Wednesday, March 11, 2009

Food and Table Rules

Michael Pollan, of "In Defense of Food" fame, has started a new project. In his last book he cautioned us to "Eat food. Not too much. Mostly plants". For his new book project he is soliciting our input on rules for eating. He believes that it is important to preserve the cultural wisdom around choosing, preparing and eating food. Sayings such as the Japanese "hara hachi bu" (eat until you are four-fifths full) and the German "tie off the sack before it is full" are examples of traditional ethnic advice to stop eating before becoming completely full. Some of the funnier ones people have quoted include "No white food after Labor Day... or ever", "No dumpster cheese" or Miss Piggy's "Never eat more than you can lift" rule.

His request reminded me of a strategy I've used with parents when we discuss healthful eating. Originally an ice-breaker activity, I uncovered some interesting obstacles to enjoyable family meals with the question "what table rules did you grow up with?". As an example, I would share that in our family we had a "no singing at the table" rule thanks to a sister with her sudden off-key, raucous opera-like singing outbursts that clearly needed to be stopped. One father shared his boarding school experience of the "clean plate" rule which included his fear of a teacher who stood over him till the last bite was downed. Another parent shared a "no talking" rule while another admitted to frequently breaking the "no talking with your mouth full" rule.

It is fascinating to talk with parents about their childhood table rules because they now set the table rules for a new generation. Some steadfastly maintain their childhood rules - I know my mother would appreciate that I mandate the "no elbows on the table" rule - while others have rebelled completely and refuse to set any rules. Many times, I've had to explore the origin of table rules or lack of table rules to help parents build useful boundaries for their child's eating habits and to set the stage for more enjoyable meals.

As we encourage our patients to have family meals as a strategy to increase healthful eating, it might be important to also discuss table rules. If nothing else you might uncover some amusing rules and anecdotes. I know my son will enjoy telling folks the story behind his mother having to mandate the "no naked people at the table" rule.

Tuesday, March 10, 2009

Reflection - a radical concept?

courtesy iStockPhotos
Last week I was part of an interviewing panel for a new first grade teacher at my daughter's school. I love to participate in things like these as I get a first hand view of another manager's interviewing process which inevitably helps my own hiring strategies.

First, we spent time bringing clarity to the job role and determining the questions that would uncover the right person, right fit for the job. Always time well-spent and very insightful to hear different stakeholders' perspectives. Then after the interviews we discussed our interpretations of the candidates' answers and body language and debated merits and drawbacks. Again, another insightful activity.

There was one point in the lively post-interview debate that caught my attention. It was pointed out that a candidate might be too entrenched in her ways and may not be sufficiently reflective to notice when curriculum changes are necessary to enhance student learning. Apparently, teachers in this school are expected to be self-reflective. It is seen as a valued and critical skill necessary for effective teaching.

What a concept! How often do we, as health care professionals, spend time reflecting how we are conversing with our patients? We are teachers too yet do we give sufficient thought to our "curriculum" or typical education points? Just how well are our current strategies working for us? Yes, we might lament that patient X just doesn't get it or that patient Y is resistant to change. But that isn't self-reflection about the things that we are doing or the things we can change.

Just remember when reflecting on your own teaching style, information-sharing techniques, and patient skill-building strategies it is necessary to do it from a results-perspective: how well are your patients doing under your current education strategy? As one of my colleagues would always say when working with a resistant patient spending lots of time justifying inaction "and just how well is that working for you?"

Monday, March 2, 2009

Mapping a conversation

Whether the disease is diabetes, heart failure, asthma or obesity, there is a lot of information that we think is necessary to share with our patients. Unfortunately, none of us have truly perfected the art of sharing that information in a way that universally makes sense to our patients. Maeve Binchy, in her latest book Heart and Soul, eloquently highlights the stories heart disease patients might tell themselves when faced with the doom and gloom of their disease diagnosis. The wise healthcare provider will hear these stories before engaging in any dialog about diets, medications and other disease-based to dos.

Fortunately, disease management organizations are looking for ways to improve the dialog between healthcare provider and patient. Many are embracing the health coaching model and enhancing their use of motivational interviewing or change talk. Lately I've seen reference to conversation mapping in the education arsenal. Medication manufacturer, Merck, has funded work on conversation mapping. Building on this work and in partnership with the American Diabetes Association, Healthy Interactions has developed the U.S. Diabetes Conversation Map Tool (R). This tool has most recently been incorporated into Kaiser Permanente Mid-Atlantic region's diabetes education curriculum. The tool (a 3 x 5 foot table-top visual display) acts as a conversation enhancer allowing a trained facilitator to use the patients' perspectives to guide the discussion and help lead participants to make sustainable lifestyle change to better manage their disease.

Conversation mapping has been around for awhile and is used frequently in organization, research and social media fields. It is a modeling process used to explore complex and ill-defined issues. It can help frame key perceptions that prevent consensus and action-oriented work in a certain area. Conversation mapping can explore the inherent tensions and problems related to changes. Better yet it can frame the various elements of the ‘root definition' of a problem.

Just imagine having the perspectives of policy makers, scientists, physicians, medication and/or surgical device manufacturers, psychologists, dietitians, nurses, town planners, food manufacturers and patients all around the table discussing the future action to take to stem the obesity epidemic? Imagine a conversation mapping tool helping these folks, with many different and divergent perspectives, navigate the complexity of the obesity epidemic to come to a unifying approach for action? What would that conversation LOOK like?

As it turns out, visualizing a conversation isn't that hard anymore. Wordle makes it very easy to "see" a conversation by creating word clouds - the larger a word is in a word cloud the more often it has been repeated. People have been using it to map email threads and Twitter feeds. Possibly we should be using this tool more often. Perhaps evaluating the effectiveness of our conversations or uncovering the focus of our beliefs. Is what we are saying aligning with what we think we are saying? And if we were to "word cloud" the text of our portion of a conversation with that of our patient's portion of the conversation - would it look divergent or similar?

Please note that the word cloud above is from this blog post and was made at