In Our Patients' Shoes Reducing Barriers to Care in Diabetes Treatment

By Frank, Jennifer | Medical Economics, March 10, 2015 | Go to article overview

In Our Patients' Shoes Reducing Barriers to Care in Diabetes Treatment


Frank, Jennifer, Medical Economics


Treating chronic diseases such as diabetes requires a strong and open relationship between physician and patient

In the last two years, I have worked intensively on improving our organizations proportion of patients with diabetes who are poorly controlled. I've looked at the issues that contribute to uncontrolled diabetes from multiple angles and have reviewed hundreds of patients' charts searching for the holy grail of diabetes control. To date, the battle has been waged uphill and we continue to lose ground.

There are certainly clinical issues at play, including physician inertia to advance treatment, but this is a small part of the larger problem. For many of our patients, financial issues play some role in their inability to successfully manage diabetes, even those with insurance coverage. However, as I delve more deeply into individual patient's experiences, the situation becomes increasingly complex and confounding.

I thought of this recently as I met a new patient with poorly controlled diabetes. Mark (not his real name) is a middle-aged father of two rebellious teenagers. His elderly parents live with him and he is the go-to guy for friends struggling with addiction, mental illness, and poverty. He was fired by his previous physician for "non-compliance." I have to admit that I didn't exactly click my heels in delight when I saw his electronic chart come across my desktop. His hemoglobin A1C measurements are usually in the double digits. He no-shows or cancels appointments. He allows his medications to run out He doesn't prioritize his medical care.

So, I took the initiative. I knew that he may not come to see me for months if I didn't reach out first I asked my nursing staff to call him and schedule an office visit About a month later, he came in. He is very likeable with an easy smile. I knew before I entered the exam room that we'd need to talk about starting insulin. However, I tried to channel all my learning from the last two years with this new patient stepping out of my comfort zone and trying to approach his diabetes in a more patient-centered way.

While I was anxious to address his diabetes-his A1C was over 12-1 held myself back and spent the first half of the visit on the various concerns he brought up (none related to diabetes). After we agreed on a plan for those issues, I broached the subject of diabetes.

"Do you understand why we care so much about the A1C, Mark?" I began.

We reviewed a risk chart that demonstrates how increasing A1C is associated with significant increases in risk of blindness, kidney failure and amputation. He took the information in stride, not fazed by my scare tactics. I moved on.

"Mark, what are your thoughts on insulin?"

"I don't want to do that."

I didn't stop. I asked him about his specific concerns with insulin which included his assumption that he'd need to inject it into a vein and that he would be taking it multiple times each day. We were able to negotiate a once-a-day regimen that he thought was manageable for a three-month trial period.

Next, I broached the topic of self-glucose monitoring which he found difficult to do. I asked him if he could commit to checking just once per day.

"No, I don't think I could do that."

When I inquired about the challenges he had with this, we were able to problem-solve around his morning schedule. I knew we established rapport when he opened up about his struggles with his family and friends. It was clear that diabetes took a backseat to the more pressing issues he faced with his children and parents. My failure to understand this would prove disastrous to any future disease management I attempted on his behalf. …

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