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How to Be a Good Diabetes Patient, From an Endo’s POV
Ever wonder what your doctor considers “a good patient”? Yeah, me too. So I figured I’d ask one of the country’s leading endocrinologists. Dr. Anne Peters is Director of the Diabetes 
Program at the University of Southern California (USC), head of the nation’s largest outreach program for community-based diabetes prevention and treatment in Los Angeles, and author of the best-selling book Conquering Diabetes. She’s the kind of empathetic doctor who seems to have enough time for everyone who needs her, and I’m thrilled to report that she’s with us here today at the ‘Mine to share her thoughts on “how to be a good diabetes patient.”
A Guest Post by Dr. Anne Peters, MD
When I arrive in my office each day, and glance down my scheduled list of patients, I have varied reactions to the names on the list. Some I am eager to see; others I feel a sense of dread at having to encounter. This sounds mean, but it is honest.
As a physician my interactions with patients are relationships, and as such some I like better and some I like worse. Part of it is chemistry. Part of it is how patients approach their medical care. Of course, deep down I love all of my patients and when confronted with each individual I focus on their individual needs. Still, some patients make it easier and some make it harder.
The one most important element that makes a doctor/patient interaction work for me is a form of time management.
Patients need to realize how short the time I have to spend with them is. An unprepared patient means I have to spend the 15–20 minute appointment searching for information, rather than integrating the data and coming to a useful conclusion.
A prepared patient makes the appointment flow easily; I am able to address all of the necessary health care concerns and help the patient set goals for the next three months. At the end of the visit the patient leaves feeling satisfied and I feel that I have been an effective physician…the disorganized patient who runs after me down the hall asking “one last question” that I can’t adequately answer leaves me unsure if I’ve accomplished any effective healing.
The key is to remember how short the “real” time is. For a 20-minute appointment there is 5 minutes checking in, 10 minutes of face-to-face time and 5 minutes of charting (which often takes much more time due to insurance battles over treatments). That 10 minutes is a very short time to take care of several month’s worth of questions and diabetes-related issues…
To illustrate the best and worst patient encounters, here are two extreme examples:
The “Ideal Patient”
* Arrives 5 minutes early
* Signs in and has ready any information regarding insurance/address changes for the receptionist
* Brings a book to read to avoid boredom
* When called for check in, remembers to hand their meter to the nurse for downloading
* Sits on chair in exam room (not exam table—creates disparity in height between provider/patient)
* Takes off shoes and socks if indicated
* Has prepared the following:
- A list of questions
- A list of all medications that need prescribing (including whether a 30 or 90 day supply is needed)
- A list of all current medications (if not available electronically)
- A copy of laboratory or other reports from other healthcare providers
- Logs of insulin doses, blood sugars, exercise, etc. for the past week or two so I can analyze it (having recent data is extremely helpful)
- For some bringing a download of pump/sensor data from the past two weeks is helpful although I often like to do the downloading myself in the office
* When the health care provider enters the room, is ready to discuss the most important topics first. Doctors are taught to write SOAP notes: Subjective (how are you feeling today Mrs. Smith, what brought you into the office?). Objective (BP is, blood sugars are, temperature is, etc…) Assessment (what we think is going on with one or more conditions) and Plan (what to do next). You say “my foot hurts” (subjective), I look at your foot (objective), figure out what I think is wrong with it (assessment) and then send you for a test (plan)… with diabetes, which doesn’t hurt and requires lots of patient self-care, it can be a very different visit, but that is why the quality of the interaction can be directly influenced by the patient.
* After spending the visit reviewing your data, answering your questions, arranging tests and providing prescriptions, you leave with all of the information you need.
Make sure, as you are checking out, that you physically have the pieces of paper for the pharmacy or referral to the ophthalmologist or whatever else you need. Take responsibility for organizing the pieces of your healthcare. No-one else will. Be sure you have written follow-up instructions if there are any changes to your regimen. Before your physician leaves the room make sure you have repeated back to him/her the treatment plan. Be sure to ask when you should return (and come back regularly!). If you feel you need to come back more often than the doctor recommends, that is fine. It is important to get the care you need.
