Amy Tenderich: The "Home Depot" method of patient engagement

The following is a reader take by Amy Tenderich.

“You can do it. We can help.”

As one of 21 million Americans living with diabetes, Home Depot’s slogan hits home. Diabetes is largely a self-managed disease. If patients don’t take a “do-it-yourself” approach to their blood glucose control, things tend to spiral downhill.

Home Depot’s motto, with its combined empowering and coaching slant, is the approach that health care providers should be applying to their interaction with diabetes patients around the country.

Instead, diabetes is escalating into a public health crisis, causing nearly 300,000 deaths in the US every year.

Physicians tend to blame the problem of poor disease management on patient “non-compliance”. Patients don’t follow instructions, they say. Often true. But why? Pure apathy or some innate self-destructive tendencies? Doubtful.

Keep in mind that most every human being is motivated to live well and long. Quite often patients just don’t understand what doctors are asking of them and why, they feel utterly overwhelmed, or both.

There ought to be a protocol for every health professional treating diabetes to first explore exactly what’s standing in a patient’s way. Next, the mandate should be to refer the person to the appropriate help – a certified diabetes educator, nutritionist, exercise physiologist, support group or seminar, depression counselor, etc.

But the inefficacy of diabetes management actually goes both ways. Clinical inertia is as rampant as patient non-compliance. In diabetes care, this means “when it takes too long for a healthcare professional to take action to improve glucose control in a patient who is not at goal.” A study conducted a few years ago showed that it took up to two years to either change or add a diabetes medication once the A1c was documented as above 8%. That’s two years of marching in the wrong direction – towards diabetic complications.

As a patient advocate myself, I got together with a prominent endocrinologist last year to write a book about what patients need to do to get a handle on their own health. In a nutshell: get a copy of your lab results and understand what they mean.

Of course this assumes that physicians are proactive about ordering the five key lab tests that everyone with diabetes needs on a regular basis: A1c, blood pressure, lipids, microalbumin, and a diabetic eye exam.

We tell our readers to think of themselves and their diabetes as a small business: you manage it, and your healthcare providers are your consultants, whose job it is to help you succeed.

If your A1c is creeping up, or your cholesterol is above 100 mg/dL, don’t wait until your next appointment. Contact your caregiver/consultant as soon as possible, just like you’d call your accountant if your financial balances were slipping.

But for this model of patient engagement to succeed, physicians have to think of themselves along these lines as well. Be a “health consultant” to your patients with diabetes. Aim not to manage their diabetes, but to help them succeed in doing so.

And what could be a more appropriate motto for “diabetes consulting” than Home Depot’s energizing slogan, “You can do it. We can help”?

Amy Tenderich is the author of Know Your Numbers, Outlive Your Diabetes: 5 Essential Health Factors You Can Master to Enjoy a Long and Healthy Life and blogs at Diabetes Mine.

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  • The Happy Hospitalist

    A great article. But it applies to those who care about themselves. The premise that all people care about themselves simply isn’t true. I see it every day. From a hospitalist stand point we have diabetics come in all the time with DKA. In med school we were taught the three most common causes of DKA are

    1) infection
    2) infection
    3) infection

    In reality, the top three causes are
    1) insulin deficiency
    2) insulin deficiency
    3) insulin deficiency

    I will agree with you that mental illness is almost always present in DKA’s. As is substance abuse a common thread. At least in my clinical experience. If you figure out a way to force someone to go to rehab you should publish a book about it. As for the mental illness, I don’t have any easy answers for that one. It’s a common thread in many many illness that end up in the hospital.

  • Bruce Small

    “Keep in mind that most every human being is motivated to live well and long.”

    I don’t agree with that premise. If it were true we wouldn’t see people scarfing down triple cheeseburgers with bacon.

  • Adam Greene

    Hey HappyHospitalist,

    You bet that many don’t take care for themselves. But keep in mind that there is the whole aspect of diabetes burnout and being proactive in dealing with diabetes at one time and then doing just the bare-bones to live the next. The point being that you can have a person who does care incredibly about themselves but doesn’t want a thing to do with Diabetes; they aren’t mentally ill or skewed to the insane, just fed-up with diabetes.

    But I don’t think that means Amy’s point only applies to those who are proactive in their care. Viewing oneself as a ‘health consultant’ instead of a purveyor of medical knowledge is a bit of a context-shift from the current modus operandi. It sets the relationship up as being one of advice and explanation, instead of treating the numbers and handing out directions to follow. It might seem subtle but remember that a diabetes patient has to make dozens of decisions every day about how to treat their disease. They constantly find themselves in situations for which there are no medical directions to follow. Amy said it really well when she wrote

    Aim not to manage their diabetes, but to help them succeed in doing so.

    Not everyone cares for themselves and some are incredibly driven; but I think you’ll find most people are in between, and I think this advice is aimed for them.

