Personalised Care: The Missing Trick in CRM

The For Kidneys Sake podcast series is brought to you by Imperial College Healthcare NHS Trust and North West London Integrated Care Board (NWL NHS).

In this episode of For Kidneys’ Sake, consultant nephrologists Prof Jeremy Levy and Dr Andrew Frankel speak with Dr. Madhvi Joshi, a GP and certified health coach, about the power of personalised care and health coaching in managing chronic conditions such as kidney, heart, and metabolic diseases. Dr. Joshi explains how shifting from a directive approach (“what’s the matter with you”) to a collaborative one (“what matters to you”) helps unlock patient motivation, improve adherence, and build more meaningful partnerships. She discusses how understanding patients’ life contexts, values, and readiness for change can transform both outcomes and satisfaction for patients and clinicians alike.

Dr Joshi highlights practical frameworks such as the GROW model (Goals, Reality, Options, Will Do) and the 5As of behaviour change (Assess, Advise, Agree, Assist, Arrange) to guide conversations. She also shares a compelling case study demonstrating how lifestyle adjustments, compassionate dialogue, and shared goal setting led to significant improvements in health and well-being for a patient with multiple cardio-renal-metabolic risk factors. The discussion underscores that true progress comes from empowering patients as active participants, helping them navigate their health journeys with curiosity, empathy, and hope.

Key Takeaways

1. Personalised Care – Focus on What Matters to the Person

Shift from a disease-focused to a person-focused approach by asking, “What matters to you?” instead of “What’s the matter with you?”. This means seeing beyond clinical data to understand the patient’s life, values, and priorities. When people feel heard and understood, engagement and adherence naturally improve.

2. Coaching Mindset – Be Curious, Compassionate, and Non-Judgmental

Adopt a collaborative mindset rather than a directive one. Use curiosity to explore readiness for change, compassion to recognise challenges, and non-judgment to create trust. Coaching helps patients find their own solutions and apply knowledge in a way that fits their lives — turning advice into sustainable action

3. Structured Tools – Use GROW and 5As for Lasting Change.

Practical frameworks like GROW (Goals, Reality, Options, Will Do) and 5As (Assess, Advise, Agree, Assist, Arrange) guide conversations and support realistic goal-setting. They help clinicians and patients co-create clear, achievable steps — moving from one-off advice to measurable, lasting behaviour change.

Resource Links:
NICE GUIDELINES [NG203] chronic kidney disease: assessment and management Overview | Chronic kidney disease: assessment and management | Guidance | NICE

Northwest London CKD guidelines for primary care Chronic kidney disease (nwlondonicb.nhs.uk)

The purpose of this podcast is to inform and educate health care professionals working in the primary care and community setting. The content is evidence based and consistent with NICE guidelines and North West Guidelines available at the time of publication.

The content of this podcast does not constitute medical advice and it is not intended to function as a substitute for a healthcare practitioner’s judgement.

Produced by award-winning media and marketing specialist Heather Pownall of Heather's Media Hub

Chapters

• 0:00 Introduction to Personalised Care in Medicine
• 2:56 The Shift to Health Coaching
• 6:19 Understanding Cardio-Renal Metabolic Disease
• 8:32 The Role of Lifestyle in Patient Care
• 12:02 Real-Life Application of Personalised Care
• 16:44 Key Takeaways for Healthcare Professionals

Transcript

Jeremy Levy 

Hello, I'm Jeremy Levy. I'm a consultant nephrologist, kidney specialist at Imperial College Healthcare NHS Trust.

Andrew Frankel 

And I'm Andrew Frankel, a colleague of Jeremy, also a consultant kidney doctor at Imperial College Health Care NHS Trust. And welcome to another episode in For Kidneys' Sake podcast series. joined today by Dr. Madhvi Joshi. Madhvi is a GP partner and certified health coach with a particular interest in lifestyle medicine and weight management. Welcome Madhvi.

