Kindelan and Kent (1986) posed a mixed group of general practice patients questions correlating with five territories: diagnosis, prognosis, aetiology and prevention, social effects of the illness and treatment, and asked them to order these in terms of their ‘importance for today’s visit’. Information on diagnosis and prognosis were deemed most important, followed by treatment and aetiology, with social effects being least important. One reading of this response would be to consider it in terms of knowledge, with an inverse relationship existing between the degree of the patient’s knowledge about the area and their need for information about it. ‘Social effects and illness’ was presented to patients in the form of the question: ‘How will it affect your daily life, for example, work, looking after the children?’ The patient’s knowledge of this, in the case of established illness, is far superior to that of the practitioner – the patient is already an expert in this subject. In the early stages of a condition however, the patient’s greatest degree of uncertainty is around the nature of the condition and its degree of seriousness (‘prognosis’ was posed as: ‘The seriousness of your illness, its likely outcome and time before you will be well’), and these are areas where the superior knowledge of the practitioner will usually be recognized. We might surmise, therefore, that although knowledge and information priorities vary between patients, they will tend to lie in the areas where the patient feels greatest uncertainty and anxiety.

Practitioners can use the relation between uncertainty/anxiety and information priorities as a guide but will be best served by asking the patient directly as to the main issues that they would like to discuss. It is important to avoid making assumptions – practitioners may, for example, emphasize information about treatment when that is only of minor immediate concern to the patient; many phytotherapy patients are already in possession of a conventional medical diagnosis but this does not mean that they are disinterested in the topic (some may have a strong desire to gain an alternative rationale); even where the prognosis for a condition is very good patients may still have deep doubts and profound worries about the future and the severity of their state; aetiological uncertainty or controversy (e.g. in fibromyalgia or chronic fatigue syndrome) may be a key focus area; social effects, although well known to the patient, may be the area where there is the greatest need for information providing help, support and enablement; patients in a relatively stable chronic condition may worry that a new treatment could disturb the balance they have found.

We will explore the various issues involved in talking about the herbal prescription later in this chapter but first we will identify and briefly consider a range of other areas of attention (and strategies related to these) in the closing stages of the consultation.

Referral: involving others

It may be necessary or desirable to connect the patient with others who are able to offer additional help. This could be for a number of reasons including referral for investigation; for assessment or treatment by another practitioner (see Appendix 3, which considers interprofessional communication); or, using the notion of ‘referral’ more broadly, to another source of support or information such as an adult education class in tai chi or meditation. It is strongly recommended that practitioners build up a network of contacts (and a portfolio of contact details) for all the sources in the local area that they might need or wish to connect patients with. In doing this, the practitioner puts in place the means to practically enable working with a broad range of advice – and to walk the holistic talk.

Information, activity and support sources that might be considered suitable include:

• Local practitioners and health services

• Specific support service, e.g. bereavement counselling

• Classes and courses, e.g. yoga, tai chi, meditation, anger management, dance, singing, cooking

• Adult education centres

• Healthy food sources, e.g. local farms, organic box schemes

• Fitness centres and sports clubs

• Social groups/clubs, e.g. walking clubs

• Birth and parenting support, e.g. a local breast-feeding counsellor

• Local council services

• Local and national condition specific support groups

• Arts centres

• Citizens advice bureau

• Parks, woods, gardens, etc.

• Aids to explanation.

In communicating explanations in such areas as aetiology and diagnosis, it is useful to have recourse to non-verbal aids such as pictures and anatomical models. Each practitioner can develop these based on the range of conditions they most commonly see. It is also frequently helpful to sketch explanations that are best appreciated visually – my own notes are littered with very rough sketches explaining everything from the heart cycle to nudge theory.

Aids to providing information

It can be helpful to develop a personal stock of information documents that can be printed off as required. These can cover a vast range of issues, including information regarding: conditions, concepts, dietary advice and recipes, breathing and massage techniques, reading lists, etc.

It is preferable to make such documents personal (do-it-yourself), brief and attractive. I print out postcards with some of the slogans described in Chapter 3 (see the ‘Engendering wellbeing’ section) such as: ALWAYS CHOOSE BIG MIND! Apparently they end up stuck on a lot of fridge doors.

Aids to memory

While giving advice or discussing key points, it is helpful, as we have already mentioned, for the practitioner to write notes down for the patient as the need arises. That works well if you can write clearly but since my writing is mostly illegible to others (and occasionally to myself!), I often write notes then post or e-mail them to the patient later (I’ve even texted them when they have been brief). There seems to be something quite useful about sending brief notes in these ways, following the consultation – certainly it communicates care but also appears to have greater impact.