    Regards,
    Adam

  • igloodoc

    Adam
    You glossed over the point. We can relabel physicians as Health care consultants or whatever term you wish, We can reduce a complex compliance problem to a trite slogan. But explain in detail exactly how to get the overweight diabetic, who is burned out about their diabetes and weight, to the appropriate weight and nutrition counsellors. The article glosses over this by saying:

    Next, the mandate should be to refer the person to the appropriate help – a certified diabetes educator, nutritionist, exercise physiologist, support group or seminar, depression counselor, etc.

    Why do I get the sinking feeling that this mandate applies to me and not the patient. And why is that feeling accompanied by the vision of the government doing the mandating. What next? Mandated ER door to therapeutic glucose levels in 1 hour or Medicare won’t pay?

    Simplistic approaches to a complex problems just exacerbate the problem with unintended consequences. Take a diabetic steroid dependent asthmatic in a seasonal flair. The steroids elevate the glucose and the Hb A1C. However, breathing trumps glucose every time. The simple (mandated) approach is to chase the glucose with insulin. But the patient lands in the ER having had a hypoglycemic seizure because he chased the glucose while on a steroid taper. Not so simple, is it?

    Teaching (or becoming a paradigm shifted health consultant or whatever is the term of the moment) motivated patients is hard enough, and takes a lifetime. Teaching unmotivated patients is virtually impossible, and that truth is in every ER in the land. Diabetes education begins with the simple patient slogan “I have diabetes and it is my responsibility”.

    igloodoc

  • igloodoc

    Adam
    You glossed over the point. We can relabel physicians as Health care consultants or whatever term you wish, We can reduce a complex compliance problem to a trite slogan. But explain in detail exactly how to get the overweight diabetic, who is burned out about their diabetes and weight, to the appropriate weight and nutrition counsellors. The article glosses over this by saying:

    Next, the mandate should be to refer the person to the appropriate help – a certified diabetes educator, nutritionist, exercise physiologist, support group or seminar, depression counselor, etc.

    Why do I get the sinking feeling that this mandate applies to me and not the patient. And why is that feeling accompanied by the vision of the government doing the mandating. What next? Mandated ER door to therapeutic glucose levels in 1 hour or Medicare won’t pay?

    Simplistic approaches to a complex problems just exacerbate the problem with unintended consequences. Take a diabetic steroid dependent asthmatic in a seasonal flair. The steroids elevate the glucose and the Hb A1C. However, breathing trumps glucose every time. The simple (mandated) approach is to chase the glucose with insulin. But the patient lands in the ER having had a hypoglycemic seizure because he chased the glucose while on a steroid taper. Not so simple, is it?

    Teaching (or becoming a paradigm shifted health consultant or whatever is the term of the moment) motivated patients is hard enough, and takes a lifetime. Teaching unmotivated patients is virtually impossible, and that truth is in every ER in the land. Diabetes education begins with the simple patient slogan “I have diabetes and it is my responsibility”.

    igloodoc

  • Anonymous

    I’m sure that Amy’s book, and others like it are really helpful to motivated folks with diabetes. For that small sub-group they can care for themselves cost effectively.

    To generalize and say that every diabetic should be MANDATED to have this same educational experience would be a waste. Although I suppose it would increase book sales!

    Back to Home Depot. How many people have garages and back porches full of little “project” materials purchased at Home Depot that they just never quite got started or finished on?

    It can work for some, but not everybody. Shoving a one size fits all approach at people isn’t the answer.

  • Adam Greene

    Hi igloodoc,
    I didn’t mean to suggest that we relabel jobs dictated by a fluffy slogan nor that the roles doctors and nurses perform is trite. Definitely not. And as you pointed out, this is an incredibly complex topic and a blog post and the following comments are nothing but a glossing over of the issue… unfortunately. This is a debate to be had, at the very least, over a good meal, don’t you think? (honesty: contact me (by clicking my hyperlinked name) if you are ever in the NorthWest and you would like to discuss.)

    Igloodoc, your point about wanting an explanation of the details on how to get an overweight diabetic (as an example) to receive the appropriate help highlights quite well the challenges of diabetes, at a high level. It would be fantastic if there was an answer, but there is no single set of directions to follow. It is, generally, very different from other conditions where if you do A, B, and C you will most likely be ‘cured’ or see significant progress.

    (I’m trying to keep my comments about diabetes general and over the long-term rather than focusing on direct medical emergencies/interventions or obese folks diagnosed with Type-2.)

    As you said, “I have diabetes and it is my responsibility” is a great place to start. Agreed. But this is just the start. Juggling a diabetic on multiple drug regimes in an emergency room cannot possibly be simple, but neither is the long-term treatment.

  • primary care=treading water

    Diabetes is the end stage of decades of over consumption and inactivity.

    If your A1C is > 8, it is too late.
    As a whole, you are now a vasculopath, and will need to be on at least 5 medications to meet “the numbers”.

    The time for referrals

    is ten years earlier.
    That is when they need to read “the book”.

    After that, it is just holding off the inevitable as long as possible.

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