Tag: patient-clinician communication

MDM in practice, minimally disruptive medicine, Reflections on MDM, Research on MDM

Making care fit in the lives of young adults with type 1 diabetes

Marleen Kunneman, Matthijs Graner, and Viet-Thi Tran

Even if care seems right from a medical perspective, if care doesn’t fit for each individual, we may ‘deliver care’ without actually ‘caring’. The recently published Making Care Fit Manifesto (1) states that for care to fit, care should be maximally responsive to patients’ unique situation and supportive to their priorities. Care should also be minimally disruptive to patients’ lives, loved ones, and social network. Making care fit requires patients (and their caregivers) and clinicians to collaborate, both in content and manner, and it is an ongoing and iterative process where care plans should continuously be evaluated and modified.

This is especially pertinent for young adults living with type 1 diabetes. Previous research showed that young adults with type 1 diabetes have relatively poor biomedical and psychosocial outcomes (2,3). For example, HbA1c levels are higher in younger adults compared to other age groups, and strikingly, they are also higher now than they were a decade ago (3).

At the same time, very little is known about what young adults do to implement diabetes care in their lives, and what price they have to pay in terms of negative effects on themselves and their surroundings. Also, how do we bridge what happens in their personal environment (‘point of life’) and what happens during clinical encounters (‘point of care’)? Because whatever is left undiscussed with their clinicians, is also left unconsidered when designing care plans.

We explored experiences of young adults with type 1 diabetes trying to make care fit into their lives. First, we asked 62 young adults with type 1 diabetes (Median age: 27, IQR 24 to 27, 80% women) from the French ‘Community of Patients for Research’ (ComPaRe) for their experiences with the burden of treatment. They reported a high burden4 of diabetes treatment (76.5 out of 150, IIQR 59 to 94). Importantly, 3 of every 4 young adults (74%) reported that their investment of time, energy, and efforts in healthcare is unsustainable over time. This is about twice as high as for other people with chronic conditions.

Second, the Dutch ééndiabetes foundation (for and by young adults with type 1 diabetes) asked its members for their experiences in making diabetes care fit into their lives. Nine of 25 young adults (36%) indicated that their diabetes care regularly or very often hinders their education, work, hobbies, leisure or social lives. When asked to describe their biggest efforts to fit diabetes care into their daily life, they responded:

“You want to live a fun and spontaneous life, but you have to nonstop keep an eye on your sugars.”

“Food. Everything you have to do then. That’s why I sometimes skip my meals.”

“Planning. Not just the hospital appointments and changing needles, but also planning with the energy I will or will not have.”

“Regulating hypo’s and then compensating for the time I couldn’t function well due to a hypo.”

“On time and constant planning ahead. What do I need? Do I have all my stuff before I leave? When do I have to place new orders to make sure I don’t run out?”

Additionally, we asked young adults what they do to fit diabetes care into their lives, but what they don’t discuss with their clinician. Some indicated they discuss “everything” or “nothing” with their clinician. Others said:

“I use a DIY loop. (I did tell my clinician but he wasn’t interested)”

“I delay my hospital appointments as long as I can.”

“I discuss everything about my diabetes with my clinician. All the better they can help me.”

“I bolus less to prevent hypos.”

Communication is key to bridge efforts of making care fit at the point of life and at the point of care. Our future work will focus on uncovering better ways to improve the quality of diabetes care through improving conversations. And to help young adults with their lifelong, daily and ongoing endeavor of making diabetes care fit.

 

References

  1. Kunneman M, Griffioen IPM, Labrie NHM, Kristiansen M, Montori VM, van Beusekom MM, Making Care Fit Working G. Making care fit manifesto. BMJ Evid Based Med. 2021.
  2. Johnson B, Elliott J, Scott A, Heller S, Eiser C. Medical and psychological outcomes for young adults with Type 1 diabetes: no improvement despite recent advances in diabetes care. Diabet Med. 2014;31(2):227-231.
  3. Redondo MJ, Libman I, Maahs DM, Lyons SK, SaracoM, Reusch J, Rodriguez H, DiMeglio LA. The Evolution of Hemoglobin A1c Targets for Youth With Type 1 Diabetes: Rationale and Supporting Evidence. Diabetes Care. 2021;44(2):301-312.
  4. Tran VT, Harrington M, Montori VM, Barnes C, Wicks P, Ravaud P. Adaptation and validation of the Treatment Burden Questionnaire (TBQ) in English using an internet platform. BMC Med. 2014;12:109.

Reflections on MDM, Views from the frontline of care

How patient-clinician communication can promote minimally disruptive medicine via shared decision-making

by Zackary Berger, MD, PhD

How can we get more clinicians to help the patient receive minimally disruptive medicine? The answer might lie in the improvement of patient-clinician communication. For many conditions, the doctor is encouraged to look into the book – or, more likely, UpToDate – and read out the recommendations of the latest guideline.

But there are two limitations to guidelines. The first, of course, is that all guidelines, whether from the United States Preventive Services Task Force or the International Association of Quackery, are only as good as the methodology and evidence that go into them. The second is that even the best guideline is not a magic recipe for appropriate care for the individual person in question.

If you are discussing screening for prostate cancer via the PSA test, whether you are a patient or provider, you will surely realize that the guidelines of the urologists and internists are now in rare agreement: universal screening is not recommended. What is now recommended is shared decision making, a series of tasks that patients and clinicians do together to communicate about the options and to deliberate to identify the one that fits best with the patient preference and context.

Whether it’s prostate cancer, diabetes, or depression, how can we bridge the gap from guidelines to individually sensitive care? I think there are two steps. The first, as I outline in my book, is to build a relationship between PCP and patient that can handle the intellectual and emotional stresses of decision making with unclear information. This requires mindfulness; emotional readiness; and specificity and clarity of options.

The second step is to contextualize clinical recommendations in a way that only good communication makes possible. Such contextualization is now being addressed by some fascinating new research. We have already known, through the work of communication researchers (chief among them Debra Roter), how to characterize a true dialogue between patient and clinician.

Unfortunately, the evidence is mixed as to the extent to which such dialogue leads to improved outcomes. In their recent work, Saul Weiner and colleagues at the University of Illinois at Chicago, and at Duke University, try to determine how often physicians take the next step after good communication: using an appreciation for the patient’s individual concerns and customizing their recommendation on that basis. It’s not enough to empathize, in other words, about someone’s job loss, poverty, broken family, or inability to navigate our health system: the doctor’s care must respond to those individualities. They find that physicians who manage that customization offer care which is more appropriate to an individual’s given situation (here is a video that demonstrates “red flags” about contextual issues designed to prompt clinician response, which rarely took place).

We know that maximally invasive care is often a shortcut taken by physicians (and patients) overwhelmed by the complexities of possible options, and daunted by the challenge of modifying medicine to a person’s unique needs. Contextualizing care through good communication can give us permission to be minimally invasive when appropriate, hopefully for the benefit of person and system alike.

Zackary Berger, MD, PhD, is an internist and researcher in doctor-patient communication at Johns Hopkins General Internal Medicine in Baltimore. He is particularly interested in the role of the primary care provider in cancer control. His book, Talking To Your Doctor, is out on July 16th, 2013.