Clinical Communication

Patient-Physician Communication and Diabetes Self-Care

From the Department of Family Medicine (Dr. Beverly) and the Department of Medicine (Mss. Worley, Court, Prokopakis, and Ivanov), Ohio University Heritage College of Osteopathic Medicine, Athens, OH.


 

References

Abstract

  • Objective: To summarize the current literature, research findings, and interventions for self-care communication in the physician-patient relationship.
  • Methods: Literature review.
  • Results: Diabetes management requires patients to follow complex self-care recommendations for nutrition, physical activity, blood glucose monitoring, and medication. Adherence to these recommendations improves glycemic control and mitigates the risk of diabetes complications; however, many patients struggle to follow these behaviors in everyday life. In the physician-patient relationship, self-care communication is largely influenced by interpersonal trust. Physicians need to incorporate interpersonal and relational skills to establish a trusting relationship. Physician-level barriers to self-care communication include lack of time, lack of collaboration and teamwork among health care providers, lack of patients’ access to resources, and lack of psychosocial support for diabetes patients. Among patients, psychosocial barriers and health literacy may affect willingness to discuss self-care. Motivational interviewing techniques may be helpful for improving communication around patient self-management and promotion of healthy behaviors.
  • Conclusion: Physicians can assist patients with their diabetes self-care by discussing self-care challenges during medical visits.

Diabetes is one of the most significant and growing chronic health problems in the world, affecting approximately 415 million people [1]. Diabetes is marked by the body’s inability to make insulin as well as the body’s inability to effectively use the insulin it produces [2]. Diagnosis of diabetes has increased sharply in recent decades and is expected to increase even more, with the largest increases in middle- and low-income countries [3]. Diabetes is a leading cause of blindness, kidney failure, myocardial infarction, stroke, and amputation [3], and in 2015 it accounted for 5 million deaths worldwide [1]. Further, diabetes’s costs to society represent 12% ($673 billion) of global health expenditures [1]. By 2040, models predict that 642 million people will be diagnosed with diabetes and costs will continue to grow as the population ages [1]. Thus, prevention of diabetes is the ultimate goal; however, more effective management for individuals already diagnosed with diabetes is critical to reduce the risk of complications and the economic burden of the disease.

Diabetes management requires patients to perform complex self-care regimens, including weight reduction, frequent blood glucose monitoring, taking oral and/or insulin medications, engaging in physical activity, adhering to diabetes nutrition guidelines, and attending clinic appointments [4–9]. These self-care behaviors are critically linked to improved glycemic control, however, integrating them into one’s daily life can be challenging [10–12]. Recent National Health and Nutrition Examination Survey (NHANES) data show that approximately half of adults with diabetes are not meeting recommended goals for diabetes care [13]. Physicians can assist patients with their diabetes self-care by scheduling frequent follow-up visits and discussing self-care challenges with their patients [14].

In this review, we discuss the current literature on physician-patient communication and diabetes self-care. First, we discuss the qualities of an effective physician-patient relationship followed by the importance of self-care communication in diabetes care. Next, we discuss barriers and facilitators to self-care communication. Finally, we review interventions for improving physician-patient communication in diabetes self-care.

Qualities of an Effective Physician-Patient Relationship

Successful diabetes care requires teamwork between physicians and patients [15]. Two components of successful teamwork are physician-patient communication and shared decision-making, both of which have been shown to improve patient satisfaction, adherence to treatment plans and health outcomes [16–23]. In shared decision-making, the physician and patient share medical information [24–26]. Specifically, the physician presents different treatment options to the patient and describes the risks and benefits of each option. Then the patient expresses his or her preferences for treatment to ensure that the care provided aligns with the patient’s values and needs [27]. Thus, shared decision-making in the treatment relationship is predicated on effective communication between the physician and patient [19].

Effective physician-patient communication is supported by continuous care [19,28], a secure attachment style [29, 30], shared goals [19], a mutual understanding of respective roles and tasks [15,31–33], and a bond characterized by liking, confidence, and trust [19,28,31]. Trust is paramount in physician-patient communication. Interpersonal trust and social trust are the 2 predominant types [34]. Interpersonal trust refers to the relationship the patient has with the physician, specifically the confidence the patient has in the physician as well as the responsibility, competence, compassion, and regard the physician has for the patient’s welfare [34–36]. For patients and physicians, interpersonal trust is developed over time with repeated interactions [34–36]. On the other hand, social trust refers to the beliefs of honesty, integrity, and reliability in others [36]. Social trust is influenced by social constructs, including the media and institutions of higher education [36].

