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September 2019, Volume 69, Issue 9

Primary Care Diabetes

The diabetes clinic: Creating an illusion of time

Sanjay Kalra  ( Department of Endocrinology, Bharti Hospital, Karnal, India. )
Hitesh Punyani  ( Department of Medicine, Maharaja Agrasen Hospital, New Delhi, India )
Munish Dhawan  ( Department of Paediatrics, Miri Piri Hospital, Shahabad, India )

Abstract

Diabetes care is challenging task, both for both the person with diabetes, and for the diabetes care provider. One of the challenges is the pressure to see a huge case load in limited time. This leads to poor patient satisfaction, and result in suboptimal outcome. Creating an illusion of time is an art which helps the astute physician enhance patient satisfaction. This opinion piece shares means of creating a feeling of time well -spent with the diabetes care professional. It explains how to "expand" the time frame, the interviewing team, the reference, the definition of health, and create remembrance points in order to improve the quality of interaction. The authors enjoin the physician to feel relaxed from within, "stimulate" all five senses of the patient, and structure the conversation in a systematic manner. Best practices for time enhancement are shared, along with relevant examples.

Keywords: Communication, insulin motivation, motivational interviewing, patient-provider relationship, psychosocial.


Introduction

Diabetes is a demanding condition, which requires efforts and energy from persons living with the syndrome, as well as their health care providers.1 The queries, doubts and concerns that a person living with diabetes has are limitless in nature and number. Thus, a clinical diabetes consultation requires ample time and energy, in order to be fruitful and satisfying for both sides. Time, however is a luxury that busy, understaffed clinics in South Asia cannot afford. Persons with diabetes often complain about the inadequacy of time spent with them by doctors. Physicians, on the other hand, feel overworked and fatigued because of the heavy case loads they have to deal with.2-4 This reality leads to suboptimal satisfaction with diabetes care, acts as a barrier to adherence, and prevents achievement of desired outcomes. Astute physicians, however, can easily master this challenge by creating an illusion of time in their patients' minds. This experience based communication shares insights and tips which help enhance the quality of the patient-physician encounter, by making the patient feel that the physician has spent ample time with him or her. We term this art of medicine as 'creating an illusion of time'.  An illusion of time can be achieved by 'touching' or reaching out to the patient, or impacting him or her, over a longer period of time, relating this to multiple phases of life, including all domains of health in discussion involving significant care givers in the process (Table 1).



The following paragraphs and tables expand upon this concept in a reader-friendly manner.


Expand the time frame
 

Even though the actual clinical appointment may be short, one can use modern technology to extend its influence before and after the face-to face meeting. Sending automated reminders, via telephone or messaging services is one way of doing so.5 Apt messages may include suggestions and tips to enhance communication with the physician. Examples include


"Remember to write your queries on a paper while coming,

so that you don't forget"


"Do pick up your investigation reports while coming for your appointment"


Post-appointment messages may focus on adherence and follow up

"Please do not forget to take your medication regularly" Your annual checkup is due on 12 September"
 

Expand the interviewing team Though time may be limited in the physician's chamber, paramedical and support staff can contribute to patient satisfaction by conversing with him or her. 6 Many centres have structured work patterns, which involve interaction with dieticians, diabetes nurses, counselors and other paramedical staff. Even smaller diabetes care facilities however, can train their receptionists, laboratory staff and assistants to enquire from patients about their well-being. This facilitates a pleasant clinical encounter, which remains in their minds for long.


"Good morning. How is your health today?"

"Good day. You have such a beautiful smile: your sugars must be behaving well".

One can to make optimal use of waiting time, by installing audiovisual educational tools in the waiting area. Diet museums, stress management counters, exercise machines, educational posters and televised programmes are examples of these.


Expand the reference

During the clinical interview, the physician should try to touch upon varied aspects of life, apart from health. A general discussion with the patient, coupled with understanding of her or his sociocultural background, will bring up many areas of life which can create an impression of having covered a wider spectrum of the person's life. This spectrum can extend in time (past, present and future health) as well as in domains of life (personal professional and social).


"How is the wheat crop coming along? The rains have been good this year"

"Do you wish to observe the Ramadan fast next year? We must get you in shape before that"

Expand the definition of health Health is not limited to just physical well-being. Managing a chronic lifestyle disorder such as diabetes requires an understanding of the biopsychosocial model of health and its various components. A clinical interview, in order to be effective, should includediscussion about all aspects of health: physical (biomedical), psychological (emotional) and social. 1 The emphasis laid on each domain will vary according to the clinical situation, as well as the patient's attitude and wish. However, touching proactively upon all the domains of health, even if the patient has not volunteered a suggestive history, creates an impression of time well spent. The Patient Health Questionnaire-2 (Whooley's 2 item questionnaire) can be used as a screening tool to explore for psychosocial morbidity.7,8


Expand the interviewee team

Diabetes is a complex condition, which requires support and cooperation from caregivers at home and work or school. Family members friends and colleagues play a significant role in living with diabetes, and their active involvement in important.9 Any persons accompanying the patient must be greeted, acknowledged, and involved in therapeutic patient education and shared decision making if possible. One may utilize the relative or friend as a diabetes care team member, requesting him or her to help in self-care and self-management.


