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How Much Does Effective Communication Matter?

The Problem: “It’s my grandmother,” explained the scared blond ten-year old. “She’s sick again.” With the help of some neighbors, Amra Omerovic’s resourceful young grandson had brought her to the emergency room. This lovely silver-haired lady was in shock; her blood sugar levels were dangerously high. The doctor was baffled. If this 58-year-old Bosnian grandmother was taking her insulin “just like they showed me” as she claimed, what was she doing here? It was the diabetes educator the next morning who thought to ask how she was taking her medicine. Omerovic demonstrated her technique; she dutifully drew up her insulin in a syringe, injected the drug into an orange, and then promptly ate the fruit.

While this is a startling case of medical miscommunication, it also highlights some new communication challenges that face everyone in health care. Evidently, the nurses taught Mrs Omerovic how to take her insulin by having her practice injections on an orange. They then gave her a booklet on diabetes and sent her home. Her English was accented, but clear. It never occurred to anyone that this distinguished, older, immigrant patient would understand the instructions so literally; it never occurred to anyone that Mrs Omerovic had never learned to read.

This example touches on many of the challenges that face health care professionals today. Virtually all of these obstacles can be handled successfully by using more effective communication skills. Because these challenges affect patient compliance and health outcomes, they should concern us all.

Course Goals: This course begins by reviewing the causes and dangers of non-compliance. It then discusses how CDE communication techniques can make a significant difference in patients’ compliance with their treatment plans and in patient satisfaction. The CDE C.A.R.E. communication strategy outlined in this course helps Certified Diabetes Educators counsel more effectively.

Effective Diabetes Educators C.A.R.E.

C create a positive, patient-focused workplace A ask questions that invite full responses R refine rapport skills E ensure comprehension by listening to patient summaries at the end of every encounter


C= Create a positive consultation environment

First impressions are established as much by environment as they are by attitude. Patients need to know they are welcome, safe, and listened to as a precondition for being able to talk about their health concerns.


Private consultation rooms are ideal and provide privacy that patients appreciate. Patients need to be able to voice sensitive concerns without the risk of others overhearing the subject matter. Likewise, interruptions break the focus (besides taking up time), so CDEs should not allow interruptions to interfere with a counseling session. There should be relative quiet in the counseling area. Quiet not only helps those with hearing loss concentrate, but it frees us all from the low level stress caused by trying to concentrate over the beeps, hums, and murmurs of printers, phones, beepers and other equipment.

Uncluttered spaces help maintain the focus of the session, and direct the patient towards the verbal and written information the CDE will provide.


Including your name and position with your initial greeting, and inviting the patient to comfortably seat themselves, helps put the patient at ease.

“Hi, Mr Guittierez, I’m Rhonda Cho, your diabetes educator. Please have a seat.”

Learn patient names, (ask for help pronouncing difficult ones), and use them often. This is an easy way to help patients feel “fully attended to,” and it quickly identifies the CDE as knowledgeable, friendly, and warm. Smiles and handshakes, too, do much to put people at ease.

Early on, it is important to explain the purpose of the counseling session and to include the time frame.

“I’d like to use the next thirty minutes or so, Mr Guittierez, to talk about the blood sugar log we are asking you to keep, and to go over the food plan Dr Nolan mentioned during your appointment. I can also answer any questions you might have about your recent lab work results.

With the patient situated, welcomed, and focused on the task at hand, both you and your patient are ready for the kind of information exchange that improves compliance.

A= Ask questions to invite full response

Any teacher will tell you that the most common response to “Are there any questions class?” includes rows of blank stares, silence, and head nodding “no’s.” Few diabetes educators should be surprised by similar “no’s” from their patients when they ask, “So, do you have any questions today?”

Open-ended questions

Closed-end questions are those we can answer with an easy “yes” or “no.” They do little to stimulate review, reflection, or the kind of systematic thinking that helps people articulate gaps in their understanding. Open-ended questions, however, invite fuller, more thoughtful responses from the respondent. “How,” “what,” and “which” at the start of a question are all signs of open-ended questions. Imagine, for example, how a patient of yours might answer the following:

Initial Consultation Exchange

1. What information did Dr Nolan give you about taking your insulin?

2. Show me, if you would, how you will use the . . . (syringe, lancet, glucose monitoring kit, etc)

3. How will you check your blood sugar (at work, on campus, at home)?

4. It’s best that you eat breakfast around 8 am and lunch about 12:30 pm. How will that work with your current schedule?

5. Which exercise plan do you think is easiest for you to follow?

These 5 open-ended questions establish the kind of sharing and information exchange vital to successful diabetes management. Question 1 elicits the patient’s understanding of insulin, and promotes further discussion about how and when the patient is expected to take her medicine. Questions 2 through 5 allow the patient and CDE to discuss in realistic terms how diabetes management will look in the patient’s weekly routine. All of the questions open up discussion, check for patient understanding, clarify vital instructions, and invite follow up questions.

