An Inspiring Conversation with Dr. Margret Cheng

Solution Focused Therapy medically complex patientI have had the immense pleasure of meeting Dr. Cheng, who has combined training in both Pediatrics and Internal Medicine. She dedicates her work to the care of medically and socially complex patients in underserved areas. She recently has been trying Solution Focused Skills in the care of her patients and has found it both inspiring for herself and beneficial for her patients. We recently spent a few hours sipping tea and conversing about the ways in which she has found Solution-Focused tools helpful in her practice. Below are a few of the pearls she has noticed in her work.

We began our conversation about a very complex patient she has been particularly inspired by. Briefly this patient is a 15y/o girl who is being treated for Diabetes and has coped with trauma and homelessness, Child protection involvement and family addiction. We will call her Sue.

Sue initially presented to the emergency room for chest pain and came to Dr. Cheng for a “sick visit” as an urgent appointment. She was not a patient she was regularly following. During this visit, Dr. Cheng discovered that she had poorly controlled diabetes (Her blood glucose in the upper 300s), and also found out she had visited the emergency room 6 times in the past 4 months and during all those ER notes, there was no mention that she had Diabetes Mellitus. During her ER visit, the focus was on her complaint of chest pain. She was given an EKG, told that her chest pain was due to anxiety and referred back to her Primary care provider.

Dr. Cheng met with both Sue and her mother for what was her initial visit with her and asked her gently how she could be helpful for them and whether it would be ok to talk with her about her Diabetes. Sue looked toward her mother for a response, and her mother said she wanted to keep her daughter out of the emergency room. Dr. Cheng had only 15 minutes during this visit, but by simply asking what they wanted help with and took time to validate and acknowledge the challenges of caring for her daughter’s complex needs, they both agreed to come back the following week.

They did return for the next appointment and also followed up with the request to get labs. During this visit, Dr. Cheng discovered Sue’s Hemoglobin A1C (A marker of how well Diabetes is managed) was the highest she had ever seen – almost 16. Dr. Cheng began the appointment by thanking them for coming to the appointment and inquiring how they were able to make it there and follow-up with the labs. She again asked their “best hopes” for this appointment so it would be helpful for them, and her mother said that she was now homeless. Dr. Cheng responded with a “for you” statement about how difficult this must be for them, followed by this question “Where do you get your strength from to continue?” This question invited Sue’s mother to open up about how she was one of 13 children and was “given nothing”. She was raised to just “carry one and not trust anyone, but to do what you needed to survive”. When asked how she had been coping, her mother said they have a place to stay with their family for now, and Dr. Cheng provided her with resources to help with housing. Sue and her mother were now making all follow-up appointments and during the next appointment when asked how she could be helpful for Sue, both her mother and Sue stated to “get her blood sugars under better control”. She asked her how she has tried to manage her sugars, and Sue and her mother said they were told by her brother’s endocrinologist to “do what he does”. Dr. Cheng asked what Sue and her mother know about how to manage blood sugars, and it became apparent they needed education on how often to monitor blood sugars. The next appointment Sue stated she was self-initiating checking her blood sugars once per day. She noticed it was high. Dr. Cheng explored this positive difference. Was it different for her to monitor her own sugars? Sue said yes. When asked how it was different, she stated she would often not check her sugars for days at a time. When asked if it was helpful for her, she stated that she is beginning to notice that when her sugars are high, she observes she is also more tired. When asked her how she managed to remember to check it, she stated she was getting a reminder from her mother and wanted to get better and get her driver’s license. Her mother was complimented on her support and asked how she managed to remember to remind her daughter.

This vignette brought up a several pearls for Dr. Cheng. The first being “You can do medicine best only after you have engaged positively with your client and their VIPs.” Dr. Cheng also noticed the paradox of starting “slowly” and how this paradoxically speeds things up. Dr. Cheng was inspired with the movement and progress of her patient. The nurses also were excited and pleased. Practicing the Solution-Focused Approach can be used to satisfy both patients and clinicians. Dr. Cheng began conversations by activating resources, identifying both Sue and her mother’s strengths toward achieving their best hopes for their future, and aiming to do more of what is already working. Dr. Cheng was inspired by the difference it made to focus on what is currently working, how clients are coping with extremely challenging life situations and redirecting the conversation towards positive elements of their situation. She was reminded that a patient’s “best hopes” may or may not align with those of the physician, but this is the place to start. At the end of the conversation, Dr. Cheng began reflecting on her excitement to try some additional questions we talked about when she returned to work: “ What’s happening that you want to continue to happen?” and “On a scale from 1-10, where 10 is you are satisfied with how you are coping with your challenges and 1 is the opposite, where are you now?” “ What keeps the number from being lower” What else? What would be a good enough number?” “How satisfied are you with how you are managing the diabetes from 1-10, where 10 is you are satisfied” “What number would your mother give you?”

We agreed to meet next month for tea and continue the inspiring conversation about how solution-focused skills are very effective tools when working with medically complex patients. Stay tuned!