Tuesday 9 June 2015

Asking Difficult Questions; Shall I, Shan't I?


The role of the physiotherapist in delivering health messages has had a lot of attention recently.  The prevalence of lifestyle diseases alongside rising concern about the sustainability of health and social care systems has brought preventative care into the spotlight.  AHPs make up approximately 6% of the NHS workforce and they have been identified as an untapped public health resource. 

As AHPs find themselves increasingly reflecting on their role in public health we have cause to consider our role in wider health promotion and Physiotalk hosted an interesting tweetchat about this just last night.  I've mentioned in previous blog posts  the huge role that health behaviours are thought to have in contributing to overall health (McGinnis et al 2002).  This challenges us to consider the balance between reactive treatment of the presenting complaint and proactive, preventative care of the whole person.

The Royal Society for Public health & Public Health England recently published a joint report on AHPs & healthy conversations.  In brief, the results from the survey show clear collective ambition amongst AHPs to be recognised for their role in public health.  It also shows that many AHPs frequently initiate healthy conversations with their patients.  This was matched with positive views from the public about the perceived credibility and trustworthiness of the advice AHPs give.




However, a number of barriers to initiating healthy conversations were raised in the report, these include being embarrassed to raise the issue and feeling that it is not appropriate or could be insensitive.  If we are to promote behaviour change we first have to identify risky behaviours and then openly discuss them and this can be awkward for both clinician and patient. We may want to ask about tobacco use, alcohol consumption, weight/nutrition or drug use, in some areas of practice it may be appropriate to ask about risky sexual practice or domestic abuse.





This blog post was published in BMJ recently, it gives an interesting patient perspective; the author asks healthcare professionals to;

Think twice before offering unsolicited advice in the guise of “education,” particularly when your patient is consulting you about something unrelated. If your patients hear the same potted advice during every appointment, it’ll soon lose its impact; and if you insist on bringing up a subject that they find traumatic you could put them off seeking your advice in future.

The author of the blog post had many negative experiences of receiving well intentioned, but poorly delivered, advice.  In contrast to this perspective, a sub-analysis of a large US study explored patients' reactions to being asked questions about smoking, diet/exercise and alcohol during primary care consultations.  The vast majority of participants stated that they felt "very comfortable" answering these questions.  They were then asked how important they thought it was for their care provider to know about these health behaviours and the vast majority considered it to be "very important". 

So, in this study, participants didn't mind being screened for health behaviours and they considered it to be an important process, I think the important thing here is about offering a service and allowing the patient to make an informed choice about whether or not they want it.  This would avoid unwanted, paternalistic advice (as per the above blog post) but would fulfil our moral and professional obligation to promote health.

In contemporary health care, health behaviour change is a key clinical skill and we need to take it seriously.   We need to look at best practice and reflect on our own strengths and weaknesses so that we can plan our development accordingly (as we would with any other important clinical skill). 

As frontline practitioners we have a real opportunity to impact on unhealthy behaviours and there is evidence that this is acceptable, desirable and effective.  We need to move this practice from being opportune and optional to being a core part of our assessment with every new patient.  If we get used to having these conversations then they might not feel quite so "difficult".  If we are to fulfil our potential role as health promoting practitioners I believe that we do have a duty of care to ask......but there is a big difference between asking and telling.




 
 

 








Thursday 4 June 2015

What does public health mean to you? Frontline Interview

I recently did an interview with Frontline magazine about public health and what it means for physios.




 The full interview can be read here