The Practical Aspects

Patient & Physician Responsibilities

The AACE Medical Guidelines for the Management of Diabetes Mellitus outlines both the patient’s and the physician’s responsibilities in the management of this very serious and complicated disease. The summarized responsibilities of each stakeholder follow.

The Patient’s Responsibilities

1. Perform monitoring of blood glucose consistently to help understand the dynamics of blood glucose changes relative to medication, diet, stress, and exercise.
2. Understand the importance of smoking cessation in decreasing the risks of diabetes-related macrovascular and microvascular complications and, if a smoker, enroll in a program of smoking cessation.
3. Learn the importance of participation in a program of prescribed exercise for weight reduction and physical conditioning.
4. Know the importance of and reasons for the consistent use of aspirin in helping to reduce the risk of macrovascular complications. This knowledge will aid in increasing adherence to recommendations.
5. Monitor blood pressure consistently to help regulate the blood pressure and blood pressure medication. Understand the effects of medication and stress on blood pressure control and the risk of the lack of blood glucose control. This understanding will encourage adherence to blood pressure monitoring and control measures and decrease the risk of complications from hypertension, a serious comorbid complication of diabetes.
6. Recognize and understand the psychologic barriers that prevent adherence to the system of intensive self-management of diabetes. Learn how to express feelings and define the barriers to expressing feelings to the physician and the self-management team. This skill might help increase adherence with the system of intensive self-management of diabetes.
7. Learn the best techniques of foot care management and make a commitment to intensive foot care.
8. Understand the reasons for the onset of retinopathy, and recognize the signs and symptoms for early detection.
9. Understand the need for establishing goals for blood glucose, lipids, and blood pressure. Learn to participate in the development of these goals and in their modification, in consultation with the physician. After the goals have been established, develop a dedication to reaching those goals through intensive self-management of diabetes.
10. Actively participate in continuing diabetes education, such as support groups and physician and educator interactions, between regularly scheduled appointments. Share this valuable resource, becoming a teacher to other patients with diabetes and thereby learning from such interactions.
11. Adhere to proper nutrition and physical activity programs. Understand the physiologic rationale for their effectiveness. To improve adherence, discuss barriers with the physician and the diabetes management team.
12. Accurately document serial blood glucose and blood pressure measurements. Understand that the purpose of keeping such records is to help clarify blood glucose and blood pressure relationships to dietary aberrations, stress, exercise, and acute illnesses such as infections. This documentation will facilitate appropriate changes in treatment.
13. Understand the importance of keeping regularly scheduled appointments. Effective treatment of diabetes depends on a continuum of care, including periodic medical consultations.
14. Adhere to the proper use of medications. Understanding the mechanism of action of the medication will enhance adherence. If changes in the medication seem necessary, learn to communicate with the physician between appointments so that appropriate alterations can be made as a collaborative effort with the physician.
15. Understand the meaning of glycosylated hemoglobin, and know the results of personal glycosylated hemoglobin values.
16. Appreciate that the patient-physician contract is a tool to help both the patient and the physician uphold their commitments in the therapeutic plan.
17. Evaluate the compliance of the physician, and communicate this assessment to the physician.

The Physician’s Responsibilities

For an effective diabetes self-management system, the physician must also fulfill the following responsibilities in the patient-physician contract.

1. Adhere to the protocol outlined in the AACE Medical Guidelines for the Management of Diabetes Mellitus: A System of Intensive Diabetes Self-Management.
2. Appropriately collect the patient data (details of the clinical course and the laboratory findings) so that clinical outcomes can be measured and related to economic outcomes.
3. Determine patient satisfaction and quality of life by use of questionnaires at yearly intervals.
4. Utilize a system of communication and documentation of the communication with the diabetes self-management team so that the team is truly an extension of the physician’s care.
5. Utilize diabetes skill evaluation programs, and objectively evaluate the patient semiannually.
6. Define the frequency of patient visits, and assess the patient’s ability and desire to adhere to the system of intensive diabetes self-management.
7. Document, evaluate, and rate the patient’s concerns every 3 months in a utilizable data format. As the key element, the patient must feel comfortable describing barriers to intensive self-management. The patient should always be the focus of the diabetes self-management team.
8. Evaluate the effectiveness of the documentation of care of the patient. Pay particular attention to the quality of the documentation; continuous improvement in the quality of documentation should be an integral part of the system of care.
9. Supervise the education of the patient. The physician must be involved in discussing preventive methods and explaining risk reduction so that the patient gains expertise in diabetes management and is encouraged by the entire diabetes care team.
10. Ensure that the patient understands and adheres to preventive measures, including detailed instructions for foot care, diet, and physical activities, aimed at reducing the risk of complications.
11. Utilize a process to evaluate the patient’s adherence to the system of intensive self-management. The assessment should be objective and amenable to evaluation in query format related to other variables. The program should include mechanisms to determine whether the patient is taking medicines and insulins safely and correctly. A continuing program should be undertaken to identify errors and misconceptions as well as to educate others in the system who help care for these patients. This effort will reduce the frequency of potential mistakes in the overall process.