The “Less Than Ideal Patient”
* Arrives 10 minutes late for a 20 minute appointment
* Spends the next 5–10 minutes arguing loudly with the staff about the parking problems or traffic or why it is they got lost
* Continues to discuss issues about arriving for appointment while staff is trying to take vital signs
* Does not remember to hand over meter for downloading
* Sits in exam room, bored and still stressed over journey to office
* Has not considered questions, medications or other issues that need addressing—more interested in discussing immediate concerns (e.g. tooth hurts, upset with billing office, doesn’t like medication provided by primary care provider for reflux symptoms) rather than speaking with diabetologist about issues related to diabetes and diabetes-management
* No logs, blood sugars or other data available for analysis
* In order to deflect focus from blood sugar management and (likely) an A1C that is elevated, has many excuses, reasons why diabetes management is impossible and is not interested in listening to practical solutions.
* Has many questions, but disorganized and not written down.
* Does not know medications and can not remember which ones need refilling.
* Chases the healthcare provider with one last question after the appointment is over that can’t be answered quickly or in the hallway
* Gets to the receptionist to check out and suddenly remembers that they need all of their prescriptions refilled
* Loses the instructions provided for on-going diabetes management
* Doesn’t have calendar for scheduling follow-up appointment
* Leaves the office without one new goal or plan in mind for improving their diabetes management
I think all of us have been both of these patients, but the more responsibility we take for our own healthcare, the better life will be. I am a resource, and I have lots of experience, but in a 20-minute appointment I can’t fix anything — I can simply provide suggestions for improvement and encouragement for all that is going well.
Obviously there are doctors who are more or less likely to listen and sometimes a visit takes me much longer, if a patient is sick or undergoing a transition. I book longer appointments for patients who are pregnant, newer onset, from out of town, etc., to allow a more intensive analysis. And if the next patient doesn’t show up, I will spend more time with the patient I am seeing. I also tend to leave all the charting until later so I maximize patient interaction time.
No matter what, we are all in this together and I see my role as forging a partnership. For all of us there will be good days and bad days — days when we are more or less organized or feeling sicker or healthier. But with treating diabetes, as in any long term relationship, it is the bond forged over time, through all of the ups and downs, that creates the connection and the healing.
Heartfelt thanks for the insight, Dr. Peters! Here’s hoping that all endos think in terms of “connection and healing.”
Explore posts in the same categories: Books & Resources, Health 2.0
Very interesting. I am going to print up the “ideal patient” example. However, as I read this article a few(?) things really struck me.
1 – Does Dr. Peters provide the “ideal patient” example to each of her new patients (or ones that aren’t “ideal”)? Alternatively, does she have her staff reinforce this on a regular basis (along with in-office signage)?
2 – 10 minutes! How can we increase that time?
3 – It may seem obvious that patients should arrive early for their appointment, but we have busy lives too! Maybe a practical fix to arriving “5 minutes early” would be to simply build it in to the appointment.
4 – 10 minutes!
5 – Downloading meter info immediately prior to the appointment…wow! Surely this could be done via the internet/e-mail the day before couldn’t it?
6 – The less than ideal patient “doesn’t have a list of meds…” OK, but shouldn’t the doctor (or staff) have a list of what was subscribed and what should need refilling? (Granted my endo doesn’t either…)
7 – Did I mention 10 minutes!?
Amy, methinks you need to have a post titled:
“How to Be a Good Endo, From a Patient’s POV
Fair Winds,
Posted by: Michael Ratrie | September 17th, 2009 at 7:25 amMike
I can understand and appreciate the time crunch, and would say that this dr would likely consider me a “good” patient. I arrive with a notecard containing my questions and current pump settings and averages and am respectful of the time allotted for our visit. I’ve brought printouts of BG readings, but there is never time to go over them. So I agree w/ Michael. 10 minutes is simply not enough if we are to review data and tweak insulin doses together. The last suggestion I got from my endoc was nonsensical. He thought my tendency to trend upwards starting around midnight was due to rebounding from lows. Ummmm, good theory, but I have a CGM, and it’s obvoius that’s not what’s happening. I asked him…”but wouldn’t I see that on my cgm data, it’s a steady line upwards?”, but he just went on and didn’t have time to look at that. So I just nodded and smiled, got my prescription renewals, and tweaked my basal rates up slightly starting at 11. He’s great at ordering the labwork, seems to keep current, and recently uncovered a vitamin D deficiency. But nope…I don’t trust the 10 minute visit advice for insulin adjustments.
