Keep Pushing On!

July 10, 2018

What to do when patients face their own "clinical inertia"? Here, 3 simple ways to help them push through. 

Do you recall a time when you knew what you should do, knew all of the intellectually sounds reasons to do it, and yet still didn’t take any action?

You’re not alone. Welcome to the state of Clinical Inertia.

What is it?

William Strain, MD, and colleagues define clinical inertia as, “the failure to establish appropriate targets and escalate treatment to achieve treatment goals. It accounts for a significant proportion of failure to achieve targets in the management of diabetes and contributes to up to 200,000 adverse diabetes- related outcomes per year.”1

Strain refers here to clinicians’ tendency to hesitate or wait longer than is appropriate before advancing therapy, despite documented lack of clinical progress. But patients, too, fall prey to their own variety of clinical inertia.

How can you help them combat it? 

1. Cultivate your curiosity.

Like the medical detective you are, ask questions to delve deeper into why your patient has been hesitant about changing his or her regimen, or has not been improving. One of my mentors, Steve Edelman, MD, who is both a renowned endocrinologist and has been living with type 1 diabetes since the age of 15, advises, “I like to start by asking, ‘What’s bothering you most about your diabetes?’” What we often label as frustrations or pain points, can just as often be springboards to innovative solutions.

Next: Partner with your patient

2. Partner with your patient! 

Think of the big picture: this is a quest for both you and your patient. It’s a continual journey to improve his or her diabetes care, for both improved quality of life and positive clinical outcomes. This assumes that the patient is engaged and wants to take the journey with you. But, a crucial difference from many other sojourns is – there is no final destination. Yes, reaching an A1c that signifies good glycemic control is a goal, and a milestone completely worthy of recognition and celebration. But, this is a dynamic, not a static, process. Backsliding can occur, and we must all remember that this requires a lifetime commitment to taking actions daily, actions that will maintain, and build upon, progress.

Next: Ask this one question

3. Again, ask the question: What one thing are you committed to change?

How often do we try to cover multiple things that need improvement in the space of a clinic visit that may last only 10, 15, or 30 minutes? In addition to improving glucose readings, we might need to address medication adherence, checking the feet, reducing bread or cake, or gradually increasing the minutes of weekly aerobic exercise toward 150 minutes. We are probably also delivering all of this in the negative, such as:

“Avoid walking barefoot.”

“Don’t forget to bring your log book.”

“If we can’t get that A1c lower, we’re going to have to talk about starting insulin.”

How can we shift gears? Motivational interviewing is key; this technique helps patients understand that they are in charge and gives them the responsibility to choose the one thing - just one, single item - they can commit to change, rather than feeling they have not only to fix everything, but also remember all 8 of those things before the next follow-up visit.

Finally, take some time to try something recommended by Kevin Eng, MD, one of the residents whom I’ve had the privilege of working with for the last 3 years: “Celebrate with your patients their successes.” We’re not just stamping out diabetes complications; we are also striving for what we all want, yet far too often, take for granted: health.

References:

1. Strain WD, Blüher M, Paldánius P. Clinical inertia in individualizing care for diabetes: is there time to do more in type 2 diabetes? Diabetes Ther. 2014;5:347–354.