When Neil and Athinyaa spoke at DPC16 at the start of the month, everyone listened - it was a heartfelt, emotive talk about providing care to people, not patients. This blog they've written continues that theme, and it's incredible. Enjoy.
It'd been a few years since I attended Diabetes UK Annual Professional Conference. I used to find some of the sessions interesting and helpful, but really I preferred other conferences for technical content and it was foremost a networking event and somewhere to catch up with colleagues. Last year I had the chance to attend just one day after several year’s absence. This one was different and it tugged on a heartstring. You see, in the last several years, in the last years of my training and first years of being a consultant, I had also changed.
What was different about #APC2015? It was people, people with diabetes were there. How was I different? The answer is the same as why I thought the APC was different: the relationship with people living with diabetes. So, what changed in me? Had I been a bad doctor? Had I a bad attitude? The answer lies in a question. My colleague, Athinyaa Thiraviaraj and I were asked this question by Dani @danianddanzel a few weeks ago. The two of us had been working together for more than 3 years by this time. We'd been slowly bouncing thoughts and ideas past each other in reaction to the vagaries and trials of diabetes care, whether that was in the acute setting or clinic.
Dani asked what had motivated us to make changes. Was it our patients? She guessed that we wouldn't have made the change otherwise. As we responded together, all the thoughts and ideas that we'd been talking over the last few years crystallised out. Athinyaa said she thought it was both a difficult and easy question. She agreed that we both knew who had motivated us - people living with diabetes themselves.
My first thought was about insight, or self-awareness, a sense that things weren't going right in what I was trying to do for people. I'd chosen this life, spent years studying, doing exams and practicing medicine. Surely, if anyone, someone like me should know what is important in diabetes care and the medical risks involved. Why couldn't the people I saw in clinic see that these things were important? Why couldn't I get this across? Even at the end of my training I knew that sense of failure was inside me; I was already realising that I wasn't getting through to people like I thought I should.
As I became established as a consultant, after a year or two, I gained something that I did not have as a trainee: continuity. In seeing people again and again, relationships began to build as I got used to people and they got used to me. As that happened, I could see that people living with diabetes had needs that were different from what I was giving. I struggled with that knowledge. I had felt a failure. I had to admit that before I could change. That's the most difficult part. Nothing can change without admitting that there is a problem. Athinyaa has been really clear that where we were now in our careers was a factor; we were now consultants and so truly owned our decisions. It takes an empowered clinician to believe in empowerment.
So what were the actual changes? We started listening. It was as simple as that. We listened to the person sitting in front of us in clinic, the person in the ward and even in the high dependency unit. Listening was simply that: actually hearing what the person wanted to say, giving space, allowing them to say what they wanted. In active listening we showed congruence, we were in the room with the person, not thinking about their numbers and risks. It allowed us to express empathy. In accepting what they felt important at the time, understanding how people actually felt and what they wanted we learnt more about them, as a person. Yes, numbers and risks were important to us as clinicians and maybe to the person talking beside us, but maybe ‘the numbers’ weren't top of the agenda for the person themselves at that time. Looking back, we both had respected people with diabetes before, but now we had begun to demonstrate that respect better.
Listening was a main factor in the other great catalyst, the diabetes online community. We listened there for weeks and months before actively taking part. It has helped change us further, adapting our attitude, behaviour and language. We both found that the more we changed, the more rewarding it seemed for both the people living with diabetes we were caring for, but also for us as healthcare professionals. It was a win-win scenario.
It is very difficult to make these changes. Medical training schools us to listen, extract information as a clinical history, analyse it and come to a conclusion about diagnoses and management plans. As Athinyaa is fond of saying, the clinician needs to put aside the 'fixer'. Life's problems don't have simple fixes, unlike medical problems. We defined the medical / diabetes problem on our agenda, but what about the person, what about what they valued and wanted? You cannot separate diabetes from someone's life. As I heard pointed out recently, if you hate diabetes, you hate a part of yourself.
The change was that we were listening to the person. We were separating the person and the problem, leaving aside the medical problem and the 'fixer' and listening to the person. Setting aside the medical problem as we saw it, it left us able to hear them. In doing so, we moved away from the traditional directive model of care to a partnership with the person with diabetes. A vital part of this partnership recognises the person with diabetes as the Expert. Our role is to be one part of the person’s wider support, adding our own knowledge and skills as diabetes specialists to theirs. And yes, this relationship based on trust is about mutual respect, but we believe that the healthcare professional must offer this respect to the people living with diabetes before deserving or expecting it in return.
The people who we saw in our clinic responded with impromptu feedback. This was part of listening rather than a formal survey. It also happened through the diabetes online community. They said the experience was better. While we strongly believed in this engaged supportive care, it was out of step with other colleagues. The feedback was important to us as we needed that encouragement to keep going. Every person with diabetes we have come in contact with, real and virtual, over the last several years has motivated us to change and adapt.
This was an organic change, to a culture of partnerships based on honesty, transparency, active listening and above all, unconditional positive regard. Now, we were not awful physicians to begin with, but to acknowledge our weaknesses and apply these principles in a focused manner meant we were able to enter into meaningful engagement with the person living with diabetes.
So what changed? Just us - as individuals and as a team.
Why did we change? For the people who trust us with their health, because they always come first