|Anne, a 52-year-old insulin-dependent diabetic patient, was admitted overnight for treatment of a disabling hypoglycaemic attack. The paperwork clearly states the patient was advised not to drive. Anne consults to get a prescription for a new insulin regimen. You saw from your consulting room window that she drove into the patient car park.|
The person receiving the feedback on how their behaviour is perceived may understand the message, but may not act on it because they lack the motivation to change.
Motivation is the drive to do something, but it often clashes with perceived powerlessness and inability to move things forward. Motivational interviewing techniques can be used in these difficult consultations.
One model of motivating change is the cost-benefit analysis, a CBT technique. Patients (or trainees, as this may be used in a teaching capacity) are encouraged to write down a list of the pros and cons of the issue.
Using a grid on a sheet of paper, on one side, they reflect on the pros of maintaining the status quo.
In our case, Anne lists all of the reasons for continuing to drive. She also writes down the disadvantages of the status quo.
On the other side of the paper, she lists the advantages of new behaviour (giving up driving) and the disadvantages of giving it up.
Before embarking on this exercise, it is important to clarify whether the patient (or trainee) is willing to change. If they are open to change, they are encouraged to spend time and effort in completing the form for the doctor or trainer to review.
The doctor reads the list and asks the patient or trainee how committed they are to changing to the new behaviour, on a scale of zero to 10. This helps to achieve greater understanding of their level of motivation.
It is important to ask why the motivation is not ranked as zero. This encourages them to tap into their motives and determination.
The doctor asks the patient or trainee how they could raise their motivation to 10. This may encourage them to explore beliefs they hold about themselves that may be limiting their growth and development.
For example, Anne may say: 'I tried using the buses, but it was so inconvenient and I couldn't get to work on time.' Or: 'I've tried to be better about my insulin regimen but it's too hard.'
These beliefs about her perceived powerlessness need to be uncovered and resolved before changes in her thinking can lead to commitment and follow-through. Problem solving techniques are then applied.
Negotiation involves an array of communication skills to resolve conflict, which usually occurs when people sense something they value is threatened. This may be a possession, but can involve principles or ideals.
When planning solutions to the conflict, facts and emotions on both sides need to be addressed.
In our case, the doctor knows the conversation about driving will be difficult. However, they have a duty of safety to the patient and the public, so it has to take place. The doctor has to decide how to try to solve the conflict, but also to investigate Anne's reasons, experiences and emotions.
The doctor has to share the effects of what they hear or see; their feelings associated with the incident. They have to state their wishes, expectations and needs, but should be willing to hear and accept the patient's views and appreciate their feelings.
Both parties need to come up with proposals for discussion before agreeing a solution. Steps toward this need to be clarified.
Negotiation involves several skills GPs already possess - active listening and asking questions to clarify the situation and gain a better understanding of what is happening.
Doctors are taught early in their training to accept that others are different, with differing abilities and strengths. Doctors try to adjust their communication to the person sitting in front of them, so their messages are clear, simple and succinct. However, negotiation requires patience, willingness and time.
It may be useful to look at this case study and write down the questions and phrases you would use when communicating with Anne.
As with all skills, practice is essential and it may be worth reviewing difficult or dysfunctional conversations to see whether the way you handle the discussion has changed or improved with time.
- Dr Naidoo is a GP trainer in Oxford
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