Communication in a consultation: It’s the vibe of the thing
Many people with diabetes struggle with self-care and meeting glycaemic targets. A recent Australian review found that only 53% of those with Type 2 Diabetes (T2D) had an HbA1c <=7%1. This rate was still lower for indigenous people (33%), and 26% for people with Type 1 Diabetes (T1D). It appears new medications and technologies, which have shown great promise in clinical trials, have not correspondingly transformed glycaemic management in real-world settings. Low treatment adherence2-4 such as delayed implementation of recommended therapies5, is implicated in these disappointing results. Low treatment adherence is, in turn, correlated with unskilled communication in healthcare professionals (HCPs)6. Poor communication skills are also linked to diabetes distress, poorer metabolic outcomes, low levels of self-management in people with T2D7, and reduced satisfaction and adherence for those with T1D8. Improving communication skills of HCPs is therefore an essential task for our health systems, and would likely lead to better collaborative care, better self-management, and improved evaluation and management of the psychosocial aspects of care9.
The main aim of the present paper is to draw attention to a higher order concept or “metaskill” that is essential for effective communication. In addition to being a skill, this is a mindset or attitude, and is difficult to articulate or teach. It is likely best learned through a process of reflective practice10 and working with practitioners who are highly skilled communicators. The secondary aim of the present paper is to list some more tangible communication skills that are implementable and potentially helpful for HCPs.
The vibe of the thing – the foundation of good communication
In the 1997 Australian comedy film The Castle, the unprepared lawyer struggles to explain himself in court, resorting to, “it’s just the vibe of the thing”. Describing the foundation of good communication can feel equally difficult – although there are skills involved, it is the overarching “vibe” – the spirit in which they are delivered – that influences their effectiveness. This vibe is difficult to quantify, and is attitudinal rather than strictly behavioural. In their book Health Behaviour Change, Rollnick, Mason & Butler call it “the spirit of the method” (p11), which involves “dancing” rather than “wrestling”. It surpasses technique and strategy in importance, and requires (among other qualities) respect, curiosity, and compassion in HCPs. It is a shift in mindset , a focus on understanding the needs and motivations of the person with diabetes, and is incompatible with a judgemental stance from a HCP11:
“With this new mindset, clinicians cannot conclude that a person with diabetes is ‘in denial’, is ‘blind’ to how their current disease management practices may be self-destructive, or is simply a ‘bad’ person with diabetes. These perceptions reflect an outdated and less fruitful model of care in which clinicians assume that people with diabetes should follow clinical directives to the letter, and that there is something ‘wrong’ with them if they fail to do so. In truth, no person with diabetes wants complications, diabetic ketoacidosis or severe hypoglycaemic episodes. All would prefer to live long and healthy lives. Thus, the changed mindset reminds clinicians that people with diabetes often have their own very good reasons for why they manage their disease as they do, even if their behaviour may be contrary to clinician recommendations.“ (p1662)
The use of communication techniques without this mindset can appear insincere. In his book “The man who mistook his wife for a hat”12, the neurologist Oliver Sacks told the story of a group of patients with aphasia laughing uproariously at a serious speech by President Ronald Reagan – they could recognise the incongruity of his expressions and body language. Without “the vibe”, a HCP’s words can be similarly meaningless. Rote learning of communication skills without attention to the spirit in which they are delivered can be hollow and wooden, and may not increase healthcare engagement.
Key components of healthcare communication
There are many descriptions of the components of healthcare communication. A simple definition is sufficient for this paper. Healthcare communication involves three key parts: relationship building, collaborative decision making, and information exchange13. As discussed previously, a shift in attitude – the vibe of the thing – is the often-neglected metaskill of communication.
Activating the vibe of the thing
It is difficult to clearly articulate the mindset of the vibe. Like all internal phenomena, it must be experienced rather than described. It is somewhat akin to the skill of mindfulness, as it involves paying attention in the present moment without judgement14. The pace of the encounter should be slowed, and the HCP prepared to do more listening and reflecting11. Sensitivity and paying attention are of utmost importance. Becoming more aware of biases and judgements towards the person with diabetes, and greater ability to see their perspective, suggests that the vibe is occurring.
Red flags in a consultation
If the HCP experiences a sense of frustration, or feels they are ‘wrestling’ rather than ‘dancing’, this indicates that the vibe is not activated. It is good practice to periodically tune into one’s own feelings behaviours in the interaction. ‘Red flags’ include (but are not limited to) noticing:
- personal feelings of annoyance, anger or frustration
- the HCP is giving out suggestions and the person with diabetes is rebutting them
- the HCP is doing all the talking in a consultation
- the person with diabetes appears disengaged
These red flags should be a reminder to take a breath and a mental step backwards. No HCP can activate the vibe perfectly and at all times. However, it takes practice to learn to stop and take alternative action. Starting to build awareness through reflective practice can lead to lifelong improvements in practice10. Of course activation of the vibe is more possible when the HCPs self-care has been prioritised. Exhaustion, stress, rushing or feeling overwhelmed will hinder the ability of the HCP to enter a consultation with a person-centred framework.
The vibe alone is necessary but not sufficient to lead a healthcare consultation. It is the constant in the equation, as the other components are used as needed. No two people with diabetes are the same, and HCPs should be flexible regarding what is called for at a given time. For example, some people with diabetes will welcome information and guidance, and be eager to put in place whatever is recommended by the HCP. Others will need a slower pace of change, time to do their own research, support to clarify their wishes and needs, or assistance to develop personal strategies9. This individualisation of consultations is similar to that for prescribed medications. The medication and dose chosen will vary for each different person, as all bodies and circumstances are different. The following list should be seen as a list of ingredients, some are staples and should be used all the time, others need to be varied depending on the occasion.
