Through the years, I have had the privilege of educating clinicians about scientific advances in diabetes care. Prior to displaying the first slide of my presentation, I ask the audience, “How many of you have seen a ‘noncompliant’ patient with diabetes within the past month?” Without fail, 99% of the attendees will raise their hand and start laughing, as if to say, “Well, of course they’re noncompliant. They just don’t get it! How incompetent can these people be?”
Blaming patients for failing to achieve metabolic control is inappropriate and misguided. How many physicians would be able or willing to monitor their blood glucose levels 4 times a day? Based on the premeal glucose level, how many physicians know how much insulin to inject in order to keep the postprandial excursions below 180 mg/dL? How many would remember to take 8 other medications daily without missing a dose? And how many physicians exercise daily; have actually looked at their feet in the past month; and have gained no weight in the past year?
Diabetes self-management is time-consuming and difficult for many patients, especially those with health illiteracy, financial restraints, or social barriers. Any patient who presents to the doctor is, in fact, “compliant.” These individuals expect to receive the safest and most effective treatments for their diabetes while learning as much as possible about lifestyle and behavioral interventions.
I challenge each of you to ask your patients: “What concerns you the most about having diabetes?” Initially, patients will express guilt and remorse about having diabetes. They will hang their heads in shame, admit to not going to the gym as often as they could, and promise to eat smaller portions. They will then look you in the eye and say, “I am worried about losing my eye, my leg, and my kidney to this life-threatening disease. I’m scared I won’t be able to see my daughter walk down the aisle at her wedding or my son graduate from college.”
These patients are terrified because they are unfamiliar with the advances in clinical science that aid our ability to improve the lives of all patients with diabetes. After hearing patients’ concerns about dying prematurely or losing an extremity to diabetes, I assure them that, “Nothing is going to happen to you on my watch. You are safe with me, and I will always have your back.” This level of trust is vitally important to the patient as well as to the treating physician. We all want our patients to achieve treatment success, just as any teacher would want their students to excel and graduate to the next grade level. Diabetes cannot be cured, yet we, as physicians, are able to heal with reassurance and expert guidance.
So, how do we help our patients achieve better adherence to their chronic disease state interventions? Here are 9 techniques that I have learned in my years helping patients manage their diabetes (all of which are more broadly applicable to any chronic disease state):
- Explain the disease state you are comanaging with the patient to the best of your ability. The more the patient understands, the easier your job as the “drug police” becomes.
- Remind the patient that he/she is the captain of the disease management team. You, the physician, serve as the personal coach. You can help the patient win the game, but he/she is ultimately responsible for achieving successful metabolic targets.
- Explain the risks, benefits, and any expected adverse effects that are likely to occur. Do this prior to initiating any medication.
- Discuss when metabolic change might be expected after initiating a given medication. Patients who observe rapid improvement in their glucose levels will be encouraged to adhere to their prescribed treatment regimen.
- Make certain that any and all screening tests are performed prior to initiating a medication. For example, renal function should be assessed prior to beginning most diabetes medications.
- Use shared decision-making to negotiate acceptable metabolic targets with each patient. Discuss the urgency and importance of achieving these goals.
- Assess the A1C reduction from baseline at 4 weeks after therapy initiation, rather than at 3 months. About 50% of the total A1C is reflective of the preceding 4 weeks of treatment.1 Thus, if the baseline A1C drops from 8.2% to 7.8%, the patient is moving in the right direction. However, if the A1C increases from 8.2% to 8.5%, the patient is not taking the prescribed medications.
- Recommend that the patient use a continuous glucose monitor; this newer technology is now readily available for patients who are covered by private insurance or Medicare. These devices allow patients to observe their glucose levels every 5 minutes of every day without fingersticks and actually cost less than self-monitoring one’s blood glucose.
- Find a reason to praise the patient at each visit. Patients who receive a powerful compliment, such as “I am so very proud of your efforts at improving your diabetes control,” will do their absolute best to remain adherent to their prescribed medication regimen. The response might be different if a patient is told, “Once again, your blood sugars are too high. At this rate, you are probably going to die, just like your father did 20 years ago. Now come back in 6 months and show me what you’re really made of!”
With more than 30 million Americans living with diabetes and another 84 million with prediabetes, the burden of preventive and intensive care lies squarely with family physicians.2 Rather than complain about our patients’ lack of metabolic control, we should provide them with the knowledge, skills, tools, and encouragement that they need to become successful diabetes self-managers.