1,000 Years of Diabetes Wisdom. David G. Marrero

based on a positive long-term relationship and continued effort. I am consistently seeing more change in my patients regarding weight loss, increased physical activity, and cholesterol reduction. Remarkably, 2002 is when I read the first studies that diabetes can be prevented with lifestyle change. I believe that much of the failure of my patients in changing their lifestyle was because I didn’t believe that people could do this. Nancy has helped me change my view on that, and suddenly, I see my patients losing weight, exercising, and feeling better about themselves. How much was I getting in their way? How much was I getting in my own way?

      I should also note that I began exercising daily on December 9th, 2000, as I was preparing to lecture the first-year medical school class about the benefits of physical activity. I have lost 25 pounds and have kept it off now for almost four years with maintained exercise. Perhaps some of my success has been noticed by my patients and perhaps it is helping my attitude about whether or not they can make these changes.

      Patients Find Their Own Answers

      by Ken Ohashi, physician, Tokyo, Japan

      It was quite some time ago that I first learned about the empowerment approach. At that time, I was frustrated with the way I delivered care to people with diabetes. I was not at all confident that what I did was helping them manage their diabetes. I felt my job was to point out my patients’ faults in their self-management of diabetes, even though they were often doing fine.

      I was afraid of being accused of not making my patients compliant. For example, when patients refused to take insulin, I tried everything I could think of to persuade them to do what I thought they should do, of course, often in vain. Although the idea of empowerment seemed to be ideal in helping people with chronic diseases, I didn’t know where to start.

      Then I met Mrs. Y, who had type 2 diabetes for nearly 25 years. Although she needed insulin for glycemic control, she refused to take it. Se seemed unmotivated, noncompliant, and uninterested in her diabetes. I had done everything to persuade her. I talked about the physiology of insulin, showed the needles and devices for insulin injection, and told stories of possible complications that would occur if she didn’t follow my advice. All of my efforts just went down the drain.

      In desperation I asked her, “Well, what would you like to do?” This simple question changed our relationship drastically. She began to talk about how and why she hated insulin and how many efforts she had made to avoid going on insulin. I was amazed at just how fluent and eloquent she was. I realized that my previous assumptions about her were wrong and irrelevant. I learned from her the value of asking patients about their problems and issues.

      This revelation relieved me quite a bit. Patients find their own answers. With good questions, we as health care providers can help patients to look inside, know themselves, find their strengths, and recognize their desires and fears. Asking questions is also the best way to stimulate genuine curiosity with our patients.

      Now I feel that being with patients is like taking a journey. Their language, foods, and customs sometimes seem strange but that’s the way they live their lives. As a guest, I must respect the differences I encounter. Each encounter with a patient is an opportunity for an exciting journey. My patients, colleagues, friends, and family have all helped me learn the power and value of really listening.

      Strength of the Human Spirit

      by Theresa Garnero, nurse, San Francisco, CA

      Setting personal goals is the cornerstone of diabetes self-management education. We are taught about the importance of helping people be realistic with their plans. In repeated individual and group settings, I thought I was supporting a science-based approach of change theory by dissuading folks not to overdo it when they set a goal. One person changed all of that.

      Kristen and I met during an individual assessment after she was newly diagnosed with type 2 diabetes. Her anger was ubiquitous. My attempts to soften the blow of her diagnosis through the use of gentle humor didn’t faze her. Her partner responded positively, but not Kristen. After she left this first educational encounter, I wondered if we connected at all, and seriously doubted she’d return to class.

      A few weeks later, Kristen did show up for class. She hardly made eye contact and only spoke when direct questions were asked. She seemed overall disengaged. Kristen was struggling with the acceptance of her diagnosis. When it came time to set a personal, self-care management goal, she chose to exercise at 60 minutes a day, every day. Since she had not been exercising at all, this goal went well above what was considered realistic. I tried all the typical statements, “How about starting out with making small changes, then build up to an hour a day?” and “If you set a goal, for example, of exercising three times a week for 30 minutes, then if you do more than that, you would exceed your goal.” She wouldn’t budge, until I muscled my way into her changing her goal to 30 minutes of walking, five times a week.

      Over the next few weeks, Kristen continued to return to class, showing she had met her unrealistic goal of walking an hour a day, every day. She was losing weight. She was less angry, interacted with other participants, and even started to laugh at some of the class-driven humor. I thought that it was great to see someone who made such a dramatic change in their self-care behavior and didn’t give it much thought. Months later, well after the completion of the diabetes program, the phone rang.

      Kristen called to say, “I’m calling to thank you and let you know that you really pissed me off.” She caught me completely off guard. After working with her over the course of the program, I felt we had developed a strong connection and contributing to her anger was not something I would have ever guessed. She explained, “When I was making exercise a personal goal, I felt you didn’t have any confidence in me. I knew you wanted me to succeed, and my logical mind knew that you didn’t want to see me set myself up to fail, but it pissed me off. I thought ‘I’ll show her. I’m going to exercise every day for 60 minutes!’ and I did. Now it feels great to exercise every day. You helped me to turn over a new leaf. I have a new lease on life. Thanks for pissing me off.” We shared a little laugh. I apologized for being too rigid, and it got me thinking.

      It goes to show that we never really know how we can affect someone’s life. Kristen reminded me the importance of partnering with a person on his or her journey instead of pushing an agenda in the name of what science shows is best. I lost sight of the individual in this scenario. I did not allow Kristen to discover what would work best for her, at her pace, on her terms. Personal goals are just that—personal. Now if someone sets a goal to what I assess as being unrealistic, I still provide the information about making small changes over time, but I don’t push it. I make sure that person decides which route to take.

      Appearances Can Be Deceiving

      by Martha Funnell, nurse, Ann Arbor, MI

      As part of a peer-to-peer project at the local Veterans Administration Medical Center, I was to lead a training session on communication skills and active listening so that the patients could work effectively with each other. All of the participants were Vietnam Veterans who had type 2 diabetes. Before the session began, I listened to them talking about their war experiences and the difficulties they had encountered in the many years since their return to the U.S., including the development of diabetes and its complications. Although I had led this type of session many times with health professionals, I felt very intimidated about the content I was to present to very tough men, and whether it would be viewed as meaningful by them.

      During the session, the patients seemed to be listening and were asking questions, with the exception of Mr. O. He was somewhat unkempt looking and didn’t speak or look up the entire time. I finally stopped trying to engage him, feeling that he probably was not getting anything out of it anyway.