins brisk walking 5 times a day
      • Activities that build up a bit of a sweat
      • Couch to 5K app
      • Swimming
  • Smoking
      • Importance of, how more dangerous in a diabetic to smoke
      • Cessation with a health advisor works better
      • Very Brief Advice (VBA)
      • Smoking cessation service
  • Medical Treatment
      • Medication  -- tablets vs insulin
      • Annual retinal scans
      • Annual foot checks
  • Is this what you would do too?
  • Do you relate to this?  

There are so many areas to cover that instead of concentrating on the patient, the average GP trainee focuses on the “tasks of the doctor”.  This unfortunately transforms the consultation into a doctor-centred consultation -- where volumes of information are vomited all over the poor patient.  The patient then goes home overloaded with information, confused with little sense of direction.   And the doctor feels exhausted after having talked so much!   They key to this type of CSA case (and in fact in real-life General Practice) is to DECIDE what to cover today (and in what way) and what to touch on and leave for another time (i.e. signpost).

The better way

Let’s first look at what outcomes we want to help us determine what would be the better way:
  • In the consultation where the doctor churns out volumes of information over the patient…
      • the doctor starts focusing on his or her tasks and in so doing,
      • will unfortunately ignore what is important for the patient
      • the doctor talks about 90% of the time, and does a lot of telling, not much listening.   
      • The patient may feel a bit hesitant, resistant or even obstructive at some of the suggestions because
      • the doctor is not taking on the patient’s point of view.   
      • The doctor won’t even pick up on these cues because
      • the doctor is far too busy with what’s going on in their own head -- which is to cover a lot of medical advice and information methodically.
  • So, what do we want?  We want a consultation where
      • we start off with the patient’s preconceptions and correct anything that needs correcting. 
      • In so doing, the patient is “awakened” and realises the importance of managing the condition and understands the seriousness of what will happen if it is not.   
      • For this to happen, as doctors we can’t just talk all the time.  We need to engage in a helical dialogue with the patient so that we totally get their world view.   
      • By helical conversation, I mean one in which what the doctor says depends on what the patient said just before and what the patient says depends on what the doctor has said, and the helical nature of the conversation continues.  What each is saying in each thread of the conversation depends on what the other has said prior to it.   
      • In doing this helical thing, because the doctor is truly engaging with the patient, they will pick up on verbal and non-verbal nuances indicating disagreement or resistance and they will stop and explore those.   I mean, why would you go on and on about a diet and the specifics of that diet if it is clear that the patient has not “bought into” that idea?   
      • If the patient is not on the same wavelength, why waste your words and your voice pounding home a message that is being met with resistance.  Isn’t it better to stop and gently explore that resistance on neutral territory and hopefully get both of you onto the same wavelength before providing the detail of that next action plan?

Ram's Tip 1: Find out the patient's starting point.

  • Find out what the patient knows about something.
  • If a patient says they know nothing -- it’s usually not true.  They know something.   Your job is to find that out and empower the patient by showing them that they know something.  Then you can start building and constructing on that pre-built foundation rather than building the foundation from scratch.  
  • Dr Sam: “So John, have you heard of the word Diabetes before”
  • John: “Yes I have. My aunt had it and a mate of mine does too”
  • Dr Sam: “So what do you know about it John?”
    John: “Nothing to be honest”

(most docs at this point would simply ASSUME John knows nothing -- without truly trying to find out -- and as a result will churn out a big chunky diabetic explanation over the patient.  Continue reading and see what Dr Sam does…)

  • Dr Sam: “Sounds like you might know something John.   From your aunt or friend John, what do you think diabetes is all about?”
  • John: “Well I know it’s the sugar level in the body and it goes all funny -- too much sugar I think”
  • Dr Sam: “Yes John, you’re basically right.    It is about sugar.   Our bodies need a bit of sugar running around in our blood to give us energy to do things.   But if that sugar level is too much, it becomes harmful to our health and starts affecting different parts of the body. 

Ram's Tip 2: Then start filling in the gaps and correct misconceptions.

