J. Terry Saunders, PhD, and Joyce Green Pastors, RD, MS, CDE, Guest Editors

This Diabetes Spectrum From Research to Practice section began with the idea that it would be stimulating and instructive to present a series of thought pieces on professional practice issues. Like other Spectrum research sections, the issues cluster around a clinical theme—in this case, lifestyle change in type 2 diabetes.

The issues we chose are an eclectic group drawn from our window on the world of professional practice, but we expect that they will look familiar to anyone who is a provider of diabetes care. They are responses to the everyday, nitty-gritty kinds of practice issues that are sometimes topics of formal presentations, but are more often voiced and debated in conversations between office mates or in the background hum of voices before a meeting starts or in the hall after a patient has been seen.

Our intent is to bring these issues forward and offer them as a stimulus for self-reflection and dialogue, with the hope that they will lead to improvements in practice.

We chose to highlight four practice issues that relate to the challenge of facilitating lifestyle change in people with type 2 diabetes:

• Integrating the counseling process with educational content in lifestyle change
• Avoiding burnout by redefining the roles and responsibilities of patients and providers
• Organizing a private practice to facilitate lifestyle change
• Tailoring an educational intervention and resources to the patient.

Our goal in developing this set of issues was neither to "cover the waterfront" nor to advocate for a one-sided perspective on the challenges discussed. Because one of our goals was to stimulate thinking and discussion among readers, we encouraged the authors to be forthcoming, both in terms of developing new ideas and expressing personal points of view.

While we provided starting points for all of the authors, all were given the freedom to develop their discussions along lines that reflected individual ways of thinking about the core issue or set of issues. We asked that authors draw primarily on personal experience and, as much as possible, suggest practical ways of dealing with the professional challenges of facilitating lifestyle change.

In choosing authors to write about these issues, we had several criteria in mind. We wanted people who were well qualified to address a given issue, but also who, because of their own experience, felt an intellectual connection to it or stake in it. In addition, given the multidisciplinary nature of working in the area of lifestyle change, we thought it was important to have a variety of professional backgrounds represented. Finally, in order to expand the discussion from an organizational frame of reference, we wanted to include perspectives from providers who work in several different types of health care settings. The result, we think, is a very interesting and diverse set of papers, which reflects and speaks, to the real-world variability of practice experience among diabetes care providers.

Integrating the counseling process with educational content in lifestyle change
It is our experience that many educators feel pulled in opposing directions by what they perceive to be the competing demands of the teaching and counseling roles. It is as if these roles require educators to function simultaneously in two separate and nonoverlapping dimensions of reality. In one dimension, educators are the clinical instructors, the people who systematically convey, explain, and clarify information essential to lifestyle management. In the other dimension, educators are the empathetic listeners to patients’ stories, the reflectors of emotions and feelings, the nondirective facilitators of planning for lifestyle change. Presently, many educators are at a loss as to how to integrate the teaching and counseling roles in practice.

Martha M. Funnell, MS, RN, CDE, and Robert M. Anderson, EdD, of the Michigan Diabetes Research and Training Center in Ann Arbor, see this integration as a critical next step in developing and delineating the patient empowerment perspective. They propose (p. 19) an approach to patient education that uses patients’ own experiences in living with diabetes as a naturally occurring template for the diabetes education curriculum. Rather than the more traditional categories of clinical, psychosocial, and behavioral issues, which provide the basis for most diabetes curriculums, they suggest building the curriculum around what a patient needs or wants to know at any given point in time.

This approach combines both the more nondirective counseling role (listening to what the patient is expressing in the way of needs and interests) and the more directive instructional role (providing accurate and useful clinical information). The authors suggest several concrete and practical techniques for stimulating patients to discuss their most salient learning needs or interests. This, in turn, creates a very personal and natural entry to discussions of the relationships among glucose monitoring, eating, and exercise, i.e., pattern management.

Avoiding burnout by redefining the roles and responsibilities of patients and providers
For diabetes educators, the risk of professional burnout seems to go with the territory. The many difficulties typically encountered in the course of helping patients with the issues surrounding lifestyle change can result in a downward spiral in educators’ perceived self-efficacy—a growing sense that nothing educators do matters, that the odds of achieving many positive patient outcomes and winning the lottery are about even.

Betty Brackenridge, MS, RD, CDE, and Kris Swenson, RN, CDE, of Diabetes Management and Training Centers, Inc., in Phoenix, Ariz., know the feeling. With humor and insight, they go back to question basic beliefs and expectations that often underlie the perceptions of those who feel burned out or see themselves as failing in their roles as diabetes educators (p. 23). They present some fresh ideas and an "emotionally healthy perspective" for both providers and patients.

Brackenridge and Swenson ask us to rethink important questions, such as "What is success in diabetes education and lifestyle change?" and "Who is responsible for diabetes patient outcomes?" They suggest that we define success by shifting our perspective from acute to chronic care. They also remind us that, with a chronic disease such a diabetes, patients need to be in the driver’s seat and, ultimately, to be responsible for their own diabetes management. With their emphasis on a patient-centered approach, the authors encourage us not to "ignore the other elephant"—patients’ experiences and feelings about diabetes—in the course of helping patients to care for their diabetes.

