You are leaving Medscape Education
Cancel Continue
Log in to save activities Your saved activities will show here so that you can easily access them whenever you're ready. Log in here CME & Education Log in to keep track of your credits.


Adherence to Type 2 Diabetes Management Plans: Developing Successful Patient Interactions

  • Authors: Luigi F. Meneghini, MD, MBA; John E. Anderson, MD
  • CME/CE Released: 4/14/2014
  • Valid for credit through: 4/14/2015, 11:59 PM EST
Start Activity

Target Audience and Goal Statement

This activity is intended for family and internal medicine physicians, endocrinologists, diabetologists, nurse practitioners, physician assistants, and nurses.

The goal of this activity is to recognize the importance of empathy in fostering physician-patient partnerships, improving patient adherence to therapies for type 2 diabetes (T2D), as well as improving awareness of solutions for overcoming barriers to patient adherence to therapies for T2D.

Upon completion of this activity, participants will be able to:

  1. Propose strategies to build effective clinician-patient partnerships to overcome barriers to treatment adherence in patients with T2D
  2. Identify the importance of empathy in addressing patient concerns that can lead to nonadherence to treatment plans for T2D


As an organization accredited by the ACCME, Medscape, LLC, requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


  • Luigi F. Meneghini, MD, MBA

    Professor of Medicine, Division of Endocrinology, University of Texas Southwestern Medical Center, Dallas, Texas


    Disclosure: Luigi F. Meneghini, MD, MBA, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Boehringer Ingelheim Pharmaceuticals, Inc.; Halozyme Therapeutics; Novo Nordisk; Sanofi;
    Received grants for clinical research from: Boehringer Ingelheim Pharmaceuticals, Inc.; MannKind Corporation; Pfizer Inc; Sanofi

    Dr Meneghini does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.

    Dr Meneghini does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

  • John E. Anderson, MD

    President, The Frist Clinic, Nashville, Tennessee


    Disclosure: John E. Anderson, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Janssen Pharmaceutical Products, L.P.; Lilly; Sanofi;
    Served as a speaker or a member of a speakers bureau for: AstraZeneca Pharmaceuticals LP; Janssen Pharmaceutical Products, L.P.;

    Dr Anderson does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.

    Dr Anderson does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.


  • Anne G. Le, PharmD, RPh

    Lead Scientific Director, Medscape, LLC


    Disclosure: Anne G. Le, PharmD, RPh, has disclosed no relevant financial relationships.

  • Karen Badal, MD, MPH

    Associate Scientific Director, Medscape, LLC


    Disclosure: Karen Badal, MD, MPH, has disclosed no relevant financial relationships.

CME Reviewer(s)

  • Nafeez Zawahir, MD

    CME Clinical Director, Medscape, LLC


    Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships.

Nurse Planner

  • Amy Bernard, MS, BSN, RN-BC

    Lead Nurse Planner, Medscape, LLC


    Disclosure: Amy Bernard, MS, BSN, RN-BC, has disclosed no relevant financial relationships.

Accreditation Statements

    For Physicians

  • Medscape, LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

    Medscape, LLC designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Medscape, LLC staff have disclosed that they have no relevant financial relationships.

    Contact This Provider

    For Nurses

  • Medscape, LLC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

    Awarded 0.75 contact hour(s) of continuing nursing education for RNs and APNs; 0.75 contact hours are in the area of pharmacology.

    Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]

Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 70% on the post-test.

Follow these steps to earn CME/CE credit*:

  1. Read the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or printed out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates from the CME/CE Tracker.

*The credit that you receive is based on your user profile.


Adherence to Type 2 Diabetes Management Plans: Developing Successful Patient Interactions

Authors: Luigi F. Meneghini, MD, MBA; John E. Anderson, MDFaculty and Disclosures

CME/CE Released: 4/14/2014

Valid for credit through: 4/14/2015, 11:59 PM EST


  • Luigi Meneghini, MD: Hello. I am Dr Luigi Meneghini, professor of internal medicine in the division of endocrinology at the University of Texas Southwestern Medical Center in Dallas, Texas. Welcome to this program on recognizing the importance of empathy to improve patient adherence to type 2 diabetes (T2D) management plans. Joining me today is Dr John Anderson, past president of the Frist Clinic in Nashville, Tennessee. Welcome, John.

    John Anderson, MD: It is good to be with you, Luigi.

  • Slide 1.

    Slide 1.

    (Enlarge Slide)
  • Dr Meneghini: Nice to be with you. Today, I would like to propose some strategies to build effective clinician-patient partnerships to overcome barriers to adherence. We are going to talk about some of those shortly. Also, I think it is important to talk about empathy in addressing patient concerns. There is quite a bit of evidence that shows that being an empathic physician actually improves patient care. To start off our discussion, John, what are some current challenges in providing optimal T2D care for our patients?

