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When patients don’t care about their diabetes care
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It’s no secret that most of my clinical and research activities involve in bone and mineral metabolism, both in the lab and the clinic. In my new position I am faced with most of my patients coming to clinic for management of diabetes.
In my role as a clinician, I view myself as a teacher to my patients with diabetes, but for the most part, it is an uphill battle. More than 30% of my new patients with type 2 diabetes turn up at the clinic without a glucose meter and/or a blood glucose diary. If they do bring a meter, it is immediately obvious that they do not look at serial blood glucose data and do not know that they should have been taught how to adjust their insulin dosing, or preferably their eating habits, to maintain a more stable capillary blood glucose. When they are concerned about a high fasting glucose (ie, >300 mg) they tend to overdose with insulin. Most often they elect to inject glargine twice a day.
Michael Kleerekoper
Oh, and I almost forgot! A large proportion of new referrals — no, not from my academic colleagues in family medicine or general internal medicine — are on a variety of oral medications for diabetes, often no less than three different classes. They are reluctant to use insulin, other than long-acting insulin, and ignore any instructions they have received regarding carbohydrate counting. And, of course they are taking numerous other medications to control diabetes-related complications.
Most of the time I am privileged to have a diabetes educator and a dietitian in the clinic, but they face the same obstacles.
As I see it, there are many cogent reasons why diabetes control is so limited in a large section of the population. As the pocketbook is getting smaller, the meals are getting too expensive and the body habitus is getting too expansive. With all the best intentions stemming from Capitol Hill, it is unlikely that this will diminish substantially over the next few years. Further, diabetes is increasingly compromised by dyslipidemia and microalbuminuria, not to mention the wear and tear on the hips and knees.
So what is the solution? I have some ideas already in progress, including group sessions for teaching purposes, planned walks on the beautiful campus and frequent emailing or mailing of blood glucose data. What I don’t have is confidence that this will be as effective as I would like it to be. After all, moderate physical activity will do little for diabetes if a patient’s BMI is extremely high.
Perspective
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Mary M. Austin, MA, RD, CDE, FAADE
I can sense the frustration that Kleerekoper must feel. Long ago when I first became a diabetes educator in Toledo, Ohio, I was given sage advice, “You should never feel that you are working harder than the patient in managing their diabetes.” Kleerekoper sees himself as a teacher, which is laudable, providing the “student” is ready to learn when the teacher is ready to teach. People generally do what is important to them and what they are confident in their ability to do well. Unfortunately, many patients with diabetes are constantly reminded of what they are not doing well. “Your A1c is still high” is interpreted by the patient as “I am a failure at managing my diabetes.” This may be how the message is interpreted when an A1c improves from 9.2% to 8.1%. Generally, people do not want to engage in activities that they are not good at doing.
How do we help patients to better manage their diabetes so they see it as a priority and are confident in their ability to do it? As providers we need to first look at ourselves.
It may be necessary to play more than one role. In a previous issue of Endocrine Today*, I outlined the different roles that health care providers (HCP) may need to assume in order to help patients better manage their diabetes. Table 1 outlines the differences in the role, goal, method and focus we assume when we approach patients as a consultant, counselor or coach. Depending on the role you are expected to play in our clinics, you may only serve as the consultant/expert, or you may be able to assume all three roles. Patients with diabetes need to have access to, and expertise of, all three roles. Counselors and coaches help patients explore what is important to them with regard to their life and diabetes management and help them become more confident in the skills required to manage their diabetes.
There are many efforts under way to transform the health care system to a more patient-centered model. This is an effort to transition from an acute illness (“fix it”) model of care to the chronic disease model of care. There are numerous efforts on many levels that, can be cited to help HCPs implement and become proficient in providing patient-centered care. However, my experience tells me that for many patients, their reality still is the “fix-it” model of care, where they see only the “consultant.” And, patients see themselves as bystanders and not as active participants. Unfortunately, you may be seeing a patient on referral who has experienced only the “fix-it” model of care.
Efforts such as group sessions, walking groups and frequent sharing of blood glucose data are steps in the right direction to engage patients in their own care and help them transition from “bystander” to active participant. Patient engagement to improve diabetes management will not happen overnight, but we must take every opportunity available to us to make it the new reality for all patients with diabetes.
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