Advice Giving and Anticipatory Guidance

1. Advice Giving and Anticipatory Guidance Julie Lord, MD Colin Dauria, MD Heidi Combs, MD

2. Objectives: At the end of this session you should be able to • Decide what content and circumstances are appropriate for giving advice to patients • Determine how directive the advice should be • Demonstrate the skill of anticipatory guidance in role play

3. The type of advice depends on the who the patient is • With higher functioning patients, limit your advice to the scope of your professional expertise such as mental illness, psychiatric treatments, medical topics, etc. Don’t give advice that they could get from others in their lives (social conversation vs therapy.) • For seriously impaired patients, it is often appropriate to give advice about activities of daily living. These folks sometimes need help with the basics and lack other supports.

4. Techniques • Try to enhance the patient’s own problem solving skills when possible. • Try to avoid giving commands. Give in the advice in such a way that the pt can reject it without feeling uncomfortable. • Phrase it as a proposal rather than a direct recommendation.

5. Example • Pt: “The cat keep me up all night again. I’m just not getting any sleep. I feel tired all day.” • MD#1: “Why don’t you give cat away?” • MD#2: “Would you consider giving the cat away?” • MD#3: “What are your alternatives?”

6. Pitfalls • Unneeded advice can be annoying or demeaning. • Take care not to impose your personal preferences or values on patients. • Giving advice that is not followed weakens the MD-Pt alliance. Pt may feel angry or embarrassed, and MD may feel frustrated or angry.

7. Needed advice vs good advice • Pt: “I was laid off. A lot of us were. I need a new job in a hurry.” • MD#1: “You should read the classified ads every day and read all of them, not just the ones for the jobs you thought about.” • MD#2: “What’s your plan for finding a job?” • MD#3: “Do you need any advice about how to go about looking for a job?”

8. Giving advice case • A patient comes to you and complains that his marriage is not happy and goes on to describe how over the years they have become more distant and have only been staying together until their kids graduate from high school. They tried marriage counseling in the past but did not find it helpful.

9. What advice should you give? • Discuss how many years they have been together and encourage him to stick it out, better times will come. • Suggest there were probably good and bad things about the marriage and recommend the patient spend some time reflecting on why they had stayed together for such a long time • Help the patient to see enough is enough and it is time to call it quits before things get really bad.

10. Definition of anticipatory guidance • You help the patient to consider what problems might come up in future situations. You anticipate potential issues and help provide guidance on what to do if issues arise.

11. Why do anticipatory guidance • The pt can prepare strategies for dealing with them. Think of it like a rehearsal. • The pt anticipates possible future situations and becomes more familiar with them leading to less anxiety. • It is much easier to think about how to deal with something when not being confronted by it!

12. Tips • Don’t work harder than the pt. • Be flexible. • Quit rather than fighting with pt. • The more impaired the patient, the more concrete and direct the guidance required. • Very confident pts may not anticipate difficulties about the proposed course of action. Try to incorporate the message that preparing for obstacles is a normal part of everyday living, not a contradiction of pt’s optimism or a put-down.

13. Example • 45 yo patient with chronic schizophrenia is really worried about discharge because he needs to go to his case manager’s office and then take the bus to Tacoma to pick up some belongings. D/C is tomorrow. • MD: “What is your plan for tomorrow morning?” • Pt: “I don’t know. I have to get my stuff

14. Example Continued • Pt cont: “from Tacoma but I don’t have any way to get there because I left all my money down there.” Pt appears anxious. • MD: “Have you thought about transportation to Tacoma?” • Pt: “Yeah, I could take the bus but I don’t have any bus money.” • MD: “Do you know of any place to get a bus token?”

15. Example Cont’ • Pt: “My case manager has them, and he also has some money for me. I guess that I should go to my case manager first. Maybe I could take the shuttle over there [to HMC] to his office.” • MD: “That sounds like a solid plan that will work for you [reinforcing problem solving and building hope]. Now, are there any problems that might come up . . .” etc

16. Difficult Pt: the “Yes, But’-er” • 50 yo trucker who had always considered himself a loner, recently lost job and does not know how to fill days. Pt knows that he has too much free time on his hands. MD first tried repeatedly to elicit ideas from pt (pt had none) and then began giving direct suggestions. • MD: “What about volunteering at the local animal shelter?”

17. Knowing When to Quit • Pt: “I don’t have enough gas to get there. They probably don’t have any openings anyway.” • MD: “Are there other ways to get there?” • Pt: “Yeah, but I hate riding the bus.” • MD: “I am trying my hardest to help you here, but none of my suggestions are working. Would you like to take a break from this topic and revisit in the future?”

18. Group Exercise: Role Play • 57 yo woman in treatment for depression. She works fulltime in a professional job and lives alone. She is starting to feel better during the work week, but she feels very lonely and anxious on weekends. When she feels this way, she stays home and ruminates about her emotional state and negative ideas about her future. She recognizes that she feels better when she has structure and is around people. Help her prepare for next weekend. One student is patient, one is doctor. In groups, take turns being the doctor.

19. Group exercise: • Break into small groups • Each member describe an example of advice giving or anticipatory guidance you have done • Discuss how the advice giving went- both the good, the bad and the ugly!