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.
