Lifestyle changes are not popular with patients.
#GPFUQ 5 What’s the T to T ratio? A high ratio of a patients tattoos to teeth may indicate the limited benefits of health education.
#GPFUQ 5 What’s the T to T ratio? A high ratio of a patients tattoos to teeth may indicate the limited benefits of health education.
#GPFUQ 6 How do GPs change patients behaviour? Slowly and with difficulty. You can’t make someone change, you can only change yourself and how you react to them, that might make them think about change. The first step is to help change the patients awareness of himself.The more patients can change themselves, the more effective doctor I seem.
#GPFUQ 7 How do you help patients change? Nudging them through each of the smaller steps that lead onto bigger changes.
The
transtheoretical theory of change brought together diverse theories of change
and psychotherapy and recognised that people go through stages of
change (i.e. precontemplation, contemplation, preparation, action, maintenance and
termination) and use different change process at different stages of change (
e.g consciousness raising, social liberation, emotional arousal, self
revelation, commitment, reward, countering, environmental control and helping relationships). Understanding and using the stages and different processes helps the teaching and learning process. An overview is available at http://www.uri.edu/research/cprc/TTM/detailedoverview.htm
From the GP point of view it makes like easier because you don't have to succeed in helping with a major change quickly, you just have to help patients with the through the different stages over a longer period of time.
#GPFUQ 8 How do you reconcile a long term relationship with giving unwelcome advise? Think hard GP v soft GP tactics. GPs usually have a relationship with their patients over many years. Now GPs have to advise stricter control in chronic diseases like diabetes. There is a conflict between having a long term relationship, that is empathic, and getting patients to make major changes in their way of life.
From the GP point of view it makes like easier because you don't have to succeed in helping with a major change quickly, you just have to help patients with the through the different stages over a longer period of time.
#GPFUQ 8 How do you reconcile a long term relationship with giving unwelcome advise? Think hard GP v soft GP tactics. GPs usually have a relationship with their patients over many years. Now GPs have to advise stricter control in chronic diseases like diabetes. There is a conflict between having a long term relationship, that is empathic, and getting patients to make major changes in their way of life.
Giving additional training of practice nurses and general practitioners in
patient centred care on the lifestyle and psychological and physiological
status of patients with newly diagnosed type 2 diabetes demonstrated better
communication with the doctors, greater treatment satisfaction and well-being.
However body mass index was higher, triglyceride concentrations were higher and
knowledge scores lower. There was no significant difference in lifestyle and
glycaemic control. The trained practitioners seemed to give greater attention
to the consultation process rather than to preventative care (reference 1). In
contrast there are stories that when doctors who have no continuity with the
patient (eg locums, GPs in other parts of the country, or hospital doctors)
give the patient feedback on their lifestyle, the patients remember the
feedback and say it made a difference.
For example.....Dr Caresalot counselled one of her patients (Mr Heartsink) weekly for many years without ever making much progress. Dr Caresalot takes a much needed and well earned six month sabbatical to study how to improve her counselling skills so that she can give a better service within the 10-20 minutes appointments that she can actually provide for patients in her practice. Upon her return to her practice she is surprised that Mr Heartsink no longer comes to see her. A year passes and finally Mr Heartsink comes to the doctor. They exchange greetings, Mr Heartsink is well except for a physical problem, shingles. They talk and eventually Dr Caresalot asks why happened that made Mr Heartsink not seek medical attention weekly. Mr Heartsink explains that the when Dr Caresalot was away he came to see the locum Dr Getalife, and the locum had listened to Mr Heartsinks usual list of worries and complaints and told him 'Stop it' and 'Pull yourself together', and so he had, and only wished someone had said this years ago. So perhaps we now need two sorts of doctors the caring and empathic that helps patients through change, and a more honest and blunt doctor that holds up a mirror and gives the patients the truth about their self destructive behaviour and prompts the patient into changing their way of life. An example of an intervention could be that we target the poorly controlled diabetes patients, from our current knowledge decide what is the most important lifestyle intervention (diet, better tablet adherence, more exercise, switch to insulin) and send the patient an invitation to see our specialist in the management of poorly controlled diabetes Dr Hammerfest. Dr Hammerfest who is not in a long term relationship with the patient gives the patient the truth about the risks to health and very clear instructions about what the patient must do to reduce the risks to their health. The usual GP & team then provide ongoing support for the lifestyle change. The good news is that this is a relatively easy intervention, one consultation per patient, and can be applied to many practices. This style of intervention is already happening with practice nurses running chronic disease management programmes that check a patients treatment against a guideline.
