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SAMJ FORUM

but this is a long-term goal. In the short term monteleucast offers


the opportunity to refocus on the goals of asthma management as
set out by the South African Childhood Asthma Working Group
(SACAWG) (Table I).

Table III. Indications for montelukast


In a child 2 - 5 years of age with asthma:
1. Diagnosis: Chronic cough or wheeze responsive to a
bronchodilator or 7 - 10-day course of oral steroids
(prednisolone 1 mg/kg/day)

Montelukast is not a panacea for asthma. Recommendation for


its use, as a new therapeutic strategy, carries a huge responsibility.
In order to meet this challenge certain guidelines are suggested for
determining the ideal patient and for safeguarding both the patient
and the reputation of the product (Table III).

The modified bronchodilator response test: Document


symptoms and signs of asthma (e.g. audible wheeze,
hyperinflated chest, prolonged expiration) and then give two
puffs of a bronchodilator/nebuliser. Assess the response
objectively at 10 - 15 minutes.

We feel that the time is right for a shift in our recommendations


for the management of young asthmatics and hope that this
treatment approach will be adopted in future guidelines, but more
importantly, improve the quality of life of our patients and reduce
the enormous financial burden resulting from poor control of this
common illness in young children.

2. Four-week trial of montelukast


3. Response to montelukast as indicated by a significant
reduction in symptoms or use of bronchodilators

asthma. Incidence notes, 1964-1983. Am Rev Respir Dis 1992; 146: 888-894.
8.

National Institute of Health. Guidelines for the Diagnosis and Management of Asthma. Expert Panel
Report 2. NIH Publication No. 97-4051. Bethesda, Md: National Institute of Health, 1997.
Ferguson AC. Bronchial hyperresponsiveness in asthmatic children. Correlation with macrophages
and eosinophils in bronchiolar lavage fluid. Chest 1989; 96: 988-992.

1.

South African Childhood Asthma Working Group. Management of chronic childhood and
adolescent asthma. S Afr Med J 1994; 84: 862-866.

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2.

Anderson HR, Bailey PA, Cooper JS, et al. Morbidity and school absence caused by asthma and
wheezing illness. Arch Dis Child 1983; 58: 777-784.

10. Centres for Disease Control and Prevention. Surveillance for asthma in United States, 1960-1995.
Morb Mortal Wkly Rep 1998; 47: SS-1; 1-26

3.

Hill RA, Standen PJ, Tattersfield AE. Asthma, wheezing and school absence in primary schools.
Arch Dis Child 1989; 64: 246-251.

4.

Ninan TK, Russell G. Respiratory symptoms and atopy in Aberdeen school children: evidence
from two surveys 25 years apart. BMJ 1992; 304: 873-875.

5.

Ehrlich RI, du Toit D, Jordaan E, Volmink JA, Weinberg EG, Zwarenstein M. Prevalence and
reliability of asthma symptoms in primary school children in Cape Town. Int J Epidemiol 1995; 24:
1138-1145.

6.

International Study of Allergy and Asthma (ISAAC) Steering Committee. Worldwide variation in
prevalence of symptoms of asthma, allergic rhinoconjunctivitis and atopic eczema. ISAAC. Lancet
1998; 351: 1225-1232.

7.

11.

von Mutius E. The burden of childhood asthma. Arch Dis Child 2000; 82: suppl 2, 112-115

12. Sazonov Kocevar V, Jonsson L, Valovirta E, et al. Inpatient cost among pediatric patients with
asthma in four Nordic Countries. European Congress of Allergy and Clinical Immunology, 9-13
May 2001, Berlin, Germany (abstract).
13. Cochrane MG, Bala MV, Downs KE, et al. Inhaled corticosteroids for asthma therapy: Patient
compliance, devices and inhalation technique. Chest 2000; 117: 542-550.
14. Milgrom H, Bender B, Ackerson L, et al. Noncompliance and treatment failure in children with
asthma. J Allergy Clin Immunol 1996; 98: 1051-1057.
15. Knorr B, Franchi LM, Bisgaard H, et al. Montelukast, a leukotriene receptor antagonist for the
treatment of persistent asthma in children aged 2 - 5 years. Pediatrics 2001; 108: 1-10.

Yunginger JW, Reed CE, OConnell EJ, et al. A community-based study of the epidemiology of

COMMUNICATION

Neurolinguisic programming in the medical consultation


Chris Ellis

I am surprised you are reading this sentence. I would have


expected the average doctors eyes to have glazed over on reading
the title of this article and for him or her to have turned over the
page in search of the locums-available- in-Australia column. As
you are still with me lets have a shot at defining what it is.

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NLP (yes, it gets shortened into one of those ubiquitous


acronyms) is about communication. It is about how we take in
and process information from the patient and how we interpret it
through our internal filters (thats the neuro part) and it is about

Chris Ellis is a family physician in practice in Pietermaritzburg,


KwaZulu-Natal.

