It would be unethical and unprofessional for me to ever denigrate a colleague to a patient, and it often takes all my tack and diplomacy to get out of situations where my patients ask me why the doctor never told them this or that.
For example, I have a patient who is an active 45-year-old man. He has had diabetes for five years, and because he is a friend of mine, he came to me for help. He was told to watch what he ate and take two metformin tablets daily. When I asked him what kind of diabetes he had, he said the doctor told him that he did not have diabetes, just elevated sugars, and to watch himself. He was not told to test his blood or have glycated hemoglobin (A1C) tests done. He was not referred to an educator nor were goals set. It was not until three years later that the physician ordered quarterly A1C, after he apologized to the patient for not having them done earlier.
Diabetes educators have had to live with the terms “borderline diabetes” or “just a little bit of sugar” for years, and it is not acceptable. If the blood sugar is not normal, 90–110 mg/dl,4 then the patient has impaired glucose tolerance. If it is above 126 mg/dl, the patient has diabetes. Short and simple. Calling these conditions anything else is frustrating and often causes delay in the patient’s ability to adapt to a long-term illness. It does nothing to assist the health educator to work more effectively with the patient in goal setting. The physician is doing the patient no favor by delaying a definitive diagnosis.
I have had to call a physician and ask for a diagnosis. One physician told me that he did not want to label the person as diabetic and put them through the stigma and insurance hassles. This is not acceptable in 2003.
What Does Having Diabetes Mean?
If the patient tells me that he has diabetes, I ask what he thinks that means and we go on from there. Some patients will say that they don’t want to have diabetes. My answer is that I don’t want to be short. It is a fact of life. I am short, and they have diabetes, and we will deal with it, and that is the pure truth.
How Do You Feel about Having Diabetes?
No one wants a disease that will not go away. It will be there for the rest of their lives. Diabetes takes no holidays, vacations, or days off. It is always there, and they will always have to deal with it. It is time-consuming and expensive and affects everything they do.
In Chapter 5, I talk about motivating patients. Before you can motivate them, you need to find out who they are and what they are about.
What Do You Know about Diabetes?
I learn a lot by asking this question. People have amazing ideas. They have often been educated by their favorite sources—neighbors, friends, relatives, pulp fiction, and tabloid newspapers. I try to keep aware of this “valid” information so I can deal with the many calls I receive when there is an article published telling people that islet cells can now be eaten to cure diabetes. Just in case you are curious, I just made that up! Our ability to unteach myths and find the realities for patients is often the most important thing we do.
This does not only apply to people with diabetes. People are happy to get information from nonprofessionals because it is never threatening or fatal. If you don’t like what your neighbor tells you, go to another neighbor. This tactic often delays care or treatment and can be life-threatening. We need to create an environment that is neither frightening nor intimidating that allows the patient to ask questions without a fear of being thought stupid or naïve. Give the patient permission to disagree with you or argue about a concept. If you tell patients that they have the final say on their own life, then you are assuring them that you respect them as people.
The rest of the assessment is the process we utilize in health care constantly. In nursing, we call it “The Nursing Process,” but most health professionals follow a close proximity. Who is this patient as a person? What are her psychosocial needs? Does she have a support structure? Is there a significant other to help her through the learning process? Are there barriers to learning? Can she afford to live with this disease? What parts of the health care system will she utilize? What referrals will she require? Which members of the health care team are needed at this time or will be required at a later date?
The data you collect from the patient will give you a clear picture of this patient and how you can help him or her achieve his or her goals and objectives.
Collecting the physical data gives us a clear picture of what is happening to this patient and what changes need to be made in his or her physical picture overall. Part of this may be determining what data need to be collected in order to make clear decisions about treatments. One or two blood tests are not going to give me all the information I need to help the patient learn meal planning and make lifestyle changes. I cannot do pattern management without a pattern to analyze.
Compare this to an educational assessment. What does the person have to know, how does he learn, how ready is he to learn, and what are the barriers? In Chapter 4 on the Do-Know-Deficit, I will take you through the entire process of assessing learning needs.
Once you have assessed learning needs, you develop an education plan for that individual. The plan is developed in conjunction with the patient and, if possible, the significant other. Be realistic. What does this person need to know? There are three considerations: needs to know, wants to know, and nice to know.
The “needs to know” are the essential components. These are the survival skills, the basic things a patient needs to know to go home safely. In diabetes, I call them the four M’s: medication, meal planning, monitoring, and motivation. The patient needs this knowledge to leave your care safely.
The “wants to know” are the things that patients ask about. They may not be the most important things to you, but if the patient asks about something and you close the subject or shut them out, they will not hear anything else you say. For example, most of us divide our classes into several sessions. Perhaps the first class is “what is diabetes?” The second class is meal planning, and the third session is medications. Sound familiar?
Perhaps the first night you notice a patient looking very nervous and fidgety. When you go over the outline for the programs, the patient states that he was told he has to start on insulin “shots” next week and is worried about that. If you close him off by telling him that the subject will be covered in the medication class, three days later, he will be completely turned off. He may not even return for the rest of the classes and will absolutely not hear anything you say for the rest of the first class.
This is a teachable moment. These are so exciting, and when they occur, you have the best opportunity to get through to patients. They want to know something, so they have opened their minds to information and concepts. This is a wonderful chance to really get through to them and, if you miss that moment, you may never get it again. You can tell them that the subject will be covered later on, but that if they are really concerned you will discuss it with them after the class. That will show your concern but also let them know that the entire class is not there to meet their specific needs. In a large class, we have to create teachable moments. It is harder and a lot of work. I strive to create an atmosphere where people want to listen to me and learn. When I lead an all-day workshop, I ask an audience to give me the first two hours, and if I am not getting through to them, they have my permission to leave and we will give them back their money. I do not hold hostages!
Finally, there are the “nice to knows.” These are things that may be interesting and fun but no one needs them to survive. I remember teaching a section on “how to travel with insulin.” It was part of my medication class and was taught regularly. It was a long time before I realized that most of the people in my class had never been out of Nashua, New Hampshire, let alone to the Grand Canyon in 110° heat. Teach what the people need, not what you enjoy. You may