“Dr. Johnson, I have roomed your patients. Mr. Jones is a new diabetic in room 1; Mr. Smith, the noncompliant diabetic, is in room 2; and Mrs. Anderson, the gestational diabetic is in room 3. This morning's schedule is filled with diabetics.”
How many of you are gritting your teeth after reading this scenario? Hopefully, all of you; it was painful even writing it. When referring to people with diabetes, we should stop using the labels “diabetic” and “noncompliant diabetic.” These terms expose our ignorance to the management of diabetes and allow us an excuse when patients are not achieving their heath outcome goals.
Currently, only 57% of people with diabetes achieve an A1C of < 7%.1 Albert Einstein once said, “We can't solve problems by using the same kind of thinking we used when we created them.”2 I agree with Einstein and argue that if we eliminate the use of the terms “diabetic” and “noncompliant diabetic” we will improve diabetes care.
Because of a feeling of helplessness, health care providers may label patients as noncompliant as a way of blaming patients when they do not follow our advice.3 Labeling patients as noncompliant as a method to motivate them to reach their health outcome goals is as successful as telling a spouse that he or she is a horrible cook and expecting him or her to happily make us future meals that exceed our expectations. Neither method of motivation will work.
I believe that, by focusing on the individual instead of the disease, health care professionals will allow patients to reach their treatment goals and will, ourselves, find greater joy in managing our patients with diabetes. Calling someone noncompliant is not just rude; it is amazingly inaccurate and vague, and it leads to obvious treatment interventions that are just wrong and worthless. If we continue to refer to patients as diabetics or noncompliant diabetics, no change will occur, and patients with diabetes will not reach their treatment goals.
The term “diabetic” has been used freely to describe people with diabetes. But the word “diabetic” should be used as an adjective, not as a noun. It is acceptable when discussing conditions of diabetes, such as diabetic ketoacidosis, or diabetic nephropathy, neuropathy, and retinopathy. “Diabetic” describes the condition, not the person.
Although “diabetic” is also, technically, a noun, it should not be used as such when referring to a person with diabetes. Using “diabetic” as a noun unfairly labels people with diabetes, and it implies that all patients with diabetes are the same. As a noun, it has a negative connotation and is seldom used in a positive tone. I have never heard a health care provider say with joy, “I specialize in treating diabetics. I find my job rewarding and would not want to do anything else.” Instead I hear, “I have this diabetic, Mr. Jones. His A1C is 9.3%. Go fix him.”
When patients with diabetes who have been labeled noncompliant are referred to me for diabetes management, I often find that the reason these patients are not at goal is not related to noncompliance; they have not willfully refused to cooperate with an eminently reasonable set of instructions that patients seeking optimal diabetes control would follow. Rather, they often are not at goal because they have never been given the tools and education to effectively manage their diabetes. Maybe these patients are uneducated about diabetes and how to most effectively care for their disease. Perhaps they were given a stack of prescriptions and not informed about their medications.
If patients with diabetes are not meeting standardized treatment goals, it is likely because of various barriers. Health care providers need to work with patients to identify and overcome these barriers, instead of throwing in the towel and blaming patients for being noncompliant. It is impossible for patients to be actively engaged with their treatment plan if health care providers do not effectively convey such plans to them.
If patients are not at goal, we need to focus on solutions, not problems. Too often, we focus on what is wrong, and this type of thinking is destructive; we get more of what we focus on. If we want solutions, we need to focus on solutions.4 Employing solution-based thinking when collaborating with patients to develop their diabetes care plan will strengthen our diabetes management skills and allow patients to become “compliant.”
I despise the labels “diabetic” and “noncompliant diabetic” and exhort all to stop using these terms when discussing people with diabetes. Living with type 1 diabetes since the age of 10 years and specializing in the management of diabetes have given me a perspective on these terms that differs from that of many health care providers, patients, and members of the general population.
Although my medical alert tag says “diabetic,” I am not “a diabetic.” The term “diabetic” on my medical alert does not define me. I have a wonderful wife and three beautiful children. I am active in my church. I have a good sense of humor, enjoy playing golf and gardening, and work as a clinical pharmacist who specializes in diabetes. And, I have diabetes. My disease does not define me, and it should not define other people with diabetes.
The words “diabetes” and “diabetic” both contain eight letters, so medical alert tags could just as easily say “diabetes.” I guarantee that any educated person could draw the conclusion that a person who has a medical alert tag that says “diabetes” must be a patient with diabetes. Using the terms “person with diabetes” or “patient with diabetes” allows people to be people, not “diabetics.”
Not everyone may agree with my opinion about these terms, and that is a personal choice. But I encourage all of us to think beyond ourselves for a moment and ponder how these terms might affect people with diabetes. Some may argue that some patients refer to themselves as “diabetic,” so the term should be acceptable. But some of our patients may not realize the difference simply because of years of unfair labeling.
Using the term “diabetic” is easier than saying or writing “patient with diabetes,” “person with diabetes,” or even “PWD.” But it is important to remember that easier is not always better. “Diabetic noncompliance” is not a syndrome, but rather is a failure to collaborate with our patients with diabetes in their care.
Some diabetes health care providers might believe that if patients with diabetes are not at goal, it is because they are willfully noncompliant; if they would just listen to the treatment plan, their disease would be better controlled. But noncompliance is difficult, if not impossible, to measure and involves many factors.
In 2000, Anderson and Funnell3 conducted a Medline search with the terms “compliance” and “diabetes” and yielded more than 1,500 citations. In March 2012, I conducted the same search and identified 5,475 citations. The purpose of the article by Anderson and Funnell was to show that most of the studies seeking reasons and answers for noncompliance failed to provide solutions because they did not address the fundamental problem of diabetes treatment at that time.3 Twelve years later, clinical inertia is alive and well, but it is time for change.5
One must consider what compliance really means. If a patient with diabetes has a candy bar and takes the correct amount of insulin, resulting in a blood glucose reading of 102 mg/dl, is the patient noncompliant because he or she ate the candy bar? Of course not.
Until you live with diabetes day in and day out, I urge health care professionals to show more compassion for people with diabetes and to not unfairly label us as noncompliant.
The next time you refer to a patient with diabetes, please do not call him or her a diabetic or a noncompliant diabetic. If you hear other health care providers use these terms, please educate them. Education will improve the overall knowledge of a disease that has a major impact on many people we care for and love.
Kyle R. Peters, PharmD, is a clinical pharmacist at the Siouxland Community Health Center in Sioux City, Iowa, and a clinical assistant professor at the University of Nebraska Medical Center College of Pharmacy in Omaha.
- American Diabetes Association(R) Inc., 2012