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- Focus on the prioritiesShow More
We need to focus on the priorities.
For prevention of diabetes, lifestyle control should be the top priority, and the elements of the chronic care model can be very important.
For treatment of diabetes – later in the natural history of glucose intolerance, after beta-cell mass and function are reduced – glucose control will depend largely on appropriate intensification of therapy by health care provid...
Competing Interests: None declared. - Response to Dr. Phillips regarding Agenda Items on the TableShow More
To answer the first question raised by Dr. Phillips will require a much more in-depth analysis of our rich data set than we have been able to do thus far. However, two points are worth mentioning. First, there was no relationship between time from the most recent A1c measurement and the likelihood of a change in medication for an elevated A1c. So physicians were not delaying a change in therapy because the A1c was mor...
Competing Interests: None declared. - Re: Response to Dr. HicksShow More
Was diabetes an appropriate target, and on the table?
Clinical inertia implies that a change in therapy is clinically indicated. To better understand the behavior of the providers studied by Parchman and colleagues, we need to know whether a change in therapy indeed was appropriate; in evaluating failure to intensify therapy for diabetes when A1c is high, it's important to have the right denominator. Was the a...
Competing Interests: None declared. - Response to Dr. HicksShow More
Concerning languages preference, many patients and physicians were Spanish speaking in this sample.
Dr. Hicks makes an excellent point about why there was no change in medication when the most recent A1c was above goal. It is entirely possible that some of the observed visits occured shortly after a visit where therapy was intensified for A1c above goal. But the observed visit was too soon to judge the full imp...
Competing Interests: None declared. - Treat the Patient---NOT the CheckmarkShow More
Physicians take care of patients---not checkmarks on a to-do list of care management chores. If family physicians believe in patient-centered medicine, then we need to allow the patient a role in setting the agenda for the visit. The article by Haidet, “Jazz and the Art of Medicine”(1), in the previous Annals made a wonderful point about why physicians can‘t just read the script (musical score) as written. We must use im...
Competing Interests: None declared. - f/u questionsShow More
Dr. Parchman
I saw your article in the Annals. Great one. Timely. Useful. Good work.
I had a couple questions…
1. I am assuming that these were English-speaking patients? Not mentioned in the methods.
2. It does not seem like you accounted for recent changes in medications. As I am sure is common in your practice, it is rare that a HgA1c comes back as a surprise to me. After...
Competing Interests: None declared. - A Care Evaluation Tool Must Consider Competing DemandsShow More
This article by Dr. Michael Parchman offers a new look at how family doctors make decisions. This new perspective is extremely important in this day of care management and pay for performance. It demonstrates how careful we must be in choosing one, isolated measurement to judge a physician’s care as good or poor care. A positive decision NOT to change a medication at the current encounter is not merely “clinical inertia”....
Competing Interests: None declared. - It IS provider behaviorShow More
Clinical inertia is recognizing that the patient is not at goal, knowing what can be done to reach goal, and not doing it. Some of apparent clinical inertia is an active decision (limited life expectancy, etc.) but most is probably more passive (didn't get around to it, etc. -- which might be due in part to competing demands and/or feeling that the asymptomatic problem generally is of low priority). But the choice is...
Competing Interests: None declared. - Author's Response to Dr. PhillipsShow More
We would like to respond to several interesting points made by Dr. Phillips. All of us have observed the phenomenon of a failure to intensify therapy when glucose or blood pressure is poorly controlled. As physician -scientists, we all recognize the importance of using terminology that accurately describes the phenomenon we are investigating: “plantar fasciitis” rather than “foot pain.” The choice of terms is important b...
Competing Interests: None declared. - Clinical Inertia Or Competing Demands?Show More
This paper by Parchman et al is an important contribution to the literature on the management of diabetes mellitus in the primary care setting. The authors present convincing evidence that there are a number of factors that may inhibit primary care clinicians from responding immediately to a higher-than-target HbA1c level by changing the patient's diabetes medications. Competeing demands such as other patient concerns...
Competing Interests: None declared. - The parallel process of competing demandsShow More
We know that family physicians address an average of 4.6 problems per visit when meeting with patients with DM. (1) In this issue, Parchman et.al. elegantly illustrate that, at times, some of these competing demands are associated with a lack of immediate intensification of diabetes treatment.
My own qualitative interviews with patients with diabetes as well as other conditions (unpublished) suggest that patien...
Competing Interests: None declared. - Competing demands vs. clinical inertia : a question of perspectiveShow More
Bravo for this well designed and clinically sound study. I completely agree that competing demands is a principle for constructing models of the primary care encounter that is more congruent with reality.
The practice of patient-centered care implies that the patient has the room to discuss his or her complaints with the physician.(1)Together, they have to find common ground and decide upon which problems should b...
Competing Interests: None declared. - Re: Re: Responding only to patient complaints IS clinical inertiaShow More
The evidence for benefit of good glycemic control in type 2 diabetes is strong -- just not based on direct, randomized, controlled trials. See Stratton's epidemiologic analysis in the UKPDS, the Kumamoto study, and Nichols' analysis of the natural history of attaining A1c <6%. All physicians should consider such evidence, and decide what to do for their patients.
What I think is more of a problem is educati...
Competing Interests: None declared. - Re: Responding only to patient complaints IS clinical inertiaShow More
Responding to patient complaints is being patient-centered. It would be most inappropriate if I pontificated, "your injured ankle is important, but we really have to work on your diabetes today."
In an ideal world, we would have time enough in any patient encounter for acute issues of the patient's concern and disease management and prevention as best judged and desired by the physician who cares about the patie...
Competing Interests: None declared. - Inertia, Distractions, and this is bad? Nope, opposite...Show More
Dear Editors,
I cannot help but respond to the lead article. "Competing Demands or Clinical Inertia" is written based on the assumption that improved glycemic control equals better treatment of our diabetics. I reject this notion. The references cited (citations 1 through 3) do not in fact support this contention. The 1st reference, UKPDS, showed that retinophotocoagulation treatments were improved with better gl...
Competing Interests: None declared. - Clinical Inertia, Competing Demands, and HypertensionShow More
Parchman et al, nicely demonstrate the effect that competing demnads place on family physicians (1). However, their assertion as to the minimal effect clinical inertia has in the practice of medicine is overstated.
Although their study provides an alternate hypothesis for physician behavior when compared to two of the three componenets of clinical inertia (physicians overestimating the amount of care they provi...
Competing Interests: None declared. - Responding only to patient complaints IS clinical inertiaShow More
As diabetes is a problem of epidemic proportions, yet guidelines for management are often not met, there is great interest in improving care. Toward this objective, it is logical to deconstruct clinical encounters to see if problems can be identified – and, ideally, fixed.
Parchman et al argue that (a) providers who do not intensify therapy for A1c >7% are responding to patient concerns already, because more...
Competing Interests: None declared.