Case Studies

Case 1 With a patient: beginning a consultation

This example takes place in a diabetic outpatient department. 30 minutes are allocated for the appointment.

The patient

Alan, aged 45, developed diabetes 5 years ago. Controlled by diet and tablets, his blood sugar levels have been erratic for the past 6 months. He is seeing a dietitian for the first time.

The dietitian

Asha, a recently qualified dietitian, prepares to assess Alan’s diet, then advise him as necessary.

From what she has read in Alan’s medical notes, Asha imagines him as overweight, a smoker, a drinker and a workaholic who sees little of his wife and children. She reminds herself that the real person may not be like this at all. She thinks it would be helpful to discuss his diabetic control with the practice nurse who has seen him regularly when she is next in the clinic.

Asha logs on to the computer and organises her paperwork so as to allow as much time as possible for the consultation. She glances around the room. It is small, windowless and contains two identical upright chairs, a clock on the wall and a computer on the desk, along with her files, notepad and pen. It is a functional, characterless room, but it is quiet and not too stuffy and has easy access to the main outpatient waiting area. She thinks it could be more welcoming, but she has known worse. She moves the chairs so they are at an angle and a comfortable distance apart, and thinks she will indicate to Alan to sit on the one furthest from the door so that she can have the one which gives her a corner of the desk to use when taking notes.

She glances at her watch and, realising she is on schedule, takes a few moments to check how she is feeling. She acknowledges to herself that she has been rushing around all day, so she decides to clear her mind and take some deep breaths in order to become more relaxed and calm. She walks into the main waiting area and looks around. Several people, both men and women, are waiting. Which is Alan? She notes three likely people and, approaching them, says in a clear voice, ‘I‘m looking for Alan Bull’.

Take time to reflect here about the way Asha has prepared herself before reading on.

‘That’s me.’ A man gets up and moves towards her.

Asha smiles in acknowledgement. ‘Please come this way’, she says. She leads the way towards the interview room.

Motioning him to one of the chairs, she says, ‘Do take a seat’.

She then sits down herself, and, looking at him, feels surprised. Alan is not at all like she had imagined. She sees a man of average height and build, with short dark hair greying at the temples, who is clean-shaven and is wearing a grey jacket and blue open-necked shirt. She thinks he has a pleasant face, although he is frowning a little at the moment and is sitting almost on the edge of the chair.

Asha wonders if he is feeling anxious and decides to concentrate on putting him and herself at ease. Smiling, she speaks in what she trusts is a welcoming manner:

‘Hallo. I’m Asha, one of the dietitians here. How can I help?’ She asks an open question as an invitation to the patient to talk, which will perhaps give her an idea of how motivated he is.

‘I don’t know, really...’ Alan replies.

Asha thinks that her patient might be feeling ambivalent about this appointment.

‘We’ve not met before, and I’m wondering if you’ve talked to a dietitian before about your diet?’

‘Yes. Some time ago, though. Just after I was told I had diabetes, I think it was.’

Asha wonders if there is a record of this in the department. She wants to assess what he knows about diet as a means of controlling his diabetes. She says, ‘I’m wondering what you remember of that meeting – what you found helpful? Or maybe it wasn’t helpful at all?’ She decides to pose both possibilities, trusting this will help him acknowledge honestly how he found the previous interview.

‘I don’t remember much about it, except being given a lot of information about how my sugar levels would go down if I didn’t eat sweet things. So I don’t – I’ve not got a sweet tooth, anyway, so it’s no great problem.’

Asha feels a little rebuffed by the somewhat abrupt tone in which he makes this last remark. She realises they are at Stage 1 of the helping process and her task is to build a helping relationship.

How can she do this? Take time to reflect here before reading on.

The interview continues...

Asha decides to apply her skills of reflective responding.

‘So, you haven’t found it difficult to avoid having sugar and foods containing a lot of sugar.’ She then decides to risk asking a direct question, to encourage him to identify what he perceives is the problem:

‘What do you think has been the biggest difficulty?’

‘Well, I guess it’s when I feel sort of dizzy. It’s not every day, but when it happens, people tell me to have something sweet, and then I feel better. It’s odd, really, because that’s the very thing I’m meant not to have.’ Alan frowns slightly.

To clarify what he has said, Asha summarises:

‘You’ve found the most difficult thing to cope with is the dizziness that happens sometimes, and you’ve discovered you feel better when you eat something sweet, but you’re thinking that doesn’t make sense because sweet foods are what you’ve been told not to have.’

‘Absolutely. Can you explain it?’

Asha thinks his dizzy spells may be signs of hypoglycaemia, and realises she can explain how he can avoid these by managing his diet. To do this, she will need to assess his diet and advise him accordingly. However, she remembers she has not clarified the time they have available, nor how they are going to spend it, and she has not set the agenda.

She also recognises Alan’s last remark was his way of challenging her and that she needs to build a helping relationship with him. And all this in a short time.

How can she manage their time together? Take time to reflect here before reading on.

The interview continues...

Asha realises that her time is too limited to cover every aspect of his diet. She will need to make another appointment. She chooses to address the issue that Alan has raised as her first priority and to find out if Alan agrees for this to be their working contract.

Glancing at the clock, Asha says, ‘I’m aware we have 15 minutes left today. How would it be if we spend some of that time discussing your dizzy spells and answering any questions you have about your diet? Then, if you’re in agreement, we might want to arrange another appointment if we can’t cover everything today.’

‘Sounds good to me’, Alan smiles, sitting back in his chair.

Further study and points for discussion

The questions below are to help you reflect on this stage of the interview. Information can be found in the relevant chapters of Counselling Skills for Dietitians.

The interview framework (Chapter 5)

• • What tasks appropriate to the beginning stage of the interview does Asha focus on?
• • Are there any tasks that you consider appropriate to this stage which she has left out?
• • How could Asha have handled these differently? What are your reasons for your suggestions?

Communication skills (Chapters 3, 6 and 7)

• • What assumptions, if any, does Asha make? How do they help or hinder the interview?
• • What significance, if any, do you attach to Asha’s non-verbal communications?
• • What different types of response does Asha make during the interview (e.g. summarising)?
• • How might you have responded differently, and why?
• • How does Asha build a helping relationship? How successful do you think she is?

Many dietitians find it helpful to role play situations such as the interview between Asha and Alan with a colleague. In doing this, it is valuable to enact both roles, so that you get an experience of being both the dietitian and the patient. Allow time to discuss with your colleague and to debrief before switching roles, and again at the end of the exercise.

You are recommended to use the book...

To read about building a helping relationship (Chapter 3).

To read about the interview framework (Chapter 5).

To read about the different types of response (Chapter 7).