Hi again! Nice to be back with a few more thoughts on diabetes and interacting with patients.

He arrives early and opens the laptop. There's his glucose log, food diary, activity record. His numbers look great, so much better than the last time. He took my suggestions to heart and now he's seen the light!!! I answer his earnest questions, offer reassurance and send him off. He shakes my hand, saying he'll nominate me for diabetes educator of the year.... The image fades and there's the smell of coffee...

"Honey wake up...you'll be late for work...."

Ah those dream patients. We love them because they get it. They're engaged, interested and ready to soak up our words of wisdom. They're one end of the spectrum...the end that already has the "why work at this?" part figured out. They need our expertise and encouragement and can take it from there. Today I'm more interested in those at the other end.

As educators we're often sent the "challenging patients." The referrals arrive with notes about non compliance and unwillingness to change. My premise has always been that there aren't that many truly unmotivated patients. After all, how many people really want to feel awful and suffer the complications of diabetes? For these folks, it seems like my job shifts from answering questions to asking them. What's getting in the way? What keeps them from making those changes, from feeling better or being around for their grandkids?

I suspect you have a lot of answers to these questions, here are a few of mine.

• Depression gets in the way. It kills motivation and it's mostly treatable. We have to advocate for screening and treatment.
• Low health literacy. I'll direct you to Cathy's fine post of April 22, on this subject.
• Life gets in the way. These are tough times. Sometimes a few calls to a social service agency did more to help my patient deal with their disease than my 20 minute talk on carb counting.

And last but hardly least: Ambivalence about change. A biggie and one we all face. Think of the last time you tried to lose a few pounds or deep clean the basement. Ambivalence fills the gap between what we want and what we're actually doing. Change depends on how the scale tips.

How do you nudge the scale in the right direction? Here are some ideas though I'm sure you have plenty of your own.

• Your relationship with the patient matters a lot. I do best when I'm more of a partner than a teacher or scold. More dancing, less wrestling.
• What's important to your patient? Family? Feeling better? Looking better? Travel? These questions are less about diabetes than what's at stake if things don't change.
• What's the difference between those values and current behavior? "So on one hand you want to be around for your grand kids. And you said your sugars are way too high and you know that can lead to some pretty serious problems. What do you make of that?" Hmmmmmm. Questions like that can shed some light on what's really going on and maybe how to get unstuck.

And next week...they'll arrive with the loaded laptop? Well...maybe not....but you never know.

But enough of my ideas, what about yours? What's your definition of a tough patient? How did you get through? What did you learn? Keep us posted.

Thanks,

Bob