บทถอดความฉบับเต็มของ From Conversation to Action: Moving Medicine with Hamish Reid

want to just Take an atypical pathway, then having having good mentors is really important. That's probably somewhere that I haven't Haven't prioritized enough, as I've gone through training.  05:45 - Callum (Host) Yeah, last question before we we get stuck into conversation about motivational interviewing With a name like Hamish on Calcutta Cup Day Are you a blue or a white fan?  05:55 - Hamish (Guest) I'm blue cup. Yeah, good answer. Not by, not by my accent, but yeah, by my. My dad and also I played a bit for Scottish Unis as well.  06:05 - Callum (Host) It's particularly easy being a blue fan at the moment, seeing that the England is a great time, isn't it?  06:09 - Hamish (Guest) It's just. It's just a world cup, draw Cal. That's the only problem.  06:12 - Callum (Host) Yeah, pretty gutted about that, to be honest. Now I wanted to touch on on a Motivational interview, particularly on the back of the active conversations course that that you and Tim set up. It's a pretty huge topic and I think will only scrape the surface. I'll probably, as ever, I'll be over ambitious and trying to fit in more than we have time for. So Please, please, stop me if I get carried away here, hamish, but I actually I thought a good place to start is probably the start of the patient journey. It's almost pre-motivational interviewing. But In terms of setting up our consulting rooms and our waiting rooms, do you have any advice or anything you'd recommend to To healthcare professionals, and particularly in primary care? But but across this the spectrum that we could do to Influence behavior through the way that we set up our waiting rooms and our consulting rooms.  07:11 - Hamish (Guest) Yeah, I guess there's a range of different ways of looking at that. For me, one of the things it makes me think about is that you know, one of the barriers to talking about physical activity that's quite pervasive amongst clinicians is the expectation of futility in terms of bringing it up and having not productive conversations that people don't want to talk about and therefore shying away from them. The other hand, to that, if if patients can be initiating conversations, then it really changes the game in terms of of that that experience for clinicians. So it is a really useful thing to focus on. So, when you look at a patient journey coming in, I think there's environmental modifications you can look at. So, for instance, making information available, posters, leaflets, clear signposting, opportunities for people to stand in waiting rooms you know things like this just clear signposting that facilitates movement. I suppose, whilst it's a very static environment, I mean there's places that set up little walking loops in waiting rooms and things like that for our patients and stuff. So there's lots of different ways of approaching that environmental Constraint, which you can just put a mindset that movement really is a part, a core part, of health and also the health care experience.  08:27 As well as that, I think everybody within the environment can be Contributing to the behavior change around physical activity, and this is the same for other lifestyle factors. But, for instance, you know reception staff, or you know if you're going for a nursing check in an outpatients department to do your height and weight, or whatever contacts there are along the way, or or porters moving somewhere around or something like that. There's, there's opportunities for conversations In all of these places and that's what I think is as a system. Actually, some of them are just as influential for some people as Conversations to clinicians probably so. So I guess that's a training thing partly as well.  09:11 - Callum (Host) Yeah, it's really interesting and you know, as doctors we often have influence but lack time, whereas People like porters have the time to have those conversations and may have a greater influence as a consequence of being able to To really engage in those in this conversation and they might be better at identifying with people's own values.  09:32 - Hamish (Guest) You know, then, there may be stories and life experiences that can connect them really brilliantly with people that actually you know. Whatever role you have in health care and you can, you can contribute to People's perception of ownership and opportunity in terms of take taking command of their own health care.  09:51 - Callum (Host) Yeah, I suppose Next step is Patience in consultation and in an ideal world We've done something correct in in the build-up to them coming in that they bring up physical activity off their own bat, yeah, and if they do, we can hopefully jump on that and have the have both the the skills and and the enthusiasm with which to do so. I Suppose futility comes in there. Maybe that's something we can talk about later. But what if that doesn't happen. What tips do you have for bringing up physical activity in a consultation?  