HJAR Sep/Oct 2023

HEALTHCARE JOURNAL OF ARKANSAS I  SEP / OCT 2023 23 how. Here is where empathy and compassion reign supreme. To help them, we need to see the world through their eyes and understand their unique life journey and cumulative set of life experiences. And inspiring each patient to change behaviors is not possible without understanding what matters most to them. Usually, as part of my initial visit with a patient, I ask them about their health-related goals. The response often comes back as wanting to be on fewer medications or to lose weight or to be healthier so that they can be there for their chil- dren and family over the long term. My favorite ones are when a patient tells me that their goal is to watch their son become the first person in their family to graduate from college or that they want to be able to get on the floor and play with their grandchildren. It is important to understand the goals that matter most to them because it becomes their beacon for change, their source of inspiration, their hope. Very rarely, I may come across a patient who doesn’t really want to change, or even rarer still, I may come across a patient with a personality disor- der who lacks insight into the need for change; but these are very much the exception. The norm is that patients are desperate for this type of care because they’ve never experienced any- thing like it before. The result is that achieving >90% rates of diabetes control not only is pos- sible but is just an incremental step along the path toward achieving what is really important to them. The person whose depression goes into complete remission, who stops stress eat- ing, who quits smoking and starts exercising, who then loses 60 pounds and gets off their insulin has essentially changed the trajectory of their life such that they are much less likely to suffer a heart attack, amputation, blindness, or kidney failure. But what restores the joy of practice for us is when that person comes back and tells us that they were able to get on the floor and play with their grandchildren again. Experiencing that joy for us providers does come at a small price. It involves a cultural mind- set change where we let go of the old hierarchi- cal “doctor knows best” philosophy. It involves sacrificing some of our autonomy in favor of reli- ability and reproducibility of clinical excellence. It involves continuous monitoring and learning from successes and failures. It involves holding ourselves accountable for the outcomes we deliver without blaming patients or other care team members when the outcomes are poor. It involves teamwork and working together in a highly coordinated and collaborative manner with the patient at the center of everything we do. And it involves becoming a different type of leader where we coach with compassion instead of compliance. For those of us who went into healthcare to truly help the patients we serve, it is a price worth paying, especially because it connects us to the deep sense of purpose of why we did this in the first place. n — this measure is important, it’s just incom- plete. We also need to concomitantly ensure that all the rest of our evidence-based practices are being reliably delivered. We need systems and processes to ensure that their blood pres- sure is at goal; that diabetics over the age of 40 are prescribed at least moderate intensity statin therapy; and that we are routinely check- ing eye exams, foot exams, and monitoring for diabetic kidney damage. We also need to be monitoring regularly for low blood sugar (hy- poglycemia) while also monitoring for when patients go to the emergency room for low blood sugar or other diabetes-related com- plications. And almost everything so far that we’ve discussed can be done under existing economic models and financing mechanisms. However, once you embrace new economic models that align clinical and financial incen- tives completely, you really get to innovate in how care is delivered. It will take teamwork, technology, talent, time, and most importantly trust . It starts by investing a great deal of time into building out a comprehensive understand- ing of each patient. Screening for anxiety and depression is essential because unless these conditions are recognized and addressed, you will not make as much progress as possible. Even more important than identifying underly- ing mental health conditions is being able to intervene with cognitive behavioral therapy and motivational interviewing through a behav- ioral therapist who is tightly integrated into the care team. Ongoing communication among providers, dietitians, diabetes educators, and therapists is essential to making steady prog- ress. Often, the most “challenging” patients have experienced significant adverse psy- chological trauma at some point in their lives, which may have led to one or more maladap- tive coping mechanisms, such as emotional eating, smoking, or risky alcohol use. Not much progress can be made until these past experi- ences are better understood and addressed by a skilled psychotherapist. Quantifying health literacy and self-efficacy becomes important because using as few medications as possible is dependent on changing certain health-re- lated behaviors. Most patients who find them- selves engaging in unhealthy behaviors des- perately want to change; they just don’t know “Most patients who find themselves engaging in unhealthy behaviors desperately want to change; they just don’t know how. ... To help them, we need to see the world through their eyes and understand their unique life journey and cumulative set of life experiences.”