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75 chapter four Your Diabetes U.S. Health Care Providers’ Orientations ­toward Patients I ­don’t manage your diabetes. You manage your diabetes. —Registered nurse, certified diabetes educator I met Rachel Frassen, an endocrinology fellow at a prestigious medical center, for coffee in a hospital food court on a sunny winter after­ noon. Dr. Frassen radiated energy and purpose as she described her packed schedule of research and practice across three local medical centers and a­ free clinic. Like her fellow younger physicians and nurse prac­ ti­ tion­ ers, she emphasized her commitment to less paternalistic, “patient-­ centered” medicine , especially for managing chronic conditions like diabetes. But as she shifted from her belief in the merits of patient-­centered care to the realities of her practice, she caught herself. “­Things need to be individualized and ­people need to make their own decisions and doctors ­ aren’t allowed to be paternalistic,” Dr. Frassen rattled off mechanically, with a note of irony. “And ­people ­here do not respond well to paternalistic,” she continued before pausing suddenly. “No, I take that back. Some ­people respond well to paternalistic doctoring, and other ­people do not, and I think it’s something that—­not having a ton of experience I am already starting to sort of get the hang of who needs to be told, and the vets at the VA need to be told.” It comes as no surprise that dif­fer­ ent providers have dif­fer­ ent bedside manners. What may be a surprise to some, though, is that the same providers have dif­fer­ ent bedside manners with dif­fer­ ent patients. Physicians’ and nurse prac­ ti­ tion­ ers’ interaction styles may say more about how they assess the needs of the patient than about their own philosophy of patient care. An older veteran, providers say, might prefer to be given clear instructions, while a younger ­ lawyer might prefer a more participatory role in managing his diabetes. Providers, in effect, find themselves trying to manage their patients into managing the disease. Though the patient management strategies they end up embracing differ, both American and Japa­nese providers report socially assessing their type 2 diabetes patients and tailoring their own practice to ­ those assessments. 76 Chapter Four Learningtomanageinteractionswithpatientsisacriticalpartofmedicalprofessionalization in almost any context. Hearing what patients are trying to say, anticipating what they want from their provider, managing their expectations , and motivating them to initiate or maintain health maintenance regimens are all necessary exam room skills for providers working with chronic disease patients. Research has shown that ­ these are not easy skills to teach (Clark & Gong 2000). Instead, the strategies providers employ to evaluate and respond to their patients largely rest on tacit knowledge: implicit understandings of “what works” that emerge within par­tic­u­lar orga­ nizational and social settings. The highly local nature of tacit knowledge accounts, at least in part, for the significant cross-­ national differences I describe in providers’ patient management strategies. Provider assessments of patients, strategies, and the orientations that underlie them can profoundly shape patient experiences of chronic disease, but they have been ­little explored. Further, the strategies that health care providers use to elicit cooperation and “compliance” are necessarily inflected by culture and context. But to what degree to they vary cross-­nationally? How do providers frame diabetes to their patients in the United States and Japan? Do differing strategies affect their patients’ orientation ­toward their illness? Might ­these strategies have public health implications? This chapter examines U.S. health care providers’ orientations ­ toward their type 2 diabetes patients through their interactions with patients, strategies for patient motivation and management, and attitudes ­ toward type 2 diabetes itself. In this chapter and the next, I argue that both American and Japa­ nese medical professionals switch between dif­fer­ ent models of the provider-­ patient relationship as they see fit given the patient and situation at hand. This is an essentially pragmatic approach to negotiating with patients in an effort to elicit cooperation and participation in their own self-­ management. Prac­ti­tion­ers in both contexts also share a belief in the power of medicalizing lifestyle recommendations to reduce stigma and improve adherence, consciously relying on medical authority to “sell” behavioral changes to some patients. But ­there is one cross-­national difference in orientation and strategy with potentially impor­tant consequences: the management of expectations. In sharp contrast to the Japa­ nese providers in the next chapter, the American health care providers in this chapter described consciously monitoring and...


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