Posted by: Carol | September 17th, 2009 at 8:43 amWow, I cannot believe this post. It is horribly condescending. I take it that this endo is not a person with chronic illness herself. Granted I am only a medical student but I can’t imagine treating my patients this way –as if they are expected to fall in line and obey orders. They are human beings struggling to stay healthy. I’m not going to treat them as if they are in boot camp.
First of all, doctors run late, and that’s unforgivable. Doctors should never, ever keep a patient waiting — if they are overbooking appointments or booking them at 5-10 minute intervals when they clearly require more time, the physician is running the office poorly. The physician is at fault for tardiness, and deserving of many complaints. As a patient, I should not have to “bring a book.” You, the doctor, should be running ON TIME.
Secondly, I decide whether my glucose data will be shared. It’s my life, my health, my body. ‘Patient autonomy,’ remember? The doctor is only a consultant there to answer my questions. I make the choices and I decide what’s best for me, and what I’m comfortable with. Downloading meters and looking at logs is 100% useless for me. I know why my glucose goes up and down. It’s not a mystery.
Third, how many times have I come in with journal articles that my endo hasn’t even heard of? I have been asking about hematopoeitic stem cell research (very promising trials) for months now, and no one seems to have a clue. How about doctors doing THEIR homework and staying current on research?
And, as for ‘leaving the charting until later,’ is that a good idea? Are you really going to remember everything about every patient at the end of the day?
Patients are people. We are vulnerable and often we feel powerless and betrayed by our own bodies. We should not be scolded, chided, lectured, told we are ‘making excuses,’ etc. This post is a wake-up call showing me how NOT to behave. I have seen medicine through both lenses — doctor and patient — and I hope to never become as detached and disconnected as the author of this post.
Posted by: Lauren K | September 17th, 2009 at 10:14 amOh Mike, I love that suggestion! Who would like to volunteer to write the “rebuttal” post??
Posted by: AmyT | September 17th, 2009 at 10:18 amI totally agree with this doctor. This is exactly how I approach my appointments with my endocrinologist (I’m putting myself in the “ideal patient” camp). I think my doctor really appreciates this, so we have a great relationship, and I usually leave feeling like we’ve got a plan and maybe we even solved a problem. When I was planning for pregnancy, I was frustrated by the short appointments and felt like I was getting nowhere… so I demanded more time and got several worthwhile appointments with an outstanding CDE at the endo’s office. Granted, I clearly have a stellar insurance policy that covers all of these things, so I know I’m one of the lucky ones. We really must be our own advocates in this health care mess. If you’re doing your very best as a patient and the doctor still isn’t giving you what you need, then you need to find a new endo. But I don’t think we should come down too hard on this one — she seems to be one of the great ones!
Posted by: strawberry | September 17th, 2009 at 10:35 amAmy–Let me know if you want me to write a “rebuttal” post. After 37 PWD years (and probably 10 endocrinologists, some good and some…um…not so good), I know what works and what doesn’t work in motivating me to take better care of myself.
From the endo’s perspective, I certainly see where she’s coming from. I understand how frustrating it must be for doctors to have to leave most of diabetes care in the hands of their patients, and then learn on follow-up visits that their advice isn’t being followed. In some respects, it probably makes them feel like a failure as well. As for the “10-minutes” and patient-unpreparedness issues, all doctors are so very, very busy…There really aren’t many endos out there, and at least with my doctor, he’s booked 2-3 months in advance. Of course their time is in demand, valuable, and shouldn’t be wasted. And although 10 minutes isn’t nearly enough for good diabetes care, it’s often all they can afford without shorting other patients. I don’t blame her at all for her frustration…
Posted by: Elizabeth Joy | September 17th, 2009 at 12:11 pmMy endo is always happy to see me, and I am one of her “ideal patients.” But this certainly gives me ideas on how to be more organized and better prepared, so thank you!