  • Rather than giving one big explanation until your voice is exhausted, why not just find out what the patient knows and fill in the gaps.  It might not seem it, but it is a far more effective method than you just churning out stuff.  Think about it.  If I speak to you for about 5 minutes about something, your mind will start wondering at the 2-3 minutes stage if not earlier.  That’s what minds naturally do!  And then you lose interest and nothing much truly sinks in.  At the end, I, as the information giver, will feel exhausted and what’s worse is knowing that most of the explanation effort has gone to waste because it has not even sunk in.
  • Allowing the patient to express what they know, and then you filling in the gaps and correcting misconceptions actually encourages a helical dialogue between you and the patient.  In a helical dialogue, patients don’t switch off and their minds to not wonder because they are so actively engaged and absorbed in the conversation.   And that ultimately means informations starts to sink in.  The information giving educative process becomes effective.
  • Dr Sam: “Yes John, you’re basically right.    It is about sugar.   Our bodies need a bit of sugar running around in our blood to give us energy to do things.   But if that sugar level is too much, it becomes harmful to our health and starts affecting different parts of the body.     Now, in terms of harm, do you know what diabetes can do to you if we don’t get it under control?”
  • John: “My mate said that diabetics get strokes and heart attacks and things like that.”
  • Dr Sam: “Yes, that’s right John, and some people survive heart attacks and strokes and others don’t.  But John, there’s other parts of your body that diabetes can affect badly too.  For instance, if it gets to the eyes, it causes blindness.  In the kidneys -- kidney failure.  And if in the vessels, in bad cases, can lead to poor circulation and in some instances amputation!”
  • John: “I knew about the eyes but amputation -- are you serious?  How come I know a few diabetics and they’re all okay.  And my mate hasn’t ever mentioned it.  And my aunt is in her 90s and she looks pretty good.”
  • Dr Sam: “Well John, that’s because these days we generally help people get good diabetic control so they don’t have to face that.  But if you went back to the 1970s, you wll have seen many diabetics who were blind or had amputated legs.  It sounds like your aunt and your mate might be doing well at controlling their diabetes.”

Would you agree that this is a far more interesting way of having a discussion that you churning things out?  Isn’t it more dynamic, more engaging and doesn’t it make you feel that as a doctor you are making a difference?

  • John: “So what do I need to do to get this diabetes under contraol?  Is it that insulin injection thing I need? I really don’t want to lose my eyesight or legs or things like that.  But also, I am not a fan of needles.”
  • Dr Sam: “No John, you’ll be pleased to hear that we don’t just stick you on an injection. There other ways to get your diabetes under control and some of them don’t even involve injections or tablets.”

Ram's Tip 3: Let the conversation FLOW naturally and gently coax it to the areas you want to cover.

  • When you let  a conversation develop naturally, what is discussed depend on what each of you is contributing.   This allows you to gently coax a discussion towards areas you want to cover anyway.  
  • The great thing about this method is that it will then seem that a particular area has been explored as a result of both of you wanting to talk about it rather than just you.   In the old style “doctors explains all, patient shuts up and listens” method -- not only (as I explained earlier) does the patient’s mind wonder off, but might even show signs of resisting against what you have to say
  • Letting a conversation to develop naturally and gently coaxing it in a particular direction creates a sort of neutral territory where matters are explored and real feelings displayed.  The patient no longer becomes resistant but instead becomes more inquisitive.  You end up ‘dancing’ with the patient, not ‘fighting’ with them -- and they do the same with you.  
  • Dr Sam: “No John, you’ll be pleased to hear that we don’t need to go straight for injections. There other ways to get your diabetes under control and some of them don’t even involve injections or tablets.”
  •  John: “Really?”
  • Dr Sam: “Yes John.  There are things that WE can do to help you get your diabetes under control -- with things like tablets and injections.  But there are also things YOU can do too.  In fact, sometimes, doctors don’t even need to do anything if you manage to do the bits that are under your control.”
  • John: “Really?  Like what?”
  • Dr Sam: “Well, they’re all about changing your lifestyle to some extent.  The research shows they make a massive difference and may mean you don’t have to take tablets or anything.”  
  • John: “Well I’d rather go down that route first.  So, tell me, like what?”
  • Dr Sam: “There are three areas I want us to focus on.  The first is your diet and what you eat.  The second is your smoking.  And the third is losing some of the weight?  Shall we start with the diet stuff first?”

Ram's Tip 4: Motivational Interviewing Techniques - dance with the patient, not fight with them.

