William H. Polonsky, PhD, CDE, has it
correct when it comes to dealing with diabetes patients. Dr.
Polonsky is a clinical psychologist and co-founder of the Behavioral
Diabetes Institute in San Diego, CA. He said, “We've got the
right medications, we have so much knowledge, and we have great tools
to help people manage their diabetes effectively. Unfortunately,
none of those things will work if we can't convince our patients to
make use of them, and that is why we all know it comes down to
behavior.”
I will be using his article in Medscape
to write about this. He wrote this column based on the talk he gave
when accepting the Richard R. Rubin Award at the 2014 annual meeting
of the American Diabetes Association.
Dr. Polonsky says all he has done for
the past 25-30 years is focus on the behavioral aspects of diabetes,
both as a clinician and as a researcher. I may not be quoting him
correctly, but he has said, “Diabetes causes nothing, it is the
lack of diabetes management that causes complications.” I firmly
believe he is correct, yet there are some that have been very vocal
in their desire to have him be more politically correct and stop
using this statement. Shame on them.
In some cases, Dr. Polonsky says, “The
way that we use behavior-change interventions with our patients may
work very, very well. But sometimes, these seemingly simple and
brilliant behavior-change interventions -- such as collaborative goal
setting and action planning -- just don't work at all.”
“I think the reason we have so
many frustrations with trying to encourage and promote behavior
change with our patients is because we make 3 fundamental mistakes.
I often make them myself.”
I feel that Dr. Polonsky is writing as
a clinical psychologist, but I see this also in CDE's. The three
mistakes he outlines are:
#1. Probably the most important
mistake is that we push a little too hard. “Most of us are
so concerned about our patients -- we so much want to help and we are
so overtrained as problem-solvers -- that we essentially demand
behavior change before our patients are ready for it. They may not
be convinced that what we are encouraging them to do is really
worthwhile, even if they seem to be cooperating with us. They may
harbor suspicions about medications, or question whether they can
really make dietary changes, or whether those changes will even make
any difference.”
He says that learning to take your time
and setting the right mood is important for patients.
#2. The second mistake involves
what he calls the principle of the mundane. “We often
"overfocus" on the obstacles that our patients face. We
view these barriers to behavior change as big, dramatic
complications, and that is probably the fault of researchers like me.
I have made a big deal out of these things over the years:
depression, eating disorders, fear of hypoglycemia.”
The one Dr. Polonsky focuses on is what
he calls "meh," or apathy or indifference. Many of the
patients do not view diabetes as a priority in their lives, and that
may be totally justified because the patients are much like us. Life
gets in the way.
“So, we need to appreciate that
the biggest barriers to behavior change may not be big stuff but
little stuff. People may simply be overwhelmed by diabetes, just
stressed and confused, and not dealing with the disease at the best
problem-solving level.”
#3. The third principle is what he
calls ATMs (actions that matter). “Many of my colleagues
who are somewhat skilled in behavior change have fallen into this
trap of diabetes empowerment: When they talk to their patients and
ask where they might want to make some lifestyle changes, they imply
that the particular answer doesn't matter. "Mrs. Smith, what do
you want to do?" "Well, I guess I should drink more water
every day. I can do that. Or maybe I should have fewer tortillas at
every meal, or maybe..."
“Certainly, the patient should be
the decision-maker in this, but I think we must remember to get the
most "bang for the buck." Instead of giving the impression
that any change is admirable and will lead to even more positive
behavior, we should be willing to collaborate and inform our patients
about the facts. "Look, you have diabetes and there are
probably 100 different things that you could do to improve your
health, but they are not all equally important. We can put them in
order of priority: knowing your glucose numbers is critical; smoking
is a bad thing; being on the right medication and then taking it may
be the most important thing. That is where you can get the biggest
bang for your buck."
I quoted much of his article because it
is important. There is much we as patients can learn from this. I
will also be using this in my role as a peer mentor and as a
peer-to-peer worker. Too often I find myself pushing and expecting
because I have experiences to relay that the others should be more
willing to accept my words. I have found out this does not always
work and that those I am working with do not want to make changes and
are looking for something easier that they can do.
One person that Allen and I had been
working with kept insisting that there had to be something that he
could take and reverse his diabetes. Nothing we were saying was
accepted and we could tell he was not even following us. After
several meetings, we had to tell him that after he wasted his money,
he would be back, probably having complications, and then we would be
able to help him. We did not have that chance as he passed the
following week. We have learned that his blood glucose became so
high that he went into a coma and died the following day.
His daughter did tell us this and asked
for information on several bottles she had found on his table. We
were able to find information on them and as you might have guessed,
they were either for supposed cures or reversing diabetes and none
were of any value. We suggested that she have a talk with his doctor
and have him consider showing them to other patients and explain that
they do not help. His doctor agreed and has been successful with
this approach.
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