  • Slide 2.

    Slide 2.

    (Enlarge Slide)
  • Dr Anderson: There are a lot of challenges. The DAWN2 study was published in 2013, just last year.[1-3] DAWN actually stands for Diabetes, Attitudes, Wishes, and Needs of patients with T2D. What we know is that patients are not always actively involved in their own care.

    Dr Meneghini: Let me stop you right there. What do you mean by not actively involved in patient care? Do they not show up to visits? Is there no interaction with physicians?

    Dr Anderson: They do, but they are really not engaged in self-management. Sometimes, they do not even understand self-management. One of the key things this study showed is that patients' psychosocial well-being is actually tied to their ability to manage their diabetes.[1] Many of these patients do not have adequate access to diabetes education. They have a lot of misconceptions as well, in particular, about things such as insulin. The other thing that came out of this study is that it is very clear that healthcare professionals (HCPs) -- those of us who provide care for people with diabetes -- need to be better about actually delivering diabetes education.[3]

    Dr Meneghini: I completely agree with you. Even as an endocrinologist, there is so much that we can learn in terms of engaging those patients.

  • Slide 3.

    Slide 3.

    (Enlarge Slide)
  • Dr Anderson: Right. This DAWN2 report emphasized that effective diabetes care is about self-management, especially in terms of psychosocial support and diabetes education.[1,3] Here are a few statistics highlighted in the study. Only 24% of people with diabetes reported that their HCP actually asked them how this disease is affecting their life.[1] Many of these patients are not actively engaged in their diabetes, and a little over 36% of people with diabetes felt that if they were left to their own devices, they could not self-manage their disease.[1] Only a third of the patients reported that the physician actually asked them or gave them an opportunity to ask questions during the visit.[4] When it comes to formulating treatment plans and actually deciding what you are going to do as you go forward, only about 29% of the patients said that their provider had them engage in that decision making.[4]

    Dr Meneghini: Is that not a little bit of fluff? As physicians, are we not supposed to just assess and treat and just get on with it?

    Dr Anderson: It is. That is the dichotomy, right? We are trained to solve the problem, but part of solving the problem means getting that patient engaged. We know from studies that if a patient is part of the decision-making process, if they actually engage with us in the decision, they are going to be better off in the long run.[5,6]

  • Slide 4.

    Slide 4.

    (Enlarge Slide)
  • Dr Meneghini: That may explain some of the statistics that we see coming out of the National Health Surveys that show only about one-third to one-half of patients ever get to an HbA1c goal that is appropriate, a blood pressure goal that is appropriate, or lipid goal that is appropriate.[7] Now, that said, these were statistics from 2010. There are some new guidelines[8] with respect to blood pressure control, are there not?

    Dr Anderson: Right. Those are 2010 statistics. What we hope, as we look at 2014, is that these numbers will get better. In this past year, the blood pressure goal was moved from 130/80 mm Hg to 140/80 mm Hg.[8] This may encompass some more patients who actually meet those 3 goals.

    Dr Meneghini: John, you mentioned earlier about the misconception about insulin therapy with some patients. What are some experiences you have had in your practice when you tried to intensify a patient's regimen with insulin?

  • Slide 5.

    Slide 5.

    (Enlarge Slide)
  • Dr Anderson: It is interesting that you bring that up because there are a lot of different fears and concerns. I think the first one is injection phobia.[9] None of us are really accustomed to poking ourselves with sharp needles, but we have such small needles now, such as the 32-gauge ultrafine insulin needles, that it is not the problem that patients think it is. They imagine that they are going to be sticking themselves with the same 20-gauge needle from which they get blood drawn.

    The other part of this is that some patients, in particular with insulin, think it is going to be complicated. They think there is math. They think, "I am going to mess this up. I do not have the capacity to do this." Then the other part of this is that they think it indicates that they failed. "If I had done a better job about paying attention to my diet, walking like you told me to, getting my weight down, I would not be here at this end stage with insulin." One of the studies of the original DAWN study[10] showed that patients who are really good about their diet and exercise regimen had less anxiety about starting insulin because it was a natural progression of their diabetes as opposed to personal failure.

    Dr Meneghini: You mentioned insulin pens and smaller needles. Does it facilitate actually teaching patients how to get on insulin vs the traditional vial and syringe that we were using before?

    Dr Anderson: Absolutely. I think the new pen systems have provided a much easier transition to injectable therapy, both insulin and noninsulin injectables.[11] The other interesting thing about insulin is that some people see insulin as the end of the road.[12] They have a relative or a friend who started on insulin and then went on dialysis or lost a limb. They forget the fact that the patient probably should have been on insulin years before.

    Dr Meneghini: Getting over the hurdle of their concern about the injection pain is just one small aspect of the whole barrier.