Learning to phrase a consultation in a series of open-ended questions is one of the most powerful counseling techniques diabetes educators can develop. It shifts more of the responsibility for understanding directly onto the patients who are ultimately responsible for the daily management of their disease. Encouraged to share their frustrations, fears, and victories, patients engage more fully and more effectively in their own care. Having verified the parts of care the patients already know, the diabetes educator can shift the attention to the information patients still need.

R= Refine rapport skills

Rapport skills include everything people use to politely put each other at ease. It is useful to think of the many levels of rapport as a spectrum we are all used to moving across every day. At one end of the spectrum are our families and friends with whom we are usually in warm rapport; we know a great deal about each other and often feel close. At the other end of the spectrum might be threatening strangers; we know nothing about that unfriendly person pushing ahead of us in line at the grocery store and we may not want to. In professional situations, diabetes educators should strive for a middle range. Professional empathy means understanding and, when appropriate, identifying with the needs and concerns of a patient. Likewise, in certain contexts it may be useful to break rapport: to cut off a conversation, to refocus a patient’s attention, or to otherwise pull away from an encounter to save time or to move on to other business.

Table 1: Levels of Rapport

  • High Rapport = cozy, loving, intimate
  • Mid-range = warm, understanding, empathetic
  • Low Rapport = tolerant, cool, stoic

While active listening is an example of a verbal rapport skill, many of the quickest and most effective ways of creating and breaking rapport are non-verbal.

Active listening Echoing

Think of active listening as a strategic echo. By reformulating a patient’s terms in words of our own we validate the content of the message, and we affirm the speaker. People need to hear that they are understood. Echoing helps make sure the facts are straight, and it gives the speakers the important verification that they are being listened to.

Active listeners simply rephrase the patient’s statements in their own words. It often helps to start the echo with the word “I.”

Patient: I don’t understand how I am supposed to eat a regular dinner at 6pm when I have to work until 4:30 and be in my law school class from 5 to 8.

CDE (Echo): I understand you are frustrated about meal planning with your hectic schedule. Let’s talk about how to adjust your insulin dosages so you can eat later on Tuesdays and Thursdays.

Patient: I didn’t record my blood sugars this past month because I was too busy caring for my ailing mother. How am I supposed to keep all this together?

CDE (Echo): I can see the stress your mother’s illness has put on you. Let’s talk about how to coordinate your mother’s medication schedule with your own blood sugar testing.

By rephrasing the patient’s concerns before moving on to explain, solve, or research a problem, CDEs can establish the very basic (but vital) kind of rapport that comes from sharing essential information and basic data. Verifying that the key facts are shared and agreed upon insures that any problem solving is focused on the right problem!

Voice volume, tone, pace, and pitch

An even quicker way of establishing rapport is to notice the volume, tone, pace, and pitch of a patient’s voice and to match it with your own. While we all know fast talkers and loud talkers, smooth talkers and squeaky talkers, few of us make full use of the resource of this awareness. Not surprisingly, people are most comfortable with others who are like them, and making even slight adjustments in our own voices can do a great deal to put patients at ease.

Lowering the volume of your voice, for example, to the volume of the person you are working with can do a great deal to help a soft-spoken person feel more respectfully addressed. Likewise, responding to a fast-talking, right-to-the-business-at-hand patient with sharply focused answers helps let this patient know you mean business. You respect his time and are proceeding professionally.

We all modify our tone, pitch, pace, and volume naturally as we move from context to context, from the breakfast table to the hospital and out to dinner with a friend. Giving a small piece of our attention to enhancing these natural variations turns our inherent flexibility into a powerful counseling tool.

Body rapport

Body language is vital because many people respond even more powerfully to what they see than to what they hear. Patient educators have all experienced how hands-on demonstrations teach more information more quickly than wordy explanations alone. This is also true in the patient consult.