Reference 1: Randomised controlled trial of patient centred care of diabetes in general practice: impact on current wellbeing and future disease risk. Kinmonth AL, Woodcock A, Griffin S, Spiegal, Campbell MJ. BMJ 1998;317: 1202-8.
#GPFUQ 9 Can GPs make a difference to problems like obesity? Yes by holding up an honest mirror to the patient (to increase self awareness and choice), and by generally influencing the community so that lifestyle problems like simple obesity are as unacceptable as spitting and smoking.
#GPFUQ 10 What stops people changing their behaviour? Three elements must converge at the same moment for a behavior to occur: Motivation, Ability, and Trigger. When a behavior does not occur, at least one of those three elements is missing. More details on the Fogg Behavior model at http://www.behaviormodel.org/
For example.....Dr Caresalot counselled one of her patients (Mr Heartsink) weekly for many years without ever making much progress. Dr Caresalot takes a much needed and well earned six month sabbatical to study how to improve her counselling skills so that she can give a better service within the 10-20 minutes appointments that she can actually provide for patients in her practice. Upon her return to her practice she is surprised that Mr Heartsink no longer comes to see her. A year passes and finally Mr Heartsink comes to the doctor. They exchange greetings, Mr Heartsink is well except for a physical problem, shingles. They talk and eventually Dr Caresalot asks why happened that made Mr Heartsink not seek medical attention weekly. Mr Heartsink explains that the when Dr Caresalot was away he came to see the locum Dr Getalife, and the locum had listened to Mr Heartsinks usual list of worries and complaints and told him 'Stop it' and 'Pull yourself together', and so he had, and only wished someone had said this years ago. So perhaps we now need two sorts of doctors the caring and empathic that helps patients through change, and a more honest and blunt doctor that holds up a mirror and gives the patients the truth about their self destructive behaviour and prompts the patient into changing their way of life. An example of an intervention could be that we target the poorly controlled diabetes patients, from our current knowledge decide what is the most important lifestyle intervention (diet, better tablet adherence, more exercise, switch to insulin) and send the patient an invitation to see our specialist in the management of poorly controlled diabetes Dr Hammerfest. Dr Hammerfest who is not in a long term relationship with the patient gives the patient the truth about the risks to health and very clear instructions about what the patient must do to reduce the risks to their health. The usual GP & team then provide ongoing support for the lifestyle change. The good news is that this is a relatively easy intervention, one consultation per patient, and can be applied to many practices. This style of intervention is already happening with practice nurses running chronic disease management programmes that check a patients treatment against a guideline.
Reference 1: Randomised controlled trial of patient centred care of diabetes in general practice: impact on current wellbeing and future disease risk. Kinmonth AL, Woodcock A, Griffin S, Spiegal, Campbell MJ. BMJ 1998;317: 1202-8.
#GPFUQ 9 Can GPs make a difference to problems like obesity? Yes by holding up an honest mirror to the patient (to increase self awareness and choice), and by generally influencing the community so that lifestyle problems like simple obesity are as unacceptable as spitting and smoking.
#GPFUQ 10 What stops people changing their behaviour? Three elements must converge at the same moment for a behavior to occur: Motivation, Ability, and Trigger. When a behavior does not occur, at least one of those three elements is missing. More details on the Fogg Behavior model at http://www.behaviormodel.org/
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