Background
Method
Study design and participants
1. Issues of confidentiality and anonymity |
Reinforce written participant information, emphasizing that no participant would be identifiable in any dissemination or publication of the study by the investigators. Establish ground rules for participants. Advise participants to draw the group’s attention to any information that they do not wish to be repeated outside the group by other participants in any further discussions. Confirm consent to audio-recording |
2. Prompts for facilitators |
What do you think are the most important things for diabetes patients? (HbA1c, blood pressure, quality of life, etc.) |
What is your experience in communicating with diabetes patients? |
Are there any barriers (gaps) or facilitators in communication with diabetes patients? |
How do you feel when your diabetes patients present with emotional difficulties? |
How do you see your attitudes and behaviors (words, emotion and expression styles) affecting your diabetes patients' self-care? |
What do you think make diabetes patients trust doctors? |
Are there any good communication skills in daily practice with diabetes patients? |
Have you received any communication skills training before? If yes, what is your experience in communication skills training, e.g., training content and methods? |
Do you think training will help improve GPs communication skills? If yes, why? |
Is there anything else about the physician/patient relationship that you want to share? |
Analysis
Results
Focus group 1 (N = 4; M1, F3) | Focus group 2 (N = 3; M2, F1) | Focus group 3 (N = 4; M1, F3) | Focus group 4 (N = 4; M3, F1) | |
---|---|---|---|---|
Participant 1 | 29, 3, E1, T1, D1 | 35, 6, E1, T1, D2 | 43, 10, E1, T2, D1 | 39, 8, E1, T2, D1 |
Participant 2 | 31, 4, E2, T1, D1 | 40, 10, E1, T2, D2 | 50, 12, E3, T2, D1 | 41, 10, E1, T2, D1 |
Participant 3 | 37, 8, E1, T2, D1 | 36, 7, E1, T1, D2 | 42, 9, E1, T2, D1 | 32, 5, E2, T1, D1 |
Participant 4 | 30, 4, E1, T1, D1 | 33, 5, E1, T1, D2 | 46, 11, E1, T2, D1 |
Themes | Subthemes |
---|---|
1. Diversity in diabetic patients | a. Diabetes patients’ attitudes, knowledge, and behavior |
b. Medication adherence | |
c. Patients’ emotional problems | |
2. Communication with patients | a. Consultation management |
b. Blood glucose monitoring and control | |
c. Communication difficulties and facilitators | |
3. Patient-doctor relationship | a. Mutual understanding |
b. Blaming doctors | |
c. Blurring of the boundaries | |
4. Communication skills training | a. Insufficient training |
b. Training needs | |
c. Practice and feedback |
Theme 1: Diversity in diabetic patients
Diabetes patients’ attitudes, knowledge, and behavior
‘The patient cannot accept that he has diabetes, and he cannot accept it psychologically, and he denied that he had the disease.’ (FG [focus group]2 P2).‘Some patients had concerns about complications that might affect them, for example, some patients had diabetic feet, and then they worried about whether they might have to have an amputation or other problems because of the infection. In some cases, because of the long-term effects of diabetes on vision, there was a serious concern about becoming blind.’ (FG1 P1).‘Not all of them are worried about their diabetes. Some well-controlled patients often told me about their diabetes experiences, such as regular exercise and a healthy diet. I think they are very optimistic.’ (FG1 P2).
'Patients are very short of knowledge about diabetes, such as how to monitor blood glucose, how to take drugs, whether to take drugs before or after a meal, the harm of diabetes, and matters needing attention in exercise and diet control. All of which are lacking.' (FG1 P2).‘Many patients who come to see me really want to know the prognosis of the disease, how serious the disease is, and what is the risk for the implications.’ (FG1 P1).‘Some patients thought that the doctor's words are not as useful as the neighbor's words. What medicine the neighbor told him to take, he immediately went to the pharmacy to buy it. The neighbor said that a certain medicine can lower blood sugar, he bought it immediately.’ (FG1 P4).‘Some patients, especially in the ‘villages’ in the city, they are very young and unable to read and write, even those in their 30 s or 40 s who were not able to write their own names. In the face of such a patient, I think it is impossible to simply expect him to understand the complications of diabetes.’ (FG3 P3).‘Patients who have been treated at hospitals or community centers for more than five years are well aware of the symptoms, harms, and complications of diabetes. They know more about diabetes than younger doctors.’ (FG4 P3).
‘Even if they face the risk of diabetes, sometimes they are really reluctant to make some lifestyle changes.’ (FG2 P1).‘He (patient) found some health products information from the WeChat Moments (online social platform) or found some home remedies and diets in other places, and then wrote them on paper. And he brought this paper to me and asked me to follow his mixed treatment plan on diabetes. But in fact, when I told him something more authoritative, he did not understand’ (FG4 P4).
