Case Studies

Case 3 With a patient: the ending stage of a consultation

This example takes place in a GP practice. 30 minutes are allocated for this follow-up appointment.

The patient

Savita, aged 48, has been a member of a dietitian–led weight – management group. A month ago she completed a course of 10 sessions in which her BMI dropped from 39 to 27 kg/m².

The dietitian

Ann is a senior dietitian with a particular interest in group work and weight management. She routinely offers a final session to each person who has been in a group. Her aims are to review good progress made, anticipate future problems, consider ways for the patient to continue with the good changes and receive feedback from the patient.

Ann welcomes Savita and asks, ‘How are you?’

‘Not too bad’, says Savita. ‘It seems strange coming here without the others.’

‘Yes, doesn’t it’, agrees Ann. ‘As we discussed at our last group meeting, I see today as an opportunity for us to complete the work we have done together and to say goodbye. I’m wondering how you feel about this being our last meeting?’

‘A bit anxious, to tell you the truth’, says Savita. ‘How am I going to manage on my own? I’m doing OK at the moment, but what if I can’t keep it up – there’s a big family wedding in 3 months’ time, which could be a difficult time for me. I don’t want to slip back to old ways of eating.’

‘Hmm...a difficult time – not only the wedding itself but all the preparations too...you’re feeling anxious when you think about it. And now the group has finished, I imagine you’re thinking you’re going to be more on your own?’ Savita nods and Ann continues, ‘Would it help if we discussed this more in a few minutes?’ Savita nods again and Ann continues, ‘I think it would be helpful first if we take a broad view and look back to when we first met, how you were then...over the work you have done on yourself since and the changes you have made to your eating habits..I’m wondering how you see yourself now?’

Savita takes a deep breath, giving herself time to think. Speaking slowly and thoughtfully, she says: ‘Well, when I first came to see you, I felt very bad about myself – I hated the way I looked, but I couldn’t see how I could do anything about it – I felt really stuck. Now I can see ways I can do things differently – like, I don’t have to always finish the kid’s leftovers and pick at food whenever I feel fed up or stressed. I have thought of other things I can do to feel better!’ Savita smiles at Ann, who, realising the significance of what Savita has said, wants to affirm this for her.

Ann says, ‘So, it has been helpful for you to understand your habits – that when you feel bored or stressed, you tend to pick at food and eat snacks. Have you found other ways to deal with how you feel at these times?’ Savita nods and Ann continues, ‘I wonder what helped you work this all out?’

Savita replies without any hesitation, ‘Oh, it was hearing some of the others in the group – going to those meetings was really useful, once I’d plucked up the courage to join’. Ann is surprised, as she remembers Savita being one of the quiet ones in the group. Savita continues, ‘I learned so much from the others – as they talked, I thought, "I’m not the only one – other people feel like me and have bad habits with food, too". I began to feel less ashamed.’

Ann wonders if she has understood correctly. ‘So, feeling better about yourself has helped you take more care of yourself – to change your eating habits?’

‘Yes, I guess so. It’s a struggle, though. Some days are easier than others, but my life feels much more interesting now.’ Savita looks at Ann, who nods encouragingly. She continues quickly: ‘It’s hardest when I’m too much alone, or when I get very tired or on days when everything seems to go wrong. Then I slip into bad habits again and I feel bad about myself.’

Ann feels moved. Savita is sharing her vulnerability with Ann, who says gently, ‘The times when the struggle seems hardest are when you feel tired and on your own and nothing seems to go right? You start snacking, and then it all goes downhill and you feel bad about yourself?’ Ann feels as though she is struggling herself at this point. She watches Savita nod miserably. ‘And how is it different on a good day?’

Savita smiles a little. ‘When I am doing something I want to. Like the computer course I’ve just started – it’s only once a week, but it’s good. And someone has asked me to help them with catering for a party they are having – I feel so pleased to be asked. They said they wanted traditional Indian dishes and I do enjoy cooking – especially for others. And when I’m busy and enjoying myself, eating isn’t something I want to do – I forget about it! Hard to believe, but it’s true!’ They both smile, sharing Savita’s moment of pleasure.

Ann asks, ‘You said how much you learned from being in the group – what, if anything, do you think you have learned about food and health that is useful to you?’

‘Oh, the discussions we had about healthy food – what was healthy about it, and new things to try. Actually, it was good to hear that many pulses, fruits and vegetables – the foods I have always used – are healthy and that others want to try them – that made me feel good! I do know, though, that too much ghee and sugar is not good. I liked the class when we each brought a favourite dish – several people said how much they liked mine!’

‘It sounds as though you really liked being part of the group, where you felt appreciated and valued and you as though you weren’t the only one. You could learn from others as well, so it was a rewarding experience for you, and it has given you confidence. Now that support has finished, what do you think will take its place?’ Ann asks.

Savita says thoughtfully, ‘Yes, it’s difficult – but it’s good to keep in touch with two people from the group. We help each other – we talk on the phone. It’s good to have someone I can call if I want to talk, and I feel pleased, too, when they call me – it’s like we’re in it together.’

‘So, being able to talk to others who you know will understand is important – and you will have this support at the time of the wedding?’

‘Yes, that’s true. I do think I’m going to find the wedding itself and the time leading up to it stressful. It’s going to be a challenge, but I can see now that I can get through it with the support of my friends. I do hope so – I’ve come this far; I’m determined to keep going this time. Thank you for all your help – it’s meant a lot to me.’

‘Thank you. I wish you well. I think you will be able to draw on all you have learned to help you – keeping in touch with the others is important, too, for them and for you. I am referring you back to your doctor now and letting him know we have completed our work together. What would you like me to say?’

‘Oh...hmm...well, I suppose that I have lost weight and that it has all been very helpful...and I hope to keep it up – something like that.’

‘How about I say, Savita has completed the weight–management course, which she found helpful and supportive. She succeeded in losing weight – her BMI has changed from 55 to 50, and she is determined to continue with her healthy eating plan"?’

‘Yes, that’s fine. Ann – thank you so much for your help.’ Savita gets up, preparing to leave. Smiling warmly at Ann, she holds out her hand, and Ann shakes it.

‘Goodbye, Savita – I have truly enjoyed our work together. Good luck with all your plans.’ Ann shows Savita to the door and closes it behind her.

Further study and points for discussion

• • What tasks has Ann fulfilled in this ending stage?
• • If you were in Ann’s place, how would you conduct these tasks?
• • How does Ann demonstrate each of the core conditions of empathy, acceptance and genuineness?
• • What effect does this have on her relationship with Savita?
• • How aware is Ann of her own feelings? How does she use this awareness?

Many dietitians find it helpful to role play situations such as the interview between Ann and Savita 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 reviewing an interview (Chapter 5).

To read about working with a group (Chapter 10).