It was a question I never thought about asking – “are you a good diabetic?”
“Oh yes”, she said, “I never miss an appointment and I have all of my blood glucose readings here in the book”. She offers me ‘the book’ that I have seen many times.
Well she was certainly right on that point, the book is excellent, but I asked the question again “so you believe you are a model patient”.
“Oh yes”, she confirmed, “I would think that my doctor and my nurse both think that I am the model patient – I do everything that I am asked – I am absolutely no trouble at all”.
I bet you are wondering why I asked. But I have read a book – How patients think: A science-based strategy for patient engagement and population health, by the fantastically clever Dr Andrea LaFountain. I met her once in a hotel by Heathrow Airport – not the most salubrious venue, but when you have half an hour between international flights it was good enough.
Of course, she said it is all about cognition and what people believe. Just remember that cognition precedes behaviour. She went on to talk very briefly about the eight cognitive constructs associated with diabetes and how to understand how people think. Once you understand then it is a matter of prioritising and tackling the cognition an area at a time with a short intervention. It is a simple matter of retesting the cognition and then behaviour and outcomes change.
I remembered the technical construct – that some patients believe that they are technically good – have it sussed – do what they are told – and I thought of someone immediately.
So now I have a lady who is convinced that she is a model patient – a good diabetic – however it doesn’t look like it from my side of the picture. Her weight is increasing and her HbA1c is poor, blood pressure not great and I could go on – hardly my definition of a good diabetic. But at least now I understand that she believes that she is technically good and I have to refocus her beliefs from the technical to the measures and outcome. I have a way forward for the time being.
I just wish that I could remember the remaining cognitive construct to explore the other areas of her belief. I am sure that this is just one of a few problem areas.
This is a very serious blog. We can educate, we can coach, but if we are ever going to get a grip on diabetes in the UK we must tackle cognition and behaviour. Dr LaFontaine’s work is exceptional – or so the guys in the US at Harvard and Cleveland clinic say – it is the way forward.
I have one copy of her book and her email address. If anyone wants to take this on then let me know.