Marilyn D. Ritholz

Look Who’s (Not) Talking: Diabetic patients’ willingness to discuss self-care with physicians

OBJECTIVE Nearly one-half of diabetic patients have glycated hemoglobin A1c (HbA1c) levels above recommended targets. Effective physician–patient communication improves glycemia and diabetes self-care; however, communication gaps may exist that prevent patients from discussing self-care problems with treatment providers. RESEARCH DESIGN AND METHODS We assessed diabetic patients’ (n = 316, 85% white, 51% female, 71% type 2 diabetes, 59 ± 11 years old, 16 ± 3 years education, 19 ± 13 years diabetes duration, and HbA1c = 7.9 ± 1.4%) HbA1c, frequency of self-care, diabetes-related distress, depressive and anxiety symptoms, coping styles, diabetes quality of life, and self-care communication in the treatment relationship. Multivariate logistic regression models examined the main and interaction effects of health and psychosocial factors associated with patients’ reluctance to discuss self-care. RESULTS Patients reported positive relationships with their doctors and valued honest communication; however, 30% of patients were reluctant to discuss self-care. Reluctant patients reported less frequent self-care (P = 0.05), lower diabetes quality of life (P = 0.002), and more diabetes-related distress (P = 0.001), depressive symptoms (P < 0.001), and anxiety symptoms (P = 0.001). Patients who reported elevated depressive symptoms, although not necessarily major depression, were more likely to be reluctant to discuss self-care (odds ratio [OR] 1.66 for 10-point change in t score; P < 0.001), whereas patients who were older (OR 0.78 for 10-year change; P = 0.05) and those who used more self-controlled coping styles (OR 0.78 for 10-point change; P = 0.007) were less likely to be reluctant. CONCLUSIONS Awareness of elevated depressive symptoms is important in clinical practice given that these patients may be more reluctant to discuss self-care. Interventions and evidence-based approaches are needed to improve both depressive symptoms and physician-patient communication about self-care.

Psychosocial factors associated with use of continuous glucose monitoring

Diabet. Med. 27, 1060–1065 (2010)

Living with Hypoglycemia

AbstractOBJECTIVE: To increase understanding of the everyday experiences of hypoglycemia for patients with type 1 diabetes through the use of a narrative research approach. SETTING: Center for diabetes treatment and research. DESIGN: Cross-sectional assessment using a narrative research approach. PATIENTS/PARTICIPANTS: Twenty outpatients (aged 21–30 years) diagnosed with type 1 diabetes for at least 10 years. MEASUREMENTS AND MAIN RESULTS: Experiences of hypoglycemia were investigated during in-depth, semistructured interviews that were tape-recorded, transcribed, and analyzed to identify common themes, Self-report measures of depression (Revised Hamilton Rating Scale for Depression) and anxiety (State-Trait Anxiety Inventory) also were administered. Subjects reported the following common themes: interpersonal conflict including fears of dependency and loss of control and problems addressing concerns about hypoglycemia with significant others; difficulty making sense of their hypoglycemic behaviors in relation to their usual ways of functioning; and perceived lack of understanding by others, including physicians, about the emotional experiences of hypoglycemia. Subjects were neither clinically depressed nor anxious. CONCLUSIONS: These findings suggest that type 1 diabetes patients’ experiences of hypoglycemia negatively affect their interpersonal relationships and views of themselves. Hypoglycemia also was described as an extremely private experience that was rarely discussed with others. Patient education and professional support in the treatment of hypoglycemia are recommended to enhance treatment decision making for patients with type 1 diabetes.

