Consultation skills - Encourage healthy behaviour

Beware of making assumptions about patients' understanding about their health, says Dr Lizzie Croton.

Eye contact and posture are of great importance in effective doctor/patient communication (Photograph:spl)
Eye contact and posture are of great importance in effective doctor/patient communication (Photograph:spl)

Health promotion is a key aspect of the general practice consultation. Encouraging patients to take responsibility for improving their health by promoting healthy behaviour is vital in our role as holistic practitioners.

Problems such as alcohol dependency continue to make huge demands on healthcare services and, with an ageing population, health promotion is vital.

Communication
Communication in the consultation can be divided into verbal and non-verbal. Surveys of family practitioners in the US examining the relationship between verbal communication and health promotion suggested that doctors are pessimistic about patients' abilities to improve their health through behavioural change.1 They also cite lack of consultation time for such interventions.

Research papers in the 1980s showed the pattern of illnesses in western society was changing and that patients were increasingly presenting to doctors with problems that were behavioural rather than pathological in origin.2,3 The researchers, who studied videoed consultations, concluded that the eye contact and movements of the body were of great importance in effective communication between doctors and patients.

Eye contact and posture, when coupled with open questions and silences, were vital if the patient was to disclose their problem and effective communication was to follow. The conclusion was that poor non-verbal communication could hinder or even prevent an effective dialogue.

Practical examples of health promotion
The following scenarios give possible approaches to health promotion in the consultation. You may wish to look at various health promotion models to understand the processes involved in behaviour change.

A 45-year-old lady presents with a chest infection. She smells strongly of cigarette smoke.

  • After examining the patient and confirming the diagnosis, raise the issue of smoking directly but in a non-judgmental way.

Most patients know smoking is bad for them and many want to give up but may be poorly motivated to take the next step. It may be that they have stressful lives and that smoking helps them cope.

  • Address the issue of smoking at every opportunity when the patient consults and ensure that the link between smoking and any smoking-related illnesses they have is explained to them. It would be helpful to give some statistics regarding smoking-related morbidity and death.
  • Websites such as the NHS stop smoking service are useful for helping patients towards the next step.

A 62-year-old lady presents with worsening arthritic pain in her knee. You suspect that her morbid obesity and lack of exercise are contributing to her symptoms.

  • This is a difficult situation as the patient may be in a situation with pain causing reduced mobility leading to secondary weight gain. Such situations can seem hopeless for both doctor and patient and it is important to talk openly about this and not direct your frustration at the patient.
  • Ensure the patient knows that losing weight will ease her symptoms. Talking about weight issues with patients is difficult as it is a personal issue for someone who probably already has low confidence. Using the question 'Has your weight changed recently?' is a more diplomatic way of asking if their weight has increased.
  • Pain relief is vital to allow full mobilisation and it is essential that patients know suitable exercise will not worsen their arthritis. A targeted exercise programme with regular review is useful to provide support and encouragement. The NHS health trainer service can provide support to patients wanting to lose weight.

A 34-year-old man presenting with gastritis. You suspect he is a heavy drinker.

  • Ask the patient what he understands by 'gastritis' and if he knows any possible causes for it.
  • Explain that excessive alcohol intake can cause these symptoms and ask how much he drinks per week.
  • Try to find out exactly what the patient drinks and when. Talking in terms of units can be confusing and so find out how many glasses or cans are consumed and then convert the amount into units. Websites such as Drink Aware (see resources) are useful.

It is imperative to meet the patient where they are on their journey towards a healthier life. Do not make assumptions about the patient's understanding about their health - most people know that smoking is bad for them but not everyone will realise that regularly drinking too many units of alcohol is also harmful.

Try to identify which stage the patient is at, for example, are they keen to change their behaviour? Then endeavour to move them along to the next stage.

Patients may appear some distance from changing their behaviour but health promotion messages at every opportunity can help them make the change.

Summarising the consultation
Once the consultation has finished, it is helpful to write down the outline of the discussion, including what stage the patient is at and what the patient's beliefs and expectations are. This will help the clinician at the next consultation revisit the topic at an appropriate opportunity.

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

CPD IMPACT: DOUBLE YOUR CREDITS

These further action points allow you to double the credits claimed by increasing the time spent and the impact achieved.

  • Read up on health promotion models and reflect and make notes about how you can fit some of these theories into your consultation.
  • Look back at consultations where you have given health promotion advice. Think about what you could have done differently and make notes.
  • Spend time researching good quality patient information on health behaviours that can help you in choosing the right terminology when talking to patients.
  • Visit the GP Curriculum Centre for hundreds of articles linked to key topics in the RCGP curriculum

References
1. Orleans CT, George LK, Houpt J, Brodie KH. Health promotion in primary care: A survey of US family practitioners. Prev Med 1985; 14(5): 636-47.

2. Byrne PS, Heath CC. Practitioners' use of non-verbal behaviour in real consultations. J R Coll Gen Pract 1980; 30: 327-31.

3. Davis RH, Jenkins M, Smail SA et al. Teaching with audiovisual recordings of consultations. J R Coll Gen Pract 1980; 30: 333-6.

Resources
NHS stop smoking service http://smokefree.nhs.uk

Drink Aware www.drinkaware.co.uk

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