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.

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?

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.

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]

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 HbA_1c 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?

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.

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.

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.

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 HbA_1c 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.

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?

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 HbA_1c 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.

Bromocriptine has been used and is safe, but not many people use it because the efficacy is very mild, with modest HbA_1c 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]

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?

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.