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Steve: We have with us a special guest, Mark Peyrot PhD. He is a professor of Sociology at Loyola University Maryland and professor of Health and Social Sciences at Bergen University College in Norway. We can start by you telling us a little bit about yourself and what you do.
Dr. Peyrot: I have been working in the field of behavioral diabetes research for a little over 30 years and the goal in my work is to try to understand what is happening with people who are impacted by diabetes. The person with diabetes, their family member, and social network, and also look at the healthcare providers for diabetes from a humanistic prospective to try to understand how diabetes impacts them and what they do to help manage diabetes and live better or treat it better.
Steve: We will be discussing here the new psycho-social position statement from ADA, which I presume you helped to work out?
Dr. Peyrot: Yes, I did.
Steve: And also recommendations for the psycho-social care of people with diabetes, kind of an overview.
Dr. Peyrot: Yes.
Steve: How did this initiative get started?
Dr. Peyrot: Back in the early 2000’s I did an international study of psycho-social aspects of diabetes amongst people with diabetes and their healthcare providers. This included a number of countries, many in Europe, some in other continents, and in United States. Through that process, I came to know many people who are the important players, researchers, and policy makers in the field and found that there were a number of countries that had established guidelines for how to deal with psycho-social factors – the impact of diabetes on the person’s psychological well-being, on their quality of life, on their relationship with their family members. It just seemed a tragedy, from my perspective, that United States, one of the most developed countries in the world, was lagging behind some of the other countries. I came to the ADA, and talked to a number of leaders there about us developing that kind of a program. They immediately said that’s a great idea, and we made a minor change to the medical standards incorporating a brief statement about psycho-social issues, like depression, anxiety, and so forth. Soon, we started an initiative to write a book collecting the views from experts in the area, which was later published by ADA. We followed that up by an initiative to actually pull together a formal position statement by ADA, which would be something that would try to influence providers, who are members of the ADA, or those who are responsive to the ADA guidelines to help them focus on how to better work with these kinds of issues. That has taken about 15 years, from the very first ideas about such a set of standards, to the position statement that came out at the end of 2016.
Steve: What is the purpose of the guidelines?
Dr. Peyrot: The purpose of the guidelines is to get physicians and healthcare providers who support physicians and work with them, including certified diabetes educators, mental health professionals, to address the underlying problems that lead to the kinds of lives people have when they are living with diabetes. Whether that be depression, barriers to effective self-care, whatever it is, to look beyond the biological and pharmacological properties of our treatment regimens and try to understand the human element behind them, that’s really the key in how people use the treatments that have available. Because in words of C. Everett Koop, “medicines don’t work in people who don’t take them” number one; and number two: you can have good health but not have good quality of life because you are making sacrifices that detract from your quality of life. So, the goal is to try and optimize not just one single parameter, like blood glucose levels, but a variety of parameters that are related to one’s health and well-being.
Steve: What are some of the key recommendations?
Dr. Peyrot: There are 5 key recommendations, major ones, that are over-arching, that cover everything. In the position statement, we also go into a number of sub-areas, and give a number of more specific focused guidelines for how they should work. One of the very first ones is dealing with the mental health states of people with diabetes. We know that diabetes has a lot of comorbidity with psychological distress, whether it be depression, anxiety, diabetes-related distress, and variety of problems with managing diabetes. We said we need to deal with these, not merely when they are diagnosable, but also when they are sub-clinical levels, which are already disturbing people’s quality of life and the ability to take care of themselves. Another aspect that we talk about is diabetes self-management. We know that people may have good intentions, but it may be difficult for them to try and achieve their goals. We feel that the best way to help patients take better care of themselves is to understand what kinds of barriers and problems they are facing and then help them deal with those barriers. So, looking at both mental and physical health.
Steve: Are these guidelines for psychologists, diabetologists, or where most patients go with type 2 diabetes and that is PCPs?
Dr. Peyrot: That is a very good question. I think in the past what has tended to happen is that anything that seems to involve the psychological aspect has been turfed to the mental health professionals. The problem is, there is not enough of them to really be able to handle all the patients who need help with these sorts of problems. The standards are written in a way that they help the PCPs and anyone else who is the primary care for a person with diabetes, because some people get their primary care from a diabetologist, especially people who have complex disease conditions like type 1 diabetes, or complications. So whoever is that first-line person who is providing care to that patient, and it may even be CDEs in some cases, they need to understand what those issues are, and one of our things is you need to screen for it. You cannot help deal with the problem if you don’t know that it exists. We have suggestions for when and under which circumstances they ought to screen for these kinds of problems. And then to take an integrated strategy, which is to try to do what they can do, to deal with these problems. That may not be providing psychological treatment, but it may be to help patient think about the things that are troubling their life and to try find ways to get over those barriers. How to deal with the pain of taking an injection? How to deal with the fear of hypoglycemia? These are the kinds of things that healthcare providers, PCP’s and others, can work with the patient on and have a relatively short and focused interaction that may be adequate in itself. But, if it’s not adequate, then they need to track the fact that this hasn’t worked and that something more is required, just like with any other health condition. If the PCP can’t take care of it themselves, it is at that point that they need to make a referral. One of the guidelines, one of the recommendations is that they need to do it when it’s detected. To not let it be a thing that lingers on for years and years before it gets any attention, but to recognize it when it occurs, to try to intervene, and if that intervention is not successful, to refer them to somebody who has got more expertise in working with these kinds of problems.
