SAN DIEGO -- Providers will be much more successful in preventing diabetes progression if they avoid judgmental words and phrases that have the effect of putting patients down and discouraging them from having confidence in managing their own care.
That's the message from members of a committee that submitted its "Joint Consensus Statement on the Use of Language in Diabetes" for publication to the American Diabetes Association and the American Association of Diabetes Educators.
Words on the no-no list include "uncontrolled," "non-adherent," and any "ic" words like "diabetic," which tend to make patients feel disrespected, hopeless, and dismissed, they said.
Other problematic terms include the use of "good," "bad," or "poor" to convey a patient's blood glucose levels. Rather, they said, it's better to explain what is a safe or unsafe level, or what is a target level, using numbers and facts rather than what the patient might see as a putdown of their character or their value as a person.
"Language conveys meaning and can reflect bias that will affect outcomes, even when you're not aware of it," said , a clinical and research psychologist at the Behavioral Diabetes Institute in San Diego. "If you're talking about a patient as 'non-compliant,' even before you go into the room, I guarantee you that they feel that from you, even if you're not calling them that to their face," she said.
Any subtle tone of voice or inflection that conveys a sense that diabetes is the result of a character flaw or a failure of personal responsibility, or that they are a burden on the healthcare system is counterproductive, experts said. Patients will not do as well at getting control of their diabetes.
Guzman -- along with , a certified diabetes educator and nurse at Teachers College Columbia University in New York and committee chair, and , director of clinical education for the Joslin Diabetes Center in Boston -- made the remarks during a session titled "Why Language Matters" at the American Diabetes Association meeting here on Sunday.
Not the Word Police
Although their proposed statement does include a list of ill-advised words and phrases to avoid, Maryniuk said, "it's not about being the word police." Rather, she said, providers should "think about the meaning, and the whole patient, and the conversation you're having with them." Providers should try to think of circumstances that caused the patient to progress, such as inability to purchase or take medications, rather than that the patient has failed or just isn't intelligent enough.
Guzman noted that clinicians' negative attitudes about patients who have been unsuccessful in managing their conditions can result in the physician not bothering to provide follow-up resources, like wound care or cardiac rehab or behavioral health, and may not take time to answer questions and concerns. "Why bother, they are not going to be adherent anyway," she said in an email.
Maryniuk said she is optimistic the consensus statement will be accepted and published, in part because the ADA last year officially banned use of the word "diabetic" from publications when referring to individuals with diabetes. In its , the organization said it will continue to use "diabetic" when referring to complications, like diabetic retinopathy.
Guzman noted during an email conversation that a good example of patient harm from insensitive language came last month, when director of the White House Office of Management and Budget, Mick Mulvaney, spoke about people with diabetes as making a bad lifestyle choice. In the context of setting policy on taxpayer-supported healthcare benefits, he compared helping cover expenses of Jimmy Kimmel's newborn son's heart defect as acceptable as opposed to covering medical costs for people with diabetes.
"That doesn't mean we should take care of the person who sits at home, eats poorly, and gets diabetes," Mulvaney was widely reported as saying, as if everyone with glucose management challenges could have prevented their diagnoses.
Mulvaney's remarks prompted a stern from the Diabetes Advocacy Alliance, an organization of 13 groups such as the ADA, the Endocrine Society, and the American Association of Clinical Endocrinologists.
Diabetes, the alliance said, is "not solely caused by excessive eating and lack of physical activity," but often occurs in "millions of people who follow all nutrition, eating, and exercise guidelines. Family history, age, high blood pressure, race, ethnicity, and a history of gestational diabetes (either during pregnancy or in a child's mother), environmental factors, and genetics also play significant roles."
Five Recommendations
The 10-person committee presented five recommendations:
1. Use language that is neutral and non-judgmental, based on facts, action or physiology/biology.
Don't say, "Your diabetes is not in good control. It seems that your efforts with meal planning, exercise, and metformin have failed, so it's time to add another medication."
Instead say, "Your recent A1C level is 8.5. That is above the target goal of 7.0 we discussed. I'm thinking that adding another medicine that works in a different way could help. How does that sound?"
2. Use language free of stigma in referrals.
Don't say, "While I'm willing to refer this patient to you (an RDN), I doubt it will do any good as she has been obese for a long time, and is unmotivated and in denial. She has not done anything I've suggested."
Instead say, "I'm referring a new patient to you. She has a BMI of 35 and while I've suggested she cut back on high calorie foods, it has not resulted in weight loss. Let me know what you learn and what you'd recommend."
3. Use language that is respectful, inclusive and imparts hope.
Don't say, "Mrs. Lee, I see that you've been non-compliant with blood glucose testing as you're not doing it after meals as we discussed. You really should be doing this."
Instead say, "Mrs. Lee, I see you've been successfully checking fasting blood glucose two to three times this past week. Great work. What might make it easier for you to also check after meals a few times?"
4. Use language that fosters collaboration.
Don't say, "Mr. Smith, I see that you didn't fill your prescriptions. Let me see your blood glucose log, please."
Instead say, "Mr. Smith, I see that your last A1C result is 9.2%. Do you have concerns you'd like to discuss ... perhaps about many challenges you face taking medicines?"
5. Use person-centered language.
Don't say, "Diabetics who suffer from hypertension should follow a DASH (Dietary Approaches to Stop Hypertension) diet."
Instead say, "People with diabetes who also have hypertension may benefit from learning about the DASH approach to meal planning."