A systemic focus on biomedical markers and diabetes
diabetic, diabetes
DIABETES
Although CSP training emphasised working with patients as persons and stressed the value of health professionals attending to patients’ concerns and priorities relating to their diabetes and broader wellbeing, participants were aware that the primary outcome of the PACE-D trial was HbA1c, and that their teamlet and polyclinic performance was judged on HbA1c and other biomedical markers, with implications for salary bonuses. Some participants also recognised that several features of the care planning letter (which they often referred to as the “results letter”) tended to encourage patients to concentrate on biomedical markers.Health professionals managed these potentially competing demands with different emphases. This had implications for their view of what was important for them to hear in CSP conversations as well as their assessment of what was agreed with patients and of subsequent outcomes.Health professionals who conveyed a narrower view of the purpose of CSP worried that inviting patients to talk about their concerns could expose them to a long list of issues to be addressed, many of which would be irrelevant to the patient’s diabetes or were not things health professionals could help with. These health professionals sometimes acknowledged that it could be useful to find out about a person’s daily routine and key concerns to be able to tailor their professional advice about diet and exercise (to help ensure action plans to achieve biomedical goals were feasible), but their reasoning about this was somewhat narrowly instrumental.In contrast, health professionals who put more emphasis on the idea that the CSP conversation should focus on the person and what mattered to them seemed also to value learning more about patients’ lives and perspectives. They appreciated getting to know people better and being able to empathise and allow a patient to feel “more human” in the conversation. Some reported a range of benefits of this broader understanding contingent on the situation. We noted above that some participants had developed strategies to “fish out” a sense of patients’ priorities even from those who seemed less able or willing to respond to unfamiliar requests to communicate their goals. A few of those with broader views of the purpose of CSP had explicitly formulated questions to encourage patients to think broadly about what mattered in their lives.Another key point of variation was whether and to what extent health professionals saw a need for a clear action or action plan to conclude a CSP conversation – particularly to know or have evidence that they had done something to address poor diabetic control. Some participants seemed determined to have a professional or biomedical last word if a person appeared disinclined to do anything for themselves to improve on poor diabetes control, reverting to “usual” consultation practice with an emphasis on their own perspective and reiteration of their advice that the patient really should be taking action. For others, in contrast, CSP training had taught them or supported a previous view that it was not necessarily a professional failure to do nothing, or not emphasise a point that a patient already knew; in some circumstances the kinds of outcomes identified in Table 