Steve: As a diabetes educator, I agree one thousand percent to what you’re saying. But, let’s talk about realistic expectations. They come in to see the doctor, and they have 15 minutes. They have to talk about their blood pressure, about their diet, eye care, kidney care, hearing, skin, and just about everything, and the doctor runs out of time. So, how do you implement it?
Dr. Peyrot: First of all, we say that the thing you have to deal with – you always have time to deal with. What we want to do is elevate these conditions to the ones that have to be dealt with. Depression is a very serious disorder. It has massive consequences for complications, for life expectancy, and so forth. It is what is sometimes called the silent killer. You may not see it on a test result, but that may be something that is shortening someone’s life dramatically, causing them to smoke, to not exercise and gain weight, to not take care of their diabetes. If you don’t address the depression, everything else you do won’t be successful. We talk about the step approach, one – you can screen before they come in, so when they come in you already know if they are depressed or not. There are simple questionnaires that can be filled out that will give you a very good idea whether this is a high-risk patient, or a low-risk patient. There is a number of informal questions you can ask in an interview that will tell you if this is a problem that needs to be followed-up or doesn’t need to be followed-up. There are ways of doing this, that are not only effective, but also efficient. That use the clinician’s time in a way that yields a major return on investment. That is really what is important. What are the actions that will give you the most impact? Those are the ones you want to engage in. We believe that these factors are important and that people need to take a very focused approach. We don’t want them to spend a lot of time just chit-chatting if they don’t have the time. There are ways to do this efficiently that yield the results without a lot of time.
Steve: What are some of the potential strategies for implementing the guidelines?
Dr. Peyrot: I mentioned one of them in my response to the last question. Screenings can be set up, so while the patient is sitting in a doctor’s or whoever’s office, they can fill out these questionnaires and they can be easily and quickly scored. If they are on a computer, the computer will just pop out a score, and it will say this is a high-risk score, or a low-risk score, and this is something that should to be followed-up, or something that doesn’t need to be a focus of the current visit. That would be one strategy, to use the waiting room time to try and gather this data. The other strategies are like I said, ask two quick questions about depression, if the patient answers either those questions yes, that indicates that there is something there and needs additional attention. If you can get something integrated in the electronic health record – that’s golden. That then becomes one of those things the providers need to deal with. If the practice can commit to doing that, that makes it a part of the standards by which providers are evaluated and becomes a target they address themselves to. There is a number of strategies, there is no a secret magic bullet that is going to solve all the problems, but we want to get people thinking about how they can make progress on this. The most important thing is to move forward from where you are, not whether you are perfect already, but if you are not good enough, how do you take first steps towards making it better.
Steve: Looking at the title of your presentation again, and I saw a program on TED talk recently, on what makes a good presenter. They said, there are presentations with beautiful slides, maybe a hundred of them. And, when people walk out they can’t remember a single slide. It’s a waste of that person’s time. What makes a good presenter is someone who presents an idea or a concept and they use it in their practice; that is what makes everybody happy and successful. If there is only a couple of things that you want your audience to take away – let’s assume the audience is nots endocrinologists, but PCPs, pharmacists, nurses, dieticians – what would you like them to take away from your presentation?
Dr. Peyrot: You need to assess peoples’ feelings about diabetes in their life to understand whether they are feeling burdened or overwhelmed by it. Because that is bad for their mental health, which in turn translates into physical health, and also bad for their diabetes self-management because they find it difficult to do. Identifying those issues, where people need psychological care and seeing that they get that care is key. Second one is, that even if people don’t have severe psychological distress, there are still a lot of psychological factors that are affecting their ability to take care of themselves – we call those psychosocial barriers. Whether that is a spouse who wants you to eat cake all the time because they bake cakes, and that doesn’t work for you as a person with type 2 diabetes, or whether it is somebody who needs help testing their blood glucose, what we want [providers] to do is find out from the patient what they are having the most difficulty doing about taking care of diabetes, because that is often what distresses them out the most and is something they have a desire to change on. When the doctor identifies something that the patient wants to change, that’s the low-hanging fruit, that’s the time when you can go and say: I can help you solve that problem, which will help them do better and it increases their trust and belief in their healthcare provider, to know their healthcare provider is not just scolding them and telling them what they are doing wrong, they are actually helping them do better. Once you get that, you have a team approach to medicine. Where the patient and the provider are working together towards the same goals, instead of working against one another, because that is not likely to be very successful. If we can get them to focus on those two things – identifying distress when it needs to be addressed and helping patients make the changes they want to make that will be beneficial to their health. If we can do that, we are achieving the goals of what the guidelines are trying to achieve.
Steve: I have to say in interviewing not just you, but other people in the field of diabetes, that everyone I’ve interviewed has a true passion for what they do, and I have to congratulate you. I can tell you certainly have the passion. I want to thank you for your time, and enjoy the rest of your stay here in San Diego.
Dr. Peyrot: Thank you. I love California, I grew up here!