    Dr Anderson: That is right.

    Dr Meneghini: Let us take a look at a vignette together about how to alleviate patients' fear of needles in a primary practice setting.

  • Slide 6.

    Slide 6

    (Enlarge Slide)

Patient Case 1

Narrator: Alfredo Ortiz, age 58, was diagnosed with T2D 10 years ago. He was prescribed metformin, 1000 mg twice daily, along with lifestyle modifications. His blood glucose was well-controlled until 2 years ago, at which time glyburide, 5 mg once daily, was added to his regimen. After a good initial response, his HbA1c increased to 8.4% 6 months ago, and he was prescribed pioglitazone, 30 mg once daily. In this simulation, we join Mr Ortiz, his wife, and his primary care physician (PCP) during an evaluation.

Physician: Do you remember at your last appointment we discussed how you would likely require insulin at some point to control your blood sugar?

Patient: Yeah, I remember.

Physician: Well, the fact that your HbA1c is still 8.4% with 3 oral medications indicates to me that insulin may now be the only effective option.

Patient: How about we give it another 6 months? I know I can do better with my diet and exercise.

Physician: Mr. Ortiz, it's important to understand that type 2 diabetes is a progressive disease: It usually gets worse over time no matter how diligent you are with your self-care. Most people with T2D eventually require insulin.

Patient: I just don't think I'm ready for insulin right now.

Physician: Do you mind if I ask you what your main concern is with insulin?

Patient: Well, it's just that... you know... um....

Wife: It's the needles. He doesn't like the needles.

Patient: It's kind of embarrassing. I was in the service, you know.

Physician: It's nothing to be embarrassed about. Many of my patients feel the same way. Do you know what an insulin pen is?

Patient: I've heard of them.

Physician: Here, let me show you. As you can see, the needles are very small and fine. Most of my patients say they can barely feel them.

Patient: Really? Are you sure?

Physician: If you're open to it, I can show you right now what the needle feels like without the insulin.

Patient: Now?

Wife: I think it's time, honey. You don't want to wait too long and have to go on dialysis like Papi.

Patient: Maybe you're right. OK, I'll try it.

Physician: That's great.

Patient: So, if I start taking insulin, do I still have to take the other diabetes drugs?

Physician: Yes, for now, although at some point we may need to stop the glyburide.

Wife: Will the insulin give him more energy?

Physician: It should. One of the symptoms of high blood sugar is fatigue.

Wife: So, he won't have any more excuses for not cleaning out the basement, right?

Physician: I'll leave that for you two to work out. Are you ready, Mr. Ortiz?

Patient: Ready as I'll ever be.

Physician: Where would you like the injection? The most typical injection sites are the abdomen, thigh, and arm.

Dr Anderson: I think this is an interesting vignette from several standpoints. I think, first of all, it is clear that when you look at this vignette, that the physician had discussed insulin before this visit. They had actually been talking about insulin being a natural progression of his disease state. It is important that there is obviously an element of trust between this healthcare provider, the wife, and the patient. There is a lot of give and take. The physician addressed all the fears, asked the questions, and inquired, "What is it that really limits you here?" Then, they found a way to solve the problem.

Dr Meneghini: That is interesting because, in my experience, you start those discussions about insulin therapy -- at least you try to start them -- early on, but often you meet patient resistance. They want another 3 months or another 6 months. They say they are going to change their diet and their food intake. As physicians, sometimes that can be frustrating, and sometimes our reaction is, "You do not want to do what I am telling you to do. Go find somebody else." That is not the way we should be practicing, is it?

Dr Anderson: No, it is not. I think this vignette illustrates this. We want to understand what the barrier is. We want our patients to participate in the decision making. Ultimately, as healthcare providers, we know what the next best therapy is, and we need to try to get our patients to understand why and to address their fears. I always tell patients, particularly those who are not under good control, insulin is not the end of the road. It is just another tool we have to control your diabetes. You may actually look forward to feeling a lot better than you have been feeling before this.

Dr Meneghini: One tool is patient engagement and building patient trust. How do you do that with a patient who seems to be resistant to carrying out the opinion of the expert?

Dr Anderson: It is a real challenge in practice when you have patients who really do not want to go where you think they need to go. Trust is not built in 1 office visit. Trust is built over time. Many of the patients I have in my practice, I have been seeing for a number of years. You have helped them through a lot of difficult problems. You have listened to social concerns. They have built that level of trust over time. I think, as PCPs, we can leverage that to say, "You know what? You need to trust me on this. Help me try this. If we are not successful the next 3 months, we can always change our game plan."

Dr Meneghini: It is a partnership that you are basically setting up with that patient, and that partnership, hopefully, takes you and them down the right road.