Understanding Physicians’ Challenges When Treating Type 2 Diabetic Patients’ Social and Emotional Difficulties: A qualitative study

OBJECTIVE To explore physicians’ awareness of and responses to type 2 diabetic patients’ social and emotional difficulties. RESEARCH DESIGN AND METHODS We conducted semistructured interviews with 19 physicians. Interviews were transcribed, coded, and analyzed using thematic analysis. RESULTS Three themes emerged: 1) physicians’ awareness of patients’ social and emotional difficulties: physicians recognized the frequency and seriousness of patients’ social and emotional difficulties; 2) physicians’ responses to patients’ social and emotional difficulties: many reported that intervening with these difficulties was challenging with few treatment options beyond making referrals, individualizing care, and recommending more frequent follow-up visits; and 3) the impact of patients’ social and emotional difficulties on physicians: few available patient treatment options, time constraints, and a perceived lack of psychological expertise contributed to physicians’ feeling frustrated, inadequate, and overwhelmed. CONCLUSIONS Recognition and understanding of physicians’ challenges when treating diabetes patients’ social and emotional difficulties are important for developing programmatic interventions.

Patient-Provider Relationships Across the Transition From Pediatric to Adult Diabetes Care A Qualitative Study

Purpose The purpose of this study was to explore perceptions that emerging adults with type 1 diabetes (T1D) have of their patient-provider relationships across the transition from pediatric to adult care. Methods Twenty-six emerging adults with T1D (mean age 26.2 ± 2.5 years) participated in 5 focus groups stratified by current level of glycemic control (A1C). Coded audio-recorded data were analyzed using thematic analysis and aided by NVivo software. Results Three major themes emerged from the analysis: (1) loss and gain in provider relationships across the transition—patients expressed 3 key responses to leaving pediatric providers that differed by A1C levels: sad reluctance and “natural progression” (mean A1C ± SD 7.4% ± 0.6%) and wanting to go (mean A1C ± SD 9.8% ± 1.0%); (2) partners in care versus on one’s own—patients valued how adult providers’ collaborative conversations promoted their involvement and accountability compared to “parent-centric” interactions with pediatric providers, but they also expressed ambivalence over increased independence in adult care; (3) improving provider approaches to transition—patients recommended that pediatric providers actively promote emerging adults’ autonomy while maintaining parental support, communication with adult providers, and follow-up with transitioning patients. Conclusions Findings highlight the importance of enhanced provider awareness of T1D emerging adults’ complex feelings about the transition in care. Improved integration of individual- and family-centered approaches to developmentally tailored diabetes care is needed to augment patient and provider relationships.

Experiences of health care transition voiced by young adults with type 1 diabetes: a qualitative study

Objective This qualitative study aimed to explore the experience of transition from pediatric to adult diabetes care reported by posttransition emerging adults with type 1 diabetes (T1D), with a focus on preparation for the actual transfer in care. Methods Twenty-six T1D emerging adults (mean age 26.2±2.5 years) receiving adult diabetes care at a single center participated in five focus groups stratified by two levels of current glycemic control. A multidisciplinary team coded transcripts and conducted thematic analysis. Results Four key themes on the process of transfer to adult care emerged from a thematic analysis: 1) nonpurposeful transition (patients reported a lack of transition preparation by pediatric providers for the transfer to adult diabetes care); 2) vulnerability in the college years (patients conveyed periods of loss to follow-up during college and described health risks and diabetes management challenges specific to the college years that were inadequately addressed by pediatric or adult providers); 3) unexpected differences between pediatric and adult health care systems (patients were surprised by the different feel of adult diabetes care, especially with regards to an increased focus on diabetes complications); and 4) patients’ wish list for improving the transition process (patients recommended enhanced pediatric transition counseling, implementation of adult clinic orientation programs, and peer support for transitioning patients). Conclusion Our findings identify modifiable deficiencies in the T1D transition process and underscore the importance of a planned transition with enhanced preparation by pediatric clinics as well as developmentally tailored patient orientation in the adult clinic setting.