Madhvi Joshi 

Hi, thank you so much for having me. I'm Madhvi and I'm a GP and I'm currently supporting the Cardio-Renal Metabolic Project in Harrow. Really you having me today as a guest on your show.

Andrew Frankel 

So, Madhvi I'm going to start by burying my soul a bit. Yeah, no, no, I know. Well, we've got to make this a bit podcasts now. So I've been working with people with kidney disease for over 35 years. I've seen and seen many patients. I try and make the accurate diagnosis and provide them with advice on how to reduce the chances of them progressing to end stage kidney failure.

Jeremy Levy 

Dangerous Andrew!

Andrew Frankel 

or indeed suffering in the future. I feel I got some certainty about what needs to be done to help these people. And although I try and involve patients as best I can, I have to be honest and accept that I'm not universally successful at initiating change. And that isn't just in relation to the medical side of their care, i.e. the tablets.

but also in changing lifestyle. What I'm hoping we're going to find in this session and in this podcast is what am I doing wrong as I have a feeling that you may be able to help me move in the right direction.

Jeremy Levy 

Andrew, it's not just you, I think we're both on the psychiatrist chair here today, and ⁓ this is true for all of us, isn't it?

Madhvi Joshi 

Absolutely, and in all honesty, my previous approach was pretty similar to yours and I'm sure many other colleagues out there. In reality, we know about 50 % of people do not take medications as we've prescribed them. And some of the biggest impacts on patients actually arise from the social determinants of health, the things that happen to them outside of our consultation room. It can feel exasperating to give the same advice repeatedly in clinics. Without seeing much progress. And this is causing low satisfaction for both parties, really. 

The game changer for me was upskilling in personalised care and health coaching. It's a mindset shift for the clinician when the patient becomes an equal partner and does most of the telling. Whilst we, as the curious clinicians, can share information, pick up clues that tell us where the opportunities or the dead ends lie. People's lives are fascinating. So being open to hearing their individual story with our ears, with our minds and our hearts open. And we can assess where they are in terms of understanding readiness for change and use our collective resources and experience to unlock the potential for change.

Jeremy Levy

Really interesting my view and I like your thought that there are of dead ends as well as opportunities here and I think certainly in secondary care there's often a tendency for us to think about the problem in front of us the problem is the kidney or the blood pressure or the number and rather than thinking overall even though we might think we are about the patient with the problem and I said even though I try very hard I suspect that I'm as much at fault as this is everybody else

Can you give us some more practical advice? mean, that sounds fantastic in theory, but what are the core elements of what you're calling this personalised care approach, which also includes health coaching?

Madhvi Joshi 

So I think you're right, we're trained to think logically, identify clinical problems, apply our knowledge and our skills to solve them. However, in real life, both the problem or the solution are actually fluid, which means that they may change with time or circumstance. 

So we need to be adaptive. There's also the general assumption that people don't know enough about how to make changes to improve their health. Well, I'd say that because of the age that we now live in with digital information out there, most people now need our help with navigation and application of that health information. 

So the personalised care approach uses a few principles that shift the clinicians mind away from asking, what's the matter with you, to what matters to you. It brings us to consider that biopsychosocial model of health care and revisit our listening and our communication skills. And what that means is, recognising that the patient is seen holistically, within the context of their experiences of life, valuing their skills, their strength and experience and their important relationships. So we create a compassionate approach. The patient's an active participant in our conversations with choices in their shared decision-making about their and the patient can take control of their own health, build their knowledge, and engage meaningfully. So this person has hope and confidence that the process and the plan will deliver what actually matters to them.

Jeremy Levy 

That's really interesting Madhvi, Lots of colleagues out there are being trained to deliver this sort of approach at the same time as you. But I really want to press you. What do you really practically mean then by health coaching and this approach that you're taking and how it links with the patient's actual problems?