Dr Anderson: Right. One of the keys -- and you and I talked about this before -- is that there is nothing about that patient visit that is about me or where I want to be. It is always about the patient, their health care, and their utmost concern. Every visit is about them, not the provider.

Dr Meneghini: That is a very important point. It takes some of the onus off the physician. As physicians, if we do not have patients where they need to be, we feel frustrated. We feel like we are failing, as opposed to actually being a partner or a coach down this road, and knowing that, sometimes you get it and sometimes you need to keep trying.

Dr Anderson: Right.

Dr Meneghini: The reaction of this patient to that insulin injection was kind of usual, right?

Dr Anderson: I get that reaction all the time. I had a lady come in about 2 months ago who had new onset T2D with an HbA1c of 6.9%. I started her on metformin. She said, "Phew! Thank goodness it is not insulin." I said, "Hang on. I will be right back." I went to the refrigerator and got an insulin pen needle. I got the little tiny 32-gauge needle. I said, "Just trust me." I did a false injection, just like we saw in the vignette. She looked up and said, "I did not even feel that." I replied, "Great." She says, "But you are not starting me on insulin." I told her, "No, but here is my point. Insulin or an injectable, especially in this day and age of glucagon-like peptide-1 (GLP-1) receptor agonists and other medications, may be a natural product of your next several years, and I do not want you avoiding something that you do not need to be afraid of."

Dr Meneghini: That is great. In fact, you started addressing one of the early barriers without even getting to the need of getting them on insulin. That is wonderful.

Dr Anderson: This last scene took place in a primary care setting. Luigi, what do you see in a specialist practice that may be different from a primary care setting?

Dr Meneghini: That is a great question. I think we see more complex cases because they are referred to us, when in the primary care setting, they might be having some challenges. We can address those because, usually, in a specialist setting, there are more resources or access to those resources. For example, I work closely with nurse educators who can always educate the patient. In that interaction, that building of trust is an informational component. The patient needs to understand why it is that you are asking them to do something that, in the long run, will be better for their health. That is where I think educators have a huge role. Access to education is important.[13]

We also just only see diabetes, and so our staff is well-trained in starting insulin injections. If I do not have the 5 minutes that it takes to teach a patient how to start insulin with an insulin pen or how to test blood sugars, I could always pass it off to my nurse or nurse's aide because these are very simple things to do. I think there is quite a bit that enables us to be more efficient, just because we have the resources, but other than that, I do not see much difference in the approach between primary care and specialists. Now, the one thing that often I would love to have is more information about the patient who shows up for the first time at my office.

Dr Anderson: I am glad you said that because in the primary care world, we send you the patient, and you ask us to send you the information about what we are doing. Whether it is a nephrologist or an endocrinologist, we, as PCPs, owe you some information at that first visit, such as how long I have been taking care of this patient, my frustration with their diabetes, some social concerns, or some financial concerns for which you may need to be aware. Here is why I am sending this patient to you, and specifying for you what the goal is and helping you target where you need to go with that patient, rather than a patient showing up and saying, "I am here because my doctor sent me."

Dr Meneghini: That is absolutely true. As the PCP, you have established a relationship. You know what is important for that patient. That piece of information can be invaluable for the referred physician consultant in quickly establishing that trust and that engagement for the patient.

Dr Anderson: That is exactly right. You can address that at the first visit.

Dr Meneghini: Yes. Absolutely.

Dr Anderson: Luigi, we discussed some of these patient barriers. How do we implement strategies to help our patients achieve adherence to their regimen?

Dr Meneghini: That is very important. I think that as physicians, again, we are trained on getting the hard stuff down and focusing on the data. "I am going to assess the patient. I am going to devise a treatment plan. I am going to hand it to the patient. I am going to see them back in 3 weeks, 3 months, and I am going to expect that patient to actually have carried out my treatment plan." Unfortunately, it only works in a minority of patients, as you well know. I think one of the things that we as physicians and healthcare providers need to address is some of the behavioral tools that are available out there. There are quite a few of them.

  • There are things such as motivational interviewing that we could weave into our discussion with the patient. We can introduce shared decision making. You have talked about collaborating with a patient in terms of setting goals. I think it is very important to engage the patient in terms of health decisions. Why do I say that? If I ask a patient to exercise for 30 minutes, and this patient has a busy professional life, perhaps as a physician who spends 16 hours at work and is trying to keep up with the literature, those health-related goals actually conflict with their life goals. Putting a priority on that might be difficult. In terms of goal setting, I think it is important to understand that there are general health-related goals and more specific goals. Telling a patient to lose 15 to 20 lb because that will improve their health is a long-term goal, and it is not easily achievable. If that is all I give patients as an instruction, they may fail, and by failing, they lose confidence in their ability to achieve those goals.

  • Slide 7.

    Slide 7.