September 2004, Vol. 94, No. 9 SAMJ

how we use language, how we label things and how we talk


(thats the linguistic part). We use all of this, and more, to improve
our rapport with the patient and collect feedback from the patient
so that we can flexibly adjust our actions, words, non-verbal
gestures and approaches to the patient in order to achieve our
particular goal, which in most cases is helping the patient change
his or her health behaviours (that, in one long sentence, is the
programming part).
Now if you think neurolinguistic programming is a mouthful,
hold on for the jargon that goes with it. For example, there is
modelling, consulting flow states, meta-programmes, metamodels, break states, pacing, chunking and verbal reframing skills.
These are all some of the skills that doctors who are good
communicators have acquired over the years and that have not

SAMJ FORUM

been recorded or written about before. All techniques and


conceptual frameworks have their gurus and NLP is no exception.
It originated in the 1970s at the University of California in Santa
Cruz when mathematician Richard Bandler and linguistics
professor John Grinder became interested in how people change.
They were interested in decoding the patterns of language that we
use and how successful people communicate, respond and achieve
their results.1 Another guru, much quoted, is the American
psychiatrist Milton Erickson, also the founding President of the
American Society of Clinical Hypnosis,2 whose legendary
techniques helped patients with, among others, the pattern of
communication called conversational trance.

go on and change behaviour patterns such as smoking, overeating,


alcoholism or sexual behaviour one needs to go into the patients
beliefs, perceptions and expectations. One attempts to find out
how the patient works and about his/her internal filtering-out
processes and repetitive behaviour patterns. To do this one can
begin ones questions with softeners rather that direct upfront
questions. One can begin a question with I was wondering . . . or
Its interesting that . . . and lead into a conversational interview.

So, if you are still with me, NLP is, in fact, of great importance to
all doctors because it is based on what makes those doctors who
are really good communicators different from the rest of us, who
are muddling along, missing the clues and the cues. What is it that
these doctors are doing differently that makes them stand out from
the rest of us? Well, firstly, they pay attention to their own state of
mind. They look after themselves and their attitudes to both the
patient, their work and their life in general.3 You cant go into a
consultation dragging the baggage from the last consultation or
under the stress of knowing that you are running an hour late
again. After making sure you are in a fit state to see the next
patient comes the skill of developing as deep a rapport as possible
with the patient. This is done by getting, almost intuitively, into
the patients body and mind by mirroring his or her body
movements and rhythm of breathing and becoming generally in
sync, which sports people call being in the zone. There is also a
technique of matching and interpreting the tone, tempo, timbre
and volume of speech and picking up and observing a whole host
of non-verbal clues such as eye movements.4

There are many ways of doing this. The one I particularly like is
called pacing, which is playing back the patients beliefs to them
even if you strongly disagree with those beliefs. Pacing is not
agreement. It is simply acknowledging that many beliefs
surrounding health are not logical or rational from a medical
perspective but are true for the patient.

Once this is done one can backtrack. This is to repeat back to


patients what their main concerns are using the exact core words
they use in telling their history so that they know they have been
both heard and understood within their own idiom. This is
because the actual words and idioms we use are not picked at
random but are personally meaningful to each of us.4 This is
something like Carl Rogers deep empathetic listening and
accepting.5
One can assess how one is doing by what is called yes-sets.
This is the strength and quality of the yes you get back from the
patient. You can assess how much they agree with you. You can
get a Yes, thats right! which would be a full agreement with your
management plan, or a Yes which means maybe, or even a Yes
that means no, but I dont want to hurt your feelings by telling
you. This strikes me as similar to the methods used by genuine
traditional healers such as isangoma and amagqira, who appear to
communicate at the intuitive level of depth psychology6 and judge
the responses to the statements they make by the enthusiasm with
which clients reply with the statement, siyavuma, meaning we
agree.
This has now hopefully got you to a state of some shared
understanding and agreement in the consultation. If one is then to

September 2004, Vol. 94, No. 9 SAMJ

This then leads on to the setting of outcomes. NLP is not only


the study of the structure of subjective experience (to give it one of
its more scientific definitions) but it is also an outcome-focused,
solution-centred technology.4

You can then run your story (called lateral chunking) along the
lines of I had a patient once, just like you . . . and then give your
version of positive change or recovery. You can personalise the
story according to your own experience, but be careful of your
own unfiltered beliefs. Constructing metaphorical stories or
analogies to the patients perceptions and expectations can also be
drawn from your previous experiences, condensing them into a
short storyline. Even appropriate quotations are sometimes
helpful. One is trying to install a solution outside of the conscious
awareness of the patient.
My other favourite is the miracle question which goes along
the lines of if I had a magic wand . . . or imagine if you went to
bed tonight . . . and you awoke and your problem had gone.7
This helps the patient to verbalise or bring together in some form
what he or she wants and at the same time brings the consultation
into a lighter and more conversational mode. Like the British army
officer serving in Northern Ireland during one of their conflicts
who said that the Irish did not know what they wanted and would
not be happy until they got it, NLP may help those patients who
do not know where they are going and are about to land up
someplace else.
All human behaviour, both the patients and our own, is often
confusing. What is perhaps comforting is that confusion can only
occur when you are learning something new.
If you wish to learn more about NLP I highly recommend the
quoted book by Dr Lewis Walker, or contact him on
lewis.walker@ardach.grampian.scot.nhs.uk
1.

Bandler R, Grinder J. Frogs into Princes. Moab, Utah: Real People Press, 1979.

2.

Battino R, South T. Ericksonian Approaches: A Comprehensive Manual. Bancyfelin, Wales: Crown


House Publishing, 1999.

3.

Neighbour R. The Inner Consultation. Lancaster, MTP Press, 1987.

4.

Walker L. Consulting with NLP. Neuro-linguistic Programming in the Medical Consultation. Oxford:
Radcliffe Medical Press, 2002.

5.

Rogers CR. On Becoming a Person. A Therapists View of Psychotherapy. London: Constable, 1961.

6.

Bhrmann MV. Living in Two Worlds. Cape Town: Human and Rousseau, 1984.

7.

De Shazar S. Words Were Originally Magic. New York: Norton, 1994.

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