Cutting the Sugar…. by Fiona Green

Over the last 2 years NHS DG have been offering a structured programme of work experience to young people in their final years at school thinking about a career in medicine. This has been very well received by the young people who attend and the success of the programme is largely down to excellent organisation and communication skills of Anne-Marie Coxon and her team in the education centre who arrange tasters in various areas of medicine including medical admissions, theatre, surgery and A&E along with some time with me in the diabetes centre

Fiona G1

Linocut by Hugh Bryden Crichton Hall- home to the Dumfries Galloway Diabetes centre

As a clinician it has been really interesting to spend time with these young people who have yet to develop preconceived ideas about healthcare and for me to try and understand what it is that excites them about spending a lifetime in medicine and to try and remember what it was that motivated me to apply for medicine and ultimately what made me move into Diabetes and Endocrinology.

For those of you who know me you will have heard me say that it is diabetes that excites me rather than the rare and esoteric conditions that I deal with in the endocrine service but I recognise that despite my real enthusiasm and commitment to improving care in diabetes that when these young work experience students come to diabetes clinic I sometimes find myself apologising to them that I don’t have any exciting procedures to show them, or new diagnoses to make; in fact in diabetes clinic I rarely examine people and I spend my time just listening to things that seem unrelated to sugar levels and talking…..

Just Listening and Talking…

The fact that I feel the need to apologise about the nature of diabetes clinic being  “just listening and talking” has made me realise  how little value we as hospital healthcare professionals place on these core skills that we all use every day. We are required to do mandatory training in many important areas such managing the deteriorating patient, infection control, awareness and fairness to name a few- yet it is possible for a healthcare professional to go through their in working career without any update, assessment or post graduate training in the core communication skills that we use every day. This lack of post graduate training in clinical communication skills is particularly apparent in the acute hospital setting compared to our colleagues in general practice and psychiatry where advanced post graduate training in consultation skills is the norm. Despite the seemingly acute nature of a hospital environment many of us spend a large part of our working week in clinics working with people to try and improve their health and wellbeing but what are we doing to ensure that these interactions are effective and meet the patient’s agenda?  Do we find it easier and quicker to pursue our own agendas and default into education mode rather that hearing about what is really important?  Several research studies have shown that by exploring a person’s background, worries and their understanding of their condition can help to avoid unnecessary investigations or anxiety for the patient as well as reduce the strain on resources[i][ii]

Fiona G2

The success of the late Dr Kate Granger’s “Hello my name is …” movement and the “What Matters to Me” campaign show that in acute setting healthcare teams are beginning to contemplate a change to a more patient centred rather than the traditional paternalistic, didactic approach to our interactions with patients but this change is slow and these important initiatives are only an entry level to improving our communication with the people we see in clinic and reaching a shared agenda.

Fiona G3

Locally Jean Robson and her colleagues from psychology, human resources and other interested clinicians have recently worked hard to put together a directory of diverse courses and programmes which are delivered locally by NHS Dumfries and Galloway aimed at improving advanced communication skills including sessions on communication skills which allow individuals to film and review their performance in real life clinic setting (been there and done that -daunting but very helpful), communicating with people with existing communication difficulties, human factors training and sessions on communicating with colleagues in meetings to name a few

So, back to the title of “cutting the sugar”. The discovery of insulin almost 100 years ago is one of medicine’s most remarkable discoveries changing the outcomes for people diagnosed with type 1 immeasurably as the before and after pictures below poignantly demonstrate

Fiona G4

December 1922

Fiona G5

February 1923

 

 

 

 

 

 

 

 

 

“Child 3” before and 3 months after insulin treatment

There is of course a but; insulin is not a cure for type 1 diabetes just a treatment and Insulin treatment brings with it a huge burden for the person with type 1 diabetes- blood testing more than 4 times a day, injecting insulin at least 5 times a day, assessing the carbohydrate content of foods are all required to achieve the tight blood sugar targets required to maintain health and wellbeing. This all needs to be balanced against activity levels and avoidance of hypoglycaemia. People with diabetes can never have a day off.  They become experts in managing their blood sugar levels and this brings me to the “just listening and talking bit”. Listening to what’s important to people when I’m clinic seemed more time-consuming in the beginning but by encouraging this shared understanding I have come to recognise that almost universally people with type 1 diabetes want to be healthy and that they fully understand the importance of controlling blood glucose but what I also now appreciate more clearly is that there are many other things that get in the way of achieving this goal. Some of these barriers to change seem obvious e.g. fear of hypoglycaemia, fear of injections but others may take gentle probing to identify e.g. the young woman who removed her insulin pump because she had a new boyfriend who didn’t know she had diabetes, the young mum on her own putting her own health after the needs of her family. Through training, practice and reflection I have come to learn is that each person is different and whilst a particular solution may work for one person it might not work for the next and whilst the temptation is for me to offer the solutions that I think will work by practicing the skills I have learnt at various communication skills sessions I now recognise that solutions generated by the person with diabetes are far more likely to be successful that anything that I may suggest. Of course very few consultations are perfect and like every skill we use practice, reflection and additional training can help us to improve which is why I believe that consultation and communication skills shouldn’t be seen as just “the icing on the cake” but more of the “meat on the bones” of our daily work.

