Imagine I have diabetes.
And they say, ‘We have to control your blood
sugar, your blood pressure, your cholesterol.
We have to see if you have depression.
We need you to move more than you have been moving.
And we need you to eat healthy food.’
Immediately I am overwhelmed.
When people get first diagnosed with diabetes,
their responses may vary.
Sometimes people are relieved
because they finally have an answer
to these strange symptoms they’ve been having for a while.
Sometimes they’re frightened.
Sometimes they need a minute
just to be with the diagnosis
and to talk about what that means.
And we make a plan at the detailed level at the next visit.
It is really important that you give them a chance
to really recognize that this is going to be a partnership
between you and them.
As a provider,
I don’t need to fix everything right away
and, actually, I can’t fix anything.
So I need to get rid of that mentality.
I need to see, what are they ready for?
In all people with diabetes,
whenever I see them,
I make sure that they’ve done a prescreen.
We call it the ABCs of diabetes, but it’s become now ABCD.
A is A1c, B is blood pressure, C is cholesterol.
There are two different Ds.
Depression and diabetes distress.
Anxiety around everything I do all day long.
Is that going to affect my ability to parent my children,
my ability to see and do my job?
What is this diabetes going to do to my long-term health?
Some people think the A1c is more important
than these other things.
It’s absolutely not true.
We need to decide where you’re going
prioritize your intervention based on the acuity
of the situation.
“So, that is a blood pressure that we’re not happy about.”
“I know. Neither am I.”
“If this kind of stress might send the blood pressure up,
then other stressors in your life might.
So, taking a medicine would be really worth it.”
“Right.”
High blood pressure
is the most urgent issue for that individual.
But all three of these things, blood pressure,
cholesterol, and blood sugar need to be addressed.
We’re going to focus on one so that they can get used to it.
And then we start another new drug 3 to 6 months from now.
If they’re willing, sometimes we start with two.
One of our jobs as physicians is to educate,
but one of the things that we often forget
is that in medical school we learned a second language.
All of the terms,
the medical jargon, that we learned
are not things that regular people know.
So you have to ask patients,
‘So tell me what you know about diabetes?’
so you can tailor what you give to them
based on their baseline working knowledge.
Over the first year, or so, you want to have multiple visits;
one visit might be all about nutrition,
one might be exercising safely.
Each time we move to something new,
we need the patient to get comfortable with it.
It takes someone learning, and unlearning, and relearning
at least five times before they really get it.
And so just level setting expectations for patients
and saying ‘It’s okay if you forgot,
it’s okay if you don’t get it, you know, that’s my fault.’
You know,
‘My job is to teach you.’
All of that makes it easier for people to be like,
‘You know what?
That was confusing. I didn’t get any of that.’
Diabetes is a lot for patients,
even the patients who have the most resources,
the strongest social support system, it’s a lot for them.
And that means that you have to plan
for equity.
We’re in a time
now of medicine where we are officially
recognizing what we call social care.
Addressing the unmet social needs
that our patients have always had,
but we have not previously really done anything about it.
Screening tools are still being developed and validated,
but it’s happening.
We need to meet patients where they’re at.
And a lot of times where they’re at
is struggling with a lot of obstacles.
Health educators have a number of screening questions
that they ask
to find out things that I would never know about.
‘What appliances do you have in your home?’
‘Do you have a stove?’
‘Do you have cookware?’
‘Air conditioning?’
This is a systemic problem.
It’s important to understand where people live and work
and what is the barriers
so we as health care providers can hear that problem
as being as important as access to medication
and help them find a solution.
The traditional or older models of health care
tend to be one on one with the physician,
or other provider,
managing the care directly with a patient,
providing instructions, providing medications,
expecting the patient to go and follow those.
More and more we’ve realized
that model is lacking.
It’s imperative that providers
are curious about what is going on
behind the scenes in the life of their patients.
Together we can actually learn what the patient
could use right at this moment,
and then go step by step
in moving towards better health.