Primary Care Physicians’ Responses to Treatment Burden in People With Type 2 Diabetes: A Qualitative Video Analysis in China

Dear Editor,

We read with keen interest the article by Lin et al. examining how primary care physicians in China respond to the treatment burden experienced by individuals with type 2 diabetes (1). As family physicians practicing in Spain, we recognize many parallels in the daily challenges of delivering diabetes care, although the structural and cultural contexts naturally differ. We wish to share our perspective on how their findings resonate with, and occasionally diverge from, our own setting.

In particular, Lin et al. highlight a paradox: longer consultations did not necessarily improve the physician’s capacity to address the multifaceted burdens of medication management, administrative tasks, and lifestyle modifications. While the median appointment length in their academic clinic setting reached over twenty minutes, almost 40% of patient-initiated concerns remained unanswered. In Spain, by contrast, consultation times in community health centers are typically shorter, often around 7 to 10 minutes, which can restrict our ability to explore patients’ challenges in depth. This situation is not unique to Spain. A global systematic review noted that the average primary care consultation time is below 10 minutes in many countries, emphasizing the universality of time constraints (2). Lin et al.’s study suggests that quality, rather than length, is central to identifying patient concerns early and ensuring each issue is duly addressed.

One of the most noteworthy elements in the article is their observation that treatment burdens, such as medication complexity or lack of sufficient personal resources, frequently emerge late in the consultation—beyond the midway point. In our experience, this delay might reflect a tendency for both clinicians and patients to prioritize routine clinical checks (eg, reviewing blood glucose logs, adjusting medications) before delving into the more personal or time-consuming matters of psychosocial support. Research on minimally disruptive medicine, for example, underscores how unrecognized burdens accumulate when health professionals do not systematically inquire about daily treatment demands (3). We have found that dedicating even a brief initial moment to invite patients to share their concerns can help surface such issues earlier, which is consistent with principles of patient-centered communication.

Lin et al.’s study also underscores that, when physicians did engage with these burdens, they often relied on strategies like active listening, shared decision making, and confidence building. These findings align with the documented benefits of motivational interviewing, which has been shown to improve adherence and glycemic control (4). However, the authors observed a limited application of this method. In Spain, we are increasingly integrating motivational interviewing and other advanced communication skills into our practice to support lifestyle modifications, although time pressure sometimes hinders a full implementation. We concur that structured training in these approaches should be pursued further, as it may allow clinicians to quickly pinpoint key burdens and address them more effectively.

Another aspect we find remarkably relevant is the article’s mention of nurse-led care and team-based interventions. In our health centers, nurses frequently conduct educational sessions on self-management, diet, and physical activity, often complementing a physician’s role (5,6). This multifaceted team approach can reduce the administrative and educational load on physicians while giving patients more time to discuss practical day-to-day challenges. Lin et al. rightly note that such multi-professional collaboration could mitigate the burden of fragmented care and ensure continuity in following up on complex medication regimens, dietary changes, and coping strategies.

We also agree that telemedicine could play a more prominent role in alleviating treatment burden, as suggested in the article when describing online follow-ups. During the recent pandemic, many Spanish health centers accelerated the implementation of video or phone consultations, and preliminary evidence points to their usefulness in diabetes management (7). Patients who struggle with transportation or mobility barriers may find telehealth both more convenient and less disruptive to their daily lives. Nonetheless, digital illiteracy and varying access to reliable technology remain barriers that must be considered, particularly for older populations or patients residing in remote areas.

A recurring theme in Lin et al.’s analysis is how administrative barriers —such as insurance documentation or prescription refills— increase the daily burden of disease. While the Spanish National Health System offers relatively comprehensive coverage, bureaucratic tasks do consume much of our limited consultation time, reducing opportunities for patient-focused dialogue. As the World Health Organization has emphasized, system-level interventions are essential for addressing the complexity of chronic disease management (8). National guidelines, such as those from the National Institute for Health and Care Excellence, consistently recommend a streamlined workflow and better coordination among health professionals to reduce fragmentation and administrative overhead (9).

Finally, we appreciate Lin et al.’s acknowledgment of cultural factors. In Spain, dietary habits influenced by the Mediterranean diet, familial support structures, and specific social expectations can affect not only how patients perceive treatment burden but also how clinicians tailor advice (10). Incorporating a cultural understanding into consultations, even briefly, can reassure patients that recommendations are grounded in practical reality and respect individual preferences. This sensitivity may encourage adherence and reduce the sense of burden.

Overall, Lin et al.’s article provides a valuable lens through which we can examine our own practices in Spain. Although our contexts differ, the fundamental challenge of how to best manage the sometimes hidden burdens of type 2 diabetes is universal. We support their conclusion that improving consultation quality and systematically seeking out patient concerns, especially at the start of each visit, may prove more important than extending appointment lengths alone. By refining communication skills, engaging nursing staff and multidisciplinary teams, taking advantage of telemedicine, and reducing administrative tasks, we can strive toward truly patient-centered diabetes management. We hope more comparative research will shed further light on these strategies, ultimately guiding us toward a more efficient and compassionate primary care model.

1. Lin K, Yao M, Andrew L, Lin R, Li R, Chen Y, et al. Primary Care Physicians’ Responses to Treatment Burden in People With Type 2 Diabetes: A Qualitative Video Analysis in China. Ann Fam Med. 2025 Jan 1;23(1):52–9.
2. Irving G, Neves AL, Dambha-Miller H, Oishi A, Tagashira H, Verho A, et al. International variations in primary care physician consultation time: a systematic review of 67 countries. 2017 Oct 1 [cited 2025 Feb 15]; Available from: https://bmjopen.bmj.com/content/7/10/e017902
3. May C, Montori VM, Mair FS. We need minimally disruptive medicine. 2009 Aug 11 [cited 2025 Feb 15]; Available from: https://www.bmj.com/content/339/bmj.b2803
4. Rubak S, Sandbæk A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract. 2005 Apr 1;55(513):305–12.
5. Carey N, Courtenay M. A review of the activity and effects of nurse-led care in diabetes. J Clin Nurs. 2007;16(11c):296–304.
6. Guo Z, Liu J, Zeng H, He G, Ren X, Guo J. Feasibility and efficacy of nurse-led team management intervention for improving the self-management of type 2 diabetes patients in a Chinese community: a randomized controlled trial. Patient Prefer Adherence. 2019 Aug 14;13:1353–62.
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8. Organization WH, others. Global Report on Diabetes. World Health Organ. 2016;
9. Overview | Type 2 diabetes in adults: management | Guidance | NICE [Internet]. NICE; 2015 [cited 2025 Feb 15]. Available from: https://www.nice.org.uk/guidance/ng28
10. Estruch R, Ros E, Salas-Salvadó J, Covas MI, Corella D, Arós F, et al. Primary Prevention of Cardiovascular Disease with a Mediterranean Diet. N Engl J Med. 2013 Apr 4;368(14):1279–90.