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CONTiNUiNg PROfEssiONAL dEVELOPMENT PRACTICAL POINTERs their behaviour. A useful technique to use when we notice ourselves feeling disapproving or annoyed by our patients is to try to ‘park’ that feeling and to first offer the patient an empathic reflection. Contrast the difference in these two responses to a patient bothered by lithium side effects: Practitioner A: How about trying to split the dose, as well as having it with food? That should help cut down the nausea. Practitioner B: It sounds like the nausea is really awful for you and taking the lithium regularly is the last thing you feel like doing. Practitioner A has got their own agenda in the foreground, and the patient is likely to feel isolated and perhaps even irritated. Practitioner B however is putting the patient’s concern at centre stage. This is not the same as approving of their behaviour. It just demonstrates to the patient that Practitioner B understands them in a non-judgemental way. After that, once the rapport is more strongly established, Practitioner B can go on to let them know their medical concerns. When styles and strategies from motivational interviewing are employed with skill, it begins to feel like a dance instead of a struggle. Rather than trying to convince the patient to change, the practitioner uses a Socratic questioning style to evoke the patient’s own problemsolving skills and to galvanise them into action. The patient is doing all the work, and the practitioner’s genuine non-judgemental reflective style steadily builds rapport. If it feels more like a struggle then usually this is because the practitioner is working very hard to convince the patient to change, resulting in either a confrontation or the patient ceasing to play an active part in the process. Compare the following interventions for someone who needs more exercise: Practitioner A: How about trying to get off the bus two stops early so that you can get in a bit of exercise that way? Practitioner B: If you were to find a way to increase your exercise even a little bit, what would you choose to try? Working in a motivational interviewing style challenges the practitioner to initially hold back their own opinions and advice, giving priority to the patient’s ideas and reflection of the patient’s illness experience, in order to strengthen the therapeutic relationship. Once this is established, the strong therapeutic relationship can then withstand the challenge of the practitioner’s medical opinion, even when this is in direct conflict with the patient’s view. Conclusion Lifestyle-related disease is of significant concern in NZ, and there is a need to raise awareness of opportunities for intervention. Brief intervention, motivational interviewing, stages of change, and the ‘catastrophe model’ are all useful frameworks for promoting behavioural change, and elements from all four may be adapted for use in primary care settings. In a short consultation the most important factor is the skilful use of empathy to strengthen rapport in the practitioner–patient relationship. Good rapport creates a platform from which the practitioner can enhance their capacity to influence health behaviour and optimise patient self-care. References 1. Goodyear-smith F, Wearn A, Everts H, Huggard P, Halliwell J. Communication in practice: Auckland general practitioners reflect on communication events and identify training needs. N Z Fam Physician 2006;33(1):30–38. 2. West R, sohal T. ‘Catastrophic’ pathways to smoking cessation: findings from national survey. BMJ 2006;332(7539):458–60. 3. Metcalf P, scragg RK, schaaf D, Dyall L, Black P, Jackson R. Trends in major cardiovascular risk factors in Auckland, New Zealand: 1982 to 2002–2003. N Z Med J 2006;119(1245):U2308. 4. Turley M, Tobias M, Paul s. Non-fatal disease burden associated with excess body mass index and waist circumference in New Zealand adults. Aust N Z J Public Health 2006;30(3):231–7. 5. Tobias M, sexton K, Mann s, sharpe N. How low can it go? Projecting ischaemic heart disease mortality in New Zealand to 2015. N Z Med J 2006;119(1232):U1932. 6. Ministry of Health. A portrait of health: Key results of the 2006/7 New Zealand Health survey. In: Wellington: Ministry of Health; 2008. 7. Goodyear-smith F, Arroll B, sullivan s, Elley R, Docherty B, Janes R. Lifestyle screening: development of an acceptable multi-item general practice tool. N Z Med J 2004;117(1205):U1146. 8. Rose sB, Lawton BA, Elley CR, Dowell AC, Fenton AJ. The ‘Women’s Lifestyle study’, 2-year randomized controlled trial of physical activity counselling in primary health care: rationale and study design. BMC Public Health 2007;7(147):166. 9. McAuley KA, Murphy E, McLay RT, Chisholm A, story G, Mann JI, et al. Implementation of a successful lifestyle intervention programme for New Zealand Maori to reduce the risk of type 2 diabetes and cardiovascular disease. Asia Pac J Clin Nutr 2003;12(4):423–6. 10. Tracey J, Bramley D. The acceptability of chronic disease management programmes to patients, general practitioners and practice nurses. N Z Med J 2003;116(1169):U331. 11. stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR. Patient-centered medicine. Transforming the clinical method. Thousand Oaks: sage Publications; 1995. 12. Emmons KM, Rollnick s. Motivational interviewing in health care settings. Opportunities and limitations. Am J Prev Med 2001;20(1):68–74. 13. Miller WR, Rollnick s. Motivational interviewing: Preparing people for change. 2nd ed. New York: Guilford Press; 2002. 