Person centered care in the Second Diabetes Attitudes, Wishes and Needs (DAWN2) study: Inspiration from India

All living creatures follow their tendencies; even the wise man acts according to the tendencies of his own nature. Of what use is any external restraint. The Bhagavad Gita 3 (33) Thus, has this wisdom, more profound than all profundities, been imparted to you by Me, deeply pondering over it, now do as you like. The Bhagavad Gita 18 (63) Patient centered care in endocrinology has been the subject of earlier editorials in the Indian Journal of Endocrinology and Metabolism[12] as well as other Indian journals related to Endocrinology and Diabetology.[3] This highlights the undoubted importance of patient centered care in modern day diabetes praxis. This recognition is limited not only to India, but has also spread across cultures.[4] The recently conducted Second Diabetes Attitudes, Wishes and Needs (DAWN2) study reported on various aspects of psychosocial management of diabetes. This was performed by interviewing approximately 16,000 respondents, including 9,000 people with diabetes and nearly 5,000 family members of people with diabetes, in 17 countries.[567] These nations were spread across four continents and included a mix of developed and developing economies, with varying socio-cultural climates and health-care system. MEASURING PERSON CENTEREDNESS Among the various issues explored in DAWN 2, the provision of person centered chronic illness care was also assessed. This was performed by administering the Patient assessment of chronic illness care-DAWN short form (PACIC-DSF) health-care climate questionnaire - DAWN short form (HCC-DSF) to persons with diabetes. They were also queried as to whether or not they had been asked by their health-care team member if their chronic illness affected their life. Health-care professionals (HCPs) were administered the Health–Care Professional Patient Assessment of Chronic Illness Care-DAWN short form (HCP-PACIC-DSF) and the Health-Care Professional Health-Care Climate-DAWN short form (HCP-HCC-DSF), so as to assess the self-reported provision of person centered chronic illness care. They too were questioned as to whether or not they asked their patients how diabetes affected their lives. PERSONS WITH DIABETES Across all 17 countries, the mean value on the PACIC -DSF scale was 36.1 (95% confidence interval 21.2-55.9). The highest scoring country was India, (55.9 [51.3-60.4]), followed by Algeria, Turkey, Mexico, and China. The best score for HCC-DSF (mean 45.2 [29.4-57.9]), was from India (57.9 [54.1-61.7]), followed by Germany, Algeria, USA, and UK. Only 16.9% (8.2-45.0%) of people with diabetes reported having been asked how their chronic illness affected their life. Here, too, India had the best showing (45.0 [37.2-53.0]%), followed by Mexico, Algeria, Turkey, and Spain. These results strongly support the person centered nature of diabetes praxis in India. HCPs DAWN 2 also assessed the views and perceptions of HCPs across the world. Mean score on the HCP-PACIC-DSP was 61.9 (44.9-74.4), much higher than the corresponding score reported by persons with diabetes (36.1). Similarly, the HCP-HCC-DSP score was 75.8 (62.8-88.2), again higher than the HCC-DSF results (45.2) 52.0% (35.1-73.3%) HCPs reported asking their patients how diabetes affected their life, most of the time, or always. This response, too, was higher than what was reported by people with diabetes (16.9%), when the same enquiry was made from them. On analyzing the country specific HCP-PACIC-DSF data, Mexico had the highest self-reported provision of person centered chronic illness care. This was followed by India, Turkey, the Russian Federation and China. In the HCP-HCC-DSF score, Mexico led the way, followed by the Russian Federation, India, USA, and Canada. When questioned about whether or not they asked their patients about diabetes affecting their lives, India scored the highest, followed by Turkey, the Russian Federation, Algeria, and Mexico. Of all participating countries, only India figured in the top three in all parameters of person centered care. The HCP cohort of DAWN 2, therefore, corroborates the finding from people with diabetes: India does provide fair person centered care to people with diabetes, in comparison with other countries. DISCREPANCY IN OPINION There is however a marked difference between the scores in patient-reported questionnaires and those on health-care provider-answered questionnaires. While the two cannot be compared directly, the stark difference in perception of patients and HCPs (16.9 vs. 52.0%) regarding asking how diabetes affects lives of patients cannot go unnoticed. These points to the need for an improvement in patient-provider communication which is an issue that has been addressed by DAWN 2 as well. In spite of the quantitative discrepancy in responses of people with diabetes and their health-care providers, another observation stands out. Countries, which score higher on the person centered care indices are not necessarily those with higher per capita income, more trained HCP or better developed medical care systems. In other words, person centeredness can be achieved even with minimal resources at hand. What is it then, which is needed to achieve this? Perhaps India has an answer. ACHIEVING PERSON CENTERED CARE Patient centered care or person centered care, seems to be a western concept, coined to bridge the gap between patient expectations and provider service, in primary health-care.[8] This terminology may be new, belonging to a modern medico academic culture, in which noun piling is a sport played to increase the volumes of onomastions and medical journals. In reality, the concepts of patient involvement, patient empowerment and patient centered care have been propounded in ancient India centuries ago. The legendary Ayurvedic physician, Atreya, posited the quadruple of Atreya, in which he discussed the equal importance of the patient, attendant (family member/nurse), physician and drug, in the achievement of optimal therapeutic outcomes.[9] Even earlier than that, Lord Krishna, delivering his sermon (The Bhagavad Gita), during the epic Mahabharata war, reinforced the concept of patient autonomy and freedom of choice.[10] It is perhaps this deep rooted sociocultural ethos, which pervades the Indian diabetes care system. It may be possible that Indian physicians and paramedical staff do not get structured or formal training in science and art of person centered care. However, their community-oriented ethos is perhaps enough to inspire Indian health-care professionals to practice person centered care in their clinics and hospitals. THE FUTURE It is not enough, however, to rest on one's laurels. While the Indian praxis of diabetes care, along with that of other countries such as Algeria, Mexico, Turkey, and China (top countries as per PACIC-DSF), can be used for best practice sharing and for inspiration, much more needs to be done. We must not forget the 26.7% of our colleagues who do not ask their patients about how diabetes has affected their lives. And even more importantly, we need to engage the 55.0% of our countrymen and women who reported that we did not ask them this question. To help improve the quality of person centered care, it is imperative that we put in place a structured patient centered curriculum at undergraduate, postgraduate and doctoral levels. This must be followed-up by regular continuing medical education programs on this aspect of diabetology. Simultaneously, people with diabetes should be sensitized to empower themselves and demand person centered care as a matter of right. This, perhaps, is what DAWN 2 hopes to achieve.

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