  • There’s a whole Bradford VTS web page devoted to Motivational Interviewing which you can access here with some wonderful video clips.
  • In a nutshell, Motivational Interviewing techniques simply help you work with the patient and find a way forwards.  
  • Motivational Interviewing stops you from using inflammatory language that the patient will then resist against or become defensive towards.
  • Motivational Interviewing helps you to “dance” with the patient rather than “fight” with them.  Have any of your patient consultations sometimes felt like a little verbal fight -- for instance, when trying to convince someone they need to do more exercise, lose weight or eat healthily?

The 4 RULES for Motivational Interviewing

  • R -- resist the urge to change the individual’s course of action through didactic means
  • U -- understand it’s the individual’s reasons for change, not those of the practitioner, that will elicit a change in behaviour
  • L -- listening is important; the solutions lie within the individual, not the practitioner
  • E -- empower the individual to understand that they have the ability to change their behaviour. (Rollnick et al 2008)

The 5 Principles of Motivational Interviewing:

      1. Express empathy through reflective listening.    When patients feel listened to and that their feelings matter, they are more likely to listen to you.
      2. Develop discrepancy between patient’s goals or values and their current behavior.    Do this gently.  Where do they want to be?  How is what they are doing now in keeping with that?  Is it okay?    Be neutral in tone when asking these questions.  Get patients towards “change talk” where they are the ones who say “I need to stop don’t I” or,  “Well, mmm, I don’t wanna carry on smoking forever though”.
      3. Avoid argument and direct confrontation.    If you argue, patients will either argue back or lose respect for you.  And would you listen to someone you had little respect for or was not fond of?
      4. Adjust to client resistance rather than opposing it directly.  If the patient shows signs of resistance, don’t judge it and certainly don’t immediately come out with an opposing comment.  Instead, explore the resistance on neutral territory.  Exploring it alone might help change the patient’s viewpoint as new perspectives are gently realised.
      5. Support self-efficacy and optimism.  Giving patients self-worth and belief in themselves is the first step to success.   Be genuine and honest in what you say.  If you do this in a “lip-fashion” style, they will pick up on the disingenuous intent and lose respect for you.

Look at these two videos and compare

If you were the patient, which scenario would you prefer to be in?  Which one engages with you.  Which one does not make you feel small?  Which one empowers you?

