December 21, 2012

Have You Been Evaluated for Patient Adherence?

This is the first in an on going series from Joslin's Diabetes Deskbook. The book is interesting as a patient and I will write blogs about the excerpts from Diabetesin Control dot com. There is much available for good discussion.

The first two paragraphs are a key to this discussion. “The gap in meeting clinical targets is in large part due to the gap that presently exists between actual and optimal treatment goals and strategies for patients and physicians.

Even when patients have an ongoing relationship with their primary physician, they often fall short of the recommended treatment goals due to gaps between actual and ideal treatment strategies. Collaboration is the key to closing this gap. Your patients are the most underused resource in your clinical practice. If you and your patients are able to jointly establish aligned goals, they will improve their health, and you will improve the efficiency of your practice and outcomes that you can achieve.”

Often there is a difference of opinion about optimal treatment goals between patients and physicians. Sometimes this is on purpose and at other times, it is difficult to determine why they are different. In reading the deskbook, it is easy to discern some of the reasons for the differences in goals. Younger patients may want to manage their diabetes very stringently and the physician does not want the goals to be so tight.

Then when it comes to the elderly, some are still capable of tight management and the physicians are demanding that they loosen up their management. This is when the physician needs to step back and reassess the patient to determine if they are indeed capable of this maintenance and if encouragement is in order rather that changing goals.

The five steps outlined in this excerpt are enlightening, if only more physicians would see them as valuable. The patient and physician may have a long history, but this does not mean that the physician is in command. The steps include:

First Step - When you enter the room where the patient is, start with a simple open-ended question like "What brings you in today?" Other questions are also useful and the doctor needs to listen to the patient. Most patients take about 32 seconds to create the answer and finish their statement. Most physicians make the mistake of interrupting at about 23 seconds to ask another question or redirect the discussion. This may make it seem to the patient that the doctor is in autopilot and not listening to them.

Second Step – Be sure to help the patient focus on their risk factors, and to appreciate their clinical importance. Many doctors fail here by not explaining carefully the risk factors and working with the patient to help them understand them. The discussion of all the risk factors at once does not work... ”This unfocused shotgun approach often leads to inaction, or to the wrong action.”

Third Step - If you and the patient have succeeded in reaching an agreement about a general goal such as A1c, then ask the patient how they would like to get there. Letting the patient set a goal can be guided to a point, to make the patient desire to take the action to obtain a better A1c. However, the doctor cannot set the goal and expect the patient to meet it. When the patient sets a goal that is attainable and does, this is the positive reinforcement that the patient needs and will work for other goals knowing that the doctor is there with him/her to make sure the goal is attainable. If the patient falls short and the doctor has the daily data – blood glucose readings, food log, and other records the patient has maintained, the doctor should be able to offer guidance to help the patient achieve the goal by the next visit.
Fourth Step - Having chosen a goal and a treatment strategy, it is important to encourage the patient not to lose momentum. “Remember that there are different paths to achieving the same result, with different combinations of lifestyle changes and medications. If their strategy doesn't seem optimal, you can then suggest: "I have some information on what strategies have worked for other patients similar to you. Would you like to hear some of these possibilities?"” Different techniques work for different patients and doctors need to work with patients to assist them and thereby increase their value and help the patient keep the desire to do more to meet the goal.
Fifth Step - Keep Cycling - The hardest work involves the first four steps described above. Often physicians and patients come up short of reaching their goals because they lose momentum. Encouragement is important. Because the patient is the person managing their diabetes on a daily basis, knowing that the doctor is helping them set reasonable goals and assisting them in achieving these goals, makes the doctor more appreciated.
This statement from the excerpt is important, and I quote, “This is a great time to be treating people with diabetes, and those without diabetes who are at risk for cardiovascular disease. Clinical results are improving dramatically; and while clinical gaps continue to exist, they are responsive to a number of different approaches. This provides an opportunity for the physician, but an opportunity that is best addressed through collaboration with your patient. The physician's role is to evaluate the patient's disease state, listen carefully to their concerns, and then provide the needed information that will help to inform and form the patient's choices. The patient controls their disease, whether they want to or not. You need to be the best guide possible in their journey toward health.”

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