TRAINING FOR PRIMARY CARE PRACTITIONERS IN ENGLAND: A challenging health check

People are being invited into primary care for health checks in many parts of the United Kingdom.  The people delivering them come from diverse backgrounds. Some are nurses, others are not in a clinical profession.  Not all the patients are easy to interview.  
I ran a workshop in England and they asked me to demonstrate rapid engagement, just the first few minutes of the interview.
I did this with a simulated patient, “Henry” whom I hadn’t met before, who was deliberately playing the role of someone who would be difficult to interview in a health check.  Henry was monosyllabic in his manner and behaviour, clearly unhappy about being there.  My assumption was that he was feeling ambivalent.
My goal was to engage with him first, before getting down to any measurements and other things in a health check.  I proposed to the workshop participants that we follow the “20% rule”: you spend the first 20% of your time only on engagement, and nothing else…  so here is how it went, warts and all.

I’ll add a few comments here and there, in italics, and also use the following key:
OQ – Open question
CQ – Closed Question
R  – Reflection
CT – Change talk – talk about changing (a normal part of ambivalence)
ST – Sustain talk – talk about not changing (a normal part of ambivalence)

Steve
OK, my name’s Stephen (shakes hand) and you are Henry. I must apologise to you for the wait. I think you’ve had quite a wait here today

Henry 
Yes at least 10 minutes

Steve
I apologise for that. It’s entirely my fault. Trying to work too hard against the clock. Apologising does no harm!

Steve  
What I’d like to tell you about is what we’re going to do today. What I want to start with you is checking out with you how you are doing at home and how you feel about coming down here today.
I’m going to explain some of the things we’re going to do in the health check in a moment but before I do that I just wanted to check with you how you are feeling about coming down here today.

Henry   
Oh it’s the wife she was going on and on and on. ST

Steve 
So she was going on at you about coming down here today and you felt obliged to come.  R

Henry   
Yes  I had a heart attack in September and she’s been on my back about coming down here.

Steve   
So you had a heart attack. How did you get on? How was that for you? OQ

Henry  
Erm, kind of crap, I went to hospital and I got a stent.

Steve   
So It came out of the blue. R You weren’t expecting it. R

Henry
No sir.

Steve   
Right, and suddenly you were there in hospital. R

Henry   
Yes.

Steve
And what happened then? OQ

Henry  
Erm, nothing really, and then I kept going to work, that’s where I go.

Steve 
I was going to ask what that meant for you. You had the stent put in , how did you feel when you left hospital. OQ

Henry  
Well it’s all right now cos I’ve got the stent in there. ST?

Steve  
So If I’d met you as you came out of the hospital you would have said. I’m doing all right now, I’m fixed. R

Henry   
Yes.

Steve  
Right, right, and then you’ve gone back to live the life that you had before. R  That’s a complex reflection, designed to “complete his paragraph”, which shows that I understand and this can also save time…

Henry   
Yes I enjoyed it.

Steve  
Right, and that enjoyment revolved around what sort of things? OQ

Henry   
The pub, drinking, darts out with the lads, and smoking.

Steve   
And smoking. It’s the sort of thing that the guys do in and around playing darts and you slotted back in to that. R

Henry   
Yes exactly  Using these reflections does not mean that I agree with him.  I’m just trying to join up with him.  When he says, “yes exactly”, it tells me that engagement is happening…..

Steve   
Right, and then you received these letters about the health check. R

Henry   
Er yes, well yes.

Steve   
And you weren’t really persuaded they were a good idea. R

Henry   
No not really.

Steve   
Can I ask you why? CQ

Henry   
Erm I don’t know.

Steve   
To the workshop participants: …. I’m not going to try and be clever here, you know, and play some trick. I’m going to make an effort. He might choose not to take this seriously. That’s his choice. I’ve got another 2 minutes of this engagement left and then I’m going to start doing the measurements. I would say that the more difficult the patient the more we might extend the 20% rule…..

