PRACTITIONER DEVELOPMENT PLAN - SPRING 2008

TO IMPROVE CONSULTATION TIMEKEEPING WITH PATIENTS IN MY PRACTICE USING THE CALGARY-CAMBRIDGE GUIDE

by Martin Kingston
http://www.massage-therapy-london.co.uk
+44 20 8400 9712 / +44 7710 314432

This article appeared in the newsletter for BodyworkersLondon.com

THIS IS A COPY OF THE REFLECTIVE ESSAY HANDED IN TO WESTMINSTER UNIVERSITY 29TH APRIL 2008 - for information to patients showing how I have reviewed my practice this winter. It may help to explain the way I have been documenting treatments, and how I have improved as a therapist in this time!

Plan statement

In my practice, poor management of a remedial massage session can lead to late finishing.
The aim for this work has been to improve competency in managing a consultation, using the Calgary-Cambridge Guide to structure consultations. The specific goal is to improve timekeeping.
Regular reflection addressed success, difficulties, and any underlying behaviour patterns that are challenged by this discipline, drawing on recommended reading to evaluate behaviour, and come up with fresh approaches.

Target

Specifically, by the end of the monitoring period (April 2008):
· 100% of consultations will finish within the timeframe allotted
· 100% of consultations will be noted to the standard defined below

Standard of consultation notes:

Patient name & contact details
Occupational physical patterns, Sports/Physical Hobbies & Contra-indications
Consent to treatment
Patient & Practitioner Objectives for treatment
Particular Patient preferences
Date of treatment and techniques adopted
Completed Session Sheet (Appended):
· logging progress of the session according to the Calgary-Cambridge Guide
· Post Consultation review by Practitioner

Tutor feedback and amended Plan:

The original plan had a more ambitious goal: to gauge patient satisfaction with the treatment by asking them to complete a satisfaction questionnaire post-treatment. This proposal was dropped with the agreement of the tutor after a trial of a month in December. Patients were not in an appropriate state of mind to critique treatment openly, and more research is needed to identify how to obtain qualitative data.
Additionally, the tutor recommended I should reflect on own assumptions and my desire for nourishment from patient satisfaction.

Resources and Strategies

Resources:
· Patient records, with Session Sheets (sample only included - to maintain confidentiality)
· Weekly Highlight Reports, reflecting on Session Sheets, and identifying future actions.
· Monthly Highlight Reports, incorporating strategies for the next period.
· An updated Practitioner Development Plan (PDP), referring to consultations structured by the Calgary-Cambridge guide, to explain my experience and help plan my actions for Continuing Professional Development.
University Library for academic research on consultancy.

Strategies;
During each Remedial Massage Consultation:
· Use a Session Sheet structuring the consultation according to Calgary-Cambridge Guide.

Weekly (Monday Mornings 1 hour, at the same time as updating book keeping records, highlight report and personal journal)
· Review Session Sheets and reflect on past week

Monthly review (end of 4 weekly period) - in addition to Weekly Review 1 hour
· Review progress in using Calgary-Cambridge Guide, identifying strengths, weaknesses, and strategies for improvement

Final Review at the end of the period.
· Review progress in consultation management and update the Practitioner Development Plan

Final Review:

Appended to his essay were Weekly and Monthly Highlight Reports on Practice, together with a sample consultation sheet showing how it might be completed in a session. Reports also included reflections on Personal and Financial performance in my work and social life, but those sections have been removed for clarity of presentation, after the tutor queried context. In retrospect, they did provide a focus for reflection, positioning my work in the context of a busy life, and highlighting issues in my social life that might impinge on my work.

I included reports from January 2008. Previously, my reviews were about patient questionnaires, that were subsequently dropped from the plan. Reading and learning about the Calgary-Cambridge framework, which is the subject of the plan, only started in class in January, and my awareness of the dynamics of consultations developed in parallel with knowledge of the framework in class.

The weekly reports highlighted:

· Interrupting the patient in the Initiating the Session stage meant "hidden agenda" only came to light near the end of the session, which was one cause of late closure. (Highlight Report 27th January). Silverman et al (2005) note in Chapter 2 how interrupting the "patient story" can be a key reason for issues emerging late and delaying closure of a consultation. I changed behaviour as a result, by staying quiet and letting the patient "tell their story" in full, without interruption until they finished or started to repeat themselves, and my key measureable objective was easily achieved.