I always bring a good book. I remember once my endo was dealing with a newly diagnosed/just-admitted-to-the hospital Type 1. I’ll sit and be patient and read a good book for that.
Posted by: Melitta | September 17th, 2009 at 1:53 pmMy endo appointment was yesterday. I believe that I would be considered an “ideal patient”. Log, notes, shoes off, prior diabetic plan with items check off, lab work pre-done. But, this is how I was trained 37 PWD years ago by my CDE.
During my appointment most of the discussion and issues are talked about with the educator. She is really the one that I have built a relationship with. 10-15 minutes into the appointment the Dr. walks in we all come to a conclusion/plan of what needs to be done. Everything is reviewed and on my way I go. That’s an ideal appointment.
I would like to bring another “Dr’s Office Foo-pa” discussion to the table. “Does your Dr. sometimes ask you questions about your health while typing in the computer?”. This is rude. I feel as though the Doctor is “twittering”, “texting” during my appointment. I realize that the medical records collection is crucial, but I do not consider this as a face to face interaction. As anyone else notice?
Posted by: dargirl | September 17th, 2009 at 6:09 pmAccording to the article, if I were the ideal pwd, then I wouldn’t need an endo but to write scripts. Next time I’m in to see my endo I’ll make sure I stick to the “diabetes only” concerns because anything else that is happening surely is not concerning. What a waste of time I am to be such an inconvenience.
Posted by: Bob S. | September 17th, 2009 at 9:08 pmI agree with everyone, but dargirl raises a point I can’t get out of my throat. My endo, my podiatrist spend more time typing into their computer than looking at me. It’s as if I’m the chair in the room and the computer screen is the animate object. Don’t know the resolution, however, as if they don’t do it then and we want computer records when will it get done? riva
Posted by: riva | September 18th, 2009 at 4:17 amI’ve sometimes had the opposite problem. I get my labwork results before the appointment, decide what I think is the most important problem, and start off summarizing it, in order to save time. I might say, “Most of my labs haven’t changed, but I’m not happy with this A1c.” The endo will say, “Slow down. Let’s go over this.” The endo then slowly goes through the lab results, comparing them with the last time. By the time this is done, half of the appointment is gone.
I realize no endo can remember previous lab results from thousands of patients, or even what they prescribed before without checking the records. But there ought to be some way they could set aside some time at the end of each day to review the records of the patients booked for the next day so that the time wouldn’t be wasted on review.
Posted by: Gretchen | September 18th, 2009 at 6:47 amFirst, I would like to send a heartfelt thank you to the dozens of high quality healthcare professional who I have selected and paid to help me with my diabetes self-care. I hope that I have done my share despite ridiculous limitations in the length of office visits and lack of use of technology to get needed glucose/food/meds records (my endo’s office stopped downloading from meters because there were too many kinds!) in making our working relationship a smooth, efficient, and results-oriented one.
Dr. Peters raises some excellent points and I appreciate she has entered them into the wider dialogue. But I have to agree that her “what you can do for me” attitude and method of delivery has, unfortunately, added to the ongoing and justified dissatisfaction many of us living with a chronic condition experience in our relationships with health care providers.
Go, Mike. We need your “patient” POV pronto!
Posted by: Kelly Rawlings | September 18th, 2009 at 8:00 amIf I had a nickel for the 30 to 60 minutes I have sat in a doctor’s office even when I’ve shown up early! Don’t tell ME to be on time! I have to take time off from work and wasting another hour doesn’t help my mood either!
Posted by: Linda | September 18th, 2009 at 9:09 amI think it’s precious that an endo is telling the world how to be a great patient. And clearly, this Dr. is one of the few that we’d all be lucky to have access to.
HOWEVER:
While I show up early to EVERY appointment, I’ve NEVER actually seen the Dr. on time. I routinely am left in the waiting room for 15-30 mins after the appointment is to start.
Once I get in to the exam room, I get asked a series of questions that may as well consist of: “I’m too lazy to look at your chart, and we LOVE redundancy here so could you tell me all of the information that I already have in this little computer thingy?”
