Targeting practical and circumstantial factors
There are many common barriers that can be addressed within the consultation. Consider these examples:
- The patient has a poor understanding of the relationship between the health problem and its likely causes. Explain how the health problem is linked to the health related behaviour and provide written information on the subject
- The patient doesn’t understand the likely benefit they could experience as a result of the suggested actions. Highlight the health benefits and provide written information on the topic. The GP could use a decision aid to show this benefit (eg. cardiovascular risk calculator)
- The patient believes that it is 'too late' for change
- The patient is reluctant to accept responsibility for making a change. Is it a lack of recognition of a problem? Explore their beliefs and expectations about the issue and how things will be improved. Ask about previous attempts to change. Determine how difficult it is for the patient to change and whether they feel they are able to change? Check the environmental context and support systems
- The patient lacks confidence in their ability to change. Identify the most difficult factor to change or the hardest thing about changing. Ask the patient what would help to overcome this difficulty. A longer appointment could be proposed to focus on motivational techniques, and to identify perceived barriers and sources of support
- There are difficulties or barriers due to cultural or gender difference, or other reasons. Consider referral to, or offer a list of appropriately matched providers or counsellors. A longer appointment could be proposed to further explore the problem
- The patient lacks support to make changes. Additional support is a potent factor in facilitating change. Studies on the management of diabetes in particular population groups, for example Aboriginal and Torres Strait Islander peoples or adolescents, have shown that including a support person with the same condition in consultations improved the patients' retention of information and facilitated understanding of the condition and its treatment. Suggest that the patient invite a partner, friend, relative or carer to the next appointment. There could be follow up by telephone. Consider an appropriate support group that covers the problem
- There is lack of success despite patient effort. Remember that initial successes and failures are powerful influences on the patient. Make change incremental, achievable and realistic.
Sustainable patient centred consultations – 'sharing tricks'
One patient who suffered from a particular illness had three sisters who had the same condition. She asked me if her sisters could come to her consultation (I made it clear that I could only deal with one consultation at a time). They had some difficulties negotiating follow up appointments at appropriate intervals and ensuring they all attended the same session, but there were several advantages to this arrangement. First, the sisters provided great support for each other by using their own cultural family support mechanisms. Second, if I had not been able to offer a 'family approach', they would have been unlikely to attend the practice again. Third, it was important that the sisters talked among themselves, as they benefited from peer learning and shared information. At follow up consultations, they usually checked the information they had been given and sought out more information on issues that were not clear or that they needed to know more about. This ensured that the consultations were formed around issues of importance to the sisters. I call this 'sharing tricks'.
Beres Joyner, Rockhampton, Queensland