An alternative strategy is to provide the patient with a sheet of paper (or better still a postcard with your details printed on it, which looks more attractive and is therefore more likely to be kept and used) and a pen to take their own notes. Not all patients like this and it seems to often cause distraction, slowing the momentum and reducing the connection in the encounter. Some patients are glad to be offered the opportunity though and a few have commented that they would have liked to take notes but had not asked in case the request was considered rude.

Low literacy

The previous item assumes patient literacy however, and Roter et al. (1998) have cautioned against assuming that patients possess this competency. It is not necessarily easy to tell if a patient has difficulties in this regard, since: ‘most people with low literacy skills are of average intelligence and function reasonably well by compensating for their lack of reading skills’. However, low literacy might be associated with poor communication skills and this may become noticeable during history-taking. Patients may find it difficult to discuss their predicament and many have never disclosed the degree of their situation, even to their partner. Roter suggests that patient-centred interviewing skills benefits these patients and that their understanding can be helped by the same techniques that work for every patient, namely:

… organizing information into logical blocks, simplifying the message, making the message specific rather than general, repeating the message, summarizing, checking understanding by asking patients to give an explanation in their own words, and reinforcing the most important messages.

Good levels of literacy do not guarantee that the patient will understand the practitioner’s, or general health messages. Shaw et al. (2008) found that, irrespective of level of literacy skill, many patients still: ‘feel unable to access, understand and utilize health information’. The authors called on healthcare professionals to: ‘improve their communication skills and ensure that health information is clear and easy to access’.

Talking about Herbal Medicines

We have already mentioned some relevant issues pertaining to the prescription but the list below details the range of factors that may require consideration and discussion:

• The aims of the treatment: what it seeks to achieve

• The content: which herbs are to be used

• The form: which type/s of preparations are to be taken and whether these pose any challenges (e.g. a patient may be able to take a tincture but unwilling to devote time to making decoctions)

• What to expect: what is the patient likely to experience in response to taking the prescription

• How long it will take to gain effects

• Palatability: what it will taste like and whether any action needs to be taken to enable consumption

• Dosage and frequency of taking: e.g. some patients may be able to take medicine once a day but find it difficult to take three doses

• Whether any adverse effects might occur and what to do if they arise

• Compatibility with other medication or treatment (e.g. addressing potential herb-drug interactions)

• Expected length of treatment course

• When the prescription will be received (e.g. immediately on completing the consultation; by post; or by collection at an arranged time)

• What to do if any query arises: how you can be contacted

• Gauging the patient’s understanding of the treatment aims and their ability to follow the treatment.

A new patient welcome sheet or short booklet can be developed to deal with frequently asked questions regarding the prescription, addressing the areas we have just listed.

Additional explanations are commonly desirable in the closing stages of the consultation to clarify the nature of herbal medicines and their differences when compared with conventional drugs (Table 7.1); these areas are explored below.

Table 7.1 Differences between herbal and conventional medicines

Herbal medicines	Conventional medicines
Chemically complex: adapts multiple targets	Chemically simple: aims to hit specific targets
Generally non-specific: modulates systems performance	Tendency to be specific: can cause precise change
Individualized herbal prescriptions tend to change at each consultation, evolving as the condition changes	Fixed courses of treatment with the same medication are the norm
Relatively gentle in nature and action	Relatively aggressive
Tends to nurture physiological change	Tends to force physiological change
Low incidence of adverse effects, which are generally minor when they do occur	Higher incidence of adverse effects, generally of greater severity
Slower to accumulate effects but more sustainable as a long-term treatment	Effects more rapid but a less sustainable form of long-term treatment
Few issues with tolerance, dependency and withdrawal	Problems associated with tolerance, dependency and withdrawal may be pronounced
Ultimate locus of control is the body	Ultimate locus of control is the drug

The Nature of Herbal Medicines

Herbal medicines tend to:

• Support, enhance or restore normal physiological function, by facilitating the body’s innate self-healing capacities

• Teach, train or ‘re-programme’ the body into better or enhanced patterns of physiological behaviour

• Gently steer the body into more appropriate courses of response and function, with each dose of herbal medicine acting as a small ‘nudge’ in the ‘right direction’

• Render themselves obsolete once they have aided the body in establishing optimal autonomous performance, or

• provide a safe long-term management option when restoration of normal function is not possible

• Work complexly across a number of body systems

• Act quickly in acute conditions but gradually in chronic conditions, accumulating greater effects over time.

The Practitioner as Leader and Manager

While the patient-centred practitioner will seek to follow the patient’s lead and work in response to the patient’s agenda, there is still a requirement for the practitioner to convey her own ideas, suggestions and recommendations with regard to such matters as diagnosis, treatment and in the domains of advice. The holistically-minded practitioner needs to reach a point where the broad appreciation of the patient that has been gathered can be translated into particular strategies and actions that can be proposed to improve the patient’s situation. In drawing the consultation to a conclusion, a plan of action needs to be negotiated with the patient and its implementation reviewed at subsequent meetings. These various imperatives call for reflection on the notion of the practitioner as ‘leader’ and as ‘manager’.

