Change is less discomforting for the patient if it occurs in partnership with a trusted resource person. A warm welcome by the health care professional, using a greeting and address appropriate for age, gender, ethnicity and language goes a long way in breaking the ice and building a rapport.

Once this rapport or trust has formed, the provider goes on to create a bond of empathy (as opposed to sympathy) with the patient. Empathy means “I understand how you feel; I know how difficult it is for you to adjust yourself-monitoring and injection schedule within your busy working shifts”, rather than “Poor you: how miserable you must be, trying to adjust your treatment schedule with your busy working shifts”.

Once rapport has been established, empathy expressed and demonstrated, and a close interaction or interview begun, it is easier for the provider to promote desired change.

TAKE HOME MESSAGE: A WARM BEGINNING, LEADING TO RAPPORT AND EMPATHY-BUILDING, IN THE MEDICAL CONSULTATION, MAKES CHANGE EASIER.

Whatever the patient’s clinical conditions there will be some bad aspects and some pleasant ones. During history taking one might elicit the presence of sexual dysfunction or recurrent infections. This is certainly bad news, but the good news may be that there are no symptoms of kidney disease.

If kidney disease is also present, it may be only 6 months old, which means there is potential to halt and reverse its progression. Perhaps an easily correctable predisposing factor such as drug toxicity might be identified, which is also good news.

If the patient has come to discuss his or her laboratory reports, there will be good as well as bad reports. In case all the values are “bad”, there may be some easily correctable abnormalities, such as a high cholesterol or LDL.

It is easier for the patient if the bad news is finished quickly and early on in the course of the consultation. Spending less (but not zero) time on the bad news leaves more time to dwell upon the positive aspects and focus on constructive coaching or discussing problem –based coping strategies.

Even the most sick and most complicated of patients with diabetes will have some positive aspect of health.

If the provider succeeds in “prolonging” the pleasant news about health status, it is easier for the patient to accept change suggested by the provider.

Reframing the problem, making a positive reappraisal or putting it in perspective minimizes the perceived impact or perceived instruction of the illness. A provider might choose to focus, for example, on the short duration of a particular symptom, or spend more time asking question about symptoms where the chances of a “healthy response” are more.

While examining a patient with frozen shoulder, the physician may emphasize the range of movement in the direction where it is not severely limited.

A patient presenting with a bunch of biochemistry values can be given bad news about kidney function or lipid profile in one sentence.

If however, these reports are normal, the physician should emphasize each good value of cholesterol or renal function separately.

“Prolonging the pleasure’ by breaking up pleasant news increases the patient’s self –esteem and self- confidence, making him or more willing to take on the stress of change , and making it less uncomfortable.

Virtually all diabetes self-care is done by the patient, and he or she has already made many changes to help him or herself.

“I eat virtually nothing but air”, I read all the self-care books. I could find”, and “I surf the net daily for information on diabetes” are common refrains in the OPD.

Find time to appreciate and praise the patient’s efforts in changes: this will encourage more change, and mitigate the unpleasantness associated with it.

“Actual diabetes control occurs in the kitchen, “Please thank your spouse from my side,” “Actual control occurs in the sports field: thanks for being so regular at badminton,” and Thanks for taking your tablets so regularly-it makes my job so easy” are sentences which cost nothing to say.

These remarks create a sense of pride in the patient, increase his or her self-esteem and sense of self-efficacy, and make him or her feel “in charge” of his condition. Success is a habit; and once the patient is made to feel responsible and proud of his or success, he or she makes at a habit.

This feeling of being in charge and being successful extends to future changes as well. The patient feels that he or she is in command of suggested therapeutic changes rather than the changes being in charge. This reduces the discomfort of change, as compared to a change perceived as being physician-driven or externally enforced.

THE TAKE HOME MESSAGE: REDUCE EMPHASIS ON UNPLEASANT ASPECTS OF HEALTH, AND SPEND MORE TIME DISCUSSING POSITIVE ISSUES TO MINIMIZE CHANGE-RELATED DISCOMFORT.

