Stanley Feld M.D.,FACP,MACE
The role of patients with chronic diseases and their physicians must be clear to both patients and physicians. Physicians are coaches. Patients are players. They live with their disease 24 hours a day. Day to day fluctuations occur in the management of chronic disease. An excellent example is patients with hypertension. Blood pressure fluctuates all day long. A single blood pressure measurement during a visit to a physician once every six month is meaningless. Patients must continually monitor their blood pressure to evaluate the effect of their medication. Physicians have to help patients evaluate these data points to make logical medication adjustments.
Patients must to be inspired to manage their chronic disease. This requires patients having confidence in their coaches. It is hard work for patients to monitor their blood pressure daily and learn the meaning of the fluctuations in their blood pressure.
Only day to day blood pressure control is going to prevent the complications of a stroke or a heart attack. Physicians along with the patients’ input must make the necessary adjustments. An effective physician and patient team can make appropriate day to day adjustments.
This idea of mutual trust and confidence between coach and player is illustrated by something that happened between a teacher and me in high school. It illustrates the essence of an effective physician-patient relationship.
It was a rainy day in the spring of 1953 during my junior year in high school. I was on the high school baseball team. The team could not practice that afternoon because of the weather. The team was sent to the Study Hall for the 8th period.
Ms. W. was one of the 8th period Study Hall teachers. She was my geometry I and II teacher. I thought she was the greatest. I never missed a question in class or on a test. She came over to me that rainy spring day to say hello. She asked how I was doing in trigonometry.
I told her I was doing terrible. I could not learn a thing from Mr. B. Mr. B. was the chairman of the math department. He taught trig very descriptively. It had no meaning to me. He did not teach us to understand the logic of trigonometry and its uses. No matter how much I tried to derive meaning from the text book by myself the material covered did not stick. I felt Mr. B. suppressed my ability to learn and problem solve. His goal was to have us memorize the material.
Mrs. W. asked me which period I had trigonometry and lunch. I told her trig 5th period and lunch 6th period. She said great she taught trig 6th period and could get me transferred to her class. I could have lunch 5th period.
I was thrilled beyond belief. She also said she hoped I was aware there was a departmental quiz being given the next day. I would be required to take it. She said the chances are I would do poorly on the test but she encouraged me to study when I got home.
The most amazing thing happened that night when I started studying for the quiz. All of a sudden I grasped concepts I could not grasp previously. Now that I was in Mrs. W. class I solved problems I could not solve previously. A difficult textbook seemed easy.
The next day I went into her trigonometry class, took the test, and got 100%. I know this has happened to all of us at some time in our life. I know it was the result of my knowing that someone had trust and confidence in me and the conviction that I could do the job.
The magical therapeutic power of the patient physician relationship.
If a relationship is positive with mutual respect and commitment by physicians and patients, patients can learn about the pathophysiology of their chronic disease. In turn they can learn to manage their disease properly.
In practicing endocrinology I developed a patient physician contract to define this patient physician relationship. My son, Daniel, alluded to this contract in his letter to me.
Physicians must be dedicated to teaching patients to be the professor of their disease. Physicians must enable patients to want to be the professor of their chronic disease to avoid the complications of the disease. Eighty percent of the healthcare dollar is spent on the complications of chronic disease.
The lesson of Mrs. W. is a powerful lesson. Mrs. W. did enable me to be comfortable and confident in my learning situation because of her trust. She empowered me to learn by myself with her confidence in me.
Many times patients with a chronic disease are frightened by their disease. This fright makes it difficult to learn how to control their disease to avoid its complications. Physicians must deal with this through a positive physician patient relationship. A positive patient physician relationship can make it easier for patients to learn to control their disease.
Converting healthcare into a commodity is discouraging physician-patient relationships. The healthcare system cannot be repaired without effective chronic disease management. Chronic disease management will not be effective without effective patient-physicians relationships.
AACE Diabetes Guidelines, Endocr Pract. 2002;8(Suppl 1)
a. Sample Patient-Physician Contract
I understand that if I agree to participate in the System of Intensive Diabetes Self-Management, I will be expected to do
1. Dedicate myself to getting my blood glucose level as close to normal as possible by following the instructions of the
diabetes self-management team
2. Regularly visit the clinic for a physical examination, laboratory tests, and nutrition counseling; follow-up visits will
be scheduled every 3 months or more frequently if deemed necessary by my physician or other members of my
3. Bring a detailed 1-day food record to each follow-up visit, provide necessary nutrition information for me and my
dietitian, and adjust my eating habits to meet the nutrition goals established by my dietitian
4. Use medications as prescribed by my health-care team
5. Monitor my blood glucose levels at home as instructed and bring the results to each follow-up visit
6. Follow my prescribed exercise plan
7. Obtain identification as a patient with diabetes, for prompt assistance in case of an emergency
8. Ask my physician and other members of my health-care team to explain any aspect of my care that I do not entirely
I understand that if I do not monitor myself carefully, there is a risk of hypoglycemia.
I also understand that if I do not strive to normalize my blood glucose, I am at increased risk of developing the
complications of diabetes mellitus.
My signature indicates that I have read and understand the above agreement.
I agree to provide the leadership for the diabetes self-management team. Team members will be available to answer
your questions and help you self-manage your diabetes. I will continue to encourage you to maintain the best possible
control of your diabetes.