A NON-Motivational-Interviewing Approach

A Motivational-Interviewing Approach

  • Dr Sam: “Well, there are three areas that I hope we can talk about at some stage.  The first is your diet and what you eat.  The second is your smoking.  And the third is losing some of the weight?  How would you feel if we chatted a little about diet today and focus on the other two on another occaision?”
  • John: “Well to be honest. I eat pretty good I think and I don’t know if there is much I can do there?” 
  • Dr Sam: “That’s good to hear.  So, what you are telling me is that you think it’s health and not sure what changes you could make?”
  • <patient nods>
  • Dr Sam: “Would you mind telling me how you eat and what you eat -- for example breakfast, lunch time, tea time and evening time?”
  • John: “Well, during breakfast it varies really -- sometimes egg, bacon and beans, but on some cases it’s just egg on toast or even toast itself.  And then when I’m at work, I have a sandwich doc.  I don’t eat much.  And sometimes it’s on wholemeal bread with a packet of crisps and fresh orange juice. See, it’s pretty healthy.  And the evening times, it’s whatever the missus makes -- casserole, Indian -- all sorts really.  And of course there is the odd snack or two… but then who doesnt?”
  • Dr Sam: “Well thanks for sharing that with me John.  You’re right, we all like a snack now and then don’t we.  What sorts of things would you snack on?”
  • John: “Well the usual, like crisps or biscuits and the odd sweet or another sarnie.”
  • Dr Sam: “That’s really helpful.  And thanks for being so honest with me.  Now, I’d like to provide you with some information and then I’d like to know what you make of it.   Is that okay John?”
  • John: “Yeah of course, shoot.”
  • Dr Sam: “The information I want to provide you with is the fact that in diabetes, it’s not just about eating a healthy diet, but actually it’s more about reducing the amount of sugars in your diet that helps get it under control.   Now, there’s a lot of food out there which we obviously know has sugars -- like chocolate, sweets, biscuits and cakes.  But there’s a lot of food that has hidden sugar.  Like potatoes, naan breads, white bread and white rice.”
  • John “Potoatoes and white rice have sugar in them?”
  • Dr Sam: “Yes John, they have a lot of what we call carbohydrates which are then turned into sugar by your body.  That’s why we call it hidden sugar”.
  • John: “So, are there lots of food that have this hidden sugar?”
  • Dr Sam: “Yes, there are.  In fact, a lot of what you’re eating actually has a lot of hidden sugar in it.   Like the toast, the rice, naan breads and so on.   Even I have to watch what I eat John, because generally, those sorts of carbs aren’t particularly good for lots of people”.
  • John:  “Gosh, there’s me thinking I’m eating okay but I’m not am I doctor?”     
  • Dr Sam: “I’m afraid so John.   Am I right in thinking John that what I have told you has put a different light on things in terms of what to eat and what to stay away from in Diabetes?
  • John: “Yeah”
  • Dr Sam: “But the good news is that in Diabetes, changing what you eat makes a massive difference.    It’s totally up to you and I only want you to do what you really want to do.”
  • John: “Mmmmmm, I’d like to but I’m not sure how to do it in my busy life.”
  • Dr Sam: “So John, am I correct in saying that on the one hand you don’t know how to fit it into your life but on the other you are interested in changing what you eat?”
  • John: “Exactly”
  • Dr Sam: “Well, I can give you a leaflet that explains it in more detail and then why don’t both you and your wife come to our practice nurse to talk about how to implement it into your life.   Would that be helpful John?”
  • John: “Yes very.  The wife needs to know too.  Don’t know how I’m going to do it mind.  Does that mean no chocolate, cake or biscuits ever again Doc?”
  • Dr Sam: “No, it doesnt mean that John.  The occasional time is okay, but not every day nor every week.  Just now and then. “
  • John: “Oh doc, in that case I’m deffo up for it if it means i might not have to take tablets.  And I deffo want to get this diabetes under control.  I’m just glad I’ve been given a second chance to turn things around.”
  • Dr Sam: “Well, let’s start with the leaflet.   We don’t have to rush things and we can go at your pace.  I just want to make sure that we do what you want to do.  Is that okay John?”
  • John; “You’ve been marvellous doc, thanks”

You don't have to do everything all in one go. Space it out. Do it over several consultations. Chunk it!

  • Most trainees want to cover everything in one go -- weight loss, diet, exercises, stopping smoking etc.  But this is bad.   You overload the patient and the patient cannot absorb it all and his or her mind will wander off.  
  • But not only that -- research shows that if a person tries to implement more than one change at a time, the more they are likely to fail.
  • So, when we advise a patient to stop smoking, change their diet, take up exercise -- all in one go -- are we setting them up for failure?
  • Remember,
      1. you will see the patient over several consultations.  So, space it out.
      2. Certainly explore one thing in detail but then signpost the others to talk about at another time.
      3. Use professionals around you like the nurses, well being worker, structured diabetes programme to do the diet and exercises things.
  • Let’s see how Dr Sams does this with John.
  •  Dr Sam: “So John, a low sugar diet is just one of the many things you can do to help limit the damage from diabetes.”
  • John: “I know you’re going to talk about my smoking aren’t you.  My only last pleasure and you’re going to take it away.”
  • Dr Sam:  Well John, I don’t want to talk about it if you don’t want to.   The main information I wanted to give you at this stage is the simple fact that stopping smoking makes a massive difference in people with diabetes.  I can see that at the moment, perhaps talking about stopping smoking is not the right time?”
  • John: “Well, I love my smoking if I am honest.   I just don’t want to give it up just yet, it relaxes me.   And I’ve been smoking for years so will it make much of a difference if I stop now?  And I’m scared about how difficult it will be with all the cravings and things even if I did want to give it a go.   I know I should but…”
  • Dr Sam:  “Mmmmmm, so John, am I right is sensing that on the one hand you’re scared of the withdrawal effects and about being able to relax and you’re wondering what good it will do now anyway BUT on the other hand stopping is something that lingers in the back of your mind”.
  • John: “Yeah, something like that”
  • Dr Sam: “Well John, one medical fact that I would like to give you is that stopping smoking has really big health benefits no matter how old you are or how long you have been smoking.  How does that piece of information make you now think or feel?  (notice how dr Sams corrects the misconception of smoking too long -- is there any point?).
  • John: “Well, I’m still scared of the withdrawal.  I really don’t think now is the right time for me  to be honest doc.   I hope you don’t mind”
  • Dr Sam: “Of course I don’t mind.  I can see though that now is not a good time for you to be talking about it.  So, why don’t we just concentrate on the food for the time being.  I just want you to know that if you ever want to talk about it again, I am here to help you.”
  • John: “So I don’t have to do it all in one go?”
  • Dr Sam: “Not at all.  The important thing is that your making steps in the right direction.  They do not all have to happen at the same time.  And I think you’re going to do well John.”
  • John: “That sounds good doc.  Thanks for being understanding.”

