Mrs K is a 55-year-old woman with type 2 diabetes of 10 years’ duration. She takes 2 oral medications. Her HbA1c level is 8.1%, and her body mass index is 33.
Dr J: Hello, Mrs K. Since this is your diabetes visit, can you tell me what concerns you most about your diabetes?
Mrs K: Well, Doctor, it’s the food and exercise.
Dr J: Okay, can you choose one of those for us to work on today?
Mrs K: I guess it would probably be exercise.
Dr J: Good! Can you tell me why it is important for people with diabetes to exercise?
Mrs K: I am not sure, but I think it helps blood sugar come down.
Dr J: Excellent! It also helps with blood pressure, lipids, and weight. Tell me, Mrs K, have you tried to exercise before?
Mrs K: Yes, I joined the Y because that is what my last doctor told me to do. He said I needed to do it to bring my weight down.
Dr J: How did that work out?
Mrs K: I went a few times, but I am too fat and did not look good in exercise clothes and the class I took made my knees hurt. In fact, I gained weight because I was so frustrated.
Dr J: Do you have any ideas about what type of exercise you would like to do?
Mrs K: I like to walk, but I can’t go very far because it hurts my knees.
Dr J: Let’s change words here and use the word activity. Is there some type of fun activity you might do that does not cause your knees to hurt?
Mrs K: Well, I like to dance, and my husband and I sometimes go to dances. If we do one or two then sit down, my knees feel pretty good. He is a good dancer and wishes I would go more often.
Dr J: Would you be willing to dance some with your husband every day? Maybe you could devote two 15-minute periods each day to dancing in your house and then go out for dancing once a week. What do you think about that?
Mrs K: I am not sure about 2 times a day, but I think once a day would be possible with my husband’s schedule. But maybe I could dance by myself, or even better I bet that my friend Sue next door would come over and dance with me. I can’t wait to tell everyone that my doctor wants me to dance to help my diabetes.
Dr J: That’s great, Mrs K. I would like for you to come back in 1 month to discuss how you are doing with your dancing and see how it influences your blood sugar. What do you think about that plan?
Mrs K: Thank you, Doctor. I think this might work. I will check my blood sugars and be back in a month.
What were the barriers in this dialogue? Was it the knee pain, the patient’s lack of control in the choice of exercise, her lack of understanding of her disease, or the previous physician’s style of telling rather than asking?
What led to the solution? Was it initially giving the patient the choice of addressing her concerns rather than the physician’s concerns? Was it asking her what exercise does for diabetes? Was it changing the word exercise to activity? Was it asking her what fun activity she likes that does not hurt her knees? Was it asking her for agreement about how many times a day she would dance?
The answer is probably all or most of the above. Using these communication techniques may help uncover and deal with the many barriers faced by clinicians and patients.
This patient has other issues that are affecting her health, and it is tempting to want to address all of them at this visit. She has had diabetes for 10 years. Traditional care has probably been addressing all the issues but does not seem to be working.
Why overwhelm her? She will have 1 month to gain confidence with a solution she created. When she returns, the clinician can build on the effectiveness of this visit and address other issues in a similar manner. Solutions that fit the patient’s values and culture are the most sustainable.