How To Influence The Overwhelmed Patient With Diabetic Neuropathy

The patient with diabetic neuropathy is truly overwhelmed.
He or she has gone through the discovery of the disease and perhaps a subsequent refusal to believe it. The patient may not have been following the diet or medication regimen, and now he or she is facing neuropathy and other complications. These patients are now facing decisions about shoes, medications and perhaps even surgical decisions. There may have been career changes, difficulty paying bills and even shifting relationships.
Diabetes is a life-changing disease and it can sometimes be a devastating, life-ending disease without the patient’s involvement in managing his or her diabetes.
As physicians, we want our patients to hear our voices among the many others that are vying for their ears and hearts. Unfortunately, our voices may be neither the loudest nor the strongest.
Long gone are the idyllic and unrealistic Saturday Evening Post days of the Norman Rockwell covers depicting grandfatherly physicians whose every word was respected and listened to without question. In years past, there was more respect for physicians, whose knowledge was held in more regard because of a wide difference in the amount of education between the doctor and the working class patient. In the past, patients did not have the easy access to modern media that gives patients a wide array of medical information today.
Current curricula offer standardized patient labs at most podiatric medical colleges. There is an examination suite in which the student physician interviews and examines patients, and is under observation by hidden video camera. The “patients” are actors who have been trained to mimic the signs and report the symptoms of particular illnesses. This is a powerful tool to help medical students learn to interview and examine their patients.
However, this exercise is not as effective in determining the skills of medical students at helping their patients to get and understand the message because these actors are not actual patients utilizing the information they receive there. Only time will tell.
Perhaps the most difficult thing of all is how one can influence the overwhelmed patient when the doctor is overwhelmed as well. There are endless treatments for neuropathy and that fact alone means that there is no perfect treatment for neuropathy. That is perhaps the definition of “overwhelmed.” In other words, if there were only one type of nail in the world, there would only be one type of hammer. In this case, we do not even know what our “nail” looks like. Neuropathy largely remains a mystery.

Massaging The Message: Secrets To Getting Patient Buy-In For Self-Management

How do we go about influencing patient behavior? There are five fundamental basics to keep in mind.
Make something appealing. This idea is as old as the first advertisements for washing machines. Whatever it is, make it seem newer, slicker, brighter. While that might seem disingenuous, marketers have been doing this with consumer products forever.
Now how can we translate this into making health advice appealing for our patients? No, the patient cannot expect to return to beer drinking and pizza eating, for instance, and expect to lose weight. However, the patient can lose weight and expect to gain time with his or her grandchilden.
It may be a matter of “selling” that alternative future to the patient instead.
Simplify the message. Few disease entities require so much of patients as does diabetes with the complication of neuropathy. To simplify the message is a Herculean task but it can be done. Enlist the help of your staff and the patient’s family, and consider other methods as well.
Blood glucose meters have been beneficial for recording multiple readings and calculating averages. Pedometers, if they are worn faithfully, have assisted patients in monitoring the actual steps they take . However, research has shown that patients have taken off the devices once they are home. Unfortunately, patients assume the amount of walking they do at home is so minimal that it is inconsequential yet it is actually quite substantial. Calendar reminders, electronic PDAs and other alarm-related reminders are reportedly effective for some patients until they establish a routine. Others may need to have another person, family member or staff person working to remind them of health-related activities.
Give the patients ownership or a stake in their health. This is the only method that will ensure lifelong positive results. If the patient continues looking for the doctor who will give him or her the “magic pill” for a cure, he or she will never get better.
The physician needs to convince the patient that he or she, and not the doctor, has the disease. I always told my patients that they did not leave their diabetes at my office between their visits although they sometimes acted like it.
Personalize it. Some patients do not respond well to statistics and studies. They do not want to know how a cohort did in a major university study. They want to know how they are going to do. Make it relevant to their life and they will find value in what you have to say.

Never Underestimate The Impact Of Listening
Listen to them. As physicians, we tend to like to hear ourselves talk a lot and we do not listen very well in general. Just letting our patients talk will reveal the keys to reaching them and finding out what is important to them.
One patient with difficult to control diabetes and painful neuropathy would often talk about how she had enjoyed travel during her lifetime. Her advice to the staff in our office was to never go back to the same place because there were too many wonderful new places to explore. Since her complications now included near blindness, she had given up travel. The appointment when she shared this new decision with us was the clear demarcation point of a period of depression when she started to forget appointments, instructions and medications.
Nursing staff had picked up on other keys from earlier conversations with this previously happy person. Although she and her late husband had never had children of their own, they had several teenage grandnephews of whom she was very fond. One of the nurses asked her if she had ever considered taking them to some of her favorite places around the world. She was familiar with most of these places, had wonderful memories of them and had the resources to enjoy them through the eyes of her young relatives who she could accompany.
At first, she balked at the suggestion. However, a few months later, she came in to announce that she needed to reschedule her next appointment because she would soon be abroad with two of her teenage grandnephews. The patient was paying particular attention to her medical regimen because she wanted to be in “tip top” shape for this trip and the many more trips that she hoped would follow.