· For bodyworkers, the Gather Information/Physical Examination/Explanation & Planning stages happen together, first when planning treatment, which unlike prescription therapies, happens during the session, and then iteratively as the therapist asks, tests, palpates, treats, tests. It is helpful to be aware of what you are doing at any moment, but difficult to document this iteration into discrete headings. (Highlight Report 4th February).

· In relation to Negotiating and Planning phase, I reflected that since treatment takes place in the consultation, there is not much negotiation needed, except for some "homework" stretches or resistance training.
I considered the ethics of arranging a course of treatments. (Highlight Report 16th March). My attention in another module has been drawn to the ethics of prescribing preparations that appear to release "mucoid plaque" from the gut, but which create a rubbery substance that looks like the purported plaque they claim to release. Translating that to bodywork confronted me with the similar vested interest in getting patients to come for treatments indefinitely. (Highlight Report 23rd March). As a result I have applied for a Physiotherapy degree course at another university, so that I can work in the NHS, and where my income is not directly related to the number of treatments I prescribe (Highlight Report 30th March).

· Subsequent to the Highlight Reporting cycle presented in this plan, I reflected on an experience in college, related to Negotiating and Planning phase. On another module students experienced cathartic groupwork at a practical exam, and then, while still in an altered state of consciousness (euphoria after a practical exam) we experienced a lecture on a topic followed by a proposal for more classes. Translated to my practice this would be me creating a euphoric state in my patient (para-sympathetic response to massage) and then persuading them to book a course of treatments. Mindful of ethical practice, unless I plan a specific course of treatment, I now ask patients to wait 2 days and decide if the session was useful, before phoning to book another session.
Neighbour (2005) proposes a more fluid approach to a consultation, with "checkpoints" of which to be aware: Connecting, Summarising, Handover, Safety-netting and Housekeeping (pages 75-80). This circumvents the bodywork difficulty in separating Gathering Information/Physical Examination/Explanation and Planning.

I found this approach useful (Highlight Report 4th February), and in re-reading it was reminded of the difficulty I have finishing things. When I worked for big companies in IT, as a consultant my job was to try to fill the appropriate team role. Aware that I am a Teamworker/Plant and the most difficult one for me was "Completer Finisher" according to Meredith Belbin (2004). I seem to be far more interested in the next task, rather than completing this one. I feel I would not hesitate to do this housekeeping for someone else, but don't value my own self in the same way. Neighbour explicitly including Housekeeping as a checkpoint is helpful in my practice: rather than in carrying the spirit of a consultation into another, but in finishing and filing consultation notes,.
Other Issues

I became aware that in spite of my philosophical commitment to ethical working, I note difficulty managing transferance or counter-transferance. Working from home can be solitary, and I seek social nourishment from appointments. The issue came to light when I noticed feelings of loss and betrayal as my practice became quieter from December 07 onwards. I felt as if my clients had abandoned me (Highlight Reports 9th & 17th March). This feeling I recognise; my mother became ill and died at the end of 2006, and at the same time my relationship ended. I feel grieving has turned into a minor depression, and it takes effort to leave the house sometimes. Just the realisation that I am experiencing a depression has helped. I am taking measures to counteract the symptoms: I go to the gym in the mornings to get out of the house and have joined a sailing club.

I also note difficulty keeping to time with outcalls (Highlight Report 17th February). I have ascribed this to patients not wishing to let me go. However, in reality, it is as much my own disinclination to leave.

Reading about assertiveness skills in Burnard (1997) I was struck by the comment: "In order to care for others we must become more clear about our own needs and wants. If we want to reduce interpersonal stress we need assertiveness skills." (Page 47). On re-reading the chapter (pages 32-47), I was reminded how although the words I say are usually measured and adult, but delivery with clients can be "pussyfooting": I am cautious with advice, but with colleagues it can be "sledgehammering" although I may consider it to be just "speaking with passion" at the time.
To assert my own needs in my personal life has always been difficult for me.

