In my last blog, we considered a lesson from my college calculus professor, that paths are more interesting than function graphs. Today, we’ll explore why it helps to see a patient’s health ecology as a life path rather than as a risk profile (a function graph), and how group visits can help that process.
I’ve known many health counselors express weariness, feeling they teach the same old things day after day but that patients never change. Health care often isn’t as exciting as portrayed on TV, because one sees a lot of the most common ailments. Today, that means seeing a long line of patients who are overweight, have cardiometabolic disease, are too sedentary, eat the Standard American Diet (SAD), protest that they “don’t have time for exercise” and who explain that stress and pressure at work and home are extreme but that they “just deal with it”.
What strategies can keep practice productivity high and avoid burn-out of addressing these same issues day-after-day, month-after-month for year-on-year?
For me, it helped to stop seeing a patient as another patient who’s sedentary, too heavy, pre-diabetic/diabetic and resistant to change, but as someone on a unique life path. Understanding the patient's life path may sound a little like psychotherapy, but in the case of lifestyle interventions it is much simpler because it is focused on the psychosocial, environmental and behavioral elements of the patient’s health ecology.
Connecting with a patient to understand his or her life is quite fascinating and rewarding, and patients really like health professionals who make the effort to do that. A wellness visit done this way turns the usual cardiometabolic diagnosis codes into a unique life story. But how can labor intensive one-on-one “connecting” with patients be converted into effective and high-productivity encounters?
To improve practice productivity as well as the efficacy of your interventions, it is useful to learn how to do small group visits. Mastery of group visits takes practice, which is best acquired by starting small with 3-4 patients and gradually increasing the group size. The optimal size for a 75-90 minute group visit is probably 6-8 patients, but skilled leaders can handle groups of up to 10 and 12 patients in a pinch (not routinely recommended, but sometimes scheduling may make it a necessity). Any larger than 12 ends up more being a small class than a group visit - it’s just not possible to do a great job of individualizing care with more than 8 participants (and even 8 is a real challenge). The advantage of small group visits that are well done is that patients get the right facts from the health professional, but - more important than the facts - patients gain emotional insights and support from each other.
Emotional issues are more important than the facts? Yes, they are.
Changes in lifestyle evokes intense feelings, something that health care professionals are generally trained to suppress in favor of facts, data and an appropriate “patient-provider relationship”. But motivation to change - note the same Latin root emovere (to move) - comes from harnessing the power of feelings to drive and sustain change. Perhaps the most important role of the facilitator is to help the participants effectively channel and focus their emotional power. For many patients, this challenge causes them to be fearful for a multitude of reasons, and the facilitator must help the patient overcome the fear.
The more patients in a group, the greater the required skill level of the leader. Larger groups have greater likelihood of a big differences in socio-economic and educational / literacy level of the participants, which increases the complexity of making the discussion valuable for everyone. Additional issues the leader must be prepared for, particularly with patients who have chronic conditions, is that affective disorders (especially depression) are common. Personality issues also crop up, and issues around anxiety and disordered eating abound. These are usually not full anxiety, personality or eating disorders, but these are sometimes uncovered in group visits and the leader must have skill to deflect these distractions to the group discussion and subsequently guide the individual with the issue into one-on-one counseling. Thus, the group leader must have skill with keeping all of these factors under control, so that the functioning of the group remains balanced and helpful to all the participants.
Teaching the facts about lifestyle is a class. Facts can be presented in in lots of ways, including group classes, but classes about the facts end up being wrote learning that doesn’t harness emotional power (and dredges up fear of failing and experiences in school). Remember, 1/2 the class in school ended up below average, the cardiometabolic issues we're discussing are skewed to that educational status, so classes are likely to evoke fear and negative self-theories learned during childhood (more on Carol Dweck's self-theory in the future). Classes are a function graph approach that relies on facts and figures making sense to the participants, who then must put 2 + 2 together and harness the emotional power on their own. It rarely works - sufficiently so that I don’t recommend them.
Guiding a group in a dynamic discussion about their own unique lives is a journey. It is never the same twice, because no 2 groups of people ever interact in the same way. Group visits can include a touch of ‘the facts’ but mainly emphasize exploration of everyone’s unique journey, and thus are much more about paths.
Mastering the art of leading lifestyle groups that emphasize the participant’s life paths turns the same-old, same-old lifestyle counseling into a dynamic and stimulating job, using highly productive group visits that provide patients a better counseling experience.
Take your practice down the path of learning how to do healthy living group visits. It will enhance your clinical skills and provide a very high value service. Most important, I think you and your patients will be very glad that you learned to see each patient’s own unique path of health ecology, rather than the same old function graph of risk factors.
Dweck, C. S. (1999). Self-theories: Their role in motivation, personality and development. Philadelphia: Psychology Press.