Have You Been Evaluated for Patient Adherence?

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This is the first in an on going seriesfrom Joslin's Diabetes Deskbook. Thebook is interesting as a patient and I will write blogs about theexcerpts from Diabetesin Control dot com. There is much available for good discussion.
The first two paragraphs are a key tothis discussion. “The gap in meetingclinical targets is in large part due to the gap that presentlyexists between actual and optimal treatment goals and strategies forpatients and physicians.
Even whenpatients have an ongoing relationship with their primary physician,they often fall short of the recommended treatment goals due to gapsbetween actual and ideal treatment strategies. Collaboration is thekey to closing this gap. Your patients are the most underusedresource in your clinical practice. If you and your patients are ableto jointly establish aligned goals, they will improve their health,and you will improve the efficiency of your practice and outcomesthat you can achieve.”
Often there is a difference of opinionabout optimal treatment goals between patients and physicians. Sometimes this is on purpose and at other times, it is difficult todetermine why they are different. In reading the deskbook, it iseasy to discern some of the reasons for the differences in goals. Younger patients may want to manage their diabetes very stringentlyand the physician does not want the goals to be so tight.
Then when it comes to the elderly, someare still capable of tight management and the physicians aredemanding that they loosen up their management. This is when thephysician needs to step back and reassess the patient to determine ifthey are indeed capable of this maintenance and if encouragement isin order rather that changing goals.
The five steps outlined in this excerptare enlightening, if only more physicians would see them as valuable. The patient and physician may have a long history, but this does notmean that the physician is in command. The steps include:
First Step - When you enter theroom where the patient is, start with a simple open-ended questionlike "What brings you in today?" Other questions are alsouseful and the doctor needs to listen to the patient. Most patientstake about 32 seconds to create the answer and finish theirstatement. Most physicians make the mistake of interrupting at about23 seconds to ask another question or redirect the discussion. Thismay make it seem to the patient that the doctor is in autopilot andnot listening to them.
Second Step – Be sure to helpthe patient focus on their risk factors, and to appreciate theirclinical importance. Many doctors fail here by not explainingcarefully the risk factors and working with the patient to help themunderstand them. The discussion of all the risk factors at once doesnot work... ”This unfocused shotgunapproach often leads to inaction, or to the wrong action.”
Third Step - If you and thepatient have succeeded in reaching an agreement about a general goalsuch 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 thepatient 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 thepositive reinforcement that the patient needs and will work for othergoals knowing that the doctor is there with him/her to make sure thegoal is attainable. If the patient falls short and the doctor hasthe daily data – blood glucose readings, food log, and otherrecords the patient has maintained, the doctor should be able tooffer guidance to help the patient achieve the goal by the nextvisit. Fourth Step - Having chosen agoal and a treatment strategy, it is important to encourage thepatient not to lose momentum. “Rememberthat there are different paths to achieving the same result, withdifferent combinations of lifestyle changes and medications. If theirstrategy doesn't seem optimal, you can then suggest: "I havesome information on what strategies have worked for other patientssimilar to you. Would you like to hear some of these possibilities?"” Different techniques work fordifferent patients and doctors need to work with patients to assistthem and thereby increase their value and help the patient keep thedesire to do more to meet the goal.Fifth Step - Keep Cycling - Thehardest work involves the first four steps described above. Oftenphysicians and patients come up short of reaching their goals becausethey lose momentum. Encouragement is important. Because the patientis the person managing their diabetes on a daily basis, knowing thatthe doctor is helping them set reasonable goals and assisting them inachieving these goals, makes the doctor more appreciated.This statement from the excerpt isimportant, and I quote, “This is a greattime to be treating people with diabetes, and those without diabeteswho are at risk for cardiovascular disease. Clinical results areimproving dramatically; and while clinical gaps continue to exist,they are responsive to a number of different approaches. Thisprovides an opportunity for the physician, but an opportunity that isbest addressed through collaboration with your patient. Thephysician's role is to evaluate the patient's disease state, listencarefully to their concerns, and then provide the needed informationthat will help to inform and form the patient's choices. The patientcontrols their disease, whether they want to or not. You need to bethe best guide possible in their journey toward health.”