Herbal practitioners may experience resistance to these terms given that they suggest paternalistic models of control (leaders imply followers; managers imply subordinates) that are usually considered anathema in holistic approaches to medicine such as phytotherapy. Yet, as we shall see, there are alternative readings (of leadership especially) that may enable practitioners to perform these necessary roles in a manner that does not restrict the patient’s autonomy. The antipathy that might be felt towards ‘leadership and management’ by healthcare practitioners can derive from a number of sources including the correlation between leadership and the ‘great man’ model, or its association with a tendency towards a charismatic or autocratic style; and in connecting management with business and bureaucracy.

Although literature deriving from the business world has traditionally contrasted leadership with management, considering them to represent different though allied roles, there has been a more recent tendency to conflate the two – seeing them as representing different aspects of a continuum. This development appears to be, at least in part, an attempt to redress the balance between management and leadership that has been tilted in favour of the latter, as Gosling and Mintzberg (2003) observe:

Most of us have become so enamoured of ‘leadership’ that ‘management’ has been pushed into the background. Nobody aspires to being a good manager anymore; everybody wants to be a great leader. But the separation of management from leadership is dangerous. Just as management without leadership encourages an uninspired style, leadership without management encourages a disconnected style, which promotes hubris.

Northouse (2007) draws on early definitions of management as having to do with ‘planning, organizing … and controlling’ and insists that, while there are similarities between the two (e.g. both involve the exertion of influence; working with people; and goal accomplishment), management and leadership have distinct differences. In fact, they may be considered to represent antithetical agendas, given that:

The overriding function of management is to provide order and consistency to organizations, whereas the primary function of leadership is to produce change and movement. Management is about seeking order and stability; leadership is about seeking adaptive and constructive change.

We may readily see the connections between the definition of leadership given here and our discussion of complexity theory at various points in this book (especially at the end of Ch. 3) and with the assertion made in Chapter 2, that the nature of life (and health) is change. (Wheatley 2006, explores the relationship between complexity and leadership in depth.) We might then be tempted to connect leadership with the holistic phytotherapy approach, in contrast to the management agenda of conventional medicine. This may lead us to reject management in favour of leadership but to do so could risk missing lessons that stand to be learned from the business world:

… if an organization has strong leadership without management, the outcome can be meaningless or misdirected change for change’s sake. To be effective, organizations need to nourish both competent management and skilled leadership.

If we substitute ‘practitioner’ for ‘organization’ in this quotation, do the assertions still hold? A final quote from Northouse (in which he draws on Bennis & Nanus 1985) might be helpful in attempting to answer this question:

To manage means to accomplish activities and master routines, whereas to lead means to influence others and create visions for change.

This perspective could be applied such that the patient is cast as self-manager (planning, organizing and controlling their own lives – including implementing and mastering treatment ‘activities’ and ‘routines’) with the practitioner acting in a leadership role to catalyse such self-management. Management priorities of ‘order’, ‘consistency’ and ‘stability’ are not incompatible with the leadership imperatives of ‘movement’, ‘adaptation’ and ‘constructive change’ – rather these two groups of qualities define each other because they perpetually engage each other. The patient’s urge towards stability drives movement and change just as the atom’s desire for electrical neutrality causes it to interact dynamically with other atoms.

The familiar concept of ‘case-management’ can be justified given that the practitioner must also ‘accomplish activities and master routines’ (such as those having to do with history-taking, diagnosis, formulating a prescription, etc.) and create ‘order’ (for instance in regard to setting and keeping appointment times); ‘consistency’ (such as acting as a source of continuing care); and ‘stability’ (being there for the patient when needed). In the light of our reflections thus far however, we also need to consider how ‘case-leadership’ might be enabled and enacted. The rest of this section will therefore focus on leadership rather than management.

The literature on ‘leadership’ has conventionally viewed the leader as an individual in charge of a team (the leader of an organization), whereas the patient–practitioner relationship is dyadic and the patient-centred version eschews the notion that the practitioner is ‘in charge’. A leadership model that fits the values and concepts of patient-centred medicine is therefore required. One approach is to change the ‘leader–follower’ relationship into one of ‘leader–collaborator’ (Rost 1995), a concept that emphasizes the active participation of the patient and which can be further democratized by suggesting that the roles of leader and collaborator may be exchanged between practitioner and patient during the course of the consultation. Other models that may inform appreciation of leadership within a patient-centred relationship include those given below.