Then work with your patients and their family members with areas of concern.
In some ethnic communities, “a diabetes diagnosis reflects a personal failure of consuming excess calories, behaving immorally, or being unspiritual” (Anderson, 2002). A wife of a Latino man, for example, may blame herself for causing her husband’s diabetes, if she is the one who is responsible for food preparation in the family (Anderson, 2002). Ask about family, holiday, or religious customs that affect how your patients care for their diabetes. If they participate in the month-long practice of fasting until sundown to mark the holiday of Ramadan, you may need to help them adjust their insulin dose, so they don’t experience fasting-related hypoglycemia or hyperglycemia (Anderson, 2002). For assistance with Ramadan, we suggest Recommendations for Management of Diabetes During Ramadan (Al-Arouj, 2009).
If your patients are of the Jewish faith and want to follow the Passover holiday’s dietary restrictions, help them locate dietary information that helps them consume appropriate portions of the foods commonly eaten on that holiday, such as products prepared with matzo. One website that offers helpful diabetes-related Passover information is http://www.Friendswithdiabetes.com.
Lessons That Linger
Here is how the supportive interactions you have with your patients can positively influence their behaviors in the future:
Ted stopped at a nearby coffee shop to pick up a decaf coffee. While waiting in line, he spied a croissant that had his name written all over it. In the past, he would have impulsively added it to his order, gobbled it down, and then hated himself for the rest of the day regardless of how well he ate later. But this time was different. At a recent appointment, his diabetes educator, Samantha, recognized how frustrated he was about his eating urges and reminded him that he tended to feel that way when his blood glucose level ran high. They brainstormed and Ted identified several ideas he thought he might like to try:
● He could go to a different coffee shop and develop a new, croissant-free, coffee-purchasing tradition.
● He could bring exact change for the coffee, so he wouldn’t purchase anything else.
● He should give himself permission to stop feeling guilty because he wants to eat the croissant. Having diabetes doesn’t mean he has to deny himself everything he loves.
● He could use pre- and post-blood glucose checks to see how the croissant affects his efforts to manage his diabetes and then adjust his medication, physical activity, and intake accordingly.
Samantha even joked about how he might have an easier time sticking to his health goals if he stared at the cashier’s lovely eyes instead of at the croissant. Ted smiled as he recalled their conversation, how much they both laughed, and how good it felt to have Samantha understand him. He felt he could make a better decision and not just follow a thoughtless reflex. He excused himself from the order line, turned around, and walked down the block to a rival shop. He decided to start a new coffee-buying ritual: one without croissants, cake, or other baked goods. Ted felt proud. He made a mental note to e-mail Samantha and thank her for her help.
What If You Don’t Like Your Patient?
Occasionally, we have to deal with patients we don’t particularly like. For some reason that may be related to our own life experiences, they push our buttons. These feelings are perfectly normal, so don’t dismiss them. Instead, use them diagnostically as a way to learn more about your patients and yourself. If Mrs. Leaf always had a lovely disposition, but suddenly comes to her appointment disgruntled and rude, SDR and then consider what physical and mental changes she may be experiencing. Is her glucose level abnormal? Is she becoming depressed? What else is happening in her life? If you feel uneasy around particular patients, your discomfort may highlight a behavior that they use with others. Note these red flags and investigate the physical, interpersonal, and emotional health issues they may represent.
Occasionally, our strong feelings can compromise the care we provide. We may not be able to connect with some patients, and they may have a harder time accepting help from us. John Bowlby’s attachment theory offers a possible explanation for the negative encounters that occur between us and some of our more challenging patients. According to Bowlby, when all of us were young, our caretakers met our needs in ways that either comforted and reassured us or left us feeling anxious, lost, and unsupported. These early experiences helped us form “enduring cognitive models or ‘maps’ of caregiving that persist into adulthood” (Ciechanowski, 2002).
Adults with secure attachment histories are more at ease with those who reach out to assist them. Those with less or unresponsive early caregivers may have more difficulty trusting health care professionals, while individuals whose caregivers’ attention was inconsistent try much harder to gain approval. These are the patients who may act more clingy and needy. Finally, individuals who experienced “overly critical or harsh rejecting caregiving” are more apt to demonstrate approach-avoidance behavior as a “manifestation of their fear of intimacy” (Ciechanowski, 2002). Their behaviors have both negative and positive aspects. For example, they may be excited to try what you suggest, but they won’t actually do it. These different attachment responses are most apparent when the individuals need assistance, which is when most of us see our patients. When they meet with us, their attachment history helps them determine whether they can trust us as their caretakers and whether they feel they deserve to be helped. Understanding the basics of attachment theory can help us all see our patients’ behaviors through a new lens and respond to them in a more positive way.
What About Our Own Attachment Issues?
We health care professionals have our own attachment histories, and develop attachments with our patients as well. We expect our patients to value us and turn to us when they are in need. We believe they should come to their appointments and follow the guidance we offer. At times, we may find ourselves trying too hard to get their approval. Our professional values also may be affected, if our attachment feelings start to unravel when patients miss multiple appointments. We may feel less committed or even threatened when patients bring conflicting opinions from other sources, such as the Internet. Instead of praising their efforts to find answers, which reflect the dedication they have to their health (and then discuss why the info may be incorrect), many of us express such strong negative responses that our patients become reluctant to share in the future:
After Maxine shared an Internet article she printed out about hearing loss, which she was developing, her doctor went on a lengthy tirade about the unreliability of Internet medical information. Maxine felt hurt and dismissed. Today, she still looks things up on Webmd.com, a reliable website, but never shares it with her doctor. She also refrains from letting him know when she tries any of the suggested treatments posted on the site. Sadly, their relationship continues to suffer. Her doctor missed an opportunity to listen to Maxine’s concern, acknowledge her efforts to learn more, and reflect back on the issues that worried her. His efforts could have positively affected the way she cared for her health.
Why Do They Push Our Buttons?
To understand and, hopefully, adjust the highly negative responses we have to some of our more frustrating patients, for their well-being and ours, we need to consider three things:
● Others may find these individuals frustrating too, so we shouldn’t take their behavior personally.
● Their behavior may remind us of the behavior of others in our past or present.
● We may have a strong response because we possess the potential to behave the very same way.
“What we see in others may exist in ourselves, both the good and the bad. If you admire someone’s courage, you notice it because it is in you as well” (Ford, 2010). What we dislike in others, we may dislike in ourselves. Think about a patient you find hard to tolerate. Identify what bothers you the most. For the sake of this discussion, let’s say that you cringe every time you encounter Mrs. Groan’s rudeness;