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