10:23 - Hamish (Guest) I guess we need to recognize at this stage that the consultation is likely to have a range of objectives and so there needs to be prioritization in the consultation about those objectives. So often like if you're you know, we're talking a lot to the primary care audience, as often as primary objectives that a patient would have come in for something's happening at the moment or there's a you know, it's a chronic disease checkup or there's some sort of issues going on. So it's going to be rarely the primary focus of the consultation unless someone's been invited back specifically for that. So I think either you can look to and again it's time dependent. So this is where what you decide to say is important within the time, because time is the pervasive barrier to all behavior change conversations, because you have to get through so many different things, as we all know. But if you feel that's important, then one of the things that we struggle with a little bit is the feeling that if

we're going to talk about physical activity, a successful conversation on physical activity is going to involve a plan and in a way that's often a quite a big barrier to the conversation, because it's pretty hard, if you've got a minute, to come up with a plan around physical activity. So often that perception of the time limitations will stop us bringing up the physical activity conversation. But so, but if we go into that conversation looking to make someone end that consultation more likely to consider changing their physical activity behavior or more likely to engage with you in a subsequent event around physical activity conversation or something like that, if those are our objectives, then actually that's, that's. That's a big help in terms of our mindset about what we're looking to achieve.  12:11 Then bringing it up, I guess in the frameworks in moving medicine, you'll find that one of the ways we hang it is around the disease itself or the medical condition. So now we've just been through your blood pressure medication and that's all looking pretty good. Now We've got two minutes left of the consultation. Would you mind if I brought up another thing that's really important for the management of this and also your health going forwards? Very good, Very few people will say no to that and you can say well, physical activities are really important thing for managing blood pressure because it can help control your blood pressure but also reduce your risk of having a stroke, and what do you think of that?  12:52 And then offer someone the opportunity to come back at you and they might say, yeah, I know all of that, or I didn't know that. I'm interested in that, or you know, and if that's, if that's your time frame, then you can follow that up and say, well, if that is of interest, perhaps it's something you'd like to come back and talk about on another occasion and try and set up that or signpost a resource or something like that, and actually that in itself is perfectly adequate, particularly in a medical consultation, to bring it up as an important thing, use the opportunity to share some information, but also respect the patient's autonomy by asking their own input on what you've said. So I think that's certainly a way of doing it, to hang it on the back of what you've just been talking about.  13:32 - Callum (Host) That last example you just gave is a perfect example of the one minute conversation Is a ask share. Ask, which is ask, or invite someone into the conversation, share a little bit about physical activity and then ask them their opinion. Yeah, yeah, I think. Putting it back to the futility thing, I think it's an important thing to talk about and mention.  13:53 You mentioned time being a big barrier and I've done some research which shown that it's the biggest barrier to anyone implementing physical activity and it's both time pressures themselves and the perceived pressure of how long it's going to take to deliver the physical activity promotion. The other interesting thing I actually don't know where this research was done, but the number needed to treat for smoking cessation is between one and 50 and 120. But for physical activity promotion it's one in 12 to have an influence on behavior and so, as a number needs to treat it, it's much better in primary care delivered than smoking cessation. It's just an attitude or an approach, and so if we can really drill into that and persuade people to do it, then the influence is likely to be much bigger.  