    (Enlarge Slide)
  • On the other hand, I could actually give them specific health-related goals, or what is called an action plan.[14] I could have them start by walking half a mile Monday, Wednesday, and Friday, or actually have them tell me what it is that they can do. I know that walking half a mile 3 days a week is not going to do much for their health, but it will enhance their self-efficacy, their ability, and their perception that they can achieve a positive health outcome. If they can build on that, we may eventually achieve the health-related goal and the overall goal of improving health outcomes.

    There are many lessons in business literature that we can import into our health management, such as looking at general goals vs more specific action plans. As we have discussed, engaging the patient in collaborative, shared decision making and having a clear purpose as to what those goals are is important. Are we trying to improve patients' self-efficacy, their ability, or their perception of their ability that they can enact change vs health outcomes? Obviously, feedback is important. We want these patients to know that we are following them, and we care for their outcomes, rewards, and also the intervention environment. We are busy clinicians. Where this discussion takes place does not necessarily need to be in the physician's exam room. For example, are you able to implement goal setting in the 10 to 15 minutes or 20 minutes that you are allotted in your patient visit? Should that be done at some other time?

    Dr Anderson: I think that is a great point. I do sometimes, in the 10 to 15 minutes, really set some concrete goals. What can you achieve? A patient newly diagnosed with diabetes recently came in to my office, and we discussed needing to lose weight. She needed to lose a lot of weight, but we talked just about short-term goals. I told her to give me the low hanging fruit in her diet. You will usually start with sugar-sweetened beverages, or something that is really easy to take away. Of course, down here in the south, it is always sweet tea. She was drinking at least 3 large glasses of sweetened tea a day with a lot of sugar. I said, "OK, let us just start there. Do you think that is something you could give up?" She said, "Sure, I could do that." Again, it is just an easy step. It is not going to accomplish all of her goals, but it is a start, and she is going to feel good about it, and invariably, she is going to lose a little bit of weight if she can do that.

    Dr Meneghini: Absolutely. That encourages patients to do more. If we are successful at achieving the goals that we set ourselves, we want to be more ambitious. Everybody cares about their health. I think goal-setting is important. I do not think we get enough training as physicians to implement that.

    I think that it is not always practical to try and do some of this during the visit, but this can be done before or after the visit. In preparation, we can get training for our staff in terms of discussing goal-setting with the patient.[13] There is technology that we can employ to help patients understand what their expectations and practical realistic goals could be.

    I think it is important to get this in our discussion, even though it may seem like fluff. Again, I am a physician, and I want to get to the bottom of this, but those 5 or 10 minutes that we take with these patients discussing the "fluff" can make a big difference compared with what we traditionally do.

    Dr Anderson: I absolutely agree. As you mentioned, we have a lot of tools at our disposal, particularly with technology now.[15] We have always talked about diabetes being a team approach. It may take several of us working together for the benefit of that patient to set those goals and to help them achieve them.

    Dr Meneghini: That is an excellent point. In this chronic disease approach, we need to take some of the responsibility off the physician and put it on other team members. This can be just as effective, and we can approach the issue as a team, with the patient as the leader of that team and the healthcare providers as the coaches and enablers for that patient achieving those goals.

    The following vignette demonstrates the implementation of a goal and specific action plan. Let us take a look.

  • Slide 8.

    Slide 8

    (Enlarge Slide)

Patient Case 2

Narrator: After being diagnosed with T2D 8 years ago, Gabrielle Mitchell, age 53, was put on a diet and exercise program and prescribed metformin, 1000 mg twice daily. Two years ago, to address increasing HbA1c levels, she was prescribed pioglitazone, 30 mg once daily, in addition to metformin. One year ago, with her HbA1c still above goal, linagliptin, 5 mg once daily, was added to her regimen. In this simulation, we join Ms Mitchell and her PCP during an evaluation.

Physician: Your HbA1c is 7.6%, which is up from 7.4% 3 months ago. You've also gained 10 lb.

Patient: Yeah, I know I've put on some weight.

Physician: Are you taking all of your medications as directed?

Patient: Yeah.

Physician: What about your diet and exercise program?

Patient: Well, truthfully, I've slipped a bit on both. I'd like to try to get back on track, but my schedule is crazy these days.

Physician: One thing that's helpful with many of my patients is to set up a goal and then come up with a specific action plan for how to reach that goal. Are you open to that?

Patient: Sure.

Physician: Good. What would you say is a realistic goal, then, in terms of how much weight you think you can lose over the next 3 months?

Patient: Well, if I gained 10 lb in 3 months, I ought to be able to lose 10 lb in 3 months.

Physician: OK. With that in mind, what would you say is the biggest barrier to losing this weight?