When people are listening to each other and focused, they often mirror each other with their posture. Sometimes the hand or arm positions match. Other times they lean in toward each other at the same angle and so on. Often, nods, smiles, and headshakes repeat one to another as if batted back and forth in a tennis game. Diabetes educators can use these physical patterns to their advantage. Some of the most helpful tips to increase body rapport include the following:

  • smile
  • maintain eye contact
  • nod your head while listening
  • notice patient posture and consider matching parts of it with your own
  • lean in toward patients as they respond to your questions
  • sit next to (not across from) the patient when demonstrating a device or reviewing patient education literature

A marked shift in body position is also one of the best ways to break rapport when you need to draw a session to a close, allowing you to signal that you must wrap up without interrupting a patient’s speech.

Technical medical information is difficult for most patients to understand. By using as many rapport skills as possible, we can help patients feel welcome, calmer, focused, and more receptive to learning how best to take care of their health.

E= Ensure comprehension with patient summaries

One bright, energetic patient I spoke with admitted that she often finds it difficult to retain all the verbal instructions from her CDE by the time she leaves the appointment and drives home. In this way, the final moments of the consultation can be the most important. The conclusion, or wrap up, offers CDEs an opportunity to provide written reminders about important changes (adjustments in insulin doses, for example), and a chance to review key information to ensure that patients understand all they need to. Rather than the CDE providing a verbal checklist of what was covered, it is far more effective to arrange for the summary to come out of the patient’s mouth.

One favorite way to achieve this is the following:

Closing Summary

“Just to make sure I didn’t leave out anything, let’s review again. Tell me how you are going to? (take your insulin, test your blood sugars, keep your log, work on your meal/exercise plan, etc).”

By requesting a final verification, the CDE has the opportunity to test the patient’s comprehension. Did Mr McCloskey really understand? Has Mrs Heiflinger retained the key information? Often, patients might feel lost in all the details of their questions and answers. A final summary gives the CDE a chance to verify that the patient has sorted things out and that a clear plan of action is in place until the next scheduled session. Now it’s time for a “thanks for coming in,” or an “is there anything else we can talk about today?” final words of an upbeat and successful consultation.

The next section of this course deals with issues of compliance. After identifying issues that lead to noncompliance, we will discuss specific techniques and strategies to improve patient compliance.


Factors Contributing to Noncompliance

Complexity of Treatment: The patient’s perception of a regimen’s complexity, and of the threat posed by their disease, substantially influences their compliance with treatment regimens. The more complicated the schedule, restrictions, and duration of treatment, and the greater interference with the patient’s lifestyle, the less likely there will be compliant behavior. Because patients with diabetes are expected to maintain lifelong disease management plans, often while undergoing additional treatment for complications, patient compliance is a challenge the diabetes educator must face each day.

Table 2: Noncompliance Risk Factors

  • Complexity of treatment
  • Threats of complications
  • Inappropriate level of written information
  • Isolation vs family relationships
  • Older age
  • Inadequate professional communication

Threats of Complications: The American Diabetes Association reports that in 1996, diabetes contributed to more than 198,140 deaths. Patients are often told that diabetes is the “Silent Killer,” leading to life-threatening complications such as blindness; kidney, nerve, and heart disease; amputations; and stroke. But does this information alone promote patient compliance? As a thirty-year-old librarian with type 1 diabetes puts it, “Yes diabetes is a silent disease. I know that the effects of my actions today might show up in a complication several years down the road. This is scary, but that fear doesn’t always motivate me to comply.”

Inappropriate Level of Written Information: Literacy barriers, style, content, and the language of written information also significantly influence the patient’s understanding of medical advice. While two years of secondary education are required to read and understand standard patient information, half of all American adults cannot read an eighth-grade level book.

Relationship with Family: Studies have shown that patients whose family members, particularly spouses, are involved in treatment and training to enhance adherence, tend to be more compliant. Conversely, single, widowed, and isolated patients are all at higher risks for noncompliance.