Medication adherence
‘Especially if you want to persuade patients to take insulin, they are even more afraid. They feel that once they use insulin, they cannot stop it and have to use it all the time’ (FG1 P2).‘For example, the drug Sitagliptin, because it can be taken one tablet a day, many patients like to use it. But for Acarbose, which is taken three times a day, seems to be too much trouble, and it is not acceptable. Patients like the simple way of taking medicine.’ (FG3 P1).
Patients’ emotional problems
‘Of course, if the patient is uncomfortable, I can feel it directly. Many diabetes patients cried in my consultation room.’ (FG4 P3).‘Because we do not have our own diagnosis and treatment system, and do not have the matching evaluation tools, I can only say that I can evaluate the emotional state of diabetes patients based on my own feelings.’ (FG1 P2).
Theme 2: Communication with patients
Consultation management
‘Frankly speaking, sometimes I'm really scared that I don't have enough time. I personally feel that if I have time to talk to patients with diabetes under current circumstances, I can do my best. But in fact, there is no more time for me, and it is really difficult to do more for patients. It really takes extra time to comfort the patient.’ (FG3 P4).‘I designed a blood glucose book by myself and made a grid for patients. I provided this piece of paper to them. I told them which monitoring points and saying that I hope you(patients) can do next time. I gave them this form to make it like homework. If the patient does what I want, I think this paper can serve as a supervision. I think this is a method for patients self-management and for me to know their control.’ (FG2 P2).
Blood glucose monitoring and control
‘Many patients are used to checking their fingertip blood glucose several times a month. Frankly speaking, the figures changed all the time. Patients are very nervous. They will say why it is high, whether it is the problem of taking drugs, and then this caused the patients to have some bad emotions, and then doctors have to deal with. Fluctuations in blood glucose do cause some unnecessary troubles and increase the amount of time we need to explain to patients each time.’ (FG4 P1).
Communication difficulties and facilitators
‘We often have some blind spots in communication with patients. Sometimes we may be clearly for the sake of their good, but we may not speak and express well, so that they do not understand, and may even cause us to dispute’ (FG3 P1).‘Sometimes words from specialists in hospitals were more useful than we said. If specialists give some treatment plans, the patient may say that the plan should be implemented all the time. When we communicate with the patient afterwards, patients always listen to the specialists and feel that our plan is wrong.’ (FG1 P3).‘When sharing bad news, such as telling the patient when he will die, or amputation, or his vision will be permanently blind, or his energy will not recover in the future. In these cases, it is difficult to tell him and let him accept such bad information.’ (FG4 P2).
‘Sometimes I will praise them (patients) in front of their families, they will feel a sense of honor and pride. In short, in some situations like this, with timely encouragement and prompt praise, they will more easily accept my suggestions’ (FG2 P3).‘Sometimes when I try to get to know my patients, to allow them to express their feelings, to respect their choices and to make decisions together, it makes our communication process more harmonious. I think that's how you get both sides on the same channel.’ (FG2 P4).‘Tell them (patient) what is the danger of diabetes, but maybe because my way of expressing is not very good, they don’t take it seriously. On the contrary, showing them some horrible pictures or video materials will impress them. I think this is an important communication skill.’ (FG3 P2).
‘Our GPs have a sense of frustration and failure. If he (patient) went to tertiary hospitals, he might be very obedient. Subconsciously, he may feel that the doctors in the tertiary hospitals are better than the doctors in our general practice.’ (FG4 P2).
Theme 3: Patient-doctor relationship
‘Trust is built in two ways, one is effective communication, and another is effective treatment. If you said well, but his blood glucose does not fall, he will not believe you. Therefore, I think we should convince him with professional knowledge, from the aspects of weight management of his diet to medication. And if he can cooperate with my suggestions, I think it is possible to achieve mutual trust.’ (FG1 P1).‘In fact, I think that if one patient follows you for a long time, sometimes it will give you an illusion that he is already your loved one or family member. Then when you are on holiday or some time you will think that he might eat too much, and his blood glucose is not good. It is really an illusion to have a long relationship with people with diabetes. It’s hard to say whether this feeling is good or not.’ (FG3 P4).
Theme 4: Communication skills training
‘Basically, there is very little relevant training in this area. There are many details about how to establish some such relationship, communication skills with the patients, how to gain the trust of patients, how to communicate with the patient, such trainings for us are rare.’ (FG3 P3).‘That's something I need to learn. It's not like I can do it by taking a few classes or lectures. I may understand everything in class, but I am not able to do it in practice. It needs to be practiced repeatedly to achieve the best.’ (FG1 P3).