Starting an exercise routine

In this scenario, the patient approaches his nurse with concerns about his weight gain and desire to start an exercise routine. For individuals with hemophilia, finding the right exercise can be challenging. We’ll explore this scenario using the “directive” and “constructive” approaches to see which approach leads the patient to a more personalized exercise routine. Each approach is followed by commentary to provide background on why one approach may have been more effective than the other. 

TRANSCRIPT

Transcript

  • Dave:

    “Hey, Michelle.”
  • Michelle:

    “Hi, Dave. Nice to see you again. How’ve you been?”
  • Dave:

    “Pretty good, I guess.”
  • Michelle:

    “Hmm. Is something up?”
  • Dave:

    “Well, I’ve put on a lot of weight since my surgery last year. It doesn’t seem like it’s going to go away unless I do something about it.”
  • Michelle:

    “You know, I’m glad that you’re bringing this up because in reviewing your chart earlier today, I noticed a big change in your weight since your last visit. You need to start taking better care of yourself, Dave.”
  • Dave:

    “Yeah, I know. I wasn’t able to exercise as much while going through my recovery. Since then, I haven’t had much motivation until I realized all the weight that I’ve gained. I have the motivation now, and I want to start making exercise part of my routine again.”
  • Michelle:

    “Okay, so what do you plan on doing?”
  • Dave:

    “Well, there’s a gym right by my house that I’m going to join so I can lift weights during the week after work, and then on the weekends when I have more time, I can do some type of cardio. Maybe even try running again!”
  • Michelle:

    “Those exercises are way too risky, Dave. You’re already at risk for joint bleeds because of the weight you’ve gained. Adding more would only increase that risk. I’m sorry, but you just can’t go into your local gym and start throwing some weights around. There are plenty of exercises you can do in their place that help to minimize the risk of joint bleeds.”
  • Dave:

    “I know there are other exercises, but I want to do these exercises. I thought that was part of why I had the surgery, so I can be more active.”
  • Michelle:

    “You can, and I’ll give you a list of exercises that you can do to help you be more active. Do these a few times a week and you’ll be on the right path to losing that weight.”
  • Dave:

    “Sure. Whatever.”
  • Michelle Witkop:

    “What happened in this conversation between the patient and his provider? The patient comes to discuss an issue he has with his weight gain, and the provider takes it as an opportunity to lecture the patient about taking better care of himself, causing him to become defensive throughout the rest of the conversation. When he discusses his plan for losing the weight, the provider continues to lecture him on the risks involved, shutting the conversation down. The patient feels the provider is only telling him what she thinks he needs to do, instead of working with him on what he would like to do.”
  • Based on this conversation, do you think the patient is still motivated to start an exercise routine? Would he feel comfortable bringing up an issue in the future with his provider? Let’s take a look at the same scenario using a more constructive approach.
  • Dave:

    “Hey, Michelle.”
  • Michelle:

    “Hi, Dave. Nice to see you again. How’ve you been?”
  • Dave:

    “Pretty good, I guess.”
  • Michelle:

    “Hmm. Is something up? What brings you in today?”
  • Dave:

    “Well I’ve put on a lot of weight since my surgery last year. It doesn’t seem like it’s going to go away unless I do something about it.”
  • Michelle:

    “You know, I’m glad that you’re bringing this up. In reviewing your chart earlier, I noticed a pretty significant change in your weight since your last visit.”
  • Dave:

    “Yeah, I know. I wasn’t able to exercise as much while going through my recovery. Since then I haven’t had much motivation until I realized all the weight that I’ve gained. I have the motivation now, and I want to start making exercise part of my routine again.”
  • Michelle:

    “That’s great. So what do you plan to do?”
  • Dave:

    “Well, there’s a gym right by my house that I’m going to join so I can lift weights during the week after work, and then on the weekends when I have more time, I can do some type of cardio. Maybe even try running again!”
  • Michelle:

    “So let me recap so I can make sure I heard everything correctly. It sounds like you’ve reached a point where you want to lose the extra weight you’ve gained after your surgery. To do this, you’re going to join the gym near your house where you can exercise by lifting weights. On the weekends, you want to substitute your weight-lifting workout for a cardio workout, like running. Is that right?”
  • Dave:

    “Yeah. I want to lose the extra weight and just be healthier in general. The gym near my house is convenient so I’ll be more likely to work out more often. And being able to run again will keep me motivated. I really enjoyed it before my surgery.”
  • Michelle:

    “Well, I’m glad to hear that you’re making exercise a priority again. I want to do everything I can to help you reach your goals. Would you be open to me sharing some concerns with you?”
  • Dave:

    “Yeah, sure!”
  • Michelle:

    “I understand that you want to start exercising and lose that weight. I think your plan is basically a good one. But I do have some concerns, specifically with starting too aggressively and the effect high impact exercises can have on your overall joint health. Because the weight gain adds stress to your joints, you could be at a higher risk of joint bleeds. Add to that the additional weight in the gym, and you could be increasing that risk even more. Running is good for you. But not if your joints aren’t prepared for that additional stress. Having a good re-entry exercise plan is essential. I know how important this is to you, and I want to help you succeed. Can we talk about that plan for you?”
  • Dave:

    “Yeah. I want to do this safely too. I know the extra weight is bad for my joints and can cause bleeds, but I plan on using lighter weights in the beginning until I build up some of the strength I lost over the past year. And the running? I know that’s something I can’t start right away. But maybe there’s another exercise I can do in the meantime until some of this weight comes off and I’m able to run again with less risk.”
  • Michelle:

    “That’s a good idea. I can see you’ve put some thought into this, and are aware of the risks. I trust you’ll be careful when beginning these new workouts. Something to consider is a walk-run program to slowly ease your body into a running program. Plus, there are a lot of exercises you can do to strengthen the muscles around your joints. If you would like, we can go through some of that right now, or we can schedule an appointment with a physical therapist to come up with a truly personalized approach to your new exercise routine. What do you think?”
  • Dave:

    “Well, since I’d like to get started right away, let’s discuss some of your exercises first. Then when I come back to talk to you about my progress, we can discuss a more personalized approach that can help me take my workouts to the next level.”
  • Michelle:

    “That is a great plan!”
  • Dave:

    “I agree!”
  • Michelle Witkop:

    “Why do you think the constructive approach was more effective? The patient comes to his provider with the same issue of gaining weight. But this time, the provider responds by showing interest and asking him about his plan to lose the weight. Once the provider hears about her patient’s plan, she repeats it back to him to make sure she understands him correctly before she asks to share her concerns. This provides the patient an opportunity to provide more explanation and to relieve some of her concerns, as well as encourages a more effective conversation. The conversation ends with the patient verbalizing his commitment to exercise and agreeing to work with his provider on an exercise plan to fit his needs.”

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