“Wow, your A1C really jumped up” – the six most dreaded words for a person with diabetes.
As I said it, I watched my patient’s face fall as they said “I thought it would have been better…”—and the entire tone of the visit changed. I wondered if one of us should have handled that better; should I have said that differently?
As providers, how do we make each visit a positive dialogue about diabetes, and take care of other things as well, without feeling like you are “checking the boxes” to make sure all aspects of care are met? Does diabetes have to dominate each visit?
For both primary care providers and patients, this balance can be a struggle. As providers, multiple aspects of care need to be addressed for people with diabetes: eye exams, lipid levels, blood pressure, and that dreaded A1C. That same burden is often extended for the patient – the visit seems to be focused on their diabetes, even when there are other things to address. Their agenda might be different from yours—things like increased stress due to work changes, a shoulder pain that seems to be getting worse, even preventative measures like, “should I be worried about my heart, my dad just had a heart attack.”
Each visit has expectations to be managed on both sides….maybe, just maybe it’s not someone’s diabetes causing that shoulder pain!
Diabetes is a chronic condition, but it doesn’t have to take up the entire portion of a general care appointment—the great part about establishing a relationship between patient and provider is that we have the ability to check in, make a change, and continue the conversation at the next visit.
But how do you prioritize?
Enter the 5-minute diabetes discussion—3 questions that can help you and your patient make actionable changes that will make a difference.
Question 1: What is frustrating you the most with your diabetes?
Diabetes distress is “the emotional stress from living with diabetes and the burden of relentless self-management”. This distress doesn’t go away with an A1C or time in range hitting a pre-determined goal. As providers, we cannot assume that just because glucose numbers are “at goal”, that there isn’t an emotional burden or distress. Diabetes distress can be mistaken as depression and can be missed if we don’t ask the question. Opening the door for identifying challenges can start a dialogue, but not all problems have to be solved at this visit.
Question 2: Have you had any lows?
It should be assessed whether or not hypoglycemia is occurring. This simple question can give unexpected insight and help you make sure you aren’t missing a dangerous situation that might need to take priority. Someone’s A1C could be perfect, but A1C doesn’t capture glucose variability—missing lows is a dangerous risk when only focusing on A1C.
Question 3: What is one change we can make today?
The last question helps tie it all together. At any given visit, there are multiple competing priorities. What is one factor you can add or decrease now that can address one of those goals or issues? Maybe this is adding a medication, using a sensor to monitor time in range, or having a plan to address hypoglycemia during exercise.
As providers, laying out a road map is helpful, but you don’t have to hit every destination today. The road map might include a plan to talk about adding a different class of medication at the next visit or revisiting frustrations with device connectivity. Setting expectations and leaving reminders sets everyone up for another successful visit next time.
Diabetes is a conversation. The key to success is knowing you can pick up the topic at each visit, but leave room for other issues. We may not be able to fix it all today, but sometimes “I hear you” gives space for competing priorities and lets us remember that sometimes, it isn’t all about the diabetes.
References:
Fisher L, Polonsky WH, Hessler D. Addressing diabetes distress in clinical care: a practical guide. Diabet Med. 2019 Jul;36(7):803-812. doi: 10.1111/dme.13967. Epub 2019 May 7. PMID: 30985025.