14:42 - Hamish (Guest) Yeah, and I think, with that influence, it comes down to the expectations of behavior change as well, isn't it? It comes down to the expectations of that behavior change as well, right, so there's going to be very few conversations you're going to have with anyone that's going to totally revolutionize their physical activity behaviors. They do happen, but that's unlikely to be the case. But as long as we're not pushing people to do something that's on our own agenda and we're hoping them bring out the things that are important to them and them strengthen their own reasons for change, that's the way that we're going to build to lasting change for them. And going into our conversations with that priority, I think for me is the most important thing. And actually recognizing that, within time limitations, as long as we focus on a bit of that, that's okay. And it's that prioritization thing around time that's important, yeah.  15:32 - Callum (Host) Just touching on that, hamish, and maybe that it's better safe to the end, but seeing it's come up. One of the biggest pressures is time and I think that's one of the biggest things that put people off. And do you have any tips of how we get out? Say that we start the conversation. It's growing arms and legs and we think, gosh, we've got three people waiting. How do we close that conversation? Or not so much prevent it from happening, but push it to a further location or a time?  16:00 - Hamish (Guest) Yeah, and it's really important to do that and it's a skill that I've trained in a few different, you know, prime in sort of general practice roles and and GPs are the ultimate masters at managing time and conversations and things of that and and always amaze me with their skills With this kind of thing. There's a couple of things probably that can be useful. One of the one of the really useful things I think to to do if we're going to be kind of as MI consistent as we can in this objective is is using a summary. So if we feel that we've we've had a lot, we've got some great content and someone's really talking and we really want to get more because we're on to a great thing, but we've got three people in the waiting room, times ticking, we're already five minutes over and you know you've got to get away to a meeting at lunchtime. You have to wrap things up. So summary is a really nice way of summarizing and that this is a.  16:55 There's an analogy of using a

summary like picking wild flowers from a field, where you go around and and the field is is all the things that that person said and what you've gone, and you've gone and picked a few things from the field and put probably like change talk and and and things like that. You've picked the real highlights and you've packaged them up and you've given them back to someone and in doing that, they can hear their own words and their own expressions for change and you can really powerfully reinforce their own position that they've just that, they've just articulated. And actually hearing your own thoughts back clarifies them in a very powerful way in your mind. So you can use a summary by saying I just like to take this opportunity to summarize what I think you've, just, what I think I've heard at this time. And so I think that you said this, this, this, and then actually, before you did this, this, this, and you're looking towards doing this, this, this, and you think you might be able to do it here and here, did I get that about right? And someone can say, no, you got that absolutely wrong. And then you know you're on to a bit of a winner and you need a new technique.  17:59 Or they might say, yeah, that's, that's a pretty good reflection of where I am.  18:04 And if they say that, then you can say OK, because now we're actually at a point where I'm afraid we're going to have to move on this conversation.  18:12 So we've got, we've got other patients in the waiting room and being honest about that People absolutely understand that and just being transparent around that but say, look, what you've told me sounds really important, then I'm really really interested in this is this is so important for your health. What you just told me that perhaps this is something that we can build on on a future conversation or signpost them to you know a social prescriber, or you know no specialist or if you if you're not going to have the time to do that yourself, but actually it's a really nice thing to be able to. You know, one of the really nice things you can do in primary care is you can bring that person back to yourself in a way that in other roles you can't necessarily, so that, if you can fit that in, is a really nice way of doing it. I think A sort of summary like that, yeah, it's nice you touched on.  19:00 - Callum (Host) If you miss as well, I think. If you summarize and the patient says no, that's not what I meant. What I meant was and they give you it, they reflect themselves, and it's almost like a win-win. I think that's. That's a cool thing to touch on, or at least it feels like that, yeah, and they help to clarify what they are trying to say.  19:19 - Hamish (Guest) So they actually hearing it back might help them think, actually, you know that isn't really and it's and we shouldn't be inhibited by the fact we might get it wrong. As long as we're honest and as long as we're curious about what we're saying, it gives them an opportunity to clarify that