Organizing a private practice to facilitate lifestyle change
One of the things we frequently find diabetes educators discussing is what makes a practice work. The generally high level of interest in this topic is mirrored by a substantial literature on organizational issues pertaining to changing practice behavior,^1-3 which itself serves as a backdrop for a developing literature on implementation of diabetes care and patient education recommendations.^4-7 One of our goals for this issue was to add to this body of information by including an organizational perspective from a diabetes care provider who has developed a successful diabetes practice.

There are many diabetes practices around the country that can serve as models for others, and we believe that there is much to be learned from attending to the perspectives of their creators. We asked Stephen L. Pohl, MD, an endocrinologist in private practice who directs the Kentucky Diabetes Endocrinology Center in Lexington, Ky., to highlight the issues that he thinks are most critical in terms of lifestyle change in the context of private practice (p. 28).

Pohl’s approach is refreshingly direct and practical. He presents what he thinks works and does not work, creating an opportunity for others to compare their own practices to his and to adopt or adapt the lessons that seem most applicable to their own settings. His central theme is that quality in diabetes care and patient education is inextricably linked to organizational supports, positive patient-provider relationships, and effective clinical goals. His article is really a primer on lessons derived from his own experience in each of these areas.

While the Pohl article suggests nothing revolutionary in a conceptual sense, the widespread adoption of even a few of his recommendations in private practice would drastically alter the landscape of diabetes care. One of the most powerful organizational supports advocated by the author is the in-house capacity for diabetes-related lab work, e.g., glycosylated hemoglobin and lipid testing. Broader use of these technologies would enhance the speed and scope of the patient assessment and planning process during an office visit and enable physicians to better track and schedule recommended tests and procedures from visit to visit.

In the area of patient-provider relationships, one might think that caution about negative provider attitudes toward patients or their potential for change would be unnecessary. But we think the author’s advice in this regard and suggestions for structuring practice in ways that actively foster positive personal relationships between staff and patients are timely and warranted. In our experience, negative provider attitudes and expectations are surprisingly common, and commitment to long-term support for patients struggling with self-management issues is far from universal practice.

Last, but by no means least, is the author’s admonition to avoid making weight loss a primary goal for pa-tients. In our view, the two most frequently used and useless bits of advice directed to diabetes patients are "lose weight" and "avoid sweets." As Pohl points out, the emphasis on losing weight is at times clinically inappropriate and, even when appropriate, an outcome rather than a behavioral goal.

Tailoring an educational intervention and resources to the patient
Over the years, we have had discussions with diabetes educators about the utility and practicality of developing a standardized process for selection of educational interventions and resources for patients with diabetes. Ironically, much of the impetus for these conversations derives from the success and growth of the field of diabetes patient education itself, which in a few short years has produced an impressively large array of assessments, interventions, and resources.

While variety may be spice to some, it may simply create confusion for others--particularly inexperienced health care professionals or educators who do not work with a multidisciplinary diabetes care team. For many, the questions "How do I decide which intervention to use?" and "What education resource might work best for the patient?" grow stronger as the field gains in complexity and sophistication.

On the other hand, even cursory consideration of the possibility of a standardized system or process for selecting educational interventions and resources raises serious questions revolving around disease complexity and individual differences. We know that a) diabetes is a chronic, complex disease that produces and interacts with a variety of complications; b) every person with diabetes has a different and unique clinical, psychosocial, and personal profile; and c) the diabetes literature strongly endorses the importance of using a logical, step-by-step process of education (assessment, goal setting, intervention, and follow-up) and an individualized, patient-centered approach to education. Any simplified, standard system runs the risk of insufficiently attending to one or more of these factors.

Our own feeling is that, given the current conceptual complexity within the field of diabetes patient education and the larger movement within health care toward systematizing clinical decision making, consideration of a standardized approach is timely and constructive.

For some time, Arlene Caban, BS, Judith Wylie-Rosett, EdD, RD, and their colleagues at Albert Einstein College of Medicine in Bronx, NY, have been considering the features that a standardized approach would possess. In their article (p. 33), they present and discuss a pilot version of a system for tailoring interventions and resources to patients. As we indicated earlier, a system such as this may be especially beneficial for beginning, inexperienced health care providers or educators who do not have access to specialized resources or the benefit of working with a multidisciplinary diabetes care team. We feel that the paper makes an important contribution by creating a relatively simple prototype that can be tested and that can serve as a starting point for further discussion of the potential benefits of this type of approach.

References

¹Adelman AM, Harris RI: Improving performance in a primary care office. Clinical Diabetes 16:154-59, 1998.

²Miller WL, Crabtree BF, McDaniel R, Stange KC: Understanding change in primary care practice using complexity theory. J Fam Pract 46:369-76, 1998.

³Oxman A, Thomson M, Davis D, Haynes R: No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. Can Med Assoc J 153:1423-31, 1995.

⁴Davis D, Taylor-Vaisey A: Translating guidelines into practice: a systematic review of theoretic concepts, practical experience, and research evidence in the adoption of clinical practice guidelines. Can Med Assoc J 157:408-16, 1997.

⁵DQIP Steering Committee and Expert Panel: Diabetes Quality Improvement Project Initial Measurement Set (Final Version). August 14, 1998. Available from American Diabetes Association website: http://www.diabetes.org/.

⁶Lawler FH, Viviani N: Patient and physician perspectives regarding treatment of diabetes: compliance with practice guidelines. J Fam Pract 44:369-73, 1997.