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Understanding Physicians’ Challenges When Treating Type 2 Diabetic Patients’ Social and Emotional Difficulties

OBJECTIVE To explore physicians’ awareness of and responses to type 2 diabetic patients’ social and emotional difficulties. RESEARCH DESIGN AND METHODS We conducted semistructured interviews with 19 physicians. Interviews were transcribed, coded, and analyzed using thematic analysis. RESULTS Three themes emerged: 1) physicians’ awareness of patients’ social and emotional difficulties: physicians recognized the frequency and seriousness of patients’ social and emotional difficulties; 2) physicians’ responses to patients’ social and emotional difficulties: many reported that intervening with these difficulties was challenging with few treatment options beyond making referrals, individualizing care, and recommending more frequent follow-up visits; and 3) the impact of patients’ social and emotional difficulties on physicians: few available patient treatment options, time constraints, and a perceived lack of psychological expertise contributed to physicians’ feeling frustrated, inadequate, and overwhelmed. CONCLUSIONS Recognition and understanding of physicians’ challenges when treating diabetes patients’ social and emotional difficulties are important for developing programmatic interventions.

CONCLUSIONS-Recognition and understanding of physicians' challenges when treating diabetes patients' social and emotional difficulties are important for developing programmatic interventions.
Diabetes Care 34:1086-1088, 2011 A recent study reported physicians' awareness of diabetic patients' social and emotional difficulties (1,2); however, whether physicians can integrate this information into their clinical practice is not known. Diabetic patients experience disproportionately high rates of social and emotional difficulties (3)(4)(5)(6)(7)(8), which are associated with poor glycemic control (9) and may interfere with the performance of self-care behaviors (10,11). Understanding how physicians perceive the severity and consequences of patients' social and emotional difficulties is important for developing solutions for these problems. We explored physicians' awareness of and responses to social and emotional difficulties in type 2 diabetic patients.
RESEARCH DESIGN AND METHODS-We used purposive sampling (12) to interview English-speaking endocrinologists and primary care physicians with at least 5% of their practice consisting of type 2 diabetic patients. We recruited physicians from the greater Boston area. The Joslin Diabetes Center Committee on Human Subjects approved the research protocol, and all physicians provided informed written consent.
We devised a structured interview guide and field-tested it for flow and clarity of the questions. Interviews lasted 30-60 min and were digitally audio-recorded and transcribed.
We performed content analysis (12) by categorizing key words and phrases to identify themes using NVivo 8 (13). This process continued until data saturation was reached. To support credibility/ validity and dependability/reliability of the data, we triangulated data sources, methods, and investigators and tracked the decision-making process. Physicians also suggested individualizing care and requesting more frequent follow-up visits:

RESULTS-Nineteen physicians (
For some people it totally shuts them down and they're immobilized. . .I try to understand that and then I tailor my approach so that I don't overwhelm somebody because I think that's the best way to be effective in getting their A1C better. (Physician 114M) The impact of patients' emotional difficulties on physicians Treating patients with social and emotional difficulties appeared to take a toll on the physicians. Physicians commented on the stress and anxiety of struggling to adhere to the time constraints of a standard medical visit: CONCLUSIONS-In our study, physicians recognized the frequency and seriousness of social and emotional difficulties in diabetes care. Many reported that intervening with these difficulties was challenging. Limited patient treatment options, time constraints, and a perceived lack of psychological expertise contributed to physicians' feeling frustrated, inadequate, and overwhelmed. The emotional toll from treating patients with social and emotional difficulties may put physicians at further risk for burnout (14,15).
Similar to our study, the Diabetes Attitudes, Wishes, and Needs (DAWN) study found that physicians recognized that a majority of their diabetes patients had psychosocial problems (1). These physicians also reported a lack of expertise in their abilities to identify and evaluate patients' psychosocial problems and/or provide needed support (1). These findings, along with ours, highlight the extent of the challenges physicians face in treating diabetic patients with social and emotional difficulties.
In conclusion, recognizing and understanding physicians' challenges are important as a first step for developing programmatic interventions. The development and testing of efficient, brief interventions that physicians can use are necessary but should not replace mental health referrals. Furthermore, medical education and training should address psychosocial difficulties that frequently occur in patients with chronic illnesses. Finally, given the brevity of treatment visits and the amount of medical information that needs to be addressed, physicians may benefit from a multidisciplinary team approach where other team members complement care by supplying assessment and treatment for patients' social and emotional difficulties.