How has this affected my professional relationship with clients? I assumed that because my therapy was focussed on a physical level, my emotional inhibitions would not affect my practice. I am cheerful and friendly, though practical with my patients. However, I am aware that I do look forward to appointments as an opportunity for social contact.

Reading Transferance Revisited by Susan Budd (1994), I took solace reading page 155 "all human bonds involve some element of transference. We never start a relationship de novo. We never love where we have not loved before". Even more when I read the quote by Karl Abraham page 161: "It is the physician's love which heals the patient."

My interpretation of the article suggests that by becoming aware of the mechanism, one can use it for the therapeutic process. Some of my patients look on me as an older mentor, and one even jokingly calls me "uncle". I feel empowered in this situation to provide advice, knowing it will not be ignored.
I don't underestimate the value of this warmth of relationship for good, therapeutically. In another part of the same book, Roy Porter (1994) talks about "fringe" medics in the past: "Irregulars commonly established personal therapeutic relations with their patients that gave at least psychological support to sufferers and often made good use of the placebo effect." (page 63).

However, I think the realisation of my involvement with my patients is probably not enough to protect me from painful counter-transference. In my efforts to maximise revenue, I am available for long hours, and never feel entirely off-duty. I cannot say "please phone back during normal working hours" or have a phone just for practice which I can switch off. I have a treatment room at home used for nothing else, but I have underestimated the effect on my life having clients visit. All public areas are restored and redecorated, but in such a way they feel anonymous and not like home.

Conclusions and looking forward:

Reflecting on my practice using the Calgary-Cambridge Framework has unearthed some poor practices, and I think I am a better therapist as a result.
It is interesting that the tutor identified a more appropriate plan might be to reflect on my own desire to get nourishment from patient satisfaction with my treatment. I have become aware in the course of the semester how this affects my practice, and consider this is the priority for work in my next plans.
I wish to separate my income from individual diagnoses and treatments. This is best achieved through working for an organisation. As I am building an interest in working with people with neuromuscular challenges - strokes, CP and spine injuries - working in the NHS would be most appropriate. I have decided to apply for a Physiotherapy degree at another university.

In my previous career working in big corporate organisations, I am used to the social aspect of team working, and have not completely adapted to the more solitary working as a therapist. I intend to work from clinics, in order to discourage socialising with patients. I will monitor my social life, to ensure I get daily and weekly social contact in other ways than through my practice. I have a contract to work from a clinic on a Wednesday evening, and am considering working at a gym 3 days a week.

Previous attempts to do this have not been successful financially, and I feel stuck and frustrated about trying it again. According to the Confidence and Conviction Grid introduced by Keller & Kemp White (2001), as quoted by Silverman et. Al (2005 ) page 196, I have high conviction of its importance, but low confidence of its success. A SWOT analysis and potential problem analysis (Kepner & Tregoe 1997) with a well resourced plan to commit to the success of this strategy is needed.

To help me stay on track, it may be useful in this plan to use the Intervention Process Stages of Change Model, originally used for addictions, developed by Prochaska & DiClemente (1986) as quoted by Silverman et. Al. (2005) page 195.

I will maintain reflective practices with my consultations, so that I can pick up red flags before they become serious.

Word Count: 2,200 Total

References

Belbin, M., (2004) Management Teams - Why they Succeed or Fail. 2nd Edition. London: Butterworth Heinemann. Chapter on Team Roles: Teamworker, Plant, Completer Finisher

Budd, S., (1994). Transference Revisited. In: Budd, S and Sharma, U., (eds.) The Healing Bond: The Patient-practitioner relationship and Therapeutic Responsibility. London: Routledge.

Burnard, P., (1997). Effective Communication Skills for Health Professionals. 2nd Edition. Cheltenham: Stanley Thornes (Publishers) Ltd

Kepner, C. & Tregoe, B., (1997). The New Rational Manager. Updated Edition. Princeton: Princeton Research Press. Chapter 8: Potential Problem Analysis

Porter, R., (1994). Quacks: an unconscionable time dying. In: Budd, S and Sharma, U., (eds.) The Healing Bond: The Patient-practitioner relationship and Therapeutic Responsibility. London: Routledge.

Silverman, J., Kurtz, S. & Draper, J., (2005). Skills for Communicating with Patients. 2nd Edition. Abingdon: Radcliffe Medical Press.