Changing Diabetes Care Have a look at the following definition:
- Diabetes Mellitus
- a metabolic disorder of multiple aetiology characterised by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both.
Question: where is the person who has this disorder, in this common definition?
Traditionally, the less glamorous chronic conditions have comprised a relatively small part of medical school curricula, leaving the new graduate without the necessary interest or the skills to effectively manage a complex physical/psychosocial/spiritual condition such as diabetes mellitus (DM). DM has been regarded as a primary care problem, fatalistically viewed as leading to almost inevitable acute and chronic complications secondary to the disease process as well as substantial "non-compliance" with treatment.
Because of this, the huge advances that have marked the last 80 years in the technical understanding of the nature and the treatment of DM have not filtered through to the average Generalist. Of equal, if not greater importance, have been the changes in the philosophy of care of this chronic condition, which have allowed a different approach to introduction of the technical advances. This has allowed better clinical outcomes as well as greater patient and Practitioner satisfaction.
To understand the direction of any different approach, it is often useful to review where we have come from developmentally. Most Health Professionals have been trained in acute-care settings dealing with "sick" people. We are used to solving the mainly physical problems of others with our vast body of knowledge and our healing skills.
What about DM? It is a chronic condition. Chronic, often means lifelong. Every part of human existence is affected. Reversible acute symptoms at the diagnosis of DM are usually accompanied by nagging disturbances in self-image, adjustment and confidence ("my body has failed me" … "can I do this?").
Chronic treatment with a physical domain bias according to the "Acute-care model" will inevitably lead to imbalance, "non-compliance" and failure to control. The traditional expectation of "cure" is insufficiently replaced in the mind of the patient by the concept of a lifetime of "control".
Table 1, below outlines some of the theoretical differences between the understanding and consequent management of, an acute illness and a chronic condition such as DM. Table 1
| || The Acute Model || The Chronic Model || |
| The Caregiver (Doctor) || |
- Often Independent
- Respected for knowledge & power
- Practices reactive medicine (problem solver / crisis manager)
- Parental role
- Gives and Directs Care – "doing"
- They are Team Players in a client centred ecosystem
- Skilled in listening & sharing knowledge
- Strategists who prevent problems
- Should role-model healthy living
- Adult mentoring role
- They facilitate self-care
| The Caregiver(s) |
(Multi-Specialist Health Care Team)
| The "Sickness" || |
- Usually a unique, defined, symptomatic "event" (e.g. ‘flu, appendicitis), needing "urgent" diagnosis and treatment
- You feel "ill", you want to get better, and still you may not take your pills ("non-compliance")
- Short-term lifestyle impact
- Affects individuals mostly (Depends on Severity)
- Limited stigma
- Costs usually containable & predictable
- A lifelong mostly asymptomatic process with uncertain progression & points of possible relapse
- Symptoms often mild / absent despite pathology – what’s the problem Doc? (What are you so worried about?) OR chronic - what’s your problem Doc? (Why can’t you fix me?)
- Lifelong, multiple lifestyle impacts
- Affects Individual, Family & Community
- Discrimination & Stigma common
- How do you quantify a lifetime of multifactor costs?
| The "Condition" |
| The Approach || |
- Goal is Cure
- Assessment & care has a Physical bias
- Superficial Therapeutic Relationship
- Minimal self-care expected – "just do what I tell you to do"
- "Compliance" with Directives expected
- Goal can only be optimum care & control
- Assessment & care founded on psychosocial & spiritual understanding of the physical person
- A deep therapeutic relationship
- Client is expected & trusted to perform major part of monitoring & care & to remain vigilant & respond to acute attacks
- Lack of "adherence" is feedback that the lifelong treatment plan is not working. Concordance is lacking in the plan
| The Approach |
| The Treatment |
(Treating the disease)
- Pharmacology / Technology / Surgery of short duration and related to the presenting crisis. Event is soon forgotten.
- Lifestyle change never asked for
- Rigid Protocols & prescriptions
- Information supplied on a "Need to know" basis
- Recognition that the human dimensions of grief, attitudes, values & beliefs modify the process leading to acceptance of diabetes & its treatment
- Lifestyle change as important as medicine
- Treatment plans & "prescriptions" validate the client’s informed choices
- Education provided with goal of insightful knowledge
| The Treatment (Treating the a person and their diabetes) |
| The "Patient" |
- Socialised into Infant / Child-like Role
- Expected to listen carefully to prescribed care
- Passive – "receiving" care
- Patient dependent, grateful, admiring
- Consultation usually associated with Sickness
- Socialised as a well adjusted adult / child
- Expected to verbalise expectations & fears
- Active role in self care with responsibility
- Independence facilitated & supported
- Learns to seek guidance whilst well - Accepts & develops a wellness role
| The "Client" |
(Person who has diabetes)
Some important points arise from a careful and insightful examination of this table:
- The philosophy and language of care of a chronic condition has to be different from the acute-care philosophy. You have to be travelling on the same road as your "client" for meaningful communion to take place.
- Chronicity, is not only a major task for the patient to deal with, but also for the caregiver who needs to assume a new professional identity. One cannot hope to facilitate the process of change (a major developmental task in DM) if one cannot identify with and manage this process oneself.
- Specialised training and knowledge is needed. This reduces morbidity, mortality, costs and incidence and duration of hospitalisation.
- DM affects every part of the human experience. One practitioner does not have the necessary knowledge and skills to treat all the different effects. Team facilitated management was shown in the Diabetes Control and Complications Trial (DCCT) to be essential in the control of Type 1 DM by "Intensive Therapy". In addition to the Doctor, input from the Diabetes Educator, Dietician, Podiatrist, Ophthalmologist, Pharmacist, Biokineticist and Psychologist (amongst others), is necessary at different times to maximise care and quality of life. The doctor is not the head of this team – it is the person with diabetes and their family. Community groups such as the Local Diabetes Association are vital to provide support where most of diabetes care occurs – in the community.
- Self-care is vital and is a major challenge for Health Professionals to facilitate when they and their patients are used to conventional (acute) care approaches. The focus is on the prevention of ill health and not its treatment.
- The acute care approach may form barriers to diabetes self-care. The traditional isolated prescription of medication to treat the symptoms of hyperglycaemia has three hidden messages for the "patient":
- "I am sick"
- "My doctor is in charge (and therefore responsible) for my diabetes care"
- "There is nothing else I need to do except take my medication"
In reality the three cornerstones of diabetes care (exercise, meal planning and medication) can only be managed, and their dynamic interplay monitored, by someone who is in a "wellness" role, who is taking responsibility for most of their care and who is supported by a knowledgeable Diabetes Care Team.
The following verse penned by Konrad Lorenz highlights the continuum between "telling" and the resultant long-term behaviour change needed to successfully manage a chronic condition like DM. Whilst it overtly highlights the barriers to self-care, by default it also shows us the potential points at which we all can improve our therapeutic success.
"Said, but not heard
Heard, but not understood
Understood, but not accepted
Accepted, but not put into practice
Put into practice, but for how long?"
The concepts contained above can be used as an "overlay" by which the various technical and teaching issues in diabetes can be made more accessible and relevant for your "patient" – the PERSON who happens to have a condition called diabetes mellitus.