Unexpected change is always discomforting A person who walks into a diabetes clinic with an appointment, and is told that the doctor has gone for a vacation, will experience significant discomfort.

Similarly, a person with diabetes who is suddenly handed a huge bill for his annual checkup will complain. If however, he has been told in advance that the annual checkup is due; he will be better prepared for the change.

Patients often resist insulin, and physicians complain about lack of compliance. If however, a patient is ‘primed’ or told in advance about the need for insulin, he or she will be more willing to accept this change in therapy, when it is absolutely necessary.

A good diabetes care provider should be reduce the concept that needs to changed, allow time for contemplation, and not push unexpected change. This will reduce the burden or discomfort of that and future, changes.

Anyone will be overwhelmed by change if it is of a large magnitude. One can reduce the discomfort of change by breaking it into small bits, or making it subtle.

A diabetes care provider need not present all the facts, and ask for all solutions, at one visit. Diabetes is a life-long condition, and takes a whole life time to manage.

One can prioritize the changes needed for optimal management, and implement them one by one. For example, the patient may be asked to begin dance classes this week, and to come for diabetes counseling classes from the next month onwards, once his or her child’s annual examinations are over.

It also helps to have a graded approach to change: any physical activity or dietary intervention should proceed with regular increments in intensity, frequency or duration of the change required.

It is much easier for a patient’s family to accept monthly cuts of 10% in the quantum of cooking oil or salt used at home, than to change to an oil-free, salt-free diet overnight.

A fitness programme which increases the duration of exercise by 5 minutes every week is more likely to be continued with, than one in which the instructor demands an overnight commitment of 2 hours exercise daily.

Subtle change, for example, taking a night turn dose of insulin at home, may be more welcome than “open” change like injecting insulin in public on the workplace, which can be discomforting for some.

Change may be enforced, for example, by a dictator or through laws, but it is rarely long lasting. Such change is associated with significant discomfort.

A change which is perceived as being inborn, internally driven and not enforced from outside associated with less discomfort and more success.

A change which is perceived as being inborn, internally driven, and not enforced from outside, associated with less discomfort and more success.

Incase a patient is not willing to accept a particular change, for example, taking insulin, one can want till the next clinical visit. Of course, in a situations which is, or which may become life-or limb-threatening. The health care provider has the responsibility of explaining the relevant facts.

The final choice, however, still lies with the patient, who has to give an informed consent for whatever change is planned.

Individuals feel uncomfortable when change is enforced upon them and there is no choice in the matter.

Giving them some amount of perceived choice lessens discomfort. A child with type1 diabetes might be shown a variety of insulin delivery devices with which to try his first injection. The same patients will appreciate a choice of low-calorie, healthy recipes at breakfast, rather than getting the same monotonous food over and over again.

One can negotiate with choice, by identifying issues which “must” be addressed by change, and listing other aspects of health care which the patient can choose to prioritize or change. The physician might, for example, say that insulin is a “must” in a particular patient, but whether or not he is willing to take extra tablets for sexual dysfunction or weight loss is upto him or her.

TAKE HOME MESSAGE: CHANGE SHOULD BE CARRIED OUT IN SMALL BITS, AND SHOULD BE PERCEIVED AS A MATTER OF CHOICE.

Whatever discussion regarding change is done, the end should be strong and posture. Having a positive end to the conversation reduces the discomfort associated with change that will take place later.

A parting sentence such as ‘Let’s work together to get this diabetes under control’ will make the changes requested to get diabetes under control a pleasant task. On the hand, a parting a lot like ‘Poor you’. I just can’t imagine how you will be able to manage all these changes’ will ensure a difficult and challenging task ahead.

TAKE HOME MESSAGE: OPTIMISM ON PART OF THE HEALTH CARE PROVIDER REDUCES DISCOMFORT ASSOCIATED WITH CHANGE.