Academic journal article The Qualitative Report

Discourses of Diabetes Management in Patient-Physician Interactions

Academic journal article The Qualitative Report

Discourses of Diabetes Management in Patient-Physician Interactions

Article excerpt

One of the most wide-spread chronic illnesses in the U.S. is diabetes. In 2012 the American Diabetes Association (2016a) estimated that 29.1 million Americans--nearly 10% of the population--had diabetes, with 1.4 million new cases of diabetes diagnosed each year. Considerable research has focused on the challenges of diabetes management, including patients' reluctance to discuss self-care behaviors with physicians (Ritholz, Beverly, Brooks, Abrahamson, & Weinger, 2014), lack of dietary knowledge (Nagelkerk, Reick, & Meengs, 2006), difficulty obtaining testing supplies and affordable medication (Handelsman & Jellinger, 2011), frustration with diabetes management requirements that conflict with patients' lifestyles (Horton, 2008), and trouble managing complex treatment regimens (Rubin, 2005).

To address these challenges, patient-centered medicine focuses on understanding the patient's view of their illness--what it means and what managing it means to the patient (McWhinney, 1989). This understanding enables patients and physicians to collaborate when making healthcare decisions. For example, the Patient-Centered Outcomes Research Institute (PCORI), established as part of the Affordable Care Act, advances rigorous research that includes the voice of patients in the evaluation of health research and outcomes (Frank, Basch, & Shelby, 2014). To date, PCORI has funded over 70 diabetes-related research projects (www.pcori.org/research-results). Patients who actively participate in medical care decisions are more likely to adhere to treatment plans, report greater patient satisfaction, and experience improved clinical outcomes (Zachariae, Pedersen, Jensen, Ehrnrooth, Rossen, & von der Maase, 2003). For example, Bailey et al. (2016) evaluated the usefulness of a patient decisional aid to promote patients' knowledge of diabetes, self-efficacy, and certainty related to making health decisions. Those patients who used the decisional aid reported higher levels of knowledge, self-efficacy, and health decision certainty than those who did not use the aid. Bolen et al. (2014) provide further evidence of the utility of patient engagement in their meta-analysis of 138 randomized-controlled trials of patient engagement interventions. Compared to control groups or usual care, individuals with type 2 diabetes who participated in patient engagement interventions had improved hemoglobin A1c levels.

Scholars have also explored barriers to patient engagement and shared decision-making in the clinical context, such as different languages, low-health literacy, lack of appropriate clinical training, patient apprehension, and time (Blackstone, Garrett, & Hasselkus, 2011; Nekhlyudov & Braddock, 2008). We argue that understanding the meanings that shape patients' and physicians' views of a medical condition such as diabetes, are also essential factors in patient-centered care as well as in the successful development and implementation of any patient engagement intervention. Therefore, this study focuses on patient-physician interactions related to diabetes management to understand what discourses inform the meanings of diabetes management. We also examine how the meanings of diabetes management are shaped in the interplay between competing discourses.

The Role of Talk in Disease Management

Mishler (1984) observed that the talk that forms the relationships between patients and physicians "has real consequences for diagnosis and treatment and for the course and outcome of patients' illnesses" (p. 12). Heritage and Maynard (2006) provide a detailed discussion of the two primary strands that have guided patient-physician interaction research. The first of these is process analysis, in which researchers systematically classify role and task behaviors within the patient-physician interview. Although there are a number of classification systems (e.g., Inui, Carter, Kukull, & Haigh, 1982), the best known of these is the Roter Interaction Analysis System (RIAS) (Roter & Larson, 2002), which has been used extensively to investigate broad types of patient-physician interaction, such as rapport-building talk, psychosocial/lifestyle talk, or biomedical talk in a myriad of contexts (Roter et al. …

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