Be Aware Of Influential Voices Outside Of The Doctor’s Office

Probably more important than how to influence behavior is knowing how not to do it. It is important not to bully or belittle. That will often intimidate the patient to the point of forcing him or her away from potential help.
I remember returning to my office one particular day, especially frustrated and wondering how in the world a patient could have misunderstood my instructions to her about how I wanted to care for her postoperative foot. It was a simple surgery for a hammertoe in a neuropathic patient with diabetes. In other words, it was a simple surgery in a patient with a complicated condition. The patient was overwhelmed and soon I was as well.
Her friend had wanted to see the surgery site and so they had pulled down the sterile dressing. The friend did not think it looked so good and wondered about that wire sticking out of the end of the toe. Well, that was ridiculous, wasn’t it? What kind of surgery left wires hanging out of the foot? You can see where this is going.
Was the friend correct or was the doctor? The friend knew a lot. After all, she had known that the children had had chicken pox before the doctor did.
Her husband advised her to take a popular acetaminophen product with whiskey for the pain that started after the friend had taken the wire out with a kitchen implement of unknown type. The girl at the shoe store convinced her that if she wore shoes just a “little bit tight,” it would act like a cast and take the swelling out.
Who are your “competitors” for the patient’s ear and opinion? It is not just the Reader’s Digest column or the late night infomercial. It is the neighbor, the spouse, Google, the friend whose cousin works with someone who has a relative who once worked for a doctor …
I have replayed this particular patient case in my mind time and time again as you can imagine. How could I have appealed to the patient who was overwhelmed? One method is providing written information that the patient can take home. This information answers many of the patient’s questions, all of which had been discussed prior to the procedure and after it as well. We did this of course.

Recognizing The Potential Problems Associated With Staff Strain
We also encouraged our patients to call with any additional questions. You have heard and most likely used the old adage “There is no stupid question with the exception of the unasked question.”
In a large multilayered office, what you may find out is that while you have a particular attitude, it may not be the office “culture.” The reasons for that may be different than what you might believe.
The front office staff, one person or a dozen, may present a welcoming face, a protective one or increasingly, as we have gotten further away from a service mentality, a sense of superiority. In speaking with staff members, I have also learned that they are tired of “being abused” by patients who are angry that they have to wait for care, patients who think an office visit should not cost as much as it does, and those who do not understand why the doctor cannot spend all morning with them.
This impasse ensures that, on occasion, staff do not ask appropriate questions or do not ask them well or, in rare situations, do not pass along the information to us. I do believe this is due to their own issues of being overwhelmed.
Regular staff meetings will help reinforce the office culture and hiring practices will reinforce this attitude with future hires. Yes, there will always be difficult patients. Some people seem to have a need to pick a fight or find fault in most situations.
Neither you nor your staff will be able to please them or solve all of their problems. However, by emphasizing listening without arguing, you will defuse the situation and learn enough about that patient to reach him or her eventually.
You will not be successful if you try to make your voice the loudest voice or the most imperious, the angriest or the most condescending. Demonstrating genuine concern and striving for an understanding of a patient’s situation is as close as you will get to resolving a potentially difficult situation with a volatile patient.

Strive To Identify Potential Hurdles To Care
The San Antonio Express-News ran a series of articles a few years ago about a neighborhood near the Westside clinic where clinicians saw many uninsured, “county” patients. Residents from the University of Texas Health Science Center at San Antonio Podiatric Residency Program saw thousands of patients each year from that neighborhood. They prescribed a variety of treatments, which often included wheelchairs, crutches and total contact casts (TCCs).
When those articles appeared, the residents learned that some of the people who had been prescribed these offloading devices lived in fourth floor walk-ups or houses without electricity. Others had no furniture or had no running water. In other words, there was little opportunity to stay cool, clean or in any sense of comfort. If these patients were not already overwhelmed, they would be by the time they left our clinics. Listening to their plights helps us to become better physicians because we learn to work around the restrictions that the patients lived with everyday.
Could the Charcot patient who would be in the TCC for an extended period of time stay with his brother rather than walk up the three flights of stairs every day? The family whose breadwinner was out of work because of an infected ulcer and had utilities turned off needed a social work consult so they could help facilitate his homecare and allow him to return to work.

In Conclusion
Where there is a will, there is a way.
Overwhelmed patients actually have many similarities regardless of whether they are rich or poor, whether they are educated or illiterate, whether they have many relatives or are alone in the world. These patients do not know where to look for any options and might not recognize one if they saw it.
What is the key to reaching overwhelmed patients and identifying potential obstacles to their care? Listening.

Dr. Satterfield is a Clinical Associate Professor in the Department of Orthopaedics/Podiatry Service at the University of Texas Health Science Center at San Antonio.

For related articles, see “Secrets To Facilitating Patient Adherence” in the March 2007 issue of Podiatry Today.