Patient: Well, like I said, my schedule is crazy. My daughter got a new job, and I have to help out with my grandkids. I work full-time and volunteer at my church. I just don't have the time to cook healthy meals or go for my daily walks.

Physician: I understand. It sounds like you have your hands full. Would you be open to meeting with a dietitian? There are all kinds of quick and easy recipes for making healthy, low-fat, good-tasting meals.

Patient: Yeah? Sure, I'd be open to that.

Physician: Great. My office will set it up.

Patient: You know, maybe, I could get my daughter and grandkids to start eating better too: They mostly eat fast food.

Physician: That's an excellent idea. You also mentioned something about not having time for your daily walks?

Patient: Well, I used to walk after work, but now I have to rush over to my daughter's home and help her with the kids.

Physician: What about mornings? Any time then?

Patient: Not really. Actually, you know what I could do? Get off the train 1 stop early and walk the rest of the way to work. It's about a half mile. I'd have to get up a little earlier but I'm OK with that.

Physician: That's a great idea. What would also be helpful is for you to keep a daily log of your eating and exercise habits, so we can keep track of what's working and what isn't. I have a sample log here.

Patient: Alright.

Physician: Also, can you call the office in a couple of weeks and let us know how your weight loss action plan is going? That way we can make early adjustments to the plan if necessary.

Patient: Sure, I can do that.

Dr Meneghini: The vignette that we just saw addresses a number of different issues. A common issue is that the patient is busy, and getting exercise goes outside of their usual scope of life. Changing their diet might not be as simple as us telling them, and there are a number of challenges that need to be addressed. It is important to have collaborative, shared decision making to discuss what is realistic, what is possible, and coming up with a plan that is feasible. There are different strategies, as we have seen in the vignette, such as using daily logs or following up with a phone call before the next visit.

In your busy practice, how do you do that?

Dr Anderson: It is difficult. In the ideal world, I would love to be able to have me or one of my staff pinpoint a future point in time and call all the patients. We are able to do that sometimes, but almost always, if I really want to have the patient give us some feedback, I will encourage them and say, "OK, we are waiting for a phone call from you in 2 weeks to hear about your progress." They know exactly how to get a hold of my nurse and leave a voicemail, and then either she or I will call them back. It keeps the patient engaged in what we have asked them to do, and it lets them know that we care that they are achieving their goals. I like this vignette, particularly because the action plan was very specific, very tangible, and something that was very achievable for which everybody agreed.

Dr Meneghini: That sounds great. The other thing is involving a nutritionist. Now, with many patients, when you mention the dietitian and nutritionist, they say that they have been there and done that, and it has not worked. When they go back to their home environment, they feel isolated in terms of trying to achieve the dietary goals that they know they need to achieve. Any ideas how to address that?

Dr Anderson: I think dietitians are a key component of chronic disease management, particularly diabetes, and so I almost always encourage my patients to meet with one.[16] I had a patient come in last week with new onset T2D. He said to me, "Yes, I did the initial appointment with the dietitian, but I want a dietitian on call. I want to set up a way to interact with my dietitian over the next 3 months." Fortunately, reimbursement was not a big issue for him, but he expressed the need for continuous involvement of the dietitian to help him over the next 3 months, and possibly over a lifetime of diabetes. We have many tools for communication. Certainly, we need to have ongoing diabetes education as it pertains to diet. It cannot be accomplished in just one visit.

Dr Meneghini: Absolutely. I think that it is important also to frame the -- diet is probably not a good word for it -- but the healthy eating that I want my patient to try and achieve as exactly the type of healthy eating that I want their brother, sister, mother, father, son, daughter to achieve because in the long run, that is what keeps health going. I think it is important to engage not only the patient but to try to engage the family in this discussion.

Dr Anderson: I absolutely agree because if you are sitting down and having meals as a family, the whole family benefits when dietary behavior is changed in the home.

Dr Meneghini: It would be incredibly difficult for a patient by themselves to eat a different meal from what their loved ones are eating.

Dr Anderson: Absolutely.

Dr Meneghini: We have talked quite a lot about engagement and involving our patients in the development of their treatment plan. Why is that important?

  • Dr Anderson: There actually have been studies in literature on participatory decision making between the HCP and the patient.[5] It actually predicted the level of participation by the patient when they came back for follow-up. Studies have found that participatory decision making during a primary care encounter, in patients with T2D specifically, can result in lower HbA1c levels, more activation by the patient, and better medication adherence.[5]

    Dr Meneghini: That is huge. We are talking about just participating in the decision making affecting clinical outcomes. That is something that really we need to look at more closely.

    In the next vignette, we see a patient who is actively participating in changes in his treatment regimen.

  • Slide 9.