it doesn't help your time pressure, but it's really can be helpful for the individual.  19:37 - Callum (Host) I suppose what you've touched on is summarizing and reflective listening, which is a huge part of being able to summarize, are a huge part of of motivational interviewing and reflective listening itself I was telling you him is just before he came on Kirsty texts me and say remember to speak about ours, and ours is an acronym to summarize reflective listening. I'm probably going to get this wrong now, but I think it stands for opening question. Oh gosh, what's the second?  20:06 - Hamish (Guest) This is your past fail off the course, isn't it, cal?  20:09 - Callum (Host) Yeah, the answer is a question. This is the first one. Yeah, that's right, yeah.  20:15 - Hamish (Guest) And then reflections and summaries. Yeah, so they're all really brilliant tools and, to be honest, when, if you do learn a bit of motivation to be honest in clinical practice, these are the things that I keep in my head, particularly when I was learning to keep using, you know, in terms of improving my listening. You know, questions, affirmations, reflections and summaries, and, on it, open questions are something that we learn. I think all health professionals learn open questions and the value of them. When, when I learned am I realized, although I'd spent quite a lot of time trying to learn open questions, I realized I wasn't very good at it and we are so many closed questions in practice that actually, if you record what you do and then look, listen back to how many closed questions you ask, it's a bit terrifying. Our objective is to ask more open questions and close questions, preferably twice as many. So then, an affirmation is something that I hadn't really learned before coming across them. I don't know about you, Cal.  21:14 - Callum (Host) No, I hadn't touched on it either.  21:16 - Hamish (Guest) Yeah, yeah and so and there's an important difference between an affirmation and praise, right and like praise is just saying, oh well done, that's fantastic, good on you, those sorts of things. But an affirmation is something that reinforces a good part about that individual, so specific to them, and something that they've said and you're pulling out something about their character, their behavior, their values that you think is a really good thing and you want to reinforce for them and that can help improve their confidence and all that sort of thing by doing that.  21:49 - Callum (Host) Could you give us an example of an affirmation Hamish, just for people that haven't come across it before or aren't quite sure exactly what that might look like?  21:59 - Hamish (Guest) Well, Cal, you're an excellent questioner in podcasts and you put a lot of thought into asking me questions in a really nice way.  22:05 - Callum (Host) I'll take that, thank you.  22:09 - Hamish (Guest) Yeah. So it's trying to pull something out that the individual's been doing for you Not for you, but it has been sort of saying to you or if someone was talking about you know, if they liked running the cake, stand at a fate or something like that, you could say something like you really give a huge amount of value to looking after the people around you.  22:37 - Callum (Host) Yeah, yeah. I think it is helpful as well that it doesn't have to be related to what we're trying to achieve, so it doesn't need to be related to physical activity or movement or then promoting health. It could be just an aspect of their character which we're trying to build into what we're trying to achieve, moving forward, and you can turn the tables on things a little bit.  22:56 - Hamish (Guest) So someone might say, like I've tried to stop smoking 15 times and I just, you know, I'm absolutely useless at it, so they might be feeling really negative. And actually you can say now you've, despite having failed to commit to stop smoking 14 times, you've gone back and you've done it 15 times. That shows that you're a really committed and strong willed person. So you can really try and, you know, like steer towards some strength that people may not see about themselves. And they might say, oh, actually, well, I suppose that did take a bit of effort when I went the 15th time and maybe I shouldn't give up because you know, here I am and maybe maybe I'm actually I'm better than I thought it was, or something like that. So, helping people try and reflect on some of those things.  23:40 - Callum (Host) Yeah, I think that's a. That's a really cool point and I think that's a conversation. Certainly I have a lot, particularly around diets and weight loss. People say I've tried so many times and nothing works for me, and actually that's a. You know, that affirmation is really powerful and I think I hadn't thought of using it, but I'll maybe steal it. Trademark unit as well.  24:00 - Hamish (Guest) Yeah, no, it's a really nice simple one, isn't it? And helping people see the good things that they've done, and we know that the more times people try, the more likely they are to succeed.  24:08 - Callum (Host) Yeah, it's amazing, it's really helpful and yeah, thanks for for kind of unpacking your oars for us and the reflective bit and the summarizing something we covered. Yeah just, you know, five minutes ago. So that's, bro, thank you. Another thing that really struck me about the active conversations course, and one technique that I love using, is the scaling or confidence question, and I was wondering if you'd be willing to talk listeners through it and the impact it can have.  24:38 - Hamish (Guest) So this is not where we put you through as a little tester post course again. Yeah to do, to do your best, yeah, nice. So it is a really nice tool and for for for ways that I think, at face value you don't necessarily realize. So the aim of it basically is it would be generally easy to looking at the importance people ascribe to a change and also the confidence that they have to