Madhvi Joshi 

Thank you, Jeremy. So, coaching isn't the same as what we know in sport. There's no blowing whistles up people. It's more of a psychological exercise where we explore the readiness or the barriers to change. And in health coaching, we ask the person to identify their goal. And this may not necessarily be the same as the clinician's goal. For example, it might be that they say, getting on a plane to see my family.

or being able to play football with the kids, or getting a good night's sleep and not feeling tired all the time is actually what they want when it comes to being healthy. So we connect these into health-related goals, like smoking cessation, healthy weight management, controlling their diabetes. The key questions that I use are using the GROW model. So GROW, of course, stands for Goals, Reality, options and will do. So a few questions I might use are, for example, what's your goal when it comes to being healthy? Tell me what you understand about being healthy. What's working well for you right now? Or what worked well before? What gets in the way right now? What happens if nothing changes? And now what feels possible?

What will you do? So this means that we're avoiding any assumptions or judgements about this person's health journey. Perhaps actually they used to be a professional athlete or a chef, or they care full time for their disabled spouse, or they work night shifts. So knowing what a normal day is for that person in turn shapes the language and the direction of our conversation.

And we can agree on SMART goals so that they are both realistic and they're possible. And then we agree on a reasonable timeframe for follow up. So there you've got the construct of a personalised care plan where we followed the five A's of behaviour change. And these are to assess, advise, agree, assist and arrange their follow up.

Andrew Frankel 

Madhvi, that is wonderful. And I am going to take that little bit of the podcast, record it, and somehow have it when I start my clinic every week. I'll probably listen to it not just at the beginning, but in the middle as well. That is fantastic.

Jeremy Levy

Andrew, you need it as a tattoo. A tattoo on the back of your head. A bit like cheating in exams when you were 15.

Andrew Frankel 

Yes. Yeah, okay, that might be a little bit difficult for the patient because I'd have to expose quite a bit of my body to read the tattoo. So, Madhvi, let's move on a little bit. So I was talking about my long-term career in kidney medicine, but I've now seen more and more that the patients I see don't just have kidney disease, but in the majority of cases have a mixture of kidney disease with cardiac disorders and metabolic disorders.

Madhvi Joshi 

Hahaha, Love that.

Andrew Frankel 

I suspect that's even more true in primary care. So how do I apply this principle of taking this approach when you're trying to do this to encompass more than one long-term condition?

Madhvi Joshi 

Thank you, Andrew. So a phrase that I use to set the scene with someone in front of me is that everything's connected to everything else. And what we now know is that what's good for your diabetes is also good for your heart, your kidneys and your brain health. And this introduces the patient to the idea of CRM, Cardiorenal Metabolic Disease, as a spectrum of conditions that falls under one umbrella and they have shared risk factors and shared treatment strategies. And then I ask sometimes, would it be okay if I ask you a few more questions that are going to help me understand your overall health? we may ask about any problems with skin, hair, weight, digestion, breathlessness, urinary problems, et cetera.

And it's that systems review that might offer clues about the other conditions like COPD, obstructive sleep apnoea, heart failure, peripheral vascular disease. And in women particularly, we often pick up those undisclosed aspects about hormonal dysregulation like PCOS or menopause or urinary incontinence, things that people don't naturally bring up in conversation.

And then we can link the shared pathway of these conditions by talking about the underlying factors that And we explore those common drivers for CRM conditions by going through the six pillars of lifestyle medicine. It's a much gentler way than launching straight into a conversation about a highly sensitive topic like obesity, which sometimes cause that patient to disengage.

Andrew Frankel 

So to me, not unsurprisingly, there's a lot of emphasis in your approach to lifestyle change. Can you convince me that this helps to optimise the treatment for people with clinical Cardio-Renal Metabolic Disease?

Madhvi Joshi 

Absolutely. So with coaching, it's a team effort rather than a battle. And it's not just useful in talking about lifestyle changes. When you use a compassionate and non-judgmental approach with coaching, there's just more room for honest disclosures. For example, why a diurestic treatment may be low. And this fosters a collaborative dialogue.

