September 11, 2014
Doctor-Patient Communication for Diabetes Patients
Today this is even more important, but communication is happening even less. The main culprit is the electronic medical record and the time that doctors need to spend at the computer during the office visit. They have boxes to check and other notes to make. Even the fastest of typists has little time for communication in at 12 to 15 minute appointment.
This doctor still emphasizes the importance of communication and lists 10 points to back this up. I find this statement very valid, especially as a patient. He says, “Communication and interpersonal skills of the physician are the heart and soul of our profession as medical doctors.”
He lists the Golden Rules for effective communication by doctors in the diabetes clinic:
“#1. Recognize the importance of patient empowerment as being fundamental to diabetes management. The physician's role is to provide knowledge and expertise to enable patients make informed decisions. But, it is the patients, themselves who are in charge of their destiny and the decisions and choices they make.
#2. Use appropriate words and language when talking to patients with diabetes. Avoid invoking guilt, laying blame, or using incriminating tactics. Perceived benefits are better than perceived threats. Negative or careless language can be harmful and can demotivate patients.
#3. Allow collaborative care, shared decision making, and "strike a deal" with the patient at each therapeutic juncture encountered. An informed communication style of the physician that included a participatory role for the patient in decision making resulted in significant improvement in patient self-care and glycemic control (glycated hemoglobin [HbA1c] improved by as much as 0.7%). In another study, the improvement in HbA1c was found to be even greater (1.5%) as a result of patient engagement in decision making. By contrast, a dominating and controlling style of communication by the healthcare provider resulted in poor metabolic control.
#4. Be practical and seek realistic goals. Focus on the achievable. Life is not about HbA1c level for every diabetes patient or every time for the regular patient attending the clinic.
#5. Be nonjudgmental. Obese patients were less likely to lose weight if they felt the attending physician was in some way judgmental about their weight.
#6. Consider cultural issues, religious beliefs, and personal values of the patient. With some individuals and in certain parts of the world, religious beliefs are dearly held and may even take precedence over other issues in life. This can present a delicate situation to the unwary practitioner who may need to tread carefully between respecting personal values of the patient, on the one hand, and not compromising medical care provided, on the other.
#7. Reward effort, not just outcome. Even modest encouragement can inspire patients to do more for their cause.
#8. Stay tuned to the patient's feelings and pick up the clues early. On average, a diabetes patient drops 2.6 clues per clinic visit. Subtle hints can be related to anything from loneliness at home to shortage of money. Although the physician does not have to solve every problem, an empathic response to the patient's concerns can improve clinic dynamics and change outcome. Furthermore, missed clues mean lost opportunities and, interestingly, lead to longer, not shorter, clinic visits.
#9. Use visual tools as much as possible: make a simple drawing or show the patient a relevant graph or picture to facilitate understanding and enhance motivation. The mere provision of a poster of HbA1c values marked with target goals improved metabolic control significantly in the patients tested. In another study, the Vision Study, investigators showed that graphic display of self-monitored blood glucose data significantly improved metabolic control, with an impressive 0.93% reduction in HbA1c in the type 2 diabetes patients studied. Patients are more believing in something they can see.
#10. Does your patient comprehend and remember the instructions given at the clinic? Patients have poor recall of decisions made at the clinic and tend to forget as much as 50% of what they are told by their physician. To explore the benefits of checking patient comprehension and recall, Schillinger et al. listened to audiotapes taken at outpatient settings and found a significant improvement in glycemic control in patients whose physicians applied this simple interactive strategy compared with those who were not assessed for comprehension and recall. Asking your patient to restate and summarize your instructions makes good sense and is obviously therapeutically rewarding.”
If doctors would do this, then they should also have a recording to give patients to play back at home to reinforce this as well. The doctors should also have approved printouts of reliable internet sources for the patients to read if they are interested.
It is interesting how little HbA1c level has changed over recent years despite the introduction of numerous antidiabetes agents and advanced diabetes technologies.
The doctor says, “The tips cited above are not meant to be a call for physicians to just "be nicer" to their patients or a ploy to improve customer service at the diabetes clinic. Rather, they emphasize the point that the quality of doctor–patient interaction is an important determinant of glycemic control and healthcare outcome for people with diabetes.”
The doctor continues, “Needless to say, communication is accessible to all physicians and is free of charge to all patients. Furthermore, communication has no cardiovascular risk or any other side effects to consider and so will not require regulatory body approval before release into the "markets." Communication should, in my opinion, be considered a universal first-line therapy in any future guidelines made for the treatment of diabetes. We should also train physicians on the art and craftsmanship of communication with people with diabetes.