make that change happen. So we might have had a conversation where you've said something like when you've, when you've dropped the this is a conversation I had some of the other day when she drops the kids off at school in the morning, that's a time that she could walk up the hill and say and so I could say something like okay, so on a, on a scale of one to 10, where one is not at all important and 10 is the most important thing you can think of how important is it to you that you start walking up and down the hill after you drop the kids off at school? And then what might you say back to me? It's about four, hamish, about four. So and you say four to me, right, this is just things that. So our natural response is all, that's a bit low, isn't it? Like, maybe you're not going to do this, but what I can use, like essentially the numbers of using this tool, is irrelevant. So what I can say to you oh, you said four, cal. How can we said like four and not two? Because what happens when I say that to you is I force you to talk about the positive things that you have towards that importance. But no, but it's really awesome like that, because it's a way that you can like whatever they say. You can basically steer them towards, like, if they say 10, you can go wow, how can me said 10 and not nine, you know, or whatever.  26:19 But the only challenge that sometimes people feel is well, what if they say zero? And people do say zero, and if they say zero, they're generally like that's see that as a resistance behavior. So, for whatever reason, like you're, you're pushing them into a conversation that they're not happy with. So you're removing their locus of control by this. They're not, they're not happy with it and they want to make that point. So you can just say something like wow, you feel really strongly about that and they'll be.  26:51 Yeah, I do feel really strongly about that, because walking up the hill is the most ridiculous thing I've ever heard, you know, or whatever it is so, but like finding a way to reflect back at them and not to create friction with what they say, like, come on, it can't be zero. No one says zero. It's not zero. Yeah, it's zero, you know. So don't get yourself into an argument. Just reflect back on something about their behavior and then they'll come back at you and explain more, and then you should hopefully move into something more constructive. But so the zero answers, the only one that it's worth just having. If I say one, you can say how come? One, not zero, it's the same thing.  27:30 - Callum (Host) That's really helpful. I think definitely having a response to zero questions probably quite helpful. Otherwise you can be caught off guard and I think sometimes it's easy to react when you're off guard by saying something like well, that's obviously not true. You must have some confidence. You might be able to achieve it.  27:47 - Hamish (Guest) And I think saying, I think saying wow, you feel really strongly about that.

For me that works well. I feel comfortable saying that, and I find that people respond to that quite well, so I just say that.  27:59 - Callum (Host) I think, touching on that, one of the huge benefits of the Active Conversations course was you and Tim, but also the open forum in which people would post their own experiences, because I think we can all learn from that and develop techniques and skills and answers to questions. When we're stumped, just having them to blow our tongue and be able to respond in ways which are non-judgmental, and also even things like the affirmations. It's really great to have stock responses because often the meaning behind a lot of what people say, although in different contexts, can be quite similar and they can work. For example, the one that you gave about gosh. Can't remember I was gonna say about obesity. You were saying smoking.  28:43 - Hamish (Guest) Yeah, 15 attempts at smoking, no, that's absolutely right and yeah, hearing real life examples and stuff, it's great.  