Addressing psychosocial issues and other barriers is crucial in the discussion of self-management because those with more negative feelings about starting insulin are most unwilling to start insulin.20 One factor that may contribute to these negative feelings is repeated experiences of failing to achieve satisfactory glycemic control with oral glucose-lowering agents.23 Conversely, those who have experienced improved glycemic control with intensification of prior glucose-lowering therapy may be more accepting of initiating insulin therapy.23,26 These findings are a reminder of the importance of a treat-to-target approach to management, in which the target glycemic goal, generally A1C < 7.0%, is achieved within 2 to 3 months of diagnosis and maintained at that level through intensification of therapy as needed.
Addressing psychosocial issues can be a challenge in today’s busy primary care practice due to limited time and lack of training in the management of such issues. However, implementation of various strategies has been reported to facilitate and, in some cases, shorten a patient’s visit. For example, one small study reported that visits were shorter if the physician acknowledged and responded positively to a patient’s stated or implied concerns (17.6 minutes vs 20.1 minutes).27 Missing or ignoring the patient’s concerns often led the patient to bring up the same concern one or more additional times resulting in a longer office visit. These results underscore the importance of asking patients to identify their concerns or questions at the beginning of the office visit. The patient can fill out a questionnaire in the waiting room or be encouraged to write down and prioritize their questions and concerns specific to the visit. If the patient identifies more concerns or questions than can be reasonably addressed in one visit, there should be agreement to address the most pressing ones during the current visit and the remaining concerns and questions during the next visit. This “agenda-setting” approach has been reported to offer several advantages.28 From the patient’s perspective, the quality of the physician-patient interaction was much improved, in part because physicians took time to explain points in a way that was easy to understand. Advantages to the physician with an agenda-setting approach included “feeling more in control,” “less stressed by simply knowing what was on the patient’s mind,” “feeling less rushed,” and “enjoying patient encounters more.” Contrary to the study cited above, physicians found that patients’ visits often were longer, especially those of older patients. One physician, however, noted that the visit “takes more time now, but saves time later.” As noted in this study, additional time spent with the patient can lead to improved job satisfaction for the physician.29
The agenda-setting approach requires that the physician ask the patient to list his or her concerns and questions, and then actively listen to the patient. Once the agenda for the visit is established, employing the “ask, listen, empathize” communication style can lead to effective physician-patient communication and problem-solving. Using this approach, the physician asks questions to gain a clear understanding of the patient’s concerns and then uses active listening with little, if any, interruption.30,31 Since the goal is to solve problems with rather than for the patient, active listening without offering opinions, judgements, or advice while offering empathy is essential. Through reflection and discussion, the physician can help the patient to identify his or her issues and acceptable solutions.
The importance of good communication between physician and patient cannot be overstated. Additional communication skills to keep in mind are: (1) speak slowly using nonmedical language; (2) limit the amount of information and repeat it; (3) draw pictures and/or use visual aids; and (4) ask the patient to repeat instructions and key concepts. In addition to enhancing patients’ understanding, visual images may be particularly beneficial in keeping patients motivated to improve self-management, including adherence to therapy. For example, it may be helpful to graphically track the patient’s glycemic progress. This can be done by establishing an actionable A1C goal (generally < 7.0%) and a time frame to achieve the goal (eg, 2 to 3 months).32 A graph can be constructed beginning with the patient’s current, preinsulin A1C level, with updates at each visit. In addition to motivating the patient and reinforcing adherence, the graph can also be used to demonstrate when further treatment intensification is needed. Additional general strategies that can be employed when considering the initiation of insulin are shown in TABLE 3. Implementation of strategies such as these by family physicians provides patient outcomes comparable to those implemented by endocrinologists or diabetes specialists.33