Encounters by Patients With Type 2 Diabetes—Complex and Demanding: An Observational Study

Dr Parchman and colleagues have in their paper carefully described the content of consultations in primary care with type 2 diabetic patients1. This description is based on well recognized markers of process in diabetic care which deal with one dimension of quality. Not surprisingly more of the process markers of diabetic care were demonstrated in consultations categorized as being focused on diabetes compared with consultations where the presentation was focused on a new acute presentation. Encouragingly even in these consultations primary care physicians were able to undertake some diabetic care consistent with the consultation model proposed many years ago by Stott and Davis2. Conversely and very much in keeping with the way of primary care 72% of patients attending for chronic disease review mentioned a symptom or complaint during the encounter. In attempting to explain the association between reduced numbers of indicated services and reduced time between scheduled appointments the authors suggest that this may be because physicians are aware of the deficits in the care during one consultation and defer some activity to the next; a proposition that seems entirely reasonable given the time constraints and range of problems that primary care doctors have to deal with.

In their discussion the authors suggest disease-specific clinics as a potential solution and also cite one reference suggesting complexity theory as a lens through which to consider change3. In respect of disease- specific clinics these are common in UK family medicine and have been successful in raising standards of care but rest assured that patients still bring along other problems to be dealt with. Complexity Theory does indeed have much to contribute to our understanding of diabetes4 as a clinical entity, of consultations with diabetics and how diabetic care can be delivered. Importantly it warns us of the dangers of reductionist solutions and implores us to beware the possible consequences of such approaches in terms of doctor-patient relationships, clinical and organizational consequences. Whilst special disease-specific clinics provide a space in which diabetic care can happen holistic care will be threatened if clinical care is reduced to achieving a limited set of process goals.

1. Parchman M, Romero R, Pugh J. Encounters by patients with type 2 diabetes - Complex and demanding: An observational study. Ann Fam Med 2006;4(1):40-45. 2. Stott N, Davis R. The exceptional potential in each primary care consultation. BJGP 1979;29:201-5. 3. Miller W, Crabtree B, R M, Stange K. Understanding change in primary care practice using complexity theory. J Fam Pract 1998;46:369-376. 4. Holt T. Complexity and Diabetes. In: Holt T, editor. Complexity for clinicians. Oxford: Radcliffe, 2004:69-82.

Competing interests:   None declared