Management of diabetes: are doctors framing the benefits from the wrong perspective?
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7319.994 (Published 27 October 2001) Cite this as: BMJ 2001;323:994All rapid responses
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Drs. Wolpert and Anderson rightfully emphasize the importance of
considering patient preferences in promoting diabetes care rather than
focusing on inflexible physiological targets such as tight glycemic
control. Their article raises legitimate concerns about the clinical
practice guidelines of the American Diabetes Association, which seem not
to emphasize this approach, but those guidelines do not fully represent
the views of the American primary care community.
For example, the
guidelines of the American Academy of Family Physicians, developed in 1999
in partnership with the American Diabetes Association, carefully
incorporate the patient’s perspective:
“The evidence demonstrates that, for an individual with type 2 diabetes,
the better the glycemic control, the lower the probability of developing
chronic microvascular and neuropathic complications (and, possibly,
cardiovascular complications). However, because of differences in
patients’ life expectancies and comorbidities, it is inappropriate to set
a uniform target glycated hemoglobin level for all patients with type 2
diabetes. Individuals with long life expectancies and few comorbidities
may wish to pursue euglycemia, but less vigorous goals may be appropriate
in elderly individuals with multiple comorbid conditions and/or limited
life expectancies. Whether the magnitude of benefit of a given treatment
goal justifies the potential inconvenience, harms, and costs involves
value judgments that must be tailored to the individual patient. Patients’
personal risk profiles and capabilities and the relative importance they
assign to the potential outcomes and supporting evidence are integral to
determining how intensively to treat” (1).
1. Woolf SH, Davidson MB, Greenfield S, Bell HS, Ganiats TG, Hagen
MD, Palda VA, Rizza RA, Spann SJ. Controlling blood glucose levels in
patients with type 2 diabetes mellitus: an evidence-based policy statement
by the American Academy of Family Physicians and American Diabetes
Association. J Fam Pract 2000;49:453-60. Available at:
http://aafp.org/clinical/diabetes/index.html
Steven H. Woolf, MD, MPH
Professor, Department of Family Practice
Virginia Commonwealth University
Fairfax, VA, USA
swoolf@vcu.edu
Competing interests: No competing interests
The article by Wolpert and Anderson(1) must have struck a chord with
all practising GP's, not least Colin Guthrie (2)whose letter about the
difficulties in changing patients lifestyles was published in the same
issue.
As a GP who is spending a year learning more about health
determinants as part of a GP Fellowship in Public Health I can see both
the drivers and the difficulties in health promotion and chronic disease
management.
We can't improve patients social conditions but equally we must make
the most of our interventions. Disciplines previously regarded as 'soft'
such as social anthropology can teach us a lot.
I do feel however that given the opportunity General Practice can be
effective. Our surgery uses software for chd protocols and templates as
part of our clinical system (EMIS). We also use CALM (computer aided
lifestyle modification) software which shows patients graphically what
their changes might achieve.(3) These are delivered mainly by the Practice
Nurses who have been shown to be better at this than GP's. Where the GP
comes in is at the follow up; having knowledge of the patient, their
lifestyle and circumstances allows a patient centered approach to change
management with the knowledge that their doctor will be there for them.
This is only possible with longer consulting times but personally I
don't regret a longer working day in exchange. I hope Wolpert and
Anderson's insights will make our interventions more successful.
Paul Reid MbChB MRCGP
1 Wolpert H, Anderson B Management of diabetes: are doctors framing the
benefits from the wrong perspective? BMJ 2001;323:994
2 Guthrie C Health promotion helps no one BMJ 2001;323:997
3 White MJ Which measurements are the most appropriate? BMJ 2001;323:999
Competing interests: No competing interests
Industrial healthcare measures, exhorts and chooses to forget the
fundamental individual human amidst it's graphs and cost-benefit studies.
The software that works from within the management and purview of the
individual is the functional home-base of care in this awkward and
difficult matter. This article reports and appears to accept the obvious
and it's challenges toward these crucial elements.
Competing interests: No competing interests
Motivational Enhancement
The need to use a new model for diabetes education is very clear and
well stated in this article. The current approach which places the
individual who has diabetes in a dependent/learner role misses many
opportunities. The Motivational Interviewing suggested here is part of an
approach to clients that was initially tested and used in addiction
behaviors and it has great potential for helping individuals make changes
in diet, activity and medication usage. As the authors note, the process
of enhancing an individual's motivation for life style changes starts with
providers who are willing to change their approach to diabetes education.
However, exploring "ambivalence about altering their selfcare behavior" is
only part of the motivational enhancement process. Education is needed on
techniques to assess readiness for change, strategies for handling
resistance to change, skills in collaboration, ways to enhance clients
self confidence, etc. These talents are not necessarily intuitive and are
also not likely to be taught in a provider's education program. Many have
taken courses in motivational enhancement and found them to be useful in
most health care situations including chronic illnesses.
Competing interests: No competing interests