Digging Deeper: The Role of Qualitative Research in Behavioral Diabetes

Qualitative research methodology is more recognized and valued in diabetes behavioral research in recent years. Qualitative methods help clinicians answer questions that quantitative research may not be able to answer, such as exploring patients’ motivations, perceptions, and expectations. This paper reviews recent (2005–present) rigorous qualitative studies of children, adolescents, and adult patients with type 1 and type 2 diabetes with the aim of answering the following research question: How has qualitative research contributed to our understanding of behavioral diabetes care? We focus on studies exploring patients’, health care providers’, and families’ interpersonal experiences of diabetes as well as patients’ psychosocial experiences of diagnosis and treatment, self-care, complications, and cultural factors. After reviewing the research in each area, we conclude by discussing how qualitative research contributes to our increased understanding of behavioral diabetes.

Depression in bulimia at 2- to 5- year followup

Previous research has indicated a strong association between bulimia and affective disorder at the time of initial clinical assessment. To investigate this relationship from a long-term perspective, 30 normal weight female bulimics were evaluated 2 to 5 years posthospital admission with psychometric measures and clinical interviews. Contrary to previous reports, the depression scores of the bulimics were surprisingly low, even though 26 of the 30 continued to fulfill DSM-III criteria for bulimia. Higher depression scores were associated with more intense bulimic symptomatology and attitudes, and greater psychiatric disturbance at followup. Although these data demonstrate a relationship between bulimic symptomatology and depression at long-term followup, they do not support recent assertions that bulimia is a variant of an underlying affective disorder.

Barriers and facilitators to self-care communication during medical appointments in the United States for adults with type 2 diabetes

Objective Diabetes self-care is challenging and requires effective patient–provider communication to achieve optimal treatment outcomes. This study explored perceptions of barriers and facilitators to diabetes self-care communication during medical appointments. Design Qualitative study using in-depth interviews with a semistructured interview guide. Participants Thirty-four patients with type 2 diabetes and 19 physicians who treat type 2 diabetes. Results Physicians described some patients as reluctant to discuss their self-care behaviors primarily because of fear of being judged, guilt, and shame. Similarly, patients described reluctant communication resulting from fear of being judged and shame, particularly shame surrounding food intake and weight. Physicians and patients recommended trust, nonjudgmental acceptance, open/honest communication, and providing patients hope for living with diabetes as important factors for improving self-care communication. Further, patients stressed the clinical benefits of physicians directly addressing poor self-care behaviors while physicians described having few strategies to address these difficulties. Conclusions Physician–patient self-care communication barriers included patients’ reluctance to discuss self-care behaviors and physicians’ perceptions of few options to address this reluctance. Treatment recommendations stressed the importance of establishing trusting, nonjudgmental and open patient–provider communication for optimal diabetes treatment. Medical education is needed to improve physicians’ strategies for addressing self-care communication during medical appointments.

Physicians' perceptions of the type 2 diabetes multi-disciplinary treatment team: a qualitative study.

Purpose The purpose of this study was to explore physicians’ perceptions of the multidisciplinary type 2 diabetes treatment team. Methods Nineteen physicians (74% endocrinologists; 26% primary care) participated in semistructured interviews. Audiorecorded data were transcribed, coded, and analyzed using thematic analysis and NVivo 8 software. Results Physicians considered the multidisciplinary team, including a physician and diabetes educator, as very important to diabetes treatment. Participants described how diabetes, with its many comorbidities and challenging lifestyle recommendations, is difficult for any single physician to treat. They further described how the team’s diverse staff offers complementary skills and more contact time for assessment and treatment of patients, developing treatment relationships, and supporting patients in learning diabetes self-care. Physicians stressed the necessity of regular and ongoing communication among team members to ensure patients receive consistent information, and some reported that institutional factors interfere with intra-team communication. They also expressed concerns about the team approach in relation to individualized treatment and patients’ reluctance to see multiple providers. Conclusions This study highlights physicians’ positive perceptions of and concerns about the type 2 diabetes multidisciplinary team. Further study of diabetes educators’ and patients’ perceptions of the team approach is needed.