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.