S Kalra, S Kumar, B Kalra, A Unnikrishnan, N Agrawal, R Sahay
S Kalra, S Kumar, B Kalra, A Unnikrishnan, N Agrawal, R Sahay. Patient-provider interaction in diabetes: Minimizing the discomfort of change:. The Internet Journal of Family Practice. 2009 Volume 8 Number 2.
Achieving change in patients with chronic disease such as diabetes is always difficult. This article discusses ways to minimize the discomfort associated with making patients change their behavior.
Domains of change
Diabetes is another name for change. A person diagnosed to have diabetes needs to change many aspects of his or her life and is sometimes overwhelmed by the condition. It is helpful to divide this change into small, easily understandable domains, which can then be tackled one by one-:
Change related to lifestyle
Coping with stress
Change related to health care
Seeking health care
Comfort with health care system
Comfort with health care providers
Change related to treatment
Various laboratory tests,
Self-measurement of blood glucose
For non-glycemic care
1° prevention of diabetes
2° prevention of diabetes
3° prevention of diabetes
These domains can be tackled one by one on a priority basis, to reduce the impact or discomfort associated with change.
The patient-provider interaction agenda
The OPD consultation is usually sought, or initiated by the patient, who has a pre-set agenda in his or his mind. This agenda comprises of his or her “felt needs.”
The patients may be interested in seeking help
Such symptoms are termed “internal cues”.
The patient may seek an appointment because someone else in the family or community has developed a diabetes-related illness, e.g., myocardial infarction or kidney failure. At times, he or she requests an OPD consultation as a proactive step, being motivated by a media campaign or a relative. These are ‘external cues’ for seeking treatment.
Patients often bring with them reports of investigations suggested by their physician or another doctor and are interested in knowing what the results mean. Results of biochemical or other investigations are like a horoscope. They predict the individual’s past, present and future reasonably well (better than astrology). These ‘laboratory cues’ are often useful in motivating patients to take to take appropriate therapy.
These “felt needs” or “cues” are aspects of life or illness for which the individual is willing to accept change.
Felt needs contrast with ‘actual needs”, which are what the physician determines after a clinical and laboratory assessment of the patient. For example, the treating doctor might feel that a particular patient needs to exercise more or some expensive tests done. All these options require some degree of change.
The patient may not be able to comprehend the link between a felt need and an actual one. The patient with weight loss who is told to eat less will feel that the treating doctor has lost hold his senses, unless he or she is explained the link between them in simple words: inappropriate diet leads to poor glycemic control, which in turn causes weight loss.
Another patient who presents with frequent urinary infection, which should be a simple condition to treat may not realize why his or her doctor has advised an ultrasound and cystocopy. As these tests intrude into the patient’s life, (and his or her wallet), they will be resisted. Acceptance of these tests will be enhanced if the link between an accurate diagnosis, a correct treatment plan, and an optimal therapeutic outcome is explained.
In simple words, therefore, the diabetes care provider should try to achieve concordance or linkage between felt and actual needs. This is the foundation stone of achieving desired change in the patient.
Patient-centric language: The need to paraphrase
The patient-provider interaction and discussion should focus around the patient’s felt needs, rather than doctor’s perceived needs.
“I think you should be on 4 doses of insulin daily” will not be as effective as “Perhaps taking 4 doses of insulin daily will help achieve good glycemic control, which will improve your nerve pains”. This in turn does not sound as good as “Your nerve pains will certainly improve once we achieve good glucose control; we can do that with 4 doses of insulin a day.”
THE KEY MESSAGE, THEREFORE, IS TO BE PATIENT-CENTRIC, TO PARAPHRASE THE PATIENT’S FELT NEEDS, AND TO ACHIEVE CONCORDANCE OR LINKAGE BETWEEN FELT AND ACTUAL NEEDS IN DIABETES CARE.
Beginning: The need for warmth
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.
“Brief” bad news
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.
“Prolong” pleasant news
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.
Praise, and create Pride
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
THE TAKE HOME MESSAGE: REDUCE EMPHASIS ON UNPLEASANT ASPECTS OF HEALTH, AND SPEND MORE TIME DISCUSSING POSITIVE ISSUES TO MINIMIZE CHANGE-RELATED DISCOMFORT.
Allow contemplation of change
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.
Break change into small bits
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.
Do not force change
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.
Allow choice in change
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.
Change is an essential part of managing chronic life style disorders such as diabetes. Creating acceptable change and minimizing the discomfort associated with it, goes a long way in increasing the acceptance of therapy. This in turn improves the efficacy of treatment, and improves the physician’s reputation as well.
Remembering the following 10 points about change will be helpful in improving patient, experience and adherence to therapy.
Achieve concordance between felt needs and actual needs
Abbreviate bad news,
Prolong pleasant news
Praise, and create pride
Allow contemplation of change
Give choice in change
Make change subtle, in small bits
Do not enforce change
End on a pleasant note