Inadequate Professional Communication: As recent studies on non- compliance repeatedly show, the quality of provider-patient communication significantly determines compliance with therapeutic regimens. But far too often, barriers get in the way. In their 1991 volume on health care communication, Davis and Fallowfield enumerate thirteen common communication “deficiencies”:

1. Failure to greet the patient appropriately, to introduce themselves, and to explain their own actions;

2. Failure to elicit easily available information, especially major worries and expectations;

3. Acceptance of imprecise information and failure to seek clarifications;

4. Failure to check the provider’s understanding of the situation against the patient’s;

5. Failure to encourage questions or to answer them appropriately;

6. Neglect of covert and overt cues provided verbally or otherwise by the patient;

7. Avoidance of information about the personal, family, and social situation, including problems in these areas;

8. Failure to elicit information about the patient’s feelings and perceptions of the illness;

9. Directive style with closed questions predominating, frequent interruptions, and failure to let the patient talk spontaneously;

10. Focusing too quickly without hypothesis testing;

11. Failure to provide information adequately about diagnosis, treatment, side effects, prognosis, or failure to check subsequent understanding;

12. Failure to understand from the patient’s viewpoint and hence to be supportive;

13. Poor reassurance.

Few of us have not been guilty of at least a few of the items on Davis’s list, if for no other reason than the constraints of time. The time has come, however, for CDEs, and all health care professionals, to use the tools of effective communication to build more productive and satisfying relationships with their patients and colleagues.


More effective verbal tools

“I am not just the numbers in my blood sugar log!”

Patients state again and again that adherence to their treatment plans is often influenced by the way their diabetes educator frames a problem. “Please don’t tell me, I didn’t do a good job when my sugars are high,” says one patient, “I would rather focus on what I can do to bring the numbers down.” When I asked this patient how she felt about her CDE’s response, she concluded, “It makes me not want to record my blood sugars, especially when they’re high.” In this way, CDEs are challenged more than ever to become communication experts, and to teach their patients to expertly communicate.

How can we help the patient comply with her treatment plan when she feels discouraged by her consistently high blood sugar readings? Communication consultant Stephanie Barnard offers the following suggestions to help her clients who treat diabetes promote more effective communication with their patients8:

Select positive words

  • Positive words are much more influential than negative ones. For example,

rather than “Your blood sugar readings are too high.”

try “I’d like to see your numbers come down a little lower.”

rather than “You shouldn’t be getting so fat.”

try “I’d like to see you weigh about 20 pounds less.”

Speak in specific terms

  • Being specific helps decrease misinterpretation. One patient I interviewed stated that he would be more compliant if his CDE assigned tasks more specifically. For instance,rather than “Call me in a couple weeks and we’ll discuss the lab work.”

try “Call me the morning of August 12 and we’ll discuss the lab work.”

When given a date and time, the patient can mark his calendar, prepare himself for the call, and feel confident that the person on the other end has reviewed the lab work and has set time aside to speak with him.

The Eye Contact Challenge

Barnard asserts that eye contact is the most powerful nonverbal tool we own and regularly asks her clients in the health care field to take the eye contact challenge. For at least two weeks, practice sustaining eye contact during casual interactions with the bank teller, at the grocery store, when meeting a new neighbor.

By maintaining eye contact while speaking, we reflect confidence and straight-forwardness; by looking someone in the eye who is speaking to us, we show that we are listening. When this skill is carried into the workplace, your co-workers and patients will feel that they are important and have been heard. Patients will be impressed when you pause to look at them while recommending a treatment or listening to a complaint. By maintaining eye contact both while speaking and listening, we become more persuasive communicators.

Table 3: Four Steps to More Persuasive Communication

1. Ask questions to build rapport

2. Establish a need

3. Focus the conversation on the benefits

4. Close the conversation with a “call to action”

Persuading Others to Change Their Behavior

Diabetes educators are on the front line of diabetes treatment and patient management more so than the physician or other health care provider who may treat patients with diabetes. In this way, CDEs are primarily responsible for making sure patients make recommended lifestyle changes and adhere to lifelong disease management plans. In short, because CDEs are responsible for ensuring patient compliance, a great deal of their time is spent persuading patients to change behavior.

Developing your skills as a persuasive communicator, Barnard asserts, will enhance your career and job satisfaction, and all your relationships. She suggests the following four steps for CDEs who would like to more effectively persuade others to change their behavior8:

1. Ask questions to build rapport. When we try to persuade someone by using the “sales pitch” method, the person we are tying to persuade is usually not listening. Many health care professionals often have a set agenda when counseling an agenda meant to convince the patient that following though with procedure X is a good idea for reasons 1, 2, and 3. Meanwhile, the patient is simply wondering, “will the procedure hurt?” Instead of approaching patients with a set agenda, consider asking the patient what concerns her, and then focus on that one item. You will save valuable time and increase patient satisfaction.


Instead of saying

“Ms Benjamin, you really need to check your blood sugar every day because that is the only way we are going to be able to tell if you need insulin.”

