There are many challenges facing patients and providers in caring for diabetes. One challenge that often frustrates both patients and providers is the pressure on providers to accomplish more in less time. Trying to deal with all the issues during a 10- or 15-minute visit virtually guarantees that there will not be adequate time to discuss all the important issues related to diabetes care. The competing pressures on providers to contain costs and adhere to evidence-based treatment guidelines further exacerbate this already difficult situation. In such an environment, reviewing patients'“numbers” and making appropriate medication adjustments are quite likely to consume the entire visit.
While this may seem efficient, this type of visit can lead to dissatisfaction and frustration by both health care professionals and patients. Health professionals feel frustrated by patients' seeming inability to manage diabetes effectively. And patients sometimes feel that they are just a blood glucose number to their provider.
Diabetes care is largely a self-care disease. In fact, people with diabetes provide > 90% of their own care. To be successful, they need to incorporate diabetes into their lives. For them, diabetes is about much more than the numbers. It affects virtually every aspect of their daily lives because of the number of diabetes-related decisions they need to make. Addressing only the numbers is a short-sighted view of diabetes and one that is doomed to fail. The Diabetes Attitudes, Wishes, and Needs study1 demonstrated that patients who are more satisfied with their relationship with their provider have better outcomes. Thus, going beyond the numbers is not just a nice thing to do; it is part of quality diabetes care. The issue is how to address the broader issues of diabetes and provide patient-centered care within the context of the short time allowed for a clinic visit in our current health care environment.
We developed the Diabetes Concerns Assessment Form(Figure 1) to help make patient visits to a provider more efficient (i.e., to save time). It is also intended to ensure that at least part of the visit is devoted to discussing patients'primary concerns about living with diabetes, along with reviewing their numbers. The form is designed to be completed by patients while they wait to see the provider.
To answer the questions on the form, most patients will need to reflect on their experience of living with and caring for their diabetes. The reflection patients do in the waiting room should prepare them intellectually and emotionally for the visit. This process has three advantages. First, it ensures that patients' major concerns will be discussed and addressed during their visit. Second, the time that might otherwise have been spent trying to understand where patients are intellectually and emotionally can be used to address their issues. Third, patients are likely to gain clarity about their issues while filling out the form, allowing for more focused discussions during their visit (Table 1).
Addressing the first two questions on the form at the beginning of the visit serves two important functions. First, it demonstrates that the diabetes care provider is interested in addressing the patient's primary concern (i.e.,providing patient-centered care). This approach may seem obvious, but many patients report that their visits usually begin with a discussion of test results (e.g., hemoglobin A1c, lipids, and blood pressure) and never get around to addressing their primary concerns. This is not to suggest that test results should be ignored, but rather that the health care provider should begin the visit by discussing the patient's primary concerns and then address the clinical/metabolic issues later.
Second, the answers to questions 1 and 2 help to identify the areas where patients are most likely to be motivated to make a change. Patients are not as likely to change behavior to address the provider's concerns (unless they are as concerned as the provider), as they are to solve problems that concern them. The provider responses below are examples of ways of helping patients describe their primary concerns.
Summarize. “Let me summarize what I've heard you say (or read on your form) to see if I've got it right.”
Expand. “How does this concern affect your diabetes self-care?”Or “Is this issue affecting other parts of your life?”
Explore. “What have you tried before to solve this problem? How did it work?”
Question 3 focuses on the emotional component of the patient's primary concern. Many providers avoid asking about feelings because they do not know how to make patients feel better. This is a mistake. Feelings do not need to be (and usually cannot be) solved. Most patients do not expect their provider to make their negative feelings disappear. Feelings need to be expressed and explored for two reasons. First, the intensity of patients' feelings usually predicts the level of their motivation to make a change to improve the situation. Giving patients a chance to express, and thus experience the intensity of, their feelings increases the likelihood that they will actually do something about the issue. Second, the expression of strong feelings to an empathetic listener is, in and of itself, therapeutic. Listening builds rapport.
The conventional wisdom is that if patients are invited to express their feelings, the visit will take too much time. However, a study in the Journal of the American Medical Association2 found that visits were, on average, shorter when physicians responded to patients' attempts to bring up psychosocial/emotional concerns than visits in which physicians did not respond to such issues. A likely explanation for this finding is that when patients are not given an opportunity to discuss their primary concern, including how they feel about it, they do not experience closure as the visit nears an end. In this situation, they are likely to try to keep the visit going. (e.g., “Oh, and another thing...”). They are also better able to focus on what their provider is recommending because they are not trying to steer the conversation back to their issue.
Below are a few examples of provider responses to patients' expressions of feelings.
Empathize. “It sounds like you have had a rough time of it.”
Clarify. “It sounds like you are really frustrated by your glucose readings when you are working so hard to bring them down.”
Express interest. “How are you dealing with these feelings?”
When patients have had a chance to fully describe their concerns and express their feelings, it is time to help them consider possible solutions. Following are some appropriate provider responses.
Identify goals. “What would have to change to feel better?”
Make a plan. “What are some steps that you could take to help make things better for yourself?”
Offer help. “What can I do to help you?”
Motivate. “What will you do when you leave here?”
Ending the Visit
If at all possible, patients should leave their visit with a concrete,specific plan. For example, “I will ask my husband when he gets home from work tonight if he will come to my meeting with the dietitian” is a more concrete plan than, “I guess I should talk to my husband about this.” Plans that are concrete in terms of who, what, when, and where are much more likely to be carried out than vague, generalized plans. It is also helpful to let patients know that you will ask how well the plan worked at your next visit, because this communicates interest and adds accountability. A strategy to help patients identify this plan is to close the visit by asking, “Can you tell me one thing you will do this week to care for your diabetes?”
Our hope is that this form will support patient-centered visits that are both efficient and effective.
Robert M. Anderson, EdD, is a professor in the Department of Medical Education at the University of Michigan Medical School in Ann Arbor. Rebecca Patrias, MD, is an internal medicine physician in private practice in Chelsea,Mich.
Work on this article was supported in part by grant numbers NIH5P60 DK20572 and 1 R18 0K062323 from the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health.