According to the International Diabetes Federation (IDF),1 communication is the most important element in diabetes care. IDF President Sir Michael Hirst said, “Health outcomes are a function of the communication between HCPs and people with diabetes.”
But the complexity of diabetes care and the demands of our medical systems create barriers to effective communication from both the patient and the provider side. Diabetes standards of care are time consuming2 and include recommendations that providers “Ensure treatment decisions are timely, rely on evidence-based guidelines, and are made collaboratively with patients based on individual preferences, prognoses and comorbidities.“ How to fit all that into a 15-minute appointment?
It helps if patients are prepared. Betsy Carlisle, PharmD, CDE, advises patients to send in advance and/or bring, blood glucose logs, a list of their medications including OTCs and supplements, and a list of questions they want answered, in order of priority.
According to a Cleveland Clinic checklist, new patients3 should fill out and bring in paperwork such as patient history forms and records from other providers. If patients receive a checklist like this in advance or from a clinic’s website, they may come in readier to get to work. Some providers customize their instructions, for example by telling patients to take off their shoes and socks in the exam room.
Cleveland Clinic also advises patients to bring a friend or family member with them. The other person can help them remember what was said. It’s OK for providers to send the other person out of the room when appropriate. If they don’t have anyone to come with them, patients can be asked to bring a recorder to remember what providers said.
The University of California San Diego Guide to Clinical Medicine advises: “Make the patient at ease, introduce yourself, call them by name, and sit as close to them as is comfortable.”
After getting comfortable, the next step recommended by Smith’s Patient-Centered Interviewing4, by Dr. Robert C. Smith and associates, is to take one or two minutes to set an agenda: Indicate how much time is available (“We’ve got about 20 minutes together today…”). Forecast what you would like to have happen in the interview ( “…and I see that we need to review the blood tests you had done yesterday …”). Obtain a list of all issues the patient wants to discuss, and let him or her know how many you can cover in one appointment, but note that you will address the rest later. Summarize and finalize the agenda.
Smith’s guide says to start with general open-ended questions, such as “So how have you and diabetes been getting along?” or “What’s been happening for you lately?” Letting patients tell their story is usually faster and more informative than asking a series of direct questions. Continue with more focused but still open-ended questions. When you feel you understand the patient’s story, you can move to more direct problem-focused questions.
Five steps for successful interviewing
1. Set the stage — is the patient comfortable, with adequate privacy?
2. Elicit the chief complaint and set the agenda for visit — obtain a list of patient and provider concerns and prioritize.
3. Open the history of present illness (non-focused) — use open-ended questions and active listening.
4. Continue the patient-centered history (focused) — use focused, but open-ended, questions to obtain description of problems. Explore the patient description of symptoms, emotional or social context of symptoms or coping problems.
5. Summarize, confirm accuracy, and move to clinician-focused medical questions.
Adapted from Smith’s Guide to Patient-Centered Interviewing
Physician anxiety can interfere with hearing patients’ stories: A 2018 study5 in the Journal of General Internal Medicine found that clinicians allow patients an average of 11 seconds of talking before interrupting with questions.
In the study, 64 percent of patients weren’t allowed to say why they were there at all. Lead researcher Dr. Singh Ospina said in a news release, “Issues such as time constraints, inadequate training on patient communication and physician burnout may be influencing physicians’ interruptions.” It helps if providers can relax before and during an appointment.
It also helps to use active listening6 techniques such as encouragers (“I see, go on”), repeating, paraphrasing, asking clarifying questions or attentive silence.
The IDF global survey found that “health-care professionals, carers, families and people with Type 2 diabetes need to collaborate as a team.” So, clinicians should treat patients as teammates. Carlisle says that if patients have brought in or sent in glucose logs, providers should take a minute to review them and give feedback. Give patients copies of lab results, if they want.
Patient barriers to communication
Although clinicians can be rushed or overly focused on biomedicine to the exclusion of patients’ felt concerns, patients have their own barriers. They may not speak the provider’s language. They may feel out of their social class and so reluctant to say what’s on their minds or to voice questions about what they are being told. Race or sex differences between patients and providers may distort both people’s understanding. Patients may lack knowledge of their bodies or their illness and be confused by instructions given in medical language.
Patients may be extremely anxious, forget things, not speak clearly or not understand what is being said. There may be embarrassing social or economic issues or family problems that impact their ability to self-manage. Open-ended questions like “What is hardest for you about diabetes these days?” might help elicit psychosocial problems with which providers can help, even if just by listening.
Sometimes other staff can help with translation or conducting initial interviews. Patients may be more open with staff they perceive as like them than they are with a more educated professional. Staff can also do foot exams and neuropathy checks, do an A1C or spot glucose check and serve as patient educators or patient coaches.
The American Association of Diabetes Educators (AADE) created a list of seven key self-care behaviors (the AADE7):7 nutrition, exercise, glucose monitoring, problem solving, medication adherence, coping and risk reduction. If patients express frustration or concern with their diabetes management, this article for case managers gives questions for exploring the seven self-management areas.
By building a relationship through patient-centered communication, providers can become more successful in helping patients change their behavior and improving their outcomes.
Texts on interviewing patients
Access additional resources and practical information to enhance the care and treatment of your diabetes patients.
About our experts: David Spero, BSN, RN, Registered Nurse