14. Miller W, Rollnick s. Motivational interviewing: preparing people to change addictive behaviour. New York: Guilford; 1991. 15. DiClemente CC, Velasquez MM. Motivational interviewing and the stages of change. In: Miller WR, Rollnick s, editors. Motivational interviewing: Preparing people for change. New York: Guilford Press; 2002. 16. West R. Time for a change: putting the Transtheoretical (stages of Change) Model to rest. Addiction 2005;100(8):1036–9. 17. Babor TF, Higgins-Biddle JC. Brief intervention. For hazardous and harmful drinking. A manual for use in Primary care. In: 2nd ed: Department of Mental Health and substance Dependence, World Health Organization; 2001. 18. Bien TH, Miller WR, Tonigan Js. Brief interventions for alcohol problems: a review. Addiction 1993;88(3):315–35. 19. Miller WR, sanchez VC. Motivating young adults for treatment and lifestyle change. In: Howard G, editor. Issues in alcohol use and misuse by young adults. Notre Dame: University of Notre Dame Press; 1993. 20. Miller W, sanchez V. Motivating young adults for treatment and lifestyle change. In: Howard G, editor. Issues in alcohol use and misuse by young adults. Notre Dame: University of Notre Dame Press; 1993. 21. Halpern J. Empathy and patient-physician conflicts. J Gen Intern Med 2007;22(5):696–700. 22. Yapko MD. Breaking the patterns of depression. New York: Doubleday; 1997. 70 VOLUME 1 • NUMBER 1 • MARCH 2009 J OURNAL OF PRIMARY HEALTH CARE
Uncertainty, fear and whistling happy tunes Katherine Wallis MBChB, MBHL, FRNZCGP ABstRACt Uncertainty in medical practice is ineradicable, despite great scientific advances over the last century. Uncertainty provokes fear, not just in patients but also in doctors. Patients cope with their fear by seeking the advice and reassurance of doctors; doctors, on the other hand, cope by denial and self-deception. But today, in this scientific, truth-seeking age doctors are encouraged to share their uncertainty with patients in order to ‘empower’ patients and improve doctor–patient relations. While in theory doctors might agree with this approach, in practice they continue to deny it and instead whistle happy tunes—deceiving both themselves and their patients. A disclosure of uncertainty requires an acknowledgement of uncertainty and, in practice, the ability of doctors to acknowledge and to tolerate uncertainty is limited. Whenever I feel afraid, I hold my head erect And whistle a happy tune, So no one will suspect I’m afraid. While shivering in my shoes, I strike a careless pose And whistle a happy tune, And no one ever knows I’m afraid. The result of this deception, Is very strange to tell For when I fool the people I fear, I fool myself as well! 1 If one thing in this life is certain, it is that the practice of medicine is a practice in uncertainty. Renée Fox, 2 in her landmark studies of uncertainty in medical practice in the 1950s, characterised three types of uncertainty: the uncertainty of medical knowledge, the uncertainty of the practitioner, and the uncertainty in discerning between these two types of uncertainty (is the answer out there somewhere and I just haven’t come across it, or has the answer not been discovered yet?). In clinical practice we face uncertainty about the diagnosis, compounded by the inherent variability in how patients perceive and describe their problems; uncertainty about the treatment, as we know patients respond differently to treatments and that applying general knowledge to individuals is flawed; and uncertainty about the role that we are expected to play today: are we to be rational scientist, shaman, social worker or counsellor? Over the last century great advances in medical knowledge have been made, leading some enthusiasts to believe that uncertainty in medicine could be eradicated. It was hoped that, with enough research, all questions would be answered and that illness and suffering could be dealt with by EtHiCs a rational scientific approach, making intuition and spiritualism redundant. Such hopes, however, look increasingly unlikely ever to be fulfilled, in part because medicine, if it is a science at all, is a science of individuals. There are no great generalisable truths to be discovered and applied; the expression and the experience of illness will always remain unique. Randomised controlled trials will never be able to tell us how a particular individual will respond to a particular treatment. As Kant once remarked, ‘Out of the crooked timber of humanity no straight thing was ever made’. 3 Uncertainty exists in all facets of life, but in the health care context in particular, uncertainty breeds anxiety and fear. There is a Chinese proverb claiming that ‘more people die of fear of their illness than die of the illness itself’. As often as not it is fear, born of uncertainty, that prompts a patient to seek the opinion of a doctor. Patients want to know whether their symptoms are significant, what can be done and, preferably, also to be reassured that all will be well. However, given that we must all die one day, there will come a day when all will not be well. It is the doctor’s role to sort out and communicate the known from the The ethics column explores issues around practising ethically in primary health care and aims to encourage thoughtfulness about ethical dilemmas that we may face. tHis issUE: Our guest ethicist and GP Katherine Wallis discusses balancing the acknowledgment to patients that medical practice is uncertain with managing their fears and anxieties. VOLUME 1 • NUMBER 1 • MARCH 2009 J OURNAL OF PRIMARY HEALTH CARE 71
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