Hello fellow medics,

I hope we are all keeping well.

“Health Promotion” is a hot topic in medicine. Our aim is to try our best to have a “preventative medicine” approach, rather than curing.

It is considered better practice to get the patient involved in their health and well being rather than have a doctor dictate what is “right or wrong”.

As a doctor, you have to be get the information, be aware of cues to introduce “health promotion” and motivate change.

Below I will highlight some areas we can focus on and as always give examples of ways of communicating this with the patient.

Key principles:

1) Avoid being judgmental. This is difficult, as you are feel that YOU as the doctor, are “all-knowing” and you have to “tell the patient off”. To avoid being seen as judgemental: try to understand their decisions to smoke/drink “I understand it is a way you reduce your stress”. This shows you have heard what they are saying rather than jumping in there with your facts and figures

2) Motivate the patient. Provide motivation by linking areas the patient has highlighted in the history and relate it back. Humans change their behaviour through a “reward”. Just telling someone to exercise more is not going to work, they need to why and how it will benefit them “By doing some light exercise once/twice a week by jogging, it may help with your insomnia and anxiety you described”.

3) Don’t suggest changes half way through history taking. Avoid asking about change in the social history, this will interrupt your flow and stand in the way of building rapport. The discussion should be summarised at the end when you and the patient are putting together a plan of action.

4) Get the patients/actors prospective on their habits/areas for change before you launch into making recommendations. This gives the patient the platform to formulate their own ideas and so you as the doctor, have something to base your management plan on. Remember “patient centred care”.

Smoking

The big topic. Yes it is always there, snuck in the “social history”.

Don’t just ask about it- ask how many and how often to get a “pack history”. Getting this information out during the social history will allow you to then come back to it at the end. If you are worried you may forget to come back to it, write it on a piece of paper.

The way to approach it would be as follows:

1) Ask if they have ever thought about quitting smoking

2) If no. Leave it there to avoid confrontation. If yes, provide them with NHS STOP Smoking info + patient information leaflet. You might want to add some extra motivation with : “Research has shown that you have a higher chance of quitting to smoke with support and medications”.

“Mrs Smith, we have spoken about ways we can help reduce your QRISK, paying attention to your weight etc but one area I would like to discuss is smoking (pause, allow patient to absorb the information). Have you ever thought about quitting smoking?”

Here you have shown 1) You have asked about smoking 2) You have acknowledged they smoke 3) You have discussed quitting in a respectful way.

Alcohol

You want to know 1) How much they drink (UNITS!) and 2) how often. If you are worried about the amount they are drinking ie above the recommended amount of 14 units/week, you may want to do further screening for alcohol dependency ie using “CAGE”.

“Mr Smith, we have discussed many factors that may have contributed to your heart attack. One area I would like to concentrate on is the amount of alcohol you are consuming, which is above the government recommendation of 14 units. Have you ever had any thoughts about it yourself?”

This can go either way:

1) “yes doctor, my family have commented on it” - great, go ahead with your motivational behavioural discussion.

2) “No, i don’t feel I have a problem” - this is also OK. Remember in a 10 minute station, you cannot do everything, but you have planted the seed of thought. You can follow up by stating “That is fine, but if you would like to discuss this further please do come to see myself/GP/colleague”. Respect the patients honesty and decision.

Exercise

Exercise is a great one, as most people understand the importance of it. It is widely known and publicised that there are many positive effects of exercise, so hopefully you shouldn’t be faced with too much counter-argument. The biggest issue I see, is getting an accurate account of the exercise. You need to ask 1) WHAT exercise they do. Walking the dog is great, but its not the same as brisk walking with your heart racing and increased breathing 2) HOW OFTEN. You want an idea of how many times a week.

For this scenario I like to print off a patient information leaflet that has more information in a way that is easy for the patient to follow.

One way of targeting this is:

“Peter, have you ever thought about doing some exercise? You said you would like to play football with your sons, maybe this will help with weight loss and stress. What are your thoughts?”.

Diet

Diet is a tricky one and can be time consuming in the consultation. Patients can take a long time describing their daily habits, so it is best to get to the important parts (In the OSCE, remember they have a script, so less likely to go off on a tangent). You might be able to ask the patient/actor to describe their typical day, or you could ask targeted questions ie “How often do you have fried food?” “Do you have a varied diet of fruit, vegetable, meat etc?”. You basically want a gist of the situation, not a whole dialogue of every food product they consume.

“Mr Smith, we have spoken about many ways we can control your blood sugars. One area that I feel we can make some changes is the amount of sugary foods you have, what are your thoughts on this?”

I hope you found this information useful. It all comes back to good history taking and building rapport with your patient without alienating them or making them feel judged.

Study well and do not hesitate to contact me if you have any queries.

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keep safe x