How Solution-Focused Therapy can enhance care of the medically complex patient
An Inspiring Conversation with Dr. Margret Chang, M.D.
Anne Bodmer Lutz, B.S.N., M.D.
I have had the immense pleasure of meeting Dr. Chang, 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 introduced the Solution-Focused Approach, and has been trying Solution-Focused Skills in the care of her patients. She 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 talking about some of the medically complex patients who have particularly inspired her. The fictional case is a composite of the types of cases Dr. Chang often works with. Briefly this fictionalized patient, who we will name Sam, is a 13y/o boy who was being treated for diabetes and has coped with trauma and homelessness, child protection involvement and family addiction.
Sam initially presented to the emergency room for chest pain and came to Dr. Chang for a “sick visit” as an urgent appointment. He was not a patient she was regularly following. During this visit, Dr. Chang discovered that he had poorly controlled diabetes (His blood glucose in the upper 300s), and also found out he had visited the emergency room 6 times in the past 3 months and during all those ER notes, there was no mention that he had diabetes mellitus. During his ER visit, the focus was on his complaint of chest pain. He was given an EKG, told that his chest pain was due to anxiety and referred back to his primary care provider.
Dr. Chang met with both Sam and his mother for what was his initial visit with him and asked gently how she could be helpful for them and whether it would be ok to talk with him about her Diabetes. Sam looked toward his mother for a response, and his mother said she wanted to keep her son out of the emergency room.
Dr. Chang had only 15 minutes during this visit, so she focused on asking what they wanted help with and validating the challenges of caring for a son with complex needs. Following this, 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. Dr. Chang began the appointment by thanking them for following-up with their appointment, appreciating the challenges of coming back, inquiring how they were able to make it there and how they were able follow-up with the labs as requested. His mother said how she hopes that I can help keep him out of the emergency room and that his Diabetes could get under better control. During this visit, Dr. Chang discovered Sam’s Hemoglobin A1C (a marker of how well diabetes is managed) was the highest she had ever seen – almost 16. She asked them their “best hopes” for this appointment so it would be helpful for them, and her mother disclosed that she was now homeless. Dr. Chang 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?”( See footnote 1 for meaning of “for You” statement) This question invited Sam’s mother to open up about how she was one of 9 children and was given nothing. She was raised to just carry on, not trust anyone, and to do whatever is needed to survive. When asked how they had been coping, her mother said they have a place to stay with their family for now, and she was taking things day by day. Dr. Chang provided her with resources to help with housing. Sam and her mother were now making all follow-up appointments and during the next appointment when asked how she could be helpful for Sam, both her mother and Sam stated to “get her blood sugars under better control”. She asked him how he has tried to manage his sugars, and Sam and his mother said they were trying to learn from his cousin, who also has to cope with Diabetes. When Dr. Chang asked what Sam and her mother know about how to manage blood sugars, and it became apparent they needed education on how often to monitor blood sugars and were open to learning more about the skills needed.
The next appointment Sam stated he was self-initiating checking his blood sugars once per day. Sam noticed it was high. Dr. Chang explored this positive difference. Was it different for you to monitor your own sugars? Sam said yes. When asked how it was different, he stated he would often not check her sugars for days at a time. When asked if it was helpful for him, he stated that he is beginning to notice that when his sugars are high, he observes he is also more tired. When she asked him how he managed to remember to check it, he stated he was getting a reminder from his mother. When asked “how else” he remembered to check his sugars, he identified wanting to get better enough so he can get his driver’s license. His mother was complimented on her support and asked how she managed to remember to remind her son given all the challenges she is also managing. Since seeing Dr. Chang, he has stayed out of the emergency room!
This vignette brought up a several pearls for Dr. Chang. The first being “You can do medicine best only after you have engaged positively with your client and their VIPs.” Dr. Chang also noticed how starting “slowly” paradoxically speeds things up. Dr. Chang 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. Chang began conversations by activating resources, identifying both Sam and his mother’s strengths toward achieving their best hopes for their future, and aiming to do more of what is already working. Dr. Chang 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” often align with those of the physician, and this was surprising for her. At the end of the conversation, Dr. Chang 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!
1 – “For You” Statements: A language technique that can help to provide empathic responses quickly and easily to clients by integrating the words “for you” within statements and questions. (ie) This must be frustrating and difficult “for you”.
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