What if we moved away from a “machine-focused” approach to diabetes care and education toward a “human-focused” approach in diabetes care and education?
It wasn’t just the tech talks at the 2019 IDF Congress in Busan that were calling for a new way of thinking about diabetes. Many of the talks about treatment and education also presented alternative ways of thinking and new approaches.
One of the most compelling talks was A Flourishing Approach: Moving from “machine” to human-based diabetes care and education delivered by Riva Greenberg, CHC, DPE, CA, HR, IS, AU, PWD, JOU, WF, CDCA.
What is machine-based thinking?
In her talk Ms. Greenberg characterizes today’s approach to diabetes management as being largely based on “machine” values. Steeped in the history and experience of the Industrial Revolution, the machine approach to health in general (and diabetes in particular) strives for accuracy and perfection. It sets forth its standards in the form of best practices. It looks at anything that doesn’t embody perfection or meet its standards as broken or defective. It assumes cause-and-effect. And it demands control.
You don’t need to look at diabetes care for very long before seeing the influence and impact of a machine-based mindset.
The aim of well-managed diabetes is to control BG levels. What we eat causes our BG levels to rise. And so does lack of sleep, mental stress, and certain kinds of physical exertion, etc. Best practice for type 2 diabetes at diagnosis is to prescribe metformin and advise lifestyle change. We download our BG meter data, look for anomalies among the readings, and then question how these failures occurred.
The problem with the machine-based approach is two-fold. First of all, humans don’t operate in the same manner as machines. Our physical and mental systems are much more complex and varied. Secondly, the machine-approach sets people up for failure. Any person who has found themselves staring at a number on their BG meter and wondered how that happened can confirm this.
The machine-based approach puts people with diabetes in a negative loop. It often starts with a BG reading or an A1C test result that is out of the target range. Soon after a question follows. How did that happen? Why is that there? What did/didn’t you do? There is no clear cut answer to any of these questions, so feelings of reproach begin to appear, followed by the admonition to “try harder.” So, the person tries again. And “fails” again. And is told to “try harder” again. Eventually, all hope and motivation are drained away and the person stops trying all together.
How is the human-based approach different?
Taking a human-based approach puts aside industrial metaphors and calls upon the wisdom and knowledge found in a set of sciences not often considered in the context of diabetes. It takes into account neuroscience, salutogenesis, and social psychology.
Neuroscience is the study of the nervous system and its impacts on a person, and how they experience and respond to the world. It looks beyond the physical aspects of the nervous system to understand the behaviors and beliefs that spring from the responses of a person’s nervous system. For example, neuroscience shows us how and why a person’s sense of hearing shuts down when they are under stress. It also shows us the long term cognitive impacts of physical and/or psychological trauma.
Salutogenesis is an approach to health aimed at fostering those things that encourage and support health, instead of discouraging disease. It focuses on the resources and capacity to generate health present in the person. Salutogenesis conceptualizes health as a continuum that we each occupy somewhere between total illness and total health, not the presence or absence of health.
Social psychology looks at the impact social environments and group interactions have on the individual and their behavior. It looks at how a person sees themselves in relationship to the group, perceives cultural norms, and how that shapes their behaviors and beliefs. These perceptions can result in feeling supported and encouraged, or rejected and stigmatized, or somewhere in-between.
With these disciplines as its basis, a human-values approach asks questions and makes assumptions that are very different from the machine-value approach.
It asks, “What’s possible?” and looks for good enough, in place of perfection. It accepts variation in place of the ideal, understanding that a person’s history and circumstances influence their actions. It sees the individual and their health as complex and non-linear instead of looking for a direct cause-and-effect relationship between, say, enjoying a family meal and the next BG reading. It’s approach is to navigate the individual’s state of health by probing for readings then responding in an individualized manner instead of relying on standard, codified approaches. It’s an approach that honors the individual and their beliefs, capabilities, and community.
This flourishing approach is based on the individual’s strengths. It looks for what’s working and how can that be encouraged to grow and spread to other aspects of their health. It’s (human) relationship-based and encourages cooperative decision making and solution building.
Flourishing is not an either-or approach
In moving toward a more human-based approach to diabetes care and education, there’s no suggestion that the machine-approach (and the medical devices it has generated) should be abandoned. On the spectrum of health, both approaches serve distinct purposes and can work together to generate outcomes that work best for the individual person living with diabetes, encouraging them to flourish overall and not focus on a few, specific data points to measure their health.