Ms Benjamin probably already knows this information. Why not find out why she will not check her blood sugar daily?


“Ms Benjamin, I would really like to help you get your blood sugar under control. Is there a reason why you don’t check your blood sugar every day?”

Be sure to give the patient time to think and respond. You may think you are too busy to allow the patient the extra time, but you will save time and effort if the problem can be addressed now instead of in a phone call or repeat visit later.

2. Establish a need. Most people will support ideas that affect them. Sometimes in order to persuade others to adopt your idea, you have to help them establish a need. For example, hypertension is an issue for many patients with diabetes. Patients may not experience symptoms, and therefore may not follow certain dietary recommendations, such as reducing sodium in their diets. They do not see a need to comply. How can you establish a need for them? Counsel these patients with a verbal consult combined with educational literature.


“Mr Barnes, I am concerned because your blood pressure is 145 over 92 and I want to encourage you to take steps towards preventing a heart attack.”

3. Focus the conversation on the benefits. Most people respond to ideas that benefit them. If you want to persuade a colleague to adopt your idea or a patient to take your advice, add a benefit. For example, you might persuade a patient to try a new medicine by pointing out the feature of the medicine: “This medicine is very effective. It last up to 24 hours.” But what is the benefit? “The new 24-hour dosing conveniently allows you to take the pill only once per day.” How do you know that once a day dosing is important? Ask the patient: “What is a convenient time of day to take this medicine?”

4. Close the conversation with a call to action. At the end of the consultation, a CDE might say to a patient, “Let’s set a reasonable goal for your blood sugars?” The call to action at the close of a conversation can help the other party buy into the idea simply by putting the idea into action.

More effective written patient education materials

In recent decades, studies considering literacy, reading level, and their effects on treatment compliance have been published in field after field.4,5 While some patients with diabetes may have problems reading because of visual impairment, others may have the barrier of little or no English, and others still may simply not know how to read. Recent estimates number 35 million adults in the United states as functionally illiterate. Simply put, about one in five adults cannot read.9 Of those who can read, about 20 million adults in the United States have an 8th grade reading level, while 20 million more have a reading level of 4th grade or below.

The average American reads at an 8th grade level or below

Given these statistics, what is to be made of the unsuspecting diabetes educator who says, “Just read these materials, and let me know if you have any questions.” “Just reading” is more problematic than most of us realize. Notice for example, the reading level required for some typical consumer products in Table 4.

Table 4: Reading Levels Required for Understanding

OTC Labels Advil 9th Grade Vicks Formula 44M 10th Grade Anusol 11th Grade Maalox Plus Junior College Condom & contraceptive foam instructions 10th Grade US Surgeon General warning on cigarettes College + Dr Spock’s Baby & Child Care 10th Grade

Written materials and notes should always be used in conjunction with verbal instructions to reinforce comprehension.

Preparing Patient Education Materials

When preparing written materials, use the following tips:

  • Simplify: Choose simpler words for longer ones. Instead of blood glucose, for example, use blood sugar. Rather than cardiovascular disease, try heart disease.

Keep sentences short (8-10 words each), and tackle only a few concepts per page.

Write conversationally, and use active voice.

  • Visual Appeal Helps: Choose easy-to-read fonts (12-point type or larger). Seriffed fonts like Times New Roman and Garamond are two especially readable ones.

White space is the reader?s friend. Open, airy layout with wide margins and blank lines make it easier to focus on the information. Patients are encouraged to mark-up and highlight key points.

Emphasize important points with bold type, underlining, simple boxes, and bullets.

Use simple drawings or photographs, but keep them realistic.

Look for Good Models: Keep your eyes open for other models you can use, adapt, and learn from. Since heart disease is a concern for many patients with diabetes, note this portion of a handout available online at The writers use remarkably simple graphics, but they get the message across. Notice how quickly simple elements work together to effectively communicate. Where in the following cholesterol handout can you find the following:

  • schematic (but realistic) illustration
  • color
  • accented font style
  • newspaper columns (which speed reading)
  • bolded texts
  • bulleted lists
  • patient-based questions
  • data that motivates

Together these elements get the message across: cholesterol clogs, but a healthy diet can help.

Table 5: How Can I Lower High Cholesterol?

Too much cholesterol in the blood can lead to heart disease America’s number one killer. Even though there?s much you can do to lower your cholesterol levels and protect yourself, half of all Americans still have levels that are too high (over 200 mg/dl).

