Enhancing Patient-Provider

Communication

Suzanne Bennett Johnson

Florida State University College of Medicine

Management Of Diabetes In Youth

Biannual Conference of the Barbara Davis Center for Childhood Diabetes
Keystone Colorado, July 14, 2008
Defining Compliance
“the extent to which a person’ behavior
(in terms of medications, following diets, or
executing lifestyle changes)

coincides with medical or health advice”

Haynes et al, 1979

 Helping People Manage Diabetes
1. Clear communication of medical/health advice
 Patient-Provider Miscommunication

Provider Patient
Recall Recall

Recall of recommendations by the health care team and by

patients in a diabetes clinic. Adapted from Page et al (1981).
Clear Communication: Do’s and Don’ts
DON’T…...
• use medical jargon
• use vague prescriptions
• provide too many
recommendations
• assume the patient
understands
• expect patients to recall
your medical advice
DO…...
• use simple explanations
• be specific
• prioritize, give a few critical
recommendations
• ask the patient to describe
the treatment plan
• give your patient written
recommendations
 Helping People Manage Diabetes
1. Clear communication of medical/health advice
2. Teach knowledge and skills necessary for good
disease management
Skill Deficits in Diabetes Management

Watkins et al, 1967 Johnson et al, 1982 Johnson et al, 1998

Knowledge/Skill Assessment and
Instruction: Do’s and Don’ts
DON’T…...
• Assume knowledge/skill
• Teach too much at one
time
• Assume one-session
learning
• Assume skills will remain
accurate over time
DO…...
• Observe behavior
• Prioritize, teach one skill
at a time
• Repeat instruction
• Make skill assessment
and instruction part of
standard care
 Helping People Manage Diabetes
1. Clear communication of medical/health advice
2. Teach knowledge and skills necessary for good
disease management
3. Make assessing behavior part of standard care
What is the Best Way to Assess
Patient Behavior?
• Glycosylated hemoglobin:
most popular method but provides limited
and often misleading information
Presumed Relationship Between
Patient Behavior and Glycemic Control
Glycosylated Hemoglobin
good poor
good
Compliance
poor
The Relationship Between Patient Behavior
and Glycemic Control in Childhood Diabetes

Glycemic Control
Compliance Good Poor
HA1C < 7.6% HA1C > 10.1%

Good 30% 18%

Poor 24% 28%
N=103
Adapted from Johnson (1994)
The Relationship Between Compliance with Medication and
Subsequent Blood Pressure in Hypertensive Steelworkers

Blood Pressure
Compliance Good Poor
< 90 mm Hg > 90 mm Hg
Good
 80% meds 23% 34%
Poor
< 80% meds 12% 31%
N=134
Adapted from Taylor et al (1978)
Glycosylated hemoglobin
• Is a poor measure of patient behavior because
– patient behavior and GHb are only weakly related
– GHb provides no specific information about what
patient behaviors need to be changed
– it can lead to
• “patient blaming”
• missed opportunities to correct problem behavior
What is the Best Way to Assess
Patient Behavior?
• Glycosylated hemoglobin:
most popular method but provides limited
and often misleading information
• Pill counts and glucose testing meters:
useful but provide limited information
• Physician/investigator ratings:
most unreliable of all methods
Diabetes Regimen Compliance
Patients do not have “compliant” or
“noncompliant” personalities

They do exhibit both compliant and

noncompliant behaviors

Behavior with one component of the

diabetes regimen does not predict
behavior with any other component
What is the Best Way to Assess
Patient Behavior?
• Observational methods are now available for
– insulin injection
– blood glucose testing

• Provide useful information for some behaviors

• Can be adapted to assess other behaviors

What is the Best Way to Assess
Patient Behavior?
• Patient self-reports: underutilized and
viewed with skepticism
• Available methods permit good quality self-
report data to be obtained when the patient
describes time limited intervals (24 hr) of
recent occurrence (yesterday) in temporal
sequence (waking to retiring)
• The only method to provide detailed,
reliable information about actual behavior
Conducting a 24-hr Recall Interview
• Patient describes yesterday’s events from waking
until retiring
• Interviewer prompts for missing information
• Interviewer is always nonjudgmental
• Family member may be interviewed separately
about the patient’s behavior
• Several interviews (about both weekend and
weekdays) provide more information
 Assessing Behavior as Part of
Standard Care: Do’s and Don’ts
DON’T…... DO.…..
• Use GHb to assess behavior • Assess behavior directly
• Ask what the patient • Ask what the patient did
“usually” does yesterday
• Ask if the patient “knows” • Observe the patient carry
how to do a regimen task out the task
• Describe a patient as • Specify which behaviors
“noncompliant” are problematic
Helping People Manage Diabetes
1. Clear communication of medical/health advice
2. Teach knowledge and skills necessary for good
disease management
3. Make assessing behavior part of standard care
4. Encourage patient honesty
Log Book vs Memory Meter Data

Mazze et al, 1984

Encouraging Patient Honesty:
Do’s and Don’ts
DON’T……. DO……
• Be judgmental • Accept less than perfect
behavior
• Criticize and threaten • Do problem solve
• Expect too much • Set realistic goals
• Ignore good behavior • Praise even small positive
behavior change
Helping People Change
1. Clear communication of medical/health advice
2. Teach knowledge and skills necessary for good
disease management
3. Make assessing behavior part of standard care
4. Encourage patient honesty
5. Build consensus about disease management
Patients do what they can do

Patients do what they want to do

BG Goals: Parents vs Pediatricians

Glycemic Profile Selected as Ideal

(Marteau et al, 1987)
Terminology: Does it matter?

• Compliance

• Adherence

• Self-Care
 Consensus Building: Do’s and Don’ts
DON’T DO
• Make arbitrary • Discuss options with patient
recommendations
• Assume patient • Provide a clear explanation
understands rationale
• Assume patient accepts • Discuss patient attitudes and
your rationale beliefs
• Force patient acceptance • Negotiate a mutually
agreeable plan
Helping People Manage Diabetes
1. Clear communication of medical/health advice
2. Teach knowledge and skills necessary for good
disease management
3. Make assessing behavior part of standard care
4. Encourage patient honesty
5. Build consensus about disease management
6. Attend to patient feelings, worries, concerns
The Anxiety/Performance Curve
Performance High

Low
Low High
Anxiety
Common Patient Concerns
• Insulin (or other medication) effects
• Pain (associated with injections, glucose testing)
• Hypoglycemia
• Weight gain (associated with intensive therapy)
• Expense, insurance access, employment
• Interpersonal (family, social) disruptions
• Complications
Helping People Manage Diabetes
1. Clear communication of medical/health advice
2. Teach knowledge and skills necessary for good
disease management
3. Make assessing behavior part of standard care
4. Encourage patient honesty
5. Build consensus about disease management
6. Attend to patient feelings, worries, concerns