"Thank you for sparing time for us today; your support is

invaluable in achieving good glucose control for Mr. Shah"


"Please remind Miss Alia to take her insulin regularly; you are so lucky to have each other as friends"


Feel relaxed from within

While a brief interview will always be brief, it is up to the physician to make it relaxed. The physician's approach to a consultation determines whether it will be perceived as 'relaxed' will hold true for both patient and physician. In other words, while one may not be able to spend 'extra' time, one can certainly improve the quality of time spent with an individual. Keeping this in mind, Tables 2,3, and 4 share best practices to ensure a relaxed, yet brief clinical communication, which provides maximal satisfaction to the patient.

Stimulate the senses



Table 2 describes simple strategies by which one can stimulate all five 'senses' of the patient. Use of these elementary ideas in daily professional life helps leave an impact on the patient which lasts far beyond the face-to face interaction. Attention to one's attire, manner of speech and external ambience help create a feeling of time well spent in the clinic.


Structure the conversation



Table 3 attempts to structure a diabetes care conversation. While no two conversations can be exactly the same, the ideal clinical interview should follow, and incorporate, the phases mentioned in Table 2. A brief well-structured discussion, which touches upon all aspects of biomedical and psychosocial health, including lifestyle and pharmacotherapy, is more effective than a rambling interaction that does not do justice to the multifaceted nature of diabetes. A warm welcome to begin with, and a reassuring reflection at the end, ensure that a perception of ample time is experienced. The mnemonic WATER offers an effective way of "watering" the plant of illusion of time.>1 WATER reminds the physician to welcome the patient warmly, ask and assess complaints, tell the truth, explain with empathy, reassure her or him, and encourage her or him, and encourage her or him to return for the next consultation.


Touch points for time enhancement




Table 4 lists and describes best practices which can enhance the feeling of time spent with the physician. An effective initiation of conversation helps strike a rapport with the patient. This can then be followed by a biomedical conversation, conducted in a psychosocially sensitive style. Recording or writing significant historical points on the patient case sheet helps remember personal details, which can be used to kickstart a conversation. If this information is not available, one may choose any current topic, such as the weather, or the economy, to 'warm up' the interaction. Potentially 'hazardous' topics such as politics or religion are best avoided, unless the physician is confident of the patient's background and preferences.

Remembrance request

If one wishes to be remembered, the easiest way is to request to be remembered

"Please remember me (fondly), when you feel the urge to eat a fried sweetmeat. I'll be there to help you resist it"


"Please think of me whenever you find it difficult to swallow

your 1 gram heavy tablet. I'll cheer for you" The reflect "how we demonstrated insulin technique today: you will remember this demonstration when you inject yourself every day"


Conclusion


Diabetes care is a science as well as an art. Through this communication, we have attempted to share a few "best art" practices, which will help create an illusion of time, and enhance the perception of time spent with the physician.


References


1. Kalra S, Sridhar GR, Balhara YP, Sahay RK, Bantwal G, Baruah MP, et

al. National recommendations: Psychosocial management of diabetes in India. Indian J Endocr Metab. 2013; 17: 376.

2. Nicolucci A, Kovacs Burns K, Holt RI, Comaschi M, Hermanns N, Ishii H, et al. Diabetes Attitudes, Wishes and Needs second study

(DAWN2™): Cross?national benchmarking of diabetes?related psychosocial outcomes for people with diabetes. Diabet Med. 2013; 30: 767-77.

3. Holt RI, Nicolucci A, Kovacs Burns K, Escalante M, Forbes A, Hermanns

N, et al. Diabetes Attitudes, Wishes and Needs second study (DAWN2™): Cross?national comparisons on barriers and resources for optimal care-healthcare professional perspective. Diabet Med 2013; 30: 789-98.

4. Peyrot M, Burns KK, Davies M, Forbes A, Hermanns N, Holt R, et al. Diabetes Attitudes Wishes and Needs 2 (DAWN2): a multinational, multi-stakeholder study of psychosocial issues in diabetes and personcentred diabetes care. Diabetes Res Clin Pract. 2013; 99: 174-84.

5. Nanditha A, Snehalatha C, Raghavan A, Vinitha R, Satheesh K, Susairaj

P, et al. The post-trial analysis of the Indian SMS diabetes prevention study shows persistent beneficial effects of lifestyle intervention. Diabetes Res Clin Pract. 2018; 142: 213-21.

6. Chester B, Stanely WG, Geetha T. Quick guide to type 2 diabetes selfmanagement education: creating an interdisciplinary diabetes management team. Diabetes Metab Syndr Obes.. 2018; 11: 641.

7. Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med 1997; 12: 439-445

8. Balhara YP, Kalra S, Das AK. Depression in diabetes: The need to screen. JOSH-Diabetes. 2013; 1: 051-2.

9. Kovacs Burns K, Nicolucci A, Holt RI, Willaing I, Hermanns N, Kalra S, et al. DAWN2 Study Group. Diabetes Attitudes, Wishes and Needs second study (DAWN2™): Cross?national benchmarking indicators for family members living with people with diabetes. Diabet Med. 2013; 30: 778-88.

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