Optimizing Communication and Overcoming Roadblocks in T2D

Transcript

This transcript has been edited for clarity.

Marie E. McDonnell, MD: Hello. I'm Dr Marie McDonnell. I am an endocrinologist at Brigham and Women's Hospital in Boston. It's my pleasure today to welcome my patient Lorraine Kalp, who's been my patient for 7 years.

Lorraine Kalp: Thank you for having me.

McDonnell: We're going to talk together about effective communication and shared decision-making and type 2 diabetes. Going back to the beginning, you were a young woman [when you were diagnosed with diabetes], and we see more and more diabetes in younger individuals. So maybe talk about that.

Kalp: I was newly married, and I had quit my job to focus on transitioning into married life, with a husband who travels and being a homemaker for a little bit. We were focusing on trying to get pregnant. I remember one day I just wasn't feeling right, and I was sure it was pregnancy, and it wasn't — it was type 2 diabetes. I called my ob/gyn and I said, I need your help. I need to find somebody else.

She hooked me up with an endocrinologist within her practice at that time. This endocrinologist did a great job of getting my A1c from 9.2 down to in the 7 range within a very few months.

McDonnell: It's interesting — I heard you say that "my endocrinologist got me down from 9 to 7." As the clinician, we know that we're empowering you to do that yourself, and it's you doing that. Do you remember feeling like it was a collaboration between you and the endocrinologist?

Kalp: No. With my first endocrinologist, I was so afraid. [I thought] if I don't achieve this, I'm not going to achieve my dream of family. If I don't achieve this, I'm not going to achieve my dream of a long-term marriage. Bad things are going to happen.

It was very stressful. I had two early-onset miscarriages, one of which is very much attributed to the inaccuracy of the diabetic care I was getting. It was really drilled into me, very theatrically, that if your sugars are not controlled, the fetus will not attach, and it will not grow as it should. Birth defects can happen. And when you're told that, saying that's scary in such a nonsupportive way, you just react, react, react.

McDonnell: Leading up to that, it sounds like you didn't necessarily always feel like you were in control of the diabetes?

Kalp: No.

McDonnell: It was sort of controlling you?

Kalp: I was not communicating with that doctor, and I never thought to say "I need help," because there was just that stigma of she's going to tell me what to do, I'm going to do it, it's going to be okay. And it wasn't. So, to no fault of the endocrinologist, that method might work with other patients, but for me, I needed someone who was going to focus on what my needs and my immediate goals were.

McDonnell: It sounds to me that the endocrinologist was afraid for you, and you were afraid and there was too much fear. I know we don't always feel, as physicians, that we have enough time with a patient. That's a universal issue. Patients feel the same way. But there is always time to make sure that you're checking in with each other. One of the questions that I think sometimes we don't always ask is, what are the patient's goals?

Kalp: We're in this hour or half-hour together, and I want to leave that hour or half-hour knowing what my next step — either the next goal, or the next medicine, or going off of medicine. I want to know there's an action plan.

McDonnell: Lorraine, I know there are certain roadblocks that can get in your way when you're trying to receive the care that you need for diabetes. You, for example, don't live close to my clinic.

Kalp: When I was traveling down to you, I was a new mom at the beginning of the pandemic.

McDonnell: That's right.

Kalp: So, I had to take the time to drive, and take the time to factor in traffic and find childcare, which is hard, because it's just mostly my husband and I.

McDonnell: As a provider, I feel like I try to help patients see it is about the future and making these commitments for your futures. It's hard for most people.

Kalp: It really is. I remember, before I was married, before I was more economically secure, when I was working and it was just my income, taking a day off from work when I didn't have one to take off. I remember going over my deductibles with my father. I had a brand-new job; and I said, well, I'm just not going to get the healthcare. Nothing's going on right now. My dad went through the roof.

McDonnell: You mentioned your dad, and you mentioned other people in your life. I find that patients do better when they can rely on other people in their life to help them. That means that they have to have a good relationship with their diabetes. Let me explain what I mean. Some people feel shame around their diabetes, and that extends to the point where they won't ask for help. They don't even want to ask for transportation support because they're going to the diabetes doctor. Whereas those patients who involve their family and engage them, in my experience, do much better.

Kalp: Could you imagine what diabetes control would look like if people looked at diabetes like they looked at a food allergy? If people went to their family and said, my body cannot process a lot of carbs or my body needs protein to help me process. If people looked at diabetes like they look at complications of food with allergies, could you imagine what type 2 diabetes care could look like?

McDonnell: That's a good point. And that is also linked with the weight issues. We know that with overweight and obesity, there is a lot of stigma related to that. And that, we know, is related to shame, and that can be the barrier.

Kalp: I think in our relationship, when I've said to you, I have a 1-year-old who's not sleeping, doing more exercise is just not what I can do right now, you always said back to me, okay, but what can you do? So, you always kind of partnered with me. I never felt like, well I'm not exercising right now, so I'm not going to be successful. You were always like, no, you need to exercise. You need to move your body. But let's look at everything else. What does your lunch look like? What does your breakfast look like? So it's always, I understand and I hear you, but you've still got to do this and we're going to do this together.

McDonnell: The guidelines are very clear that you need to take care of the whole patient. And that includes helping them with food.

Kalp: Saying that, what we're trying to do different now is not attribute personality traits of food. There's no food that's going to make you "good." There's no food that's going to make you "bad." I know in my relationship with you, I never felt shame. No matter what that little spreadsheet I brought you said or what my meter downloaded, I never felt shame.

We hit roadblocks. You've see my roadblocks. Some were big, some were little. But you never made me feel like they were anything more than a roadblock. What other blocks have you had with patients that we haven't talked about?

McDonnell: I'll tell you that I don't discover the blocks with a questionnaire. The way I usually uncover the roadblocks, the barriers, is by walking patients through their daily routine, and it's amazing how helpful that can be. If you can just say, walk me through your day, from the moment you woke up yesterday. Yesterday they'll remember; they won't remember last week. That's when I can learn that they are taking care of a parent with dementia, and the first thing they have to do is make sure they didn't fall overnight. And that sets the stage for their entire day.

You mentioned your spreadsheet that you were keeping when we first met in the setting of the intense management around pregnancy.

Kalp: From my experience of friends and family I've talked to, I had the idea of having your meter downloaded; you can't hide anything.

McDonnell: The glucose meter — like the finger stick meter, or any meter?

Kalp: Any meter. When you go to the doctor and the doctor says, where's your meter? I think every diabetic cringes a little bit and we go, "Last Thursday, oh no, that's on there." Having the medical portal through which I was able to message you — was a great tool. It kept me nice and calm.

McDonnell: You may or may not be aware, but the standard practice now during pregnancy, based on randomized trial data, is to use continuous glucose monitors.

Kalp: How was it for you as a doctor having all this at your fingertips? How has it changed your communication?

McDonnell: That's a great question. On the one hand, it's additional data that we need to sift through as clinicians. But on the other hand, it's data we didn't even have. So, if you were to ask endocrinologists about their perspective on say, for example, continuous glucose monitoring and digital apps, they would say that it's been transformative in a really good way. And I always teach my patients, it's just a number.

This has been a valuable conversation. Thank you for working with me today.

Kalp: Thank you for having me.

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