GO! Diabetes :: News On The GO!

There's no denying the truth behind "We are what we eat," but what about the validity of "We feel what we think?" If we believe what we think about determines how we feel as we face challenges, we have powerful insight to the heart and art of telling a patient they have diabetes.

Understanding a patient's temperament, coping mechanisms, family dynamics, and medical history is where Family Medicine has the advantage over other medical specialties. "Usually, we have longstanding relationships with our patients, so time is on our side," said Heidi Pomm, PhD, Coordinator of the Behavioral Sciences Program at St. Vincent's Family Medicine Residency Program in Jacksonville, FL. "With chronic disease management, our history with our patients matters especially over the long haul."

Dr. Pomm coaches residents to never make the assumption patients want to hear they've been diagnosed with diabetes. Some would prefer a family member hear the news first or may want to remain in the bliss of unknowingness or denial.

"We address the patient by name and let the patient know we have bad news from the labs. Then we ask if they would like to hear the news," said Dr. Pomm. "After receiving the patient's permission, we tell them they have diabetes and then quickly follow-up with, 'How do you feel now that I've let you know you have diabetes?'"

The question puts the focus on how the patient feels, not on the implications of being diagnosed with the disease. The patient's answer helps uncover initial thoughts and fears providing the caregiver with a good indication of how the patient's responded to other life-altering events in the past.

Dr. Pomm coined the phrase "reality vertigo" to describe how many people respond to a traumatic life-changing event like an unexpected loss of a loved one, a severe car accident or the daunting news of a chronic disease like diabetes.

"A patient's reality and plans for the future are seemingly shattered in an instant and an emotional tailspin often ensues," said Dr. Pomm. "Most patients think diabetes is a death sentence. With a gentle voice and a tender touch, reassuring them it's not a death sentence is vital at this point to help them understand diabetes can be controlled. Our quest is to slow or stop the vertigo process and help empower the patient to regain perceived control over their life again."

Patient reaction runs the gamut of emotion from a stoic, unpenetratable "minimizer" to an emotionally charged Chicken Little "maximizer" and everything in between. According to Dr. Pomm, it's important to teach the patient to refocus and reframe their self-defeating or sabotaging thoughts, which may run amuck like an unruly child, and help replace them with empowering and positive messages.

If the patient minimizes the news –for example, acts like having diabetes is "no big deal" – caregivers should strip away the patient's protective sugarcoating and discuss the dangers of living with uncontrolled diabetes. If the patient maximizes the news and becomes overwhelmed, caregivers should avoid information overload. The goal is to help the patient cope with the news of having diabetes, not to cope with the disease itself. Educating the patient about the affects of diabetes at this point is futile, as it is almost impossible to assimilate new information when highly distressed or just entering the "reality vertigo" spiral. Without addressing patients' fears first, explaining long-term behavior modification after breaking the news falls on deaf ears and defeats their spirit.

Instead listen, validate their feelings and steer any defeating thoughts toward a positive way of thinking. Only then can we help our patients achieve lasting change and avoid a tailspin of despondency and fear.

Tips to break the news without breaking the spirit:

1. Ask your patient permission to share the bad news.

2. Avoid "reality vertigo" by focusing on patients fears first not on disease education and management.

3. Teach patients their thoughts create feelings. Encourage them to become aware of thoughts that create distressful feelings. Ask them to ask themselves, "What would the wise part of me (or God, if they are spiritual) tell me right now to comfort me?" Ask them to write down those positive thoughts and read them on a regular basis.

4. Set goals and expectations low and attainable for success. How does the patient want to start controlling their disease?

5. Get the patient to write a goal down in their handwriting. Praise their choice and encourage them in their decision to make a positive change.

6. Write down for the patient a re-cap of the office visit. For example: 1) Diabetes is not a death sentence. 2) Walk an extra five minutes per day. 3) Try eating two salads this week.

7. Reassure the patient you'll be there every step of the way.

Faculty category
Lissa Lansdale, MSN, CRNP
UPMC McKeesport, PA
Latterman Family Health Center
Poster: "Implementing Change to Promote Diabetic Care"

Resident category
Abbegail Collantes, MD with Vincent Lo, MD and Tam Nguyen, MD
San Joaquin General Hospital
French Camp, CA
Poster: "A Follow-up Study on Diabetes Care after Implementing Quality Improvement Measures in a Family Medicine Residency"

Jacqueline Harris, MD, MPH with Shahla Namak, MD, Stephen Davis, MD, Richard Lord, MD, MD and Julienne Kirk, PharmD, CDC
Wake Forest University SOM
Department of Family and Community Medicine, Winston-Salem, NC
Poster: "Change in Process and Outcome Measures in Diabetes Patients with Implementation of EMR Reminders"

Whitney Lyn, MD with Louvenia Ward, MSN and Jessica McIntyre, MD
Loyola University Chicago, Stritch SOM
Cook County-Loyola-Provident FMRP, Chicago, IL
Poster: "Making Improvements to Comprehensive Diabetes Care in an Underserved Setting"

A recap of the Oklahoma and Atlanta Summits will be featured in the next News on the GO!