Diabetes Care as Public Health

Every family physician knows the frustration of seeing patients with diabetes who never seem to be able to control their blood sugar level. Since the prevalence of diabetes mellitus in the United States has tripled in the past 30 years to 6% of our population,¹ the care of these patients is a large part of the family physician’s workload. In this issue of the Journal, Freeman and Loewe² have researched the family physician’s understanding of patients who have diabetes. The authors used qualitative research techniques to explore in detail how providers at an urban family practice residency program feel about caring for people with diabetes. Almost all the issues the providers felt were important were classified under the themes of control and frustration; that is, the inability of providers and patients to communicate effectively about control often led to frustration.

As discussed by Freeman and Loewe, control has a variety of meanings in the context of diabetes management: metabolic control; control of diet, exercise, or other lifestyle decisions; control of medical decisions; and so forth. All levels of control interact with and affect one another. Physicians, especially those still in training, struggle with patients when confronted with these issues of control-sometimes overtly, sometimes covertly. Physicians would like to see themselves as air traffic controllers with many patients hovering around the control tower (ie, clinic or office) doing exactly what they are told to do. But in the real world, social and cultural pressures are much more complicated. It is the wise and experienced physician who understands that ultimate control lies with the patient and that genetic, social, cultural, and environmental influences may affect lifestyle decisions more than encouragements about blood sugar control.

Complicated medical problems are rarely dealt with effectively when only addressed within the physician-patient relationship. Although some health problems have routinely been thought of as public health issues (eg, infectious diseases and tobacco use), other diseases such as coronary artery disease, stroke, and diabetes are only now being looked at as such.¹ Social, cultural, and environmental influences are often far stronger than the physician-patient relationship. Yet as Freeman and Loewe point out, these nondrug issues are rarely taught and are usually learned experientially. We suggest that the failure of physicians to address diabetes as a public health issue is a major gap in medical education and practice and is a primary cause of the frustration felt by physicians caring for patients with the disease.

The current environment

Diabetes continues to strike individuals of all ages, and even children are developing type 2 diabetes at a remarkably increasing rate.³ As Hill and Peters⁴ report, “Our current environment is characterized by an essentially unlimited supply of convenient, relatively inexpensive, highly palatable, energy-dense foods, coupled with a lifestyle requiring only low levels of physical activity for substinence.” Media pressures aimed at young Americans stress watching television and playing video games while consuming junk food, soft drinks, and eventually beer and cigarettes. A sedentary lifestyle and poor dietary choices are increasingly tied to obesity, which can lead to diabetes in those genetically inclined. Grocery and convenience stores have aisles lined with foods high in fat, calories, and taste, and low in nutrition. Children no longer clamber for their first bicycle as much as they want their first Nintendo. A physician’s message of “lose weight and exercise more” can barely be heard over the conflicting messages from television, print advertisements, movies, schools, and peers. Our office patient education will not easily reverse the attitudes and habits resulting from years of influence from these environmental pressures.

Physicians see patients within the physician’s environment, surrounded by others of their own social class (other physicians and nurses). Rarely does a physician know the patient’s reading ability when handing out a pamphlet. When recommending a low-fat, low-calorie diet, does the physician know how the patient gets to the grocery store? Is it by car, by foot, or by bus with 3 transfers? Is the neighborhood safe enough for the patient to walk 20 minutes every day as recommended by the physician? What is the patient’s cultural or ethnic group, and how do these influences affect his or her view of diabetes? When physicians made house calls, the visit took place in the patient’s environment surrounded by others of the patient’s social class and culture. Although this was not the most time-efficient way for the physician to conduct a routine visit, the amount of information learned about the patient was invaluable for effective communication between the patient and the physician.⁵

Both literally and metaphorically, the abandonment of house calls during the past century has led to a change in the physician’s perception of his or her patients. Placed within a 15-minute visit in a sterile examination room environment, physicians justifiably complain of having no time to deal with cultural differences, media influences, educational problems, social difficulties, and the spiritual crises of their patients with diabetes.⁶ Is it any wonder that physicians are more comfortable talking about controlling hemoglobin A1c than barriers to healthy eating? And yet, the outcomes hoped for by physicians (ie, better metabolic control, fewer long-term complications, less death and disability, and happier patients) do not occur as often as the physicians would like, and frustration ensues.

Share the community

Freeman and Loewe recommend that providers, “open themselves to learning the beliefs and attitudes of their patients with diabetes.” We would take this recommendation even further. Physicians also need to approach diabetes both as a public health problem and as an individual patient problem. They need to get involved in the community of the patient and have the patient join them in the community of medicine. Within the 15-minute office visit, physicians can begin to address the social, cultural, and environmental issues of patients’ lives. Kleinman⁷ suggests asking patients to define and discuss not just the disease but also their illness and their desired care. Understanding the role diabetes plays in the patient’s life and being willing to compromise one’s own control is often necessary for establishing a working partnership.

