A Physician’s Challenge: Teaching Self-Sufficiency to Patients

For the last two weeks, I’ve had two big projects brewing - one at work and one at home. Not surprisingly, there are some similarities between the two. At work, I’ve been tackling a quality-improvement project that focuses on patients with diabetes with very poor glycemic control. At home, I’ve been “managing” my son’s social studies project, actively and specifically not doing it for him.

What I’ve discovered with the diabetes-improvement project is that the reasons why patients experience poor control are as numerous as the patients themselves. In some circumstances, patients simply cannot afford the medications they are prescribed. With other patients, there are so many different medical problems, medications, and physicians involved in their care that they can’t do it all. I’ve also found poor hand-offs between primary care and specialty care, patients who simply will not come in to the clinic for reasons that aren’t clear, and patients who have very specific needs that we somehow fail to address (which leads to the downstream effect of poor control). 

Likewise my son has numerous reasons why he cannot do the project in the manner in which I would like to see it done. There are the typical excuses - an important book was left at school (for four nights in a row), the deadline was pushed back so it really doesn’t need to be done now, and the plain old “I don’t wanna do this.” There are also additional complicating factors which include a proclivity to avoid reading directions at all costs, leading to a complete meltdown when the project has to be redone. Finally, is the battle I have with myself - what is reasonable to expect from him, how much can I help without becoming one of those parents who do the project themselves, and do I let him fail on his own and reap the consequences? 

In both of these situations, my role is important but limited. I can’t go to each patient’s home and make sure they are taking their medications just like I can’t type up the report for my son. That impotence is frustrating because I cannot fix what I’m trying to solve. However, what is really needed is a coach, someone to walk alongside and help my patient or my son do what they need to do for themselves. Coaching someone can be much more challenging than just doing it for them. 

One thing I found helpful for my son was to break the project down into smaller tasks so that it didn’t seem so intimidating. I also used his enthusiasm for certain aspects of the project to give us momentum for the less exciting parts. With my patients, I haven’t articulated it quite as clearly but I’ve learned from experience that I can’t solve everything at once. Piling on four new medications may technically be the medically right thing to do but patients get overwhelmed with so much at one time. One of the reasons I don’t like having the self-management discussion with my patients is that the goals are so small - give up one dessert a week, walk for 10 minutes each day. I really want them to do a 180 and completely transform their lives - something I can’t do in my own, if I stop to think about it.  However, self-management can be more effective than my four medication prescriptions because it is generated by the patient and taps into something they have a modicum of enthusiasm for - we’ll get to those medications eventually, but achieving small victories can build the momentum to make larger ones.

A lot of what I’m shepherding - whether a quality improvement process or my son’s academics -  involves sitting on my hands not doing but being with them in their struggle, and coaching them along.