Time to redefine the doctor-patient relationship in diabetes management
Changing the nature of the relationship between primary care doctors and their patients will be critical to Singapore's success in managing diabetes as a community.
Primary care doctors play an important role at the frontline in chronic disease management. They are patients’ first contacts when new and existing problems arise and, over the long term, can ensure care continuity and coherence for the patient as they coordinate and refer services to and from other providers.
Yet their relationships with patients have not evolved much over the decades, even as technology, payment systems and delivery models continue to evolve dramatically.
Most patients still view the relationship as one where they list static updates on their condition to their doctors, then passively receive instructions on how to manage the condition until the next visit.
Chronic conditions involve factors that are complex, dynamic, long-term, and highly unique to individual life circumstances and cannot be managed effectively by such a form of doctor-patient relationship.
Doctors continuing to give generic instructions without a deeper level of behavioural context and insights into a patient’s lifestyle are like pilots flying without complete visibility, course correcting only after hitting turbulence.
Take diabetes for instance. If a doctor does not understand the personal lifestyle factors influencing a patient’s behaviour and adherence to diet or medication instructions, how can he or she provide useful advice to the patient?
As we mark World Diabetes Day on Nov 14, let’s consider how patients can work with their primary care doctors to better manage their diabetes.
A simple intervention is to focus on lifestyle management during consultations.
Evidence from key efficacy trials has shown that making lifestyle changes and keeping them can be more effective than some pharmacologic interventions in reducing acute complications and long-term risk for patients with diabetes.
Patients can prepare in advance to share a more comprehensive snapshot of their typical visit to the doctor.
They should take a bit of time before they see their doctor to think of specific questions they would like to ask (e.g. whether certain food items are harmful or beneficial for their condition), as well as any typically relevant information (e.g. side effects from medication) they would like to report.
Taking this extra step can make a tremendous difference in the quality of the visit.
While the number of topics that can be discussed is limited in a single consultation, taking mini-steps, focusing on a topic and target at each visit, and reviewing it in follow-up sessions, can be highly productive.
On the part of doctors, they have to be better prepared to respond to a broader range of queries from patients.
One area in which doctors caring for patients with diabetes can provide deeper insights is medication optimisation. When the choice of medication, dose and/ or timing of taking the medication are suboptimal, unintended side-effects and misinterpretation of their inefficacy can result.
For example, some patients typically take a morning dose of sulfonylureas, a relatively low-cost drug class which enhances pancreatic insulin secretion, and forget to take sufficient breakfast in their rush.
They then work through lunch time and hypoglycaemia (a state of low blood sugar level with symptoms of palpitations, sweating and nausea) sets in. They quickly consume large amounts of sweet foods and overcompensate for the condition, resulting in hyperglycaemia (an elevated level of blood glucose with symptoms of thirst, polyuria and a dry mouth).
Affected patients often develop negative perceptions of their medications and stop taking them regularly.
Doctors can help explain the lifestyle factors behind this and work with patients to propose options that best fit their routine.
Alternative drug classes which work by other mechanisms that rarely result in hypoglycaemia could also be considered. The “best” choice of medication can then be tailored to an individual’s needs, balancing the benefits and potential unwanted effects.
Doctors can also provide guidance and advice on judicious use of tools and technology to help patients track and upkeep their lifestyle decisions. These include use of carbohydrate counting guides and diabetes mobile apps that can aid monitoring food choices, carbohydrate intake and blood glucose levels.
Apple’s “Diabetes Kit Blood Glucose Logbook”, for example, allows input of blood glucose data through a phone camera shot of the glucometer screen, alongside manual entry of other data such as insulin dosing and activity.
Future developments in continuous glucose monitoring, where sensors inserted under the skin measure glucose level without the need to draw blood samples, may also be useful for appropriate patient groups.
Chronic disease management is often linked to psychosocial issues and poor blood glucose control that can be a result of lack of motivation resulting from family or financial issues.
Doctors can help identify this and link the patient up with voluntary welfare organisations or support groups who provide psychosocial support.
Walking the journey with people familiar with the subject or others in similar shoes can help make it less challenging.
In some primary care settings, doctors can be supported with the participation of nurses, pharmacists and other allied health professionals (e.g. dietitian, podiatrist, medical social worker, psychologist and physiotherapist with exercise prescription).
Such allied health professionals and services are available at most polyclinics and will in future be located in the community.
General practitioners in the Primary Care Networks can refer patients to these services for more detailed assessment and management.
Such multidisciplinary support can help doctors better manage the patient’s condition in the different areas of care.
Working hand in hand, the healthcare community can support patients in navigating the growing number of options in nutrition, technology, services and medication.
In Singapore, we are truly spoiled for choice in innovations that can help us keep track of adherence to diabetes care targets over the longer term as well as provide data and insights to both patient and doctor for improved consultations.
But knowledge alone will not drive this critical change in behaviour to redefine the relationship between doctors and patients.
We need a nationwide effort for a more personalised and holistic approach to patient-doctor consultations, where patients play a more active role.
A strong patient-doctor relationship that is collaborative and builds on mutually reinforcing knowledge can go a long way in making diabetes care a success.
ABOUT THE AUTHORS:
Dr Sue-Anne Toh is Chief Executive Officer and Medical Director at NOVI Health, and Dr Lew Yii Jen is Chief Executive Officer and Family Physician, Senior Consultant, at the National University Polyclinics.