Engaging the Disengaged Patient: Strategies for Successful Diabetes Self-Management

When we think about a patient with diabetes who’s disengaged from their disease, typically what we’re talking about are the people that we meet in clinical care who don’t seem to care—who seem to be struggling around following typical recommendations, whether that means taking medications or making healthy lifestyle changes. It’s a bit vague, but it isn’t meant to capture just people who are struggling with recommendations, but who seem kind of disinterested.

There’s lots of reasons why people with diabetes end up feeling and being really disengaged from their disease. One of the biggest is that, over the course of time—and this is really true for anyone—if you’re putting out your best efforts, if you’re really doing your best to be successful with diabetes and wanting to live a long and healthy life, but as far you can tell your personal actions aren’t really leading to any tangible positive results—people get tired, people get disappointed, and people say, “Why am I bothering?” and that’s a big problem when you’re dealing with a relatively invisible disease, especially a disease like type 2 diabetes. Often people are disengaged for what, from their perspective, are pretty good reasons that we have to be understanding and respectful of if we’re going to be successful in terms of addressing that.

One of the biggest problems health care professionals face when we talk about the behavioral and psychological issues and diabetes is somehow finding the time to do this. I learned a lot from my endocrinologist colleagues about how they deal with this issue. They know desperately that these are some of the critical issues about emotions and motivation and behavior that are important, and they know they don’t have time. And I’ve talked with endocrinologists all over the world about it, and I’ve heard two really good answers about how they’ve done that. One of them is they’ve started doing group medical visits, and when you start doing group medical visits and you have a group of eight, nine, ten patients in a room, and you have a lot more time. The other approach that I just love, one of my colleagues for years said, “Look, I know my patients are so angry at me because I don’t even look at them because I’m so busy typing into the electronic medical record all the time, and they hated it and I hated it.” And he said, “I finally figured out what to do, so now I just have all my patients sit next to me and we go through the EMR together, shoulder to shoulder, and we make that the center point of our conversation, but we’re doing it together and that’s made a huge difference.”

What we want health care professionals to understand when they meet someone with diabetes who really seems disengaged, disinterested, unmotivated to want to manage their disease, the first thing I want them to do is to have a new perspective on how they think about their patients. Often what they’ll mention is, “Gee, how do I change my patient’s mindset?” And I respond, “Well, really, the most important thing is to change your own mindset.” And again, your own mindset being this person in front of me, I’m pretty sure underneath all this, would prefer to live a long and healthy life, and if I can believe that, I’m going to start approaching this person differently.

But for the busiest health care professional, what we ask them to consider is to do at least one thing when they see their patients, and that’s to take a moment and ask this one question: “Mrs. Smith, it’s nice to see you. Can you tell me one thing about your diabetes that’s driving you crazy?” And just even acknowledging that that person’s agenda is important is extraordinarily powerful. It tells your patients that you care, and I know that sounds kind of touchy-feely, but actually, we have pretty good research evidence that one of the drivers of positive behavior change over time—especially medication adherence over time—is when patients report that they trust their physician. So any way we can convey that to our patients, even when we have the littlest and tiniest bit of time, that’s what’s really critical.