‘Tedious, tiresome and dull’: Strategies to improve diabetes self-management education
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The dropout rate for participants in diabetes self-management education and support classes remains high, and diabetes care and education specialists must look in the mirror to make needed improvements, according to a speaker.
Adults with newly diagnosed type 2 diabetes are often never referred to diabetes education self-management education and support classes, William H. Polonsky, PhD, CDE, president of the Behavioral Diabetes Institute and associate clinical professor at the University of California, San Diego, said during the Outstanding Educator in Diabetes Award Lecture for the virtual American Diabetes Association Scientific Sessions. When they are referred and attend a class, they are overwhelmed with information in a “tedious, tiresome and dull” way that does not make room for questions and discussion about what really matters, he said.
“I ask you, as educators, to think about your own programs. Maybe it’s time to face the truth,” Polonsky said. “Problematic attrition is not happening because our programs are inconvenient, although that does have some role to play. To a much larger degree, the problem is us. Our programs are boring.”
Many studies demonstrate that diabetes self-management education and support, or DSMES, makes a difference for people newly diagnosed with type 2 diabetes; however, few are referred and even fewer attend a DSMES program, Polonsky said. Few studies are done assessing why participants drop out of programs or are not referred in the first place, although anecdotal evidence suggests that some — including health care providers — do not believe the classes are worthwhile, Polonsky said.
“It is clear that, in the best case, less than 30% of patients referred ever make it,” Polonsky said. “Most people who do make it never make it through the whole program. They drop out early. The evidence on this is very limited, but we all know this is true.”
More than boredom
As diabetes care and education specialists, it could be easy to see the problem of poor attendance at DSMES classes as the fault of the participant, Polonsky said. Surveys conducted with people who stopped attending DSMES classes often cite convenience, which could lead specialists to think tweaking class times or locations will fix the problem, he said.
Convenience is an issue, but there is more to it, Polonsky said.
“When people say, I’m too busy to come back, to an extent what they are thinking is, ‘Your program is not that worthwhile,’” Polonsky said. “That is something we need to think about. It is polite to say you are too busy. People are voting with their feet.”
Often, attendees drop out of DSMES programs for reasons beyond convenience or even boredom. Too many people do not feel engaged or interested, he said.
“Of all the educators I have met, we don’t mean to be boring, but we see that it happens,” he said. “It happens when educators feel pressured by their health care systems to deliver way too much information, when educators are fearful that too much interaction will make it difficult to deliver all the information, and when educators are concerned they won’t be able to answer participants’ questions.”
Strategies for improvement
Polonsky said diabetes care and education specialists can take several steps to improve DSMES for participants:
Cut down on content. Addressing participants’ concerns about their education is more important than explaining how each class of medications works, Polonsky said. The ability to estimate carbohydrates or read food labels — a focus in many programs —may be less important than helping participants identify one dietary change they might make, and understand why that change is meaningful, Polonsky said. “Most of our participants are just like us,” he said. “We’re not interested in learning what an HbA1c is, but we might be interested in learning what our HbA1c is and why that might be important. It’s a principle of psychology, most of our universe is about us. We need to appreciate that.”
Make programs personally meaningful. Programs should make room to talk about the “why bothers,” starting every class with a reminder and discussion about why participants are there, Polonsky said. On a white board, list participants’ questions and confusions about the subject at hand, for every class. “Every session should end with asking each person what they think about what they learned, and what they might now try or do differently,” he said.
Admit educators have a problem. Keep track of no-show and drop-out rates. Find and interview program dropouts and ask them what was missing for them. If the participant claims the class was inconvenient, ask more questions, Polonsky said. Brainstorm solutions to address the “boring” problem. “Imagine what we could really accomplish with an 8- to 10-hour DSME program if we had more free time?” Polonsky said. “We need to think about that and get much more innovative and creative.”
“The bottom line is this — let’s refuse to be boring,” Polonsky said. “We educators can be cool. We are often knowledgeable and innovative people. We don’t have to be straightjacketed by this belief that we have to be lecturing and powering through tons of facts to shove onto diabetes patients. Let’s transforms diabetes education to focus on what is really the key principle of education that can lead to successful behavior change, and that is this, as said by William Butler Yeats: ‘Education is not the filling of a pail, but the lighting of a fire.’”
Perspective
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Donna Ryan, MPH, RN, RD, CDCES, FADCES
Dr. Polonsky shared a fresh look at the challenges we have with retention rates for DSMES and provides some key insights and solutions: Cut down on nonessential curriculum content and focus on the person; talk about the “why bothers” and their questions and concerns; and track the “whys” for dropping out of the program. To avoid being “tedious, tired and dull” and improve class engagement and retention, Dr. Polonsky discussed “boredom research” and doing a “state of boredom scale.” Yes, there is a scale for that. We need to brainstorm innovative solutions to address any boredom issues with group classes if we are going to improve retention rates.As diabetes care and education specialists — formerly known as diabetes educators — our call to action is to “brainstorm solutions” and transform DSMES to focus on the key principle of education: Not the filling of a pail, but the lighting of a fire. Dr. Polonsky reminds us to put the person with diabetes first, and look beneath the iceberg of '”no-shows, dropouts and poor retention rates” for solutions and innovative ways to engage and enrich people and build ongoing relationships. His message is critical and he continues to serve as a beacon for all who provide care and education for people with diabetes.
Congratulations to Dr. Polonsky on being this year's Outstanding Diabetes Educator.
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Hope Warshaw, MMSc, RD, CDE, BC-ADM
Let me begin by congratulating my colleague and friend William Polonsky, PhD, CDE, on his well-deserved award for Outstanding Educator of the Year in Diabetes. Dr. Polonsky, never one to shy away from asking provocative questions, asked an important question in his lecture, “Tedious, Tiresome, and Dull – An Unrecognized Program That We Can Solve,” given to an audience filled with diabetes care and education specialists. Nervy, but necessary. His message is one we all need to hear loud and clear. Unfortunately, the way DSMES is most often delivered is steeped in history and, even more challenging, within the reimbursement structure set up by CMS back in the late 1990s, with no significant changes to date. And yes, reimbursement matters. It’s important to note that the Association of Diabetes Care and Education Specialists, and other organizations, have been advocating via federal legislation with the Expanding Access to Diabetes Self-Management Training Act (H.R. 1840, S. 814) to reduce current barriers (see Link). But, as Polonsky detailed, we cannot wait for CMS to make changes. Diabetes care and education specialists must innovate now. Many are, in myriad ways too numerous to detail here. Interestingly, busting through CMS regulations with emergency waivers implemented during the COVID-19 pandemic may promote significant changes in delivery of DSMES over time. I also hope that the new joint consensus report aimed at increasing referrals and access, published by seven organizations on DSMES in adults with type 2 diabetes, mentioned by Mary de Groot, PhD, and Dr. Polonsky in their ADA lectures, will promote changes (Powers MA, et al. Diabetes Educator. 2020;doi:10.1177/2309499020926790). As they say, timing is everything. I believe with people, like Dr. Polonsky, raising provocative questions as he did during his ADA presentation, changes towards more person-centered, individually delivered DSMES over the course of a person’s life with diabetes will occur, slowly but surely.
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Polonsky WH. Tedious, tiresome and dull — an unrecognized problem that we can solve. Presented at: American Diabetes Association Scientific Sessions; June 12-16, 2020 (virtual meeting).
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