從獨白到對話－－糖尿病自我管理教育的演變

From Monologue to Dialogue: The Evolution of Diabetes Self-Management Education

糖尿病是一種慢性病，病友需要積極改變自己的飲食習慣和運動習慣，不能只靠藥物治療。有糖尿病的人需要控制高血糖、高血壓、高血脂等三高的控制。但糖尿病控制現況在美國及台灣目前都不盡理想，文獻研究結果也顯示，將來所引發的糖尿病併發症，如失明和洗腎的病人會越來越多。本文從探討三高控制不佳可能的因素如：醫師的治療惰性（又稱慣性），病人的服藥順從性（adherence）及糖尿病自我管理教育目前所面臨的挑戰等，提供臨床醫護人員在糖尿病自我管理教育所需改變的方向。過去我們提供衛教課程時，往往站在講台上獨白（monologue），近幾年我們嘗試運用在美國發展出來的共享門診及共享決策等創新看診模式，盡量鼓勵病人與病人、病人與衛教團隊人員的對談（dialogue）。初步研究結果皆有不錯的成效。最後台灣在健保論量計酬的環境裡，要推廣這樣費時的工作，確實困難。希望健保局早日改行論價值（考量成本的品質）計酬的制度，讓更多的醫護人員偕同病友，努力提升糖尿病照護的品質。 Diabetes is a chronic disease. Patients with diabetes must actively change their eating and exercise habits and cannot rely solely on medication. Moreover, these patients need to control high blood glucose, high blood pressure, and high blood cholesterol, commonly known as control of the “three highs”. As the current state of diabetes control is not ideal in the United States and Taiwan, diseaserelated complications such as blindness and the need for dialysis is expected to continue to increase in these countries in the future. This article highlights the possible factors of poor control of the “three highs” such as the therapeutic inertia of physicians (also known as clinical inertia), patient adherence, and current challenges in diabetes self-management education. In the past, courses in health education at our institution have been frequently delivered in monologue format. In recent years, we have tried a form of group therapy known as shared medical appointment (SMA) in order to encourage dialogue among patients and minimize didactic teaching. The preliminary results have been promising. In recent weeks, we began to discuss targeting SMA therapy on the topics of food metabolism and the typical effects and side effects of new and old drugs. We hope this will ease our introduction of shared decision making (SDM) in the near future. Promoting time-consuming procedures such as SDM is difficult in Taiwan because national-insurance health insurance payments to the healthcare provider are based on volume rather than value. We hope that the Health Insurance Bureau begins to recognize and appreciate the contribution of nurse educators and dietitians in the care of patients with diabetes and approve compensation for their hard work.