Taking Charge Of The Non-Adherent Patient With Diabetes

Thomas Belken, DPM, and Neal Mozen, DPM, FACFAS, CWS

Every physician, regardless of specialty, faces the non-adherent patient. When the patient has diabetes, things become even more complicated. Even though we as podiatrists are not actively managing the patient’s diabetes, his or her glycemic control directly impacts the effectiveness of our treatments.

   The HbA1c does not lie but proper management of the patient’s blood sugar is only part of the equation. Subtle or sometimes not so subtle signs can tell the physician if the patient is changing the dressing as instructed or remaining non-weightbearing. The majority of patients with diabetes develop the disease later in life, long after they have become “set in their ways.” Humans are creatures of habit. As physicians, it is our responsibility not only to educate patients but also to form a relationship with them that will overcome their disregard for their health.

   Obviously, this is easier said than done. A patient may think to him or herself, “Why do I need to stay off my foot? It does not hurt and I feel perfectly healthy.” Since the patient has the lost “the gift of pain,” this patient does not realize the detriment that his actions are having.1 In regard to the patient’s knowledge of the disease process and adherence, the physician must assume both ignorance and non-adherence. The doctor must build a foundation of understanding and help patients be aware of the consequences of their actions.

   How do we as physicians overcome these obstacles that compromise our surgical and wound care outcomes? As with many other facets of life, the answer may lie in establishing relationships and communication. Identifying the problem is the first step in fixing it. Is it something as simple as a language barrier or one’s income/social standing? Alternately, is it something much more complex such as cultural or religious barrier? “The greater the discord between the culture of the practitioner and of the patient, the greater the opportunity for miscommunication and misunderstanding.”2

   Other variables that may contribute to patient adherence are: psychological issues; neurological diseases, such as dementia or Alzheimer’s; psychosocial stress; and secondary gains, such as when a patient uses the disease or condition to get off work or to get sympathy. Additionally, the doctor, because of his or her education, intellect or demeanor, may intimidate patients. Subsequently, patients sit in silent bewilderment instead of expressing their confusion, questions or concerns.

Establishing A Rapport With The Patient To Jump-Start Adherence

Establishing a relationship with the patient will go a long way to getting the patient to open up and trust you and your advice. Understanding the stresses in the patient’s life and being able to devise a feasible means of managing those stressors can be the difference between adherence and non-adherence, success and failure. As I like to tell patients, “An ounce of prevention is a pound of cure.”

   So where do we begin? Something as simple as getting the patient’s family involved can make a significant difference. The family can provide another person to reinforce the treatment protocol that you have set forth. They can help address some of the external stresses on the patient. Taking it a step further may involve getting the patient’s clergy involved to help both physically and spiritually. As doctors and surgeons, we may prescribe a pill, dispense a shoe or fix a broken bone. However, we may often neglect to address or even consider the mental and emotional anguish that patients deal with while they are being treated month after month for ulcers or other problems.

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