Sometimes, let's be honest, patients are dreading their appointment because they're expecting to hear more bad news and getting more pills. So when I share their recent test results, we actually focus on the points on the graph when things were looking good when they were on target. And then I ask, what was going so well at that point in their life? We then shift to where the graph looks less good and they can often map out for me those key events or changes in their life that match the good times and the bad times. And then we can use that to empower them to see what might be possible to be on target again. And linking that back to their own goal. How do I make sure you can get on that plane to see your relative? How can I make sure that you can get with the kids to the park? And that amplifies the self-motivation.

So it's not just my goal, it's their goal as well.

Jeremy Levy 

That's really interesting and it is a different mindset and a different approach that sharing the goals with the patient, not just talking to the patient. And I know you've been practicing this approach for some time yourself and you've been now rolling it out, haven't you, across Harrow for lots of practitioners who are working at the Cardio, Renal and Metabolic Hub and on these diseases. But again, can you give us an example with a patient where you've actually used this approach to affect change, ⁓ a real patient?

Madhvi Joshi 

Yeah, I'd like to share with you a real life case. And this is a 65 year old lady of black Caribbean origin who's approaching retirement, but she's also a carer for her husband who has early dementia. Actually, he's recently had a heart attack as well. She attended a health check and it was noted that she already had hypertension and an abnormal lipid profile as well as early CKD and her BMI was now rising over 30. She also mentioned that she had back pain, she was constantly tired, and her husband was complaining that she snored heavily at night. She was struggling to carry her laptop into work, and she was no longer able to pay for the personal trainer at the gym due to finances. So she was feeling pretty low, pretty depressed. And in the CRM clinic, what we did was we explored her heart and her kidney health risks and also re-identified that she might have sleep apnoea. Her rising waist circumference also indicated she had a future risk for type 2 diabetes. And she disclosed that her mother had kidney problems and her father had heart failure. So now if her heart age risk was accelerating, currently it was calculated at 72 years. Then there was this increased chance of a negative impact, not only for her, but also her husband who now relied upon her. So it became a moment of motivation to address her lifestyle. 

And then when we followed her up at eight weeks, she was taking both her blood pressure and her cholesterol lowering medicines and had already lost six centimetres from her waistline. With a 3 % reduction in her weight. So her QRISK heart age had now returned to her expected chronological age of 65. Well, how did she do this? What did she do? It was about changing her working pattern. So she could work flexibly from home and that reduced her stress levels. It gave her back time to eat more home cooked food, making meals that she prepared with her husband. And that quality time also reduced his depression. And they took up this idea of a kitchen disco where they'd play their old favourite music and they danced around the kitchen. She now goes to Zumba and she no longer needs antidepressants and she doesn't take any analgesia for back

Andrew Frankel 

I know that is a single example but it really is truly inspiring, Madhvi It really is. But let's give you now the opportunity to give the audience the three key takeaways that you would like them to leave with.

Madhvi Joshi 

So my three takeaway messages, number one, personalised care. Think about the person as a whole, knowing what matters most to them and really tailor your language and personalise a plan that fits to that individual. Remember, there are only a patient in our clinic, the rest of the time, there are a person out there in the real world.

Tip number two is a coaching mindset. So be curious and compassionate. Never assume anything. And remember, helping people with navigation and application, not just giving them more information. And number three, try the GROW or the 5As model. So remember GROW is Goals, Reality, Options, Will Do. And the 5As is assess. Advise, agree, assist and arrange. To guide your conversations for successful behaviour change and to make those small, sustainable steps.

Andrew Frankel 

Madhvi, thank you so much for coming on the podcast.

Madhvi Joshi 

Thank you very much, it's been a delight.

Jeremy Levy 

No, no, I've learned so much as well. Grow, follow theys I need to remember that, I've written them down on a piece of paper. I'm taking them to clinic with me because I'm not going down the tattoo route that Andrew's going down. Madhvi that was fantastic. Thank you so much.

Madhvi Joshi 

It's my pleasure. Thank you.