Physicians should make a home visit to patients with diabetes to better understand the cultural and social contexts of their lives. Every visit would not have to be in the patient’s home, but just think what a physician could find out in 30 or 45 minutes of seeing how a patient lives. It could save hours of interviewing time during the next few months and years.

Physicians should become involved in the community. Preventive health efforts are needed in every social group. Talk to kids in schools; review the school cafeteria menu; lead efforts to remove the soda and candy machines in the high school. Affect public policy with letters, telephone calls, and information. Lobby for having bike paths put into the community to encourage regular biking or walking to work. Be a role model not just in the office, but in your neighborhood as well.⁶

Freeman and Loewe provide a realistic picture of how physicians, especially those in training, think and feel about caring for patients with diabetes. It is not always a pretty picture, but it is one we need to see clearly if we are to improve our care of these patients. The authors performed this study by immersing themselves in the environment of their participants, talking to the care providers, and observing them in the clinical setting. This is how qualitative research helps to answer questions that cannot be addressed in a structured controlled clinical trial. The analogy is obvious. If we want to get a realistic view of patients with diabetes, we need to see them in their environment and their homes. We need to ask the hard questions as well as the easy ones. We need to take the time to listen as they explain their culture. We may not always see what we want to see as physicians, but this will allow us to help patients take back control of their lives and achieve their own goals.

Every family physician knows the frustration of seeing patients with diabetes who never seem to be able to control their blood sugar level. Since the prevalence of diabetes mellitus in the United States has tripled in the past 30 years to 6% of our population,¹ the care of these patients is a large part of the family physician’s workload. In this issue of the Journal, Freeman and Loewe² have researched the family physician’s understanding of patients who have diabetes. The authors used qualitative research techniques to explore in detail how providers at an urban family practice residency program feel about caring for people with diabetes. Almost all the issues the providers felt were important were classified under the themes of control and frustration; that is, the inability of providers and patients to communicate effectively about control often led to frustration.

As discussed by Freeman and Loewe, control has a variety of meanings in the context of diabetes management: metabolic control; control of diet, exercise, or other lifestyle decisions; control of medical decisions; and so forth. All levels of control interact with and affect one another. Physicians, especially those still in training, struggle with patients when confronted with these issues of control-sometimes overtly, sometimes covertly. Physicians would like to see themselves as air traffic controllers with many patients hovering around the control tower (ie, clinic or office) doing exactly what they are told to do. But in the real world, social and cultural pressures are much more complicated. It is the wise and experienced physician who understands that ultimate control lies with the patient and that genetic, social, cultural, and environmental influences may affect lifestyle decisions more than encouragements about blood sugar control.

Complicated medical problems are rarely dealt with effectively when only addressed within the physician-patient relationship. Although some health problems have routinely been thought of as public health issues (eg, infectious diseases and tobacco use), other diseases such as coronary artery disease, stroke, and diabetes are only now being looked at as such.¹ Social, cultural, and environmental influences are often far stronger than the physician-patient relationship. Yet as Freeman and Loewe point out, these nondrug issues are rarely taught and are usually learned experientially. We suggest that the failure of physicians to address diabetes as a public health issue is a major gap in medical education and practice and is a primary cause of the frustration felt by physicians caring for patients with the disease.

The current environment

Diabetes continues to strike individuals of all ages, and even children are developing type 2 diabetes at a remarkably increasing rate.³ As Hill and Peters⁴ report, “Our current environment is characterized by an essentially unlimited supply of convenient, relatively inexpensive, highly palatable, energy-dense foods, coupled with a lifestyle requiring only low levels of physical activity for substinence.” Media pressures aimed at young Americans stress watching television and playing video games while consuming junk food, soft drinks, and eventually beer and cigarettes. A sedentary lifestyle and poor dietary choices are increasingly tied to obesity, which can lead to diabetes in those genetically inclined. Grocery and convenience stores have aisles lined with foods high in fat, calories, and taste, and low in nutrition. Children no longer clamber for their first bicycle as much as they want their first Nintendo. A physician’s message of “lose weight and exercise more” can barely be heard over the conflicting messages from television, print advertisements, movies, schools, and peers. Our office patient education will not easily reverse the attitudes and habits resulting from years of influence from these environmental pressures.