You can reduce cholesterol in your blood by eating healthful foods, losing weight if you need to and exercising. Some people also need to take medicine because changing their diet isn’t enough. Your health care providers will help you set up a plan for reducing your cholesterol and keeping your heart healthy!

What should I limit?

  • Whole milk, cream and ice cream
  • Butter, egg yolks and cheese ? and foods made with them
  • Organ meats like liver, sweetbreads, kidney and brain
  • Bakery goods made with egg yolks and saturated fats
  • Saturated oils like coconut oil palm oil and kernel oil
  • High-fat processed meats like sausage, bologna, salami and hot dogs
  • Fatty red meats that aren?t trimmed
  • Duck and goose meat
  • Solid fats like shortening, soft margarine and lard
  • Fried foods

Printed Materials for the Visually Impaired

According to the 1998 Consensus Conference Results sponsored by the American Association of Diabetes Educators, the following recommendations can make printed patient education materials more accessible for the visually impaired11:

  • Black ink on cream or yellow, non-glossy paper
  • Footed font, such as Times New Roman, in 14-point or larger type
  • Normal mix of capital and lower case letters (using all capitals is difficult to read and is considered the visual equivalent to shouting)
  • Short, concise language
  • Bulleted lists
  • Customer service phone numbers emphasized, using all numerals instead of letters/words

The AADE makes the following recommendations for the preparation of all patient education literature:

  • Field test on visually impaired as well as fully sighted consumers
  • Make material adaptable to non-print formats

Using Written Materials

Be on the look out for patient education materials that are most appropriate for your patients. While bilingual materials are useful in areas with speakers of Spanish, Mandarin, Creole, or Tlingit, these materials still do not address issues of low literacy or no literacy.

The only useful handout is one that is read and understood. Look for opportunities to read through and review informational and instructional materials whenever feasible. Here are some useful tips:

  • Sit down next to the patient whenever possible. It immediately focuses attention and puts you in the role of teacher and guide.

“Let’s read this over for a minute or two, Ms Katz; this handout helps explain how and why yeast infections develop more often in diabetic women and how certain medications can help.”

  • Provide pencils, pens, or a highlighter. Point to key points with your finger and ask the patient to circle, check, underline, or highlight. You will dramatically increase the speed and efficacy of the consultation, and your patients will walk out with customized notes. They won’t have to take time to read it all over to pick out the 2 or 3 points they need to remember.

“From this list of foods to avoid, Mr Simic, which three do you think will be the easiest for you to cut down on? Go ahead and circle or underline them as a reminder.”

  • Use written materials to review and make priorities. Patients often feel overloaded with technical names, difficult quantities, and confusing schedules. The best communicators have the knack of boiling down all the information into a handful of essentials. Help your patients internalize the information by putting it in order of priority.

“Of all we’ve talked about, Ms Sidney, what?s the most important to remember?”

“To remember to keep my blood sugar log.”

“Right! Let’s put a ‘1’ there. Now the second most important would be?”

Even streamlining this review into a skimming glance at the materials together and a few quick checkmarks with the patient’s pen turns “just another piece of paper” into a stronger informational resource.

By working to develop patient understanding, CDEs can have significant positive effect on patient compliance. As one patient with diabetes put it, “Just because I am an adult doesn’t always mean I ‘get’ everything that’s said especially during an appointment.” CDEs minimize unnecessary conflict, confusion, and miscomprehension when they emphasize their role as teacher.


The Angry or Upset Patient

An essential shift in attitude occurs when we recognize “problems” as opportunities to sharpen communication skills. Professor Helen Meldrum of the Massachusetts College of Pharmacy, communication consultant Stephanie Barnard, and others, suggest versions of the following steps to help constructively move through a conflict situation with a patient:

Listen: When a patient presents a problem, avoid interrupting. Sometimes patients need to vent and the diabetes educator is the first human being they have had a chance to vent with. Other times, patients may need several minutes to fully explain their perception of the problem. As a test, try explaining a problem you’ve recently encountered to a colleague or a friend. Most of us need 3-5 minutes just to explain what happened. Maintain eye contact, breathe deeply, and let the patient finish. A patient’s sense that she has been fairly heard is a precondition for any problem solving that is to follow.

Echo: It’s almost always useful to echo back to the patient what you’ve heard. Statements like the following insure both parties have the facts straight:

“I understand, Mrs Martin, that your are upset about not having your HbA1c test results explained to you sooner.”