    Slide 9

    (Enlarge Slide)

Patient Case 3

Narrator: Tom Evans, age 43, began treatment for T2D 3 years ago with lifestyle modifications and metformin, 1000 mg twice daily. Two years ago, glyburide, 5 mg once daily, was added to his regimen. In this simulation, we join Mr Evans and his PCP during an evaluation.

Physician: Good morning, Tom.

Patient: Good morning, doctor.

Physician: How's everything going?

Patient: Alright, I guess.

Physician: I have your HbA1c results here: 7.7%, which is up from 7.5% a few months ago.

Patient: It's gone up? That's not good.

Physician: Have you been taking all of your medications?

Patient: Yep.

Physician: What about your dietary guidelines and exercise program? Any problems there?

Patient: No, not really. I mean, you know, sometimes I eat things I'm not supposed to eat: meals with clients, things like that, but most of the time I eat well, and I've been going to the gym pretty regularly. I just can't seem to lose any weight.

Physician: Well, it may be time to add another diabetes drug to your regimen.

Patient: What type of drug?

Physician: There are several options; they differ primarily in their side effects and how they're administered.

Patient: OK.

Physician: One option is a thiazolidinedione (TZD). They're reliable and effective; they've been around for years: oral administration, once a day, with or without a meal. Side effects can include weight gain, hypoglycemia....

Patient: Weight gain? No, look, I really don't want to take another drug that causes weight gain.

Physician: OK, fair enough. Another option is a dipeptidyl peptidase-4 (DPP-4) inhibitor. They're also administered orally, once daily, with or without a meal. They're classified as weight-neutral: They don't cause significant weight gain or loss. Also, unlike the TZDs, they're not associated with an increased risk of edema or heart failure.

Patient: That sounds better. I don't want to gain any more weight.

Physician: There's also a GLP-1 receptor agonist, which is associated with weight loss in most patients.

Patient: Seriously? How much weight loss?

Physician: It varies depending on the patient, and, of course, you will need to continue your dieting and exercise regimen.

Patient: It would be great if I could lose some weight. I have a big family wedding in a few months. My brother always gives me a hard time about my weight.

Physician: You should know that GLP-1 receptor agonists are not oral drugs. They need to be injected subcutaneously: under the skin.

Patient: Hmm. What do you think I should do?

Physician: It's up to you. With diabetes, you're largely responsible for your own care, so you need to be comfortable with your choice. Why don't we go through the rest of the options before you make your final decision?

Patient: OK.

Physician: Another option is an...

Dr Meneghini: John, this patient is mostly likely a good candidate for a GLP-1 receptor agonist. I am wondering, what is your experience in introducing the idea of using an injectable drug in your patients?

Dr Anderson: Sometimes you meet resistance, but if you can get over that injection phobia and have that discussion early on with your patients, even when they are just taking metformin, you can break down some of those walls and barriers. I have also found that noninsulin injectables are more accepted because you are not dealing with the fear and prejudice with insulin, and you are also talking about weight loss. I have found that the GLP-1 receptor agonists have been a very useful tool, and I have had some patients who have had tremendous success, not only in terms of lowering their HbA1c but in feeling better about themselves because they lost a substantial amount of weight as well.

  • Dr Meneghini: That is an important point. We have actually separated the injection from the insulin, and by doing so, I think the statistics, or data, show that patients are much more willing to engage in that.[17] Once they have gotten over the fear of the injection, if they need to go to insulin, then the education just needs to be in terms of the benefits of the insulin and demystifying some of the misconceptions.

    Dr Anderson: Right.

    Dr Meneghini: When individualizing a patient's treatment plan, it is important to educate him or her about not only the benefits but also the risks of the medication. Can you highlight for us some of the main concerns associated with the different drug classes that we have to treat T2D?

  • Slide 10.

    Slide 10.

    (Enlarge Slide)
  • Dr Anderson: I would be happy to. We could do a whole lecture on all the medications for diabetes, but I will just go through some of them. Sulfonylureas (SUs) are inexpensive, and they are frequently used simply because of that, but they do have the potential for hypoglycemia, weight gain.[18] We do not think they are very durable, and there is a continuing debate about the beta cell. The TZDs have been much maligned, particularly with rosiglitazone,[19] which recently received US Food and Drug Administration (FDA) approval. TZDs can cause weight gain and edema, they cannot be used in patients with heart failure, and there is an 8% increase in bone fracture for which we need to be careful.[18]

    One of the more promising classes that has just come on the market is sodium-dependent glucose cotransporter 2 (SGLT2) inhibitors. We have 2[20,21] of them now approved in the United States, with a third[22] probably later this year. They actually cause you to urinate out more glucose, so you get weight loss and good HbA1c reductions.[20-22] There is the issue of genitourinary infections, and particularly with canagliflozin,[21] there is a low-density lipoprotein cholesterol (LDL-C) increase, so they are still looking at that.

  • Slide 11.