In the physician-patient relationship, self-care communication is largely influenced by interpersonal trust. A patient’s trust can be acquired through multiple medical appointments with the physician. Further, how the patient is treated during these appointments as well as how much time and attention the physician invests in the patient’s care influences the level of interpersonal trust. A high level of trust in the relationship can lead to in improvements in adherence to self-care, continuity of care, physician-patient communication, and overall quality of the physician-patient relationship [37–39].

In the diabetes physician-patient relationship, minimal research has explored how trust in one’s physician impacts self-care communication. In a study by Beverly and colleagues, diabetes patients emphasized the importance of a trusting physician-patient relationship for diabetes care [27]. Another study by Ritholz and colleagues found that physicians and patients both stress the importance of developing trust to facilitate self-care communication [40]. Specifically, trust as well as acceptance from the physician contributes to open and honest self-care communication in the physician-patient diabetes relationship[40]. Additional research is needed to determine whether a high level of physician-patient trust is associated with increased self-care behaviors and improved diabetes outcomes over time.

Importance of Diabetes Self-Care Communication

Diabetes self-care communication in the physician-patient relationship increases patient satisfaction, improves adherence to treatment regimens, and leads to better clinical outcomes [22,41–43]. For physicians, effective self-care communication requires the performance of specific communication tasks and behaviors, including collecting a medical history, explaining a diagnosis and prognosis, and providing clear and concise therapeutic instructions [44]. In addition, physicians must incorporate interpersonal and relational skills to establish a trusting relationship [44,45]. Both physicians and patients agree that a trusting treatment relationship is a requirement for open and honest self-care communication [45]. For patients, effective communication necessitates the disclosure of self-care successes and failures [46]. Diabetes patients face challenging self-care regimens, and these challenges can interfere with glycemic control and increase the risk for diabetes complications [47,48]. For this reason, patients must feel comfortable discussing their self-are challenges so that their physician can individualize treatment prescriptions and recommendations, thereby increasing the likelihood of treatment success.

Barriers to Self-Care Communication

Physician-patient self-care communication is essential to improving patient adherence [29,49] yet numerous barriers exist that undermine effective physician-patient self-care communication. From the physician perspective, the most commonly cited barrier to self-care communication is time [50]. A recent study of family medicine practices found that the time physicians spent discussing self-care with their patients varied from 1 to 17 minutes, suggesting that time is a major barrier to self-care communication [51]. Other barriers include lack of collaboration and teamwork among health care providers, lack of patients’ access to resources, and lack of psychosocial support for patients with diabetes [50]. Relatedly, Beverly and colleagues [52] found that physicians often feel inadequately trained to address diabetes patients’ psychosocial issues and this perceived lack of expertise may contribute to physicians feeling overwhelmed and frustrated within the physician-patient relationship, which may hinder open self-care communication.

For patients, barriers tend to differ from those perceived by physicians. A qualitative study using semi-structured interviews with patients and clinicians, and direct observation of clinical encounters at an inner-city family practice training site, revealed different perceptions of the term “control” between physicians and patients. In practice, physicians used the term “control” to focus on the management of blood glucose levels rather than trying to understand the patients’ understanding of diabetes and subsequent treatment goals. Differing viewpoints contributed to frustration and hindered effective communication [53]. In another qualitative study with physicians and patients, both noted that patients were reluctant to discuss self-care for fear being judged or shamed about food intake and weight [45]. This finding was supported in a quantitative follow-up study assessing patient reluctance to discuss self-care. Thirty percent of surveyed patients reported reluctance to discussing self-care with their physicians for fear of being judged, not wanting to disappoint their doctors, guilt, and shame [14]. Interestingly, patients reporting elevated depressive symptoms were more likely to be reluctant to discuss their self-care [14]. Cognitive behavioral changes (eg, cognitive distortions, avoidance behavior, attention deficits) associated with major depression and depressive symptoms may impair patients’ ability to recall self-care information. Also, patients reporting more depressive symptoms may be more socially withdrawn during a medical appointment, and thus less willing to communicate with their physician about self-care.

Other studies found that psychosocial factors such as diabetes distress [54,55] and pessimistic attitudes [56–59], cultural differences [60–66], lack of family and social support [60,67–70], lack of readiness to change behavior [71], introversion and social isolation [72,73], hypo-glycemia fear [74,75] and ineffectual coping styles [76,77] interfere with self-care and glycemic control. Further, low health literacy is associated with difficulty adhering to self-care, particular medication regimens, and negative health outcomes [78].

In summary psychosocial barriers and health literacy may affect a patients’ willingness to discuss self-care during a medical visit. Therefore, routine assessment of psychosocial factors and health literacy may be necessary to address a patient’s barriers to self-care as well as to promote open and honest self-care communication. Interventions and evidenced-based approaches that address psychosocial factors, health literacy, and physician-patient self-care communication are needed.

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