Echo statements confirm the facts, and they give the patient proof that you are listening, focused on the problem, and moving with them towards a solution.

Clarify your intention: Rather than wasting time on what may have happened or dwelling on who made which mistake when, shift the patient’s focus with an intention statement like this one:

“It is our intention, Mrs Martin, to get back to you with your lab results as quickly as possible.”

Intention statements are useful because they ease the patient towards solutions you are about to suggest. They pull attention away from past actions and move it towards the future.

Offer solutions: Whenever possible, offer patients options. This helps to avoid “I’m right; you’re wrong” polarizations and moves patients more quickly towards a satisfactory resolution. Consider this CDE’s reply to Mrs Martin:

“Well, Mrs. Martin, we have options here. If you call with a question and I am with another patient, the receptionist can check your file and let you know when your lab results are expected in. If you leave a time when you can be reached, I can return your call that same day or, if you prefer, arrange for a time when you can call in and speak with me.”

Imagine a few of the possible responses Mrs Martin might have to this series of solutions. Now imagine how she might respond to “I’m sorry M’am, but we’re very busy?” Both replies are accurate. The first, however, listens, teaches and solves the problem. The “I’m sorry M’am?” response may explain, but it can also infuriate.

Table 6: Dealing with Difficult Patients

1. Listen first

2. Echo the patient

3. Clarify your intention

4. Offer solutions


Compliance and the Family. Recent studies show that adolescents who maintain good metabolic control may have even better mental health than their nondiabetic peers. It is widely understood in the field of diabetes management, however, that compliance in teens is greatly influenced by the family’s pre-existing relationships and by their ability to adapt to the diagnosis of diabetes and to the demands of the treatment plan.

When counseling adolescents with diabetes, effective communication skills for the diabetes educator are essential. The CDE is responsible for educating not only the patient, but also the patient’s primary caretakers and extended family. And the CDE must accomplish this task while remaining mindful of the family dynamics that influence the treatment plan. The following are just some of the communication issues CDEs might address to ensure successful diabetes management for adolescents:

  • educate primary caretakers and (when possible) extended family members
  • promote family’s understanding of the demands of diabetes management
  • suggest lifestyle changes for the family that support the patient
  • include both parents in treatment plan
  • encourage realistic expectations
  • promote expressions of encouragement and, when appropriate, concern
  • persuade family members to remain nonjudgmental, and to avoid over protectiveness and enmeshment with the patient
  • determine when troubled families need referrals to psychologists or social workers

Because adolescence is a time of such profound physical and emotional transformation, the CDE is made to consider the psychological issues of the teenager, such as body image, self-esteem, peer influence, social acceptance, autonomy, risk taking, and goal setting, alongside physical changes such as erratic growth spurts, fluctuating insulin requirements, and unstable blood sugar levels. The American Diabetes Association suggests the following assertiveness tools to help adolescents adhere to their treatment plans13:

1. Learn to say “no.”

  • expect people to accept “no” for an answer
  • suggest alternatives when appropriate, but don’t feel responsible for doing so
  • explain why you’re saying “no” if you want to, but keep it short and don’t apologize

2. Value Yourself

  • show you value yourself by making diabetes care important
  • know that your health needs are as important as others’ needs

3. Pay Attention to Your Language

  • Practice saying what you need assertively, with phrases such as:

I want to? I am going to? I?d rather not? I don’t want to? I’d like you to?

  • Avoid passive phrases such as: I have to? I can’t? I don’t have time to? I hope you’ll? I don’t suppose you’d?

4. Keep it Courteous

  • Treat the needs of others with respect
  • Remember: You can be courteous and firm at the same time

As every CDE knows, children and adolescents are a particularly challenging group when it comes to issues of compliance. Offering our children practical, concrete tools with which to navigate through the many decisions they face may not only assist them in adhering to their treatment plans, but it may also help them mature into articulate, assertive adults a worthy goal for us all.