Steve   
So when you kind of got those letters how did you feel? OQ

Henry   
Erm I didn’t see how it would help. My father smoked and drank till he was 93 and erm.  ST  This is what is called “sustain talk”. These are his reasons for not changing, a normal part of ambivalence.

Steve  
Right so.

Henry   
Then he got run over.

Steve   
What, then he got run over, right, right, and so you got these letters, almost like they felt a bit irritating to you. R

Henry   
Yes it seemed like more spam. ST more sustain talk

Steve 
Right, right, and your wife got back on top of you about it. R

Henry  
Yes so she was nagging and nagging and nagging.

Steve   
And then you decided to come down. R

Henry   
Er yes.

Steve   
Tell me deep down for you is this really about coming down to satisfy your wife? CQ

Henry   
Yes I think so, I mean (shrugs) I mean I like drinking, smoking, I like being in the pub. If I’m not there I’ve got nothing else to do. ST  More sustain talk

Steve  
Right, right, right. So you might have a little concern about your health but the force of the pub and every day normal life is a strong one for you. R  This is a complex reflection. He has not mentioned being concerned.  Was I putting words in his mouth? I think I noticed a look of concern on his face. As long as you are being genuine this is OK, because if you are wrong in your guess, he’ll put you right.

Henry   
Yes well I know I should stop smoking, stop drinking and lose some weight (CT) but I like being round the pub.  Here it is, the other side of his ambivalence

Steve   
And what do you mean by ‘You know you should stop doing these things?’ How do you really feel about your own health? OQ

Henry  
Erm  it’s not really something I ever really did things in… I never did any sports, I never got around to doing any cooking…

Steve 
Just got on with it. R

Henry   
Yes.

Steve   
Now that we are sitting down together talking about your health, how do you really feel about it, with that heart attack. We know that your wife’s obliged you to come and all that but I’m really actually interested in  how you really feel deep down about this. OQ

Henry  
Well obviously I don’t want another heart attack (CT), so if there’s something I can do to avoid that, something I can watch out for  then that’s definitely a good thing.  CT

Change talk emerges from listening to him.  It’s the other side of his ambivalence

Steve   
Right so you, you don’t want to have another heart attack yourself. R

Henry  
No, definitely not.  CT

Steve 
If there was something you could do to avoid that you would think about it.

Henry   
Yes, I’d think about it. I’m not sure how I’d approach it. CT

Steve   
Yes yes, It sounds like you’ve come down here partly because your wife’s nagged you but also because there’s a part of you that wants to stay as healthy as possible. R

Henry  
Yes. CT

Steve 
That’s reasonable.

Henry  
I don’t want to get another heart attack. CT

Steve   
And then somehow you you’d have to fit in your normal every day social life in there and you’re not sure how that’s going to pan out. R

Henry   
Yes. I’d hate to lose that. 

Steve   
You wouldn’t like to lose that- You’ve mentioned that a few times. OK Is there anything else that you want to say to me before we begin. OQ

Henry   
Ern not really.

Steve 
OK do you think I’ve got a reasonable grasp on how you feel about things.

Henry
Yes I’d say so. 

Steve  
Good OK.

Steve 
To the workshop participants: it’s interesting how there was this shift from “it’s all to do with my wife”. It was a ‘song’ called “it’s all my wife, she’s made me come here”. Why do you think there was the change?

Comment from workshop participant: ‘He was saying my wife made me come, my wife made me come… when you started to collude with it he gave up and started to do the opposite’- Exactly right. Possibly combined with a genuine way of getting across to him the conviction that beneath all of that he’s a really nice guy whose not 100% happy with stuff.

Concluding comments:  I started wanting only to work on engagement, then he started emitting change talk quite naturally, and soon I was right there, in the heart of MI. I don’t think this early part of the consultation took very long, and in that sense it seems that listening saved time, and got us efficiently to him saying why he wanted to change. ….