I am routinely spoken to as if I have a third grade comprehension of physiology, even though I make it clear from the outset that I have a thorough understanding of my chronic illness and its treatment.
Worst of all, I can’t get in to see my endo with less than 3 months notice and if I have to change my appointment I go to the bottom of the list. This makes me feel like I am absolutely last priority and absolutely not a “partner” in facilitating health treatment.
All that being said, I’ll be sure to sit in the chair so as not to create “a disparity in height between provider/patient.” I wouldn’t want my Dr. to feel as screwed by the process as I do.
Posted by: Robert | September 18th, 2009 at 2:12 pmWell from now on I’ll take some of the “Ideal patient points” as my guide to follow when visiting my Endocrinologist. I think that as patient we must be aware that our Doctor is still a “normal human being” ((with lots of knowledge’s and abilities)) and we most treat him/her as we like to be treated. Thanks for this interesting article
Posted by: Symposier | September 19th, 2009 at 6:12 pmWell, I’m glad to know that I fall in the category of “ideal patient!” In fact, I routinely arrive 15 minutes early for an appointment, though I often have to wait at least 1/2 hour after my appointment slot to actually be seen by the endo. I’ve been writing lists of questions for years – I think it’s a great idea for everyone to do that. Rather than blast this endo, who is trying her best, just realize that there are time constraints placed on her by insurance companies. It would be lovely if “Obamacare” would solve all of these problems, but I doubt that it will.
Posted by: June S. | September 20th, 2009 at 4:03 pmWow! I agree with Lauren K…. the med student and Type 1 diabetic.
Unless you live with this disease day by day… hour by hour…. minute by minute…you really just can’t look at the numbers and expect to have a grasp on what to recommend and do for someone. There are too many variables. Insulin dosing changes constantly depending on all of the variables that a doctor can’t or should not predict.
I think doctors think that their formulas/ I:C ratio’s etc. are the only and absolute way to handle diabetes and they are the “LAW”.
Posted by: Cathy | September 20th, 2009 at 6:28 pmThanks for the information.
Posted by: Santosh | September 21st, 2009 at 5:12 am“a disparity in height between provider/patient.”
Would someone explain this one to me? If I am reading it correctly the Dr. does not want the patient to appear taller than her? For what reason? At best this seems condescending but perhaps someone can offer a different view of this comment by the doctor.
Posted by: Sasha | September 22nd, 2009 at 2:19 amGreat suggestion!
Posted by: Edwin | September 22nd, 2009 at 4:23 amI hearing that the millions of afflicted Americans are confused, frightened, and often receiving sub-par treatment from inexperienced primary care physicians.
I agree with somethings that the Dr. wrote and others piss me off.
First off… The closest Endo to me is almost 2 hours away… So although I am normally 15-20 min early please understand that I drive almost 2 hours with no traffic and well over 2 hours with traffic… Also I have a job, go to school, as well as take care of a 5 year old since my borther is in Iraq. and I AM ONLY 21!!!!
Two: I usually do write down my blood sugars, carb intake, and insulin (as well as where a pump and CGMS) although if I forget it or lose it on the way PLEASE FORGIVE ME! But I am only one person trying to do a job of a village.
Three: You do NOT live with this illness everyday… It is a frustrating, non forgiving illness. So if I forget to check my blood sugar or plain just don’t want to do it, forget to bolus or just don’t… Keep in mind that I am suffering the consequenes of my actions (or inactions) you are not… you are not my parent, my uncle, my aunt, or my grandparent. DO NOT TREAT ME LIKE I AM A 5 YEAR OLD! In the case of my doctor I have had Diabetes longer then you have had a medical degree. So lay off it!
Four: YES I do get depressed from Diabetes as well as fed up and sometimes wish I could grab it by the shoulders and throw it against a wall! But other times I don’t… So forgive me when I tell you this because MAYBE JUST MAYBE I need to get it off my chest or maybe I just need to cry! Don’t look at me like I’m crazy and keep typing… Why don’t you stop and talk about it with me…
Why don’t Doctor’s try to understand what we are going through and treat me/us like adults that have to deal with everyday stressors as well as this damn illness.
Posted by: Emily | September 30th, 2009 at 10:58 pm