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From Seattle, Washington, USA:

I am a dietitian working at an outpatient dialysis facility. I received a call from the father of a 15-year-old girl with type 1 diabetes who says her endocrinologist thought it would be a good thing if she took a "tour" of the kidney center where people are on dialysis, so she could see where she will end up if she doesn't straighten up and keep her blood sugars under control.

My intent is to call the dad back, encourage him that he is being a good father, but that:

  1. Fear does not motivate

  2. Touring a dialysis facility might only make his daughter less compliant.

  3. I am going to suggest he and his daughter see a psychologist or psychiatrist or social worker to work on issues of control and rebellion

  4. Any other suggestions?


I know colleagues who have taken the approach of this physician. Personally, I agree that this type of fear-factor might make a patient feel resigned to a terrible fate and then simply "live for the moment" and take poor control. But, certainly some people are motivated by this type of approach.

I agree with counseling for the girl (and family!). I would not exclude the possibility of a tour - or maybe better yet - a discussion with a type 1 patient on dialysis. Whether this approach should be done now versus later is worthy of a follow-up call to the physician requesting the tour. If I were the physician in this case, and I finally decided to try to motivate the patient in this manner, and then someone ignored my request, I would not be a happy healthcare provider.


Additional comments from Debbie Butler, MSW, LICSW, Licensed Clinical Social Worker:

I agree with you that it is not a good idea to bring a 15-year-old teen to a dialysis center to help motivate her to take care of her diabetes. Developmentally, teens do not usually worry about long term health complications. When I work with teens, I try to think of developmentally appropriate ways that may motivate them to take care of themselves, because teens think more in the present. For example, I might say that better blood sugar control may improve their concentration in school, help them perform better with sports, make them less irritable with friends, etc. For an adolescent female, I may say that better blood sugar control will keep their skin healthier and help with hair or nail growth. Another thing that I would stress with a 15-year-old that is struggling with diabetes management is increasing family involvement. Can this father help more with day-to-day diabetes tasks? I also like the idea of this family meeting with a psychologist or social worker that is knowledgeable about diabetes.


Additional comments from Dr. Stuart Brink:

You are right; they are wrong. It sounds like a frustrated endocrinologist. You could be a good "do-bee" and call this doctor to find out what he might want to accomplish. But, I like your idea about psychosocial assistance even if it is not perfect. I also like empowerment techniques as well under such circumstances as promoted by Anderson and Funnell, authors of "Patient Empowerment: A Look Back, A Look Ahead" and "National Standards for Diabetes Self-Management Education" and many other diabetes-related articles.


Additional comments from Jeff Hitchcock, CWD Founder and Editor:

I agree that negative motivation isn't effective. Far more effective for a 15-year-old is setting ground rules for driving that include active participation in diabetes care.


Additional comments from Jane Seley, diabetes nurse specialist:

I would also recommend that the dad find another endocrinologist!


Original posting 21 Jan 2008
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