The HCP should:
- Always avoid actions that may be perceived as judgemental, stigmatising, or generally insensitive.
- Changing the language of diabetes can make a powerful and positive difference to the emotional well-being, self-care and health outcomes of people affected by diabetes15 and a useful guide can be downloaded from Diabetes Australia16
- Diabetes Australia also has a guide on stigma, with information on HCP behaviours that increase shame or self-blame in a person with diabetes17
- use active listening skills, with attention to body language and pace (slowing down is often required). More on this is available in the Diabetes and Emotional Health Handbook published by the NDSS18.
- Try to “step into the shoes” of the person with diabetes, particularly if health behaviour seems inexplicable. Try to understand, in a non-judgemental way, what drives behaviours. It may be helpful to be aware of some common issues that people with diabetes wish their HCP understood 19.
- Ask the person with diabetes about their emotional health, and their experience of living with diabetes. Note that in the DAWN 2 study, while half of HCPs reported that they asked people about their emotional health, only a quarter of people with diabetes reported that this had been addressed20. While the reasons for this discrepancy are unclear, it does point to the need to address this in an explicit way in a consultation.
- Ask specifically about diabetes distress. Dr William Polonsky, clinical psychologist and head of the Behavioral Diabetes Institute, suggests starting the conversation with, “What’s driving you crazy about your diabetes?”21. Be aware that most people will not volunteer this information if not directly asked, however, many people with diabetes want to be asked about how diabetes affects them22. Keep in mind some common problem areas, such as worrying about future complications, feeling guilty about getting off track, or not knowing how mood is related to diabetes23.
- Be aware of seemingly insignificant clues that may be causing distress or be barriers to managing diabetes. For example, a person with diabetes may have difficulty making apparently small changes, or even have unusually good glycaemic management.
- Realise that, if possible, everyone wants to live a long and healthy life11. If the person with diabetes appears disengaged or indifferent24, there is a reason. An attitude of compassion and curiosity can assist in uncovering barriers and motivating factors.
- Remember that it takes courage for a person with diabetes to discuss perceived failures, and puts them in a space of vulnerability – respectfulness and sensitivity by the HCP are crucial.
- Allow for multiple appointments.
Collaborative decision making
Active involvement is needed from both the HCP and person with diabetes:
- The person with diabetes is aware of the available choices, and the benefits and costs of the different choices (ie., can make an informed choice).
- The person with diabetes has an opportunity to ask questions.
- The HCP is aware of the impact of what is being asked – for example on the person’s family or social life, or on their stress level – the change must be realistic and increase the chance of an early success rather than feeling overwhelming.
- The HCP builds hope that making a change will make a difference both now and in the future. It is best to choose a behaviour that is likely to show quick results, such as increased energy from fewer spikes in blood glucose, or understanding the link between mood/food/activity and blood glucose through regular monitoring.
- The HCP encourages small, realistic and sustainable changes. The use of formal goal-setting methods may be useful, for example information is available on healthdirect.gov.au25. The goals set should be within direct control of the person with diabetes (i.e., a behaviour change). For example, a goal of “I will eat dinner at 6pm and go for a walk afterwards” is better than “I will lose 5 kg”.
Good information exchange includes:
- Using plain language and avoiding jargon. For example, it may be better to use “diabetes in pregnancy” rather than “gestational diabetes”. Particular care must be taken with written materials, and some helpful information is available from the Centre for Culture Ethnicity & Health26.
- Providing only the right amount of information at each appointment – this will vary for each person with diabetes. Be clear of “what’s needed vs what’s nice”26. Cutting down on content and ensuring that it is personally meaningful increases engagement with that content27.
- Focus on “making the invisible visible”21 – help the person with diabetes understand numbers such as HbA1c and other blood pathology so that they can make informed choices.
- Leave time for questions and to address concerns that may be barriers to behaviour change. Many common problems of adherence are caused by misinformation. For example, timely commencement of insulin in people with T2D can be increased by demystifying the process and addressing misconceptions28. The NDSS has a helpful brochure addressing common concerns about insulin29.
- Clarify the content of the consultation before it ends. Ask the person for their understanding. Research suggests that the HCP and person with diabetes often have different memories of the points covered, and neither is accurate30, 31. It can be helpful to ensure the person with diabetes has written information to take away with them, either a summary of the points covered, or a pertinent handout.
- Tell the person that their experience of difficulty is not out of the ordinary, that diabetes is a tough condition to manage, and that struggle with management or with change is normal. It is not their fault that they have diabetes, or that they are struggling with it. Ensure that they are aware that factors such as hormones, mood, stress, fatigue and many more can affect glycaemic management, that it is not something they can ever fully control. Help them focus on what they CAN control (their behaviour).
- Predict that there will be difficult times in the future, and plan for these32. Attention to relapse prevention can decrease self-blame and hopelessness when setbacks occur, and increase the chance of getting back on track.
- Do not attempt to use fear as a motivator. Providing stories of hope is far more effective.
Communication skills can be surprisingly difficult to implement well, and HCPs will experience similar barriers to behaviour change as people with diabetes who implement changes – lack of time, unsupportive systems, or difficulty changing habits and acquiring new skills. It can be helpful to seek formal training and/or ongoing supervision with the more complex skills. Failing this, paying attention to the vibe will be a good starting point for noticing what other techniques may be useful at any given time.
Good communication by HCPs is essential to support optimal self-management of diabetes. It involves multiple skills, the most important being a shift in mindset.
To summarise, I pay homage to The Castle…
It’s just person-centred communication – it’s relationship building, it’s collaborative decision making, it’s ‘dancing’ not ‘wrestling’, it’s a mindset shift. It’s the vibe. I rest my case.
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