2 months later John comes in to have a chat about his smoking

  • Dr Sam: “So, John I am truly impressed.  You sugars have stabilised just with your diet alone.  How are you finding it?”
  • John: “To be honest doc, it was flaming hard at first.  But me and the wife persisted and because we all eat the same things, it has become easier cutting out the carbs.     And actually, both me and the missus feel we are eating healthier than ever before rather than the rubbish we didn’t know about.”
  • Dr Sam: “Well, I’m delighted to hear that.  Don’t forget it was down to both of you being committed.  The last time we were together, we touched on smoking.   Can I just ask how that has left you feeling?”
  • John:  “Well, I feel so good about the diet stuff and losing that weight and even better now that I know my Diabetes is better.   So, I do want to give it a go, but I’m still afraid.”
  • Dr Sam: “Why afraid John?   I certainly don’t want you to feel that way and I’m sorry if I have made you feel like that.”    (shows compassion)
  • John: “No, it’s not you really doc but I do like the smokes.   And some of my mates smoke and I know a lot of people even in their 80s who smoke and they seem to be just fine.   So, there’s still part of me wondering whether I will be fine like them too if I carry on.”
  • Dr Sam: “John,  I’ve got some more medical information for you and then tell me what you think.   First of all, there are some people who smoke and actually have a deteriorating health as a result  But to you, you won’t see those medical problems and they will keep them from you so that they appear in good form.  Everyone wants to look in good form don’t they?”
  • John: “I suppose”
  • Dr Sam: “And you’re right, there are some people who seem to get to their 80s with smoking and do ok.  The only thing I want to say to you John is that as a medical person, I can tell you that you are definately not going to be one of them.  Did you know that ppeople who have diabetes and smoke have worse medical problems with those who just have diabetes or those who just smoke?”   
  • John: “Really?”
  • Dr Sam: “Yes, really.      So John, having heard all of that, where are your thoughts and feelings now?”
  • John: “But what you’re saying is that if I continue, my medical health will get even worse.”
  • Dr Sam: “Yes, that is what I am saying that John.”  (pause)
  • John: “So, it’s clear to me that I have to stop.  I don’t have a choice do I?”
  • Dr Sam: “Well John, some people would say you always have a choice.  The question is whether you want, whether you feel ready and whether you feel you can commit to it. “
  • John: “Mmmmm….   I don’t think I’m ready just yet doc.   What would you say doc if you give me a couple of month sand then I start giving it a go?”
  • Dr Sam: “That sounds good to me John.”
  • John: “Yeah, let’s go with that.  I’d appreciate that.   May be I’ll get the wife to quit too!”
  • Dr Sam: “Well John, the research shows that when couples stop together, it’s easier to do and the more likely you are to stay stopped.  Have a think about that.”
  • John: “In that case, I’ll talk to her about it.   Thanks again.”

In the CSA

  • In the CSA, I am not saying you can just talk about say diet in Diabetes and forget even mentioning smoking or exercise.
  • In the CSA you have to mention (i.e. signpost) all the important  areas you feel you and the patient need to cover.   
  • BUT you don’t have to go into each one in detail.   That’s my point.  So, rather than going into each one in depth, focus on just one or two.
  • What areas you cover and the depth really depends on the agenda set by you and the patient and whether the patient is in an engaging status or not.  If not, surely you’re time is better spent gently and kindly engaging them.

Please leave a comment if you have a tip, spot an error, spot something missing or have a suggestion for a web resource.
And of course, if you have developed a resource of your own, please email it to me to share with others.

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