The Elderly

The elderly are at particular risk for noncompliance because of several factors, among them, physical and mental deficits, social isolation, multiple drug regimens, chronic illness, and other physical complications as a result of diabetes. The following suggestions can help CDEs communicate a clear message to seniors about how they can best care for their diabetes on a daily basis:

Scheduling Cues: Choosing personalized schedule reminders or cue times can be beneficial for the older patient. Timing devices that beep reminders or flash displays have proven helpful in promoting patients’ compliance. Likewise, simple calendars, reminder charts, and cue cards can all help, and even motivate seniors to check blood sugar levels, take their insulin, eat regular meals, and exercise daily. Typically effective cues include the following:

  • clock time: 8 am; 12:30 pm; 6:00 pm, etc.
  • meal time: at breakfast, after lunch, with dinner
  • personal daily rituals:

after you read the morning paper

while your afternoon tea kettle is coming to a boil

after brushing your teeth at night

before putting in your dentures

Dosage regimen: Whenever possible, select the fewest number of daily doses for any given medication. Simplifying a treatment plan with longer acting drugs or with dosage forms that can be administered less frequently makes regimens easier to follow.

While all that we have said about conflict and problem solving applies to older patients, there are also some additional qualities of aging that are worth pointing out. For example, when do you consider someone is “old?” Many of us differ widely in our perceptions of older adults, and few of us know enough about the normal changes we can expect with aging.

3 classes of “old”: While some may consider retirement age “old,” to others, an adult approaching retirement might still seem spry. Because of dramatic increases in the average lifespan during the last century, scholars of aging now talk about three classes of “older adult.” The “younger old” (60-70), the “middle old” (70-80) and the “oldest old” (80+). Notice how the health concerns of each of these groups vary. While the younger old may be experiencing poor night vision, the middle old may be increasingly uncomfortable with driving and fearing this important loss of mobility. The oldest old may be finding walking increasingly difficult.

To get another sense of how very different each of these group’s attitudes might be, consider the kind of music they were listening to when they were in their twenties. The “oldest old” patients came of age during the Great Depression and the end of the era of the “Roaring Twenties” Charleston. Seventy-year-olds probably listened to the big band music we associate with World War II. For the sixty-year-olds, Como, Sinatra, and Fitzgerald were more likely the crooners of the time. Which is all to say that older adult patients are as different and diverse as younger adults are. The most useful attitude may be to avoid age-based generalizations as carefully as we avoid those of gender and race.

Table 7: 3 Classes of “Older Adults”

  • Younger Old (60-70 years)
  • Middle Old (70-80 years)
  • Oldest Old (80+ years)

Normal Aging: Many older adults experience different degrees of hearing and vision loss, and large-type written materials and slower explanations can often help consultations go more smoothly. As we age, however, it also becomes increasingly difficult to immediately process quantities of new information. The kind of careful, systematic, and caring communication we have discussed throughout this lesson becomes even more essential with older patients.

Patients with Language Barriers

Multi-cultural America: Bosnians like Mrs Omerovic are not the only new ethnic group to flow into America’s cultural mix. In the late seventies Persian Farsi speakers flowed into Los Angeles and Atlanta. Guatemalans have immigrated en masse to Houston, Haitians to Orlando, Laotians to Sacramento, Gujaratis to Hartford, and the list could go on and on.14 No longer restricted to national urban centers like New York, Miami and Chicago, rich ethnic and cultural diversity appears in most communities and at most hospitals. Cultural difference may signal language barriers that make a CDE’s job to clearly communicate harder than ever.

Cultural differences, like aging populations, are only going to increase in the years ahead. The sooner we develop constructive, solution-focused attitudes to address our truly multicultural clienteles, the better. Here too, it is helpful to remember that heavy accents, lower reading levels, or silent stony responses to a CDE’s questions are far more often simple signs of cultural difference than they are markers of education or attitude. One savvy CDE from Queens, New York explained it this way:

Every time I feel frustrated by a patient’s really thick accent, I remind myself of all the things about the patient I don’t know. Once, when I asked an older Asian gentleman with a heavy accent which other language he spoke, he laughed a bit and replied, “I don’t speak one other language, I speak six!” For many of my patients, English isn’t a second language, it’s a third, fourth or fifth language.

Most multi-lingual patients are more than aware of linguistic barriers, and they deeply appreciate any effort on the part of the CDE to understand and to be better understood. Notice how well many of the strategies we’ve talked about throughout the length of this course work well with multi-lingual patients. Which of the following do you think would make the biggest difference to your multi-lingual patients?

  • Asking for help at learning to pronounce foreign names
  • Using written materials about diabetes in a patient consult
  • Rephrasing statements using different words
  • Speaking more slowly
  • Echoing a patient’s question
  • Choosing scheduling cues for meals, insulin injections, blood sugar testing, etc.
  • Asking patients to repeat their request
  • Learning a simple greeting in one of the patient’s primary languages
  • Hiring multi-lingual staff

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