Dr Fiona Green is a Consultant in Diabetes and Endocrinology at NHS Dumfries and Galloway

[i] Heisler M, Bouknight RR, Hayward RA, Smith DM, Kerr EA (April 2002). “The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management”. J Gen Intern Med. 17 (4): 243–52. doi:10.1046/j.1525-1497.2002.

[ii] eisler M, Bouknight RR, Hayward RA, Smith DM, Kerr EA (April 2002). “The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management”. J Gen Intern Med. 17 (4): 243–52. doi:10.1046/j.1525-1497.2002.

The Listening Project by @fionacgreen

I was gutted when I read Professor Leitch’s blog – the idea of asking people “what matters to you?”Fiona1 was exactly what I planned for my Blog. I now had to convey my own pathway into this area in such a persuasive way

PRECONTEMPLATION

My journey (unlike Professor Leitch’s) did not begin in a formal Quality Improvement class with international experts in the USA but began in a more slow burning fashion right here in Dumfries and Galloway.

I arrived in Dumfries in the spring of 2004 –a newly trained consultant. My head was full of evidence-based treatments and guidelines combined with naivety and a genuine enthusiasm to improve diabetes care.

At that time empowerment, self-management and structured education were emerging as factors to improve outcomes in people with diabetes and other long-term conditions. Shortly after my appointment we were fortunate enough to be given funding from the Scottish Diabetes Group to pilot DAFNE. For those of you unfamiliar with the diabetes world DAFNE is not a person but stands for Dose Adjustment For Normal Eating and is an evidence based weeklong structured educated programme for people with type1 diabetes.Fiona2 Structured education means that there is a defined curriculum delivered using adult education theory and delivered by trained and peer-reviewed educators.

6-8 people with diabetes participate in each course and bring with them years of experience of diabetes – on a recent course within the room we had amassed 254 years of experience of diabetes

CONTEMPLATION

DAFNE didn’t just empower, educate and motivate those individuals with diabetes who attended but also provided our local diabetes team (myself in particular) a unique insight in what it was really like to live with diabetes. I listened with interest and a growing sense of shame as people with diabetes described their experiences of diabetes in hospital , the sense of foreboding they felt when they attended clinics – they felt chastised, felt failures and felt that they were not always listened to. They told us how seeing high blood sugars despite trying to balance food, exercise and insulin was frustrating and many said that they simply didn’t bother to test as the results made them anxious.

I listened and I learned and I reflected.

I learnt that our interactions with people were often more powerful than we realised but not always in the ways we hoped. I realised that we were often ineffective in promoting improvements in diabetes self-management.

I reflected on my own training -despite my knowledge of trials and guidelines I had little training in consultation technique and promoting behaviour change.

Somewhat shamefully over the years I had become very skilled at moving people away from topics that were important to them to focus on the topic of blood sugar which was what was important to me.

DECISION

I realised if we were to achieve continued engagement of our newly educated and empowered cohort of DAFNE graduates that this traditional medical model of diabetes clinics had to change

Alongside this realisation we became involved with our local psychology department who took on the task of teaching us the theory of behaviour change and demonstrating the use of motivational interviewing, Socratic questioning, functional analysis and other tools to help change unhelpful health behaviours. This training was further complimented and developed by the “Doing Diabetes Better” programme and PIDPAD (Psychology in Diabetes, Psychology and Diabetes) project funded by the Scottish Diabetes Group

The heart of the training was active listening and in particular listening to what was important to people.

Initially I struggled to use the tools- I worried about the time factor involved; I worried about opening up emotions that I was uncomfortable dealing with and it often seemed easier to stay in a traditional role but as I practiced more and began to see people with diabetes begin to successfully generate their own goals and solutions I knew that this was a way forward

LAPSE/RELAPSE

Behaviour change is difficult not just for people with diabetes but for all of us in all aspects of our lives and just like the people I see in clinic I have found that old habits die hard and I know that when I am tired, stressed or running late I don’t always listen as well as I should or apply the tools I have learnt as effectively as I should.Fiona3 In these circumstances I find myself slipping back into my comfort zone of focussing on blood sugars, targets and guidelines but through the increased self- awareness I recognise these factors and try to avoid dictating care plans

Finally I suppose it is important to know whether it has made a difference-I now have a better understanding of the reasons why people find it difficult to implement and sustain changes to improve health and wellbeing. I know that I now find clinics more tiring -exploring thoughts and feelings in relation to diabetes is emotionally exhausting but the things I hear and results I see encourage me to continue.

By changing from what from “what’s the matter?” to “what matters to you?” patient satisfaction scores have increased significantly as has HbA1c (a marker of blood sugar control)-both of these improvements matter to me.

Now when a consultation takes a diversion into areas unrelated to diabetes I stick with the diversion as I realise what I hear matters to us both

Dr Fiona Green is a Consultant Endocrinologist and Diabetologist at NHS Dumfries and Galloway

Next week we will have a joint blog from myself (@kendonaldson) and Peter Bryden (@peterbryden1) summarising the recent Enhanced Patient Experience Event.