Physicians see patients within the physician’s environment, surrounded by others of their own social class (other physicians and nurses). Rarely does a physician know the patient’s reading ability when handing out a pamphlet. When recommending a low-fat, low-calorie diet, does the physician know how the patient gets to the grocery store? Is it by car, by foot, or by bus with 3 transfers? Is the neighborhood safe enough for the patient to walk 20 minutes every day as recommended by the physician? What is the patient’s cultural or ethnic group, and how do these influences affect his or her view of diabetes? When physicians made house calls, the visit took place in the patient’s environment surrounded by others of the patient’s social class and culture. Although this was not the most time-efficient way for the physician to conduct a routine visit, the amount of information learned about the patient was invaluable for effective communication between the patient and the physician.⁵

Both literally and metaphorically, the abandonment of house calls during the past century has led to a change in the physician’s perception of his or her patients. Placed within a 15-minute visit in a sterile examination room environment, physicians justifiably complain of having no time to deal with cultural differences, media influences, educational problems, social difficulties, and the spiritual crises of their patients with diabetes.⁶ Is it any wonder that physicians are more comfortable talking about controlling hemoglobin A1c than barriers to healthy eating? And yet, the outcomes hoped for by physicians (ie, better metabolic control, fewer long-term complications, less death and disability, and happier patients) do not occur as often as the physicians would like, and frustration ensues.

Share the community

Freeman and Loewe recommend that providers, “open themselves to learning the beliefs and attitudes of their patients with diabetes.” We would take this recommendation even further. Physicians also need to approach diabetes both as a public health problem and as an individual patient problem. They need to get involved in the community of the patient and have the patient join them in the community of medicine. Within the 15-minute office visit, physicians can begin to address the social, cultural, and environmental issues of patients’ lives. Kleinman⁷ suggests asking patients to define and discuss not just the disease but also their illness and their desired care. Understanding the role diabetes plays in the patient’s life and being willing to compromise one’s own control is often necessary for establishing a working partnership.

Physicians should make a home visit to patients with diabetes to better understand the cultural and social contexts of their lives. Every visit would not have to be in the patient’s home, but just think what a physician could find out in 30 or 45 minutes of seeing how a patient lives. It could save hours of interviewing time during the next few months and years.

Physicians should become involved in the community. Preventive health efforts are needed in every social group. Talk to kids in schools; review the school cafeteria menu; lead efforts to remove the soda and candy machines in the high school. Affect public policy with letters, telephone calls, and information. Lobby for having bike paths put into the community to encourage regular biking or walking to work. Be a role model not just in the office, but in your neighborhood as well.⁶

Freeman and Loewe provide a realistic picture of how physicians, especially those in training, think and feel about caring for patients with diabetes. It is not always a pretty picture, but it is one we need to see clearly if we are to improve our care of these patients. The authors performed this study by immersing themselves in the environment of their participants, talking to the care providers, and observing them in the clinical setting. This is how qualitative research helps to answer questions that cannot be addressed in a structured controlled clinical trial. The analogy is obvious. If we want to get a realistic view of patients with diabetes, we need to see them in their environment and their homes. We need to ask the hard questions as well as the easy ones. We need to take the time to listen as they explain their culture. We may not always see what we want to see as physicians, but this will allow us to help patients take back control of their lives and achieve their own goals.

Every family physician knows the frustration of seeing patients with diabetes who never seem to be able to control their blood sugar level. Since the prevalence of diabetes mellitus in the United States has tripled in the past 30 years to 6% of our population,¹ the care of these patients is a large part of the family physician’s workload. In this issue of the Journal, Freeman and Loewe² have researched the family physician’s understanding of patients who have diabetes. The authors used qualitative research techniques to explore in detail how providers at an urban family practice residency program feel about caring for people with diabetes. Almost all the issues the providers felt were important were classified under the themes of control and frustration; that is, the inability of providers and patients to communicate effectively about control often led to frustration.

As discussed by Freeman and Loewe, control has a variety of meanings in the context of diabetes management: metabolic control; control of diet, exercise, or other lifestyle decisions; control of medical decisions; and so forth. All levels of control interact with and affect one another. Physicians, especially those still in training, struggle with patients when confronted with these issues of control-sometimes overtly, sometimes covertly. Physicians would like to see themselves as air traffic controllers with many patients hovering around the control tower (ie, clinic or office) doing exactly what they are told to do. But in the real world, social and cultural pressures are much more complicated. It is the wise and experienced physician who understands that ultimate control lies with the patient and that genetic, social, cultural, and environmental influences may affect lifestyle decisions more than encouragements about blood sugar control.

