www.diabeticretinopathy.org.uk

The consultation for professionals

David Kinshuck

 

Sharing Decisions: for professionals

An extract of article JAMA,2004, Epstein et al, Communicating evidence for participatory decision making Steps for Discussing Evidence With Patients, and Examples of What Physicians Might Say

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

The Patient Letter

 

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

 

 

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

 

Betari's box

See

Consulting with NLP, Lewis Walker

 

Persuasion in clinical practice, L Walker

PDF   See
 

Change

Prochaska

Motivational interviewing

Positive psychology

An Overall Strategy

Styles of change

Conflicts

Language

Look at the problem structure rather that the content

Structuring solutions

Problems to solutions

Solution strategy

Need to know if have skills and confidence to make change

Is the problem what you think?

Identify process behind problem

Going where problem isn't

Assess importance, confidence, readiness to change

Listening

Roadblocks

Don't

Do

 

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)
  • 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..

 

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

 

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

 

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

 

  1. listen
  2. state information you have..
  • I know, 
  • I feel,
  • I would like
  1. ask what action would lie
  • I want
  • I need
  • I would like
  1. ask for commitment...
  • will you do that for me

 

  1. consider
  • consequences of saying no
  • consequences of further actions
  • consequences of letting then continue to act
  1. listen..show person understand what they want
  2. refuse
  • I don't want to,
  • would rather not
  • i would find that difficult
  1. Tell
  • I know
  • I believe
  • I feel
  1. repeat 'tell' as necessary
  2. ? compromise

 

  1. specific positive feedback, what went well and the reason i say that
  2. feedback on observed behaviors, not attitude/impressions
  3. offer description of what you saw & felt, not judgement
  4. focus on behaviour which can be changed
  5. ask questions rather than make statements
  6. set ground rules in advance
  7. comment on things done well as well as areas for improvement
  8. observe personal limits
  9. 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?

Consultation and the doctor..for professionals

This paper   notes

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

Assesses patient

Asks patients what other information would be helpful

explain at appropriate times

Aiding accurate recall and understanding

Organizes explanation

Uses explicit categorization or signposting

Achieving a shared understanding: incorporating the patient's perspective

Planning: shared decision making