Volume 22, Number 4 - December 2019

Two Sides of a Coin – A Journey Through Clinical Appointments from an Australian and Indigenous Perspective

By
Ashley Ng,

MDiet, BFS&N(Hons), BHsc, Accredited Practicing Dietitian

PhD Candidate, Deakin University (VIC)

Amira Howari,

Clinical Optometrist and Member of Diabetes & Endocrine Network at NSW Health, Agency for Clinical Innovation

B.Optom(Hons), MOptom(UNSW), GradCertOcTher

Person with diabetes

Chris Lee and

Manager, Aboriginal and Torres Strait Islander Engagement at Diabetes Australia

AssocDipAppSc(Broadcasting and Journalism),

Person with diabetes

Chris Aldred

Diabetes Advocate at The Grumpy Pumper

Person with diabetes

Introduction

Person-centred or collaborative care is a model of care that acknowledges the expertise of both the clinician and client1. In diabetes management, clinicians provide clinical expertise and translate research into meaningful information for the person with diabetes, which allows the individual to make an informed decision in line with their current life situation and their body’s needs1. The effectiveness of collaborative care has been increasingly discussed alongside diabetes self-management education, particularly given that people with diabetes only spend about 0.1% of their time with a clinician2. Therefore, it becomes crucial that the time spent with a diabetes clinician is efficient, effective and focused on the person’s needs.

In a true collaborative approach, the Australian Diabetes Educators Association in conjunction with Diabetes Australia organised a symposium driven by consumers at the recent 2019 Australasian Diabetes Congress. The symposium consisted of a panel of people living with diabetes from a variety of backgrounds, at different life stages and professions, as well as clinicians who live with diabetes. The panel discussed considerations before, during and after clinical appointments through the perspectives of clinicians and people with diabetes. This article will summarise the practical takeaways discussed during the panel across the three main timepoints of a standard clinician consultation within the broader Australian and Aboriginal and Torres Strait Islander (ATSI) community context.

Appointment Setting and Physical Setting of Clinical Appointment

 Key information needed when making an appointment:

Making an appointment is usually the first introduction to the clinic a person will have. Basic information should be related to the client around the length of appointment, out of pocket costs and referrals required. Consider any information that would help you make decisions such as a medication list, food diary or recent blood glucose logs. Some appointments may also require additional precautions such as having blurred vision or limited mobility after the consultation. Let clients know if they need to arrange for someone to bring them home.

From the perspective of ATSI people, many community members regularly move from place to place for family or in pursuit of new job opportunities. Therefore, the local health provider will often be a new environment to them. Seeing Aboriginal faces is important; having ATSI staff can help to break that barrier. For ATSI people who remain on their birth country, the local Aboriginal Medical Services (AMS) is a place where many relatives are also staff members. Consequently, this may dissuade family members to attend the AMS for a lack of privacy and a fear of being labelled or judged for their condition.

Impact of physical setting of clinic and consult room:

Consider the environment that your client will walk into and how it would make them feel. Pieces of artwork may hold different interpretations for each person, from joy to anxiety. Similarly, health-related posters can be used in a positive way for education or in a negative way through scare tactics. Consider how these will make an already anxious client feel when sitting in the waiting room where attending clinical appointments often feels like a daunting task3. Within the ATSI community, this is especially true as a medical clinic, including the Aboriginal Community Controlled Health Services, is associated with ill health. Most ATSI families have seen relatives struggle with or pass from ill health, which elicits fear and apprehension around chronic health conditions.

Research suggests that various strategies in waiting areas can reduce client anxiety4. Clinic spaces can be made inviting by including culturally relevant posters and plants to create a welcoming environment. Most importantly, staff need to be aware of their own cultural prejudices and that their style of communication will influence a client’s overall visit and subsequent return.

Information Exchange and Collaboration During Consultation

 Impact of communication on collaboration:

A key part of utilising a collaborative approach is communication between the clinician and the client. From things like facing the client when talking to them instead of the computer, to being mindful around words. Language used by clinician can highlight respect for the person with diabetes and setting up the appointment without judgements or assumptions that often comes with certain language5. Medical jargon is another area we, as clinicians, are often guilty of using, which can further intimidate and confuse clients6. Such is the case for many ATSI people who may not understand the scientific names of medications. Rather, they take a keen interest in what it does, when to take it, its side effects and how it may interact with other medications.

Clinical appointments are often filled with information that may be difficult for the client to remember and process at once. In ATSI families where women are often the carers and caregivers, it is a good idea to invite family members to sit in on the consultation. If blood tests needs to be done for future appointments, write whether fasting is required on the pathology request slip and let the client know.

To better engage clients with the conversation around their healthcare, it is important to understand their personal circumstances and tailor strategies around them1. Involving clients in making informed decisions about their healthcare can be an empowering moment for them, which is the key outcome for person-centred care1. Provide clients with a few take-home points and when using handouts, make sure that the resource caters to individuals of all literacy levels without the use of medical jargon.

Considerations when discussing diabetes-related complications:

Talking about diabetes-related complications can be daunting as they are often referred to as an end-point or used as threats. Doing so only further dissuades people with diabetes from attending regular screening and seeking treatment for fear of being judged. Explain the situation pragmatically to clients and focus on diabetes care and risk reduction. ATSI clients will prefer to understand the background to their condition through a story that they can relate to. Diabetes-related complications are a risk of living with diabetes and not a failure of diabetes management. While it is important to be realistic, building hope is an important aspect of managing a diabetes-related complication. Setting realistic goals and acknowledgment of the individual’s efforts will help drive motivation, perseverance and ultimately achieve progress.