28:48 - Callum (Host) I just wanted to touch on developing discrepancy, which is another thing that's covered in the course, and I think it's a really helpful tool as well for almost prompting change in individuals. I realize I keep pushing this onto you, hamish, but could you just quickly talk us through what we mean by that? And yeah, bring in the two possible futures model if you fancy, but no worries if not.  29:18 - Hamish (Guest) Yeah. So developing discrepancies I guess one of the you know like a fundamental component of my duration interviewing but what it involves is getting someone to reflect upon their own value system and what's important to them and identifying the difference between what's happening in their life and what that value system is. So quite often you'll find that people will in, like I said, they used to play football. So you take a 54 year old man who used to play football and be really sporty and then you got into his career and got a knee injury and put on some weight and these sorts of things. Often in his you know, in his heart he might see himself as a fit and active person, but the reality of his life he's not that person anymore. So developing discrepancies, helping someone see the difference between what is their values and what's important to them and what's happening at the moment, and that can be a really, really powerful, really powerful driver of change to help people see that difference. The two possible futures model is kind of a construct of trying to help people see discrepancy and I think that's a good thing to do. It's kind of a construct of trying to help people see discrepancy and the way that you use. That is to say, okay, if we take a behavior change, to say, you managed to go twice a week to your aquafit classes and you managed to keep that up and you decide you want to do it and you managed to keep it up for the next four months.  30:58 If you managed to do that, what do you think your life might look like then?  31:04 And that gives someone an opportunity to say well, I feel that actually I know that I need to get a bit stronger and move more to help my knee pain and also I'm trying to lose weight.  31:15 And if I'm more active, then that generally helps me feel more healthy and need a bit better. So I think I'd have lost a little bit of weight and I think my knee would be feeling a bit better if I did that. And then you can say well, let's say, actually you left today and you thought that's really actually not for me at the moment, I don't really want to go and start doing those classes and you just carried on your life as you are at the moment. What might your life look like then? And then they might say something like well, I guess I'd be as I am now. I might put on more weight because I've been put on quite a bit of weight over recent months or something like that. So helping them see the difference, to look project forwards and see what that sort of fork in the road might look like and what might mean to them and the important things in their life.  32:02 - Callum (Host) Great. Thank you. I think it's a really cool tool. I've used a couple of times. It's to help people. It's similar to the scaling question and creating a priority and a reason for engaging in action. But it's a really cool tool and I've enjoyed using it. So I can't really say whether it's been effective. I hope it has, but it's the long-term effective. This is hard to tell. We'll see. Maybe we'll have another one in a couple of years' time here. I'll let you know, Give you some feedback.  32:36 - Hamish (Guest) Yeah, you'll have all these skinny people running into your clinic room without cigarettes.  32:44 - Callum (Host) Yeah, I hope so Cool. I've really enjoyed that. We could have talked for ages longer and that's just a marker of how much there is to cover. And also, again, the importance of doing the course or doing more reading into motivation, interviewing and how it can be used, particularly in healthcare settings. I'll put some resources in the link in the podcast, but just for reference. How can I sign up for active conversations if I decide I want to do it for a second or even a third time?  33:21 - Hamish (Guest) Yeah Well, on your performance today, cal. I would recommend doing it again just to get some refreshers. So, if you go to the Moving Medicine website, there is a link at the top that says online course. So the Moving Medicine website is movingmedicineacuk and there's a link to online course. If you click on that it will take you through to the course and you can just sign up to the course there. And yeah, there's lots of different motivation interviewing courses around our courses, specifically around physical activity and behaviour change, looking at person-centered conversations and we've tried to make it as user-friendly as possible, focus on clinical scenarios and accessible to as many people as want to use it. So, hopefully, hopefully there's. You know, people will find some value in that and we love seeing people on it and hearing all the different stories people get up to and different clinical conundrums. Like you say, it's great to share that stuff and that's how we learn. Yeah, it keeps teaching me lots.  34:23 - Callum (Host) Oh well, look, you've taught me lots and I really appreciate it, and hopefully the lessons have learned something as well. So yeah, thanks Hamish, thanks for joining us, and if you want to find out more, check out Moving Medicine and active conversations online.  34:34 - Hamish (Guest) Thank you Cal, it's been a pleasure.