September 2018

Diabetes Self-Care Adherence: Whose Responsibility Is It? What’s a Clinician’s Role?

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By Richard Schilling, DPM, FACFAS

As an expert, specialist, trained foot and ankle physician, you have worked hard for your place in the medical landscape, your degree and your confidence. You think you do your job well, but what if you are not getting through to your patients to the extent you thought you were? Over the years, I have prided myself on being an educator. I educate students, residents, my colleagues, the public, my patients and even myself. Like you, I work  to make my patients’ lives better through foot and ankle care and health. I read articles and journals, go to conferences, listen to my colleagues’ lectures, teach in a residency program, and constantly look for opportunities to better myself as a podiatric physician. While we all know that diabetes causes the most morbidity in our specialty, with November as National Diabetes Month, it serves as a good reminder that we have the biggest opportunity for making a difference in our patients’ lives and overall health by treating the sequelae of diabetes. It is our job to keep our patients as informed as possible to give them the best chance for controlling their disease. This starts with education.

Part of our job is relaying information to educate patients. Recently, the article “People with diabetes foot complications do not recall their education: a cohort study,” was published by Yuncken et al (see excerpt page 27). Reading it gave me pause as to how successful we as physicians actually are inside the treatment room. The article’s overwhelming theme is that patients are not absorbing the important information we are trying to relay. This article focuses on diabetes health, but likely can be extrapolated to include most of what we say and do, inside the treatment rooms. Unfortunately, according to Yuncken, our delivery of information may not be effective enough. Furthermore, the authors found that many patients were ineligible for the study due to lack of education or capacity to understand. The participants were screened, and some of those who passed the screening for minimum education threshold still had a difficult time absorbing or understanding the educational message presented in the treatment rooms.

There are certain themes in diabetic lower extremity care that are universally agreed upon as important to express to patients. These include monitoring blood sugar, use of appropriate footwear, daily foot inspections, who to contact (and when to contact) if there are concerns or issues, and what referrals need to be made. Additionally, the connection between blood flow, nerve health, and diabetes are important aspects on which to educate the patient. Sadly, the Yuncken study demonstrated that the amount and quality of information relayed at the study’s office visits were poor.

Yes, patients need to take ownership of the treatment plan, but patients should feel you are a partner in care, a resource, and a trusted advisor.

I firmly believe that education—the absorption of information and confirmation of the understanding of that information—is  the educator’s responsibility; in this case, it is physician’s responsibility. I employ many tactics to get my point across. Some patients may be visual learners, some auditory, some hands-on. We need to connect with patients on their level in order to be successful. I will use graphics, drawings, repetition (usually saying the same thing at least 3 times, often in a different way), analogies, handouts, and anything else that will get the patient to understand what I am trying to teach.

We all have heard the saying “see one, do one, teach one.” What does that really mean? It means you have to be so proficient in a subject (especially diabetes education) that even the most difficult of concepts can be simplified. We have to understand what to filter out as superfluous so that a patient with a 9th grade education can truly understand. But note,  the study did discuss how repetitive messaging can be a detriment to education as the patient has the tendency to stop listening to something they have heard “a thousand times.” I find this can be mitigated, somewhat, by asking the patient their knowledge base of diabetes.

It is our duty as the experts in foot and ankle health to become the best educators of our patients. This not only solidifies your place in the delivery of medicine, but also makes you a better physician, allows you to retain more of your patient base, and makes you more successful on every level. We need to connect with patients and make them partners in care. Patients need to share in the responsibility of maintaining the health and well-being of their feet, legs, and bodies; after all, this is their life, their disease, and their feet. Yes, patients need to take ownership of the treatment plan, but patients should feel you are a partner in care, a resource, and a trusted advisor.

There is nothing wrong with “canned speech.” It is time to streamline your thoughts. It is time to write down what is important to relay to the patient and practice it. Have an outline in mind of what you want to accomplish with each diabetic patient, and then customize it to the individual patient in the treatment room. Remember, trying to do too many new things at once is a recipe for disaster. Patients will feel overwhelmed and then will resort to doing nothing. It is important to give “bite-sized” tasks for our instant-gratification, microwave world.

It is important to give “bite-sized” tasks for our instant-gratification, microwave world.

The news from Yuncken et al. is not all bad. The authors make some suggestions that I employ and encourage you to do the same. Family participation is encouraged as it may be beneficial for them to attend consultations. Bottom line, the authors conclude—and I concur—that “education should be simple, relevant, consistent, and repeated to patients with diabetes.”

Richard A. Schilling, DPM, FACFAS, is a board-certified and fellowship-trained foot surgeon. President and owner of ABC Podiatry in Columbus, Ohio, he is Past President of the Ohio Foot and Ankle Medical Association, Co-Chair of the Ohio Podiatric Physicians and Surgeons Group, a Founding Board Member of the Ohio Foot and Ankle Foundation, and currently serves as faculty for the Grant Medical Center Podiatric Surgical Residency Program.

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