Managing online information:

With a world of knowledge at our fingertips, it is not uncommon for clients to bring information they have sourced online to an appointment. Rather than shutting it down, use this opportunity to have an open discussion with clients around their goals, help them interpret the evidence and ultimately assist them in making an informed decision. Remember that as clinicians, you have the expertise of your profession and in translating the evidence into practical information. There is also no shame to admit that you are not fully informed in a certain area. People with diabetes would rather the honesty and your efforts to look into a certain topic rather than being brushed aside.

Follow-Up Care 

 Healthcare professional’s role in ensuring people with diabetes receive adequate care

Building a relationship with your client is important as they may disclose information they would not otherwise during side conversations. These situations highlight the importance of working in a multidisciplinary approach and ensuring that all providers involved with the client’s care receive a report from your consultation with their permission. Using consistent language and messaging within the multidisciplinary team can avoid confusion and reinforce messages provided to the person with diabetes. Similarly, maintaining a wide network of health providers you can refer to when needed, can help in providing multidisciplinary support to people with diabetes. Offer to share your reports or medical notes from the session with clients7. Some clients appreciate the transparency this provides, and it reminds us as clinicians that what we do impacts a person and their loved ones too.

Follow up with your clients if they cancel or miss an appointment and on referrals you have made for them. Simple acts like these show care and you will be able to address any concerns clients may have about the reason they have to attend or their experience. If a person has a bad experience on their first appointment, they are usually unlikely to return. By following-up you can ensure they find a healthcare provider who can meet their needs that they receive the medical treatment or assistance they need. Ultimately, this is how you can make a difference in preventing people with diabetes from slipping through the cracks of the healthcare system.

Managing questions between clinical appointments

Diabetes requires active management of the condition 24 hours, 7 days a week. Therefore, it is inevitable that people with diabetes will have questions about their diabetes in between appointments. Support their participation in peer support communities, which can often assist with minor troubleshooting. Teach clients to recognise credible sources of information or have a list of peer support groups you would recommend. A recent scoping review of consumer-led diabetes online communities found that they provide more benefits to a person’s wellbeing and diabetes management than harm8. Additionally, misleading and misinformation were found to make up less than 10% of content and to be unlikely to lead to harm8.

Some clinicians share their work email or mobile number with clients. If you choose to do this, it is important to set boundaries on acceptable situations to use those contact methods and what to do in during an emergency situation. Additionally, ATSI health workers and health professionals are generally on-call for their community and will continue to be their first point of contact. Every clinic and clinician will have different systems. It is important that whatever you decide to do is supported by the clinic, staff and that it works for you.

Conclusion

As clinicians, we can do many things to support the person with diabetes even before we see them. From creating a welcoming and culturally inviting space to acknowledging your own biases and preconceptions; every little action counts. Respect is a two-way street when communicating with clients and building a relationship with your client is a key component of ongoing care. As one cog in the multidisciplinary wheel, you can proactively ensure that people with diabetes receive the care they need from other members of the team. Stay up to date with medical and technological advances in your field, topics of discussion within the diabetes communities and diabetes services to refer on. As people living with diabetes, we know too well the challenges it brings and having a great multidisciplinary team can make all the difference in the world.

Acknowledgements

We would like to acknowledge the other contributors to this panel of the symposium: Renza Scibilia and Frank Sita.

References

1.

Funnell, M. M., & Anderson, R. M. (2004). Empowerment and Self-Management of Diabetes. Clinical Diabetes, 22(3), 123-127.

2.

Marrero, D. G. (2016). Diabetes Care and Research: What Should Be the Next Frontier? Diabetes Spectrum, 29(1), 54. doi:10.2337/diaspect.29.1.54

3.

Lawson, V. L., Lyne, P. A., Harvey, J. N., & Bundy, C. E. (2005). Understanding Why People with Type 1 Diabetes Do Not Attend for Specialist Advice: A Qualitative Analysis of the Views of People with Insulin-dependent Diabetes Who Do Not Attend Diabetes Clinic. Journal of Health Psychology, 10(3), 409-423. doi:10.1177/1359105305051426

4.

Biddiss, E., Knibbe, T. J., & McPherson, A. (2014). The Effectiveness of Interventions Aimed at Reducing Anxiety in Health Care Waiting Spaces: A Systematic Review of Randomized and Nonrandomized Trials. Anesthesia & Analgesia, 119(2), 433-448. doi:10.1213/ane.0000000000000294

5.

Dickinson, J. K., Guzman, S. J., Maryniuk, M. D., O’Brian, C. A., Kadohiro, J. K., Jackson, R. A., Funnell, M. M. (2017). The Use of Language in Diabetes Care and Education. Diabetes Care, 40(12), 1790. doi:10.2337/dci17-0041

6.

Reach, G. (2009). Linguistic barriers in diabetes care. Diabetologia, 52(8), 1461-1463. doi:10.1007/s00125-009-1404-x

7.

Ross, S. E., & Lin, C.-T. (2003). The Effects of Promoting Patient Access to Medical Records: A Review. Journal of the American Medical Informatics Association, 10(2), 129-138. doi:10.1197/jamia.M1147

8.

Litchman, M. L., Walker, H. R., Ng, A. H., Wawrzynski, S. E., Oser, S. M., Greenwood, D. A., . . . Oser, T. K. (2019). State of the Science: A Scoping Review and Gap Analysis of Diabetes Online Communities. Journal of Diabetes Science and Technology, 1932296819831042. doi:10.1177/1932296819831042

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