Complicated medical problems are rarely dealt with effectively when only addressed within the physician-patient relationship. Although some health problems have routinely been thought of as public health issues (eg, infectious diseases and tobacco use), other diseases such as coronary artery disease, stroke, and diabetes are only now being looked at as such.¹ Social, cultural, and environmental influences are often far stronger than the physician-patient relationship. Yet as Freeman and Loewe point out, these nondrug issues are rarely taught and are usually learned experientially. We suggest that the failure of physicians to address diabetes as a public health issue is a major gap in medical education and practice and is a primary cause of the frustration felt by physicians caring for patients with the disease.

The current environment

Diabetes continues to strike individuals of all ages, and even children are developing type 2 diabetes at a remarkably increasing rate.³ As Hill and Peters⁴ report, “Our current environment is characterized by an essentially unlimited supply of convenient, relatively inexpensive, highly palatable, energy-dense foods, coupled with a lifestyle requiring only low levels of physical activity for substinence.” Media pressures aimed at young Americans stress watching television and playing video games while consuming junk food, soft drinks, and eventually beer and cigarettes. A sedentary lifestyle and poor dietary choices are increasingly tied to obesity, which can lead to diabetes in those genetically inclined. Grocery and convenience stores have aisles lined with foods high in fat, calories, and taste, and low in nutrition. Children no longer clamber for their first bicycle as much as they want their first Nintendo. A physician’s message of “lose weight and exercise more” can barely be heard over the conflicting messages from television, print advertisements, movies, schools, and peers. Our office patient education will not easily reverse the attitudes and habits resulting from years of influence from these environmental pressures.

Physicians see patients within the physician’s environment, surrounded by others of their own social class (other physicians and nurses). Rarely does a physician know the patient’s reading ability when handing out a pamphlet. When recommending a low-fat, low-calorie diet, does the physician know how the patient gets to the grocery store? Is it by car, by foot, or by bus with 3 transfers? Is the neighborhood safe enough for the patient to walk 20 minutes every day as recommended by the physician? What is the patient’s cultural or ethnic group, and how do these influences affect his or her view of diabetes? When physicians made house calls, the visit took place in the patient’s environment surrounded by others of the patient’s social class and culture. Although this was not the most time-efficient way for the physician to conduct a routine visit, the amount of information learned about the patient was invaluable for effective communication between the patient and the physician.⁵

Both literally and metaphorically, the abandonment of house calls during the past century has led to a change in the physician’s perception of his or her patients. Placed within a 15-minute visit in a sterile examination room environment, physicians justifiably complain of having no time to deal with cultural differences, media influences, educational problems, social difficulties, and the spiritual crises of their patients with diabetes.⁶ Is it any wonder that physicians are more comfortable talking about controlling hemoglobin A1c than barriers to healthy eating? And yet, the outcomes hoped for by physicians (ie, better metabolic control, fewer long-term complications, less death and disability, and happier patients) do not occur as often as the physicians would like, and frustration ensues.

Share the community

Freeman and Loewe recommend that providers, “open themselves to learning the beliefs and attitudes of their patients with diabetes.” We would take this recommendation even further. Physicians also need to approach diabetes both as a public health problem and as an individual patient problem. They need to get involved in the community of the patient and have the patient join them in the community of medicine. Within the 15-minute office visit, physicians can begin to address the social, cultural, and environmental issues of patients’ lives. Kleinman⁷ suggests asking patients to define and discuss not just the disease but also their illness and their desired care. Understanding the role diabetes plays in the patient’s life and being willing to compromise one’s own control is often necessary for establishing a working partnership.

Physicians should make a home visit to patients with diabetes to better understand the cultural and social contexts of their lives. Every visit would not have to be in the patient’s home, but just think what a physician could find out in 30 or 45 minutes of seeing how a patient lives. It could save hours of interviewing time during the next few months and years.

Physicians should become involved in the community. Preventive health efforts are needed in every social group. Talk to kids in schools; review the school cafeteria menu; lead efforts to remove the soda and candy machines in the high school. Affect public policy with letters, telephone calls, and information. Lobby for having bike paths put into the community to encourage regular biking or walking to work. Be a role model not just in the office, but in your neighborhood as well.⁶

Freeman and Loewe provide a realistic picture of how physicians, especially those in training, think and feel about caring for patients with diabetes. It is not always a pretty picture, but it is one we need to see clearly if we are to improve our care of these patients. The authors performed this study by immersing themselves in the environment of their participants, talking to the care providers, and observing them in the clinical setting. This is how qualitative research helps to answer questions that cannot be addressed in a structured controlled clinical trial. The analogy is obvious. If we want to get a realistic view of patients with diabetes, we need to see them in their environment and their homes. We need to ask the hard questions as well as the easy ones. We need to take the time to listen as they explain their culture. We may not always see what we want to see as physicians, but this will allow us to help patients take back control of their lives and achieve their own goals.