    Slide 11.

    (Enlarge Slide)
  • Bromocriptine has been used and is safe, but not many people use it because the efficacy is very mild, with modest HbA1c reductions.[18] There is no hypoglycemia, and patients can experience mild nausea or dizziness. DPP-4 inhibitors also target that incretin defect.[18] They are weight-neutral, but their efficacy is modest. Again, just like GLP-1 receptor agonists and SGLT2 inhibitors, being newer agents, they are very expensive. With the GLP-1 receptor agonists, you can get a lot of nausea, and there is the issue of pancreatitis[18]; however, when used correctly, these agents can be very effective.

    Of course, we have insulin. Our insulins are so much better than when we used human insulin. We are much more physiologic with our basal insulins and our rapid-acting analogs.[23,24] We have new rapid-acting and basal insulins coming out in the future. They have great efficacy, but you have to be careful about hypoglycemia, and there is always the concern about weight gain.

    Dr Meneghini: I would say those are very important points. I just wanted to go back to the pancreatitis issue because that is a big looming Damocles sword when you are prescribing a GLP-1 receptor agonist. It is my understanding that when you look at the large databases, for the most part, there is not much of an increased risk of pancreatitis[25]; however, in patients who are predisposed to developing pancreatitis, such as those with gallstones, alcohol use, or hypertriglyceridemia, it clearly increases those patients' risk of developing pancreatitis.[26] Is that your understanding?

    Dr Anderson: I think the problem is that a lot of people with T2D have an increased risk of pancreatitis overall.[27] If you look at the GLP-1 receptor agonists as a class, there is no clear causation between their use and pancreatitis.[28] It is more of an association. A lot of it came out in the early reporting data. I do agree with you. If you have a patient who has had pancreatitis or is at a significant risk for pancreatitis, you choose a different class of agents.[29-31]

  • Slide 12.

    Slide 12.

    (Enlarge Slide)
  • Dr Meneghini: As we saw in these 3 vignettes, empathy is a key component to overcoming patient barriers to nonadherence, as well as misconceptions of diabetes treatment. There is actually a very interesting study[32] that was done in my home country, Italy. They surveyed 300 physicians using the Jefferson Empathy Score Scale and looked at how often their patients were admitted to the emergency room or hospital due to acute complications of diabetes, such as diabetic ketoacidosis, hyperosmolar state, and severe hypoglycemia.

    Interestingly, they found that physicians with higher empathy scores had patients who accessed the hospital or the emergency room fewer times. This is actually tangible evidence that demonstrates that employing an empathic approach, listening to and engaging the patient, and partnering with the patient reduces a hard outcome. This is not the only study that has shown benefits of an empathic approach to patients.[33]

    Dr Anderson: It is that 5 minutes you talked about, is it not?

    Dr. Meneghini: It is.

    Dr Anderson: There is evidence there for that extra 5 minutes of trying to engage the patient in your office visit.

    Dr Meneghini: Absolutely. That is an important point because, again, we are pressed for time. We want to get that patient a treatment plan and get them out the door, but those additional 5 or 10 minutes that we invest in that patient seems to make a huge difference. I think that there are a number of takeaways that we could touch upon. I do not know if you want to take the first stab at it?

  • Slide 13.

    Slide 13.

    (Enlarge Slide)
  • Dr Anderson: Sure. I think what we have talked about is you have to listen, get to know your patient, what they are afraid of, what is going on at home, and what is going on at work. If you can spend the time and develop that relationship over time, you build trust and empathy. They really do think you care about their health.

    Dr Meneghini: We do care, do we not?

    Dr Anderson: We do. The other thing I have found is that the reward of practicing medicine is knowing your patients as people, not just as numbers and statistics. Whether it is a specialty or primary care setting, that is what motivates us and made us do this in the first place.

    Dr Meneghini: Absolutely. I think as physicians, if we are able to provide care that is delivered in an empathic manner, to engage patients in goal setting, to see them improve in terms of health, it is a huge reward. It just makes the practice of medicine so much better.

    I would like to thank you, John, for joining me in this interesting discussion. I think we have had great conversation, covered some wonderful points, and I hope that our audience will take away something from this interaction.

    Dr Meneghini: Thank you for participating in this activity. If you want to earn CME/CE credits, just click on the link to take you to CME/CE posttest evaluation.

  • Slide 14.

    Slide 14.

    (Enlarge Slide)

Dr Meneghini: Thank you for participating in this activity. If you want to earn CME/CE credits, just click on the link to take you to CME/CE posttest evaluation.

Practice Assessment

How will you improve your practice? Please click on the "Continue" button to assess your planned changes in comparison with your peers by completing this brief survey. (Note: The following questions were developed by an independent consulting group with expertise in assessing the effectiveness of medical education.)

  • Print