From suspicion to confirmed diagnosis
Many of the GPs described type 2 diabetes as one of several diseases with a subclinical presentation that need to be considered. Many of the doctors focused more on health promotion through advice on diet and physical activity, rather than on a systematic identification of patients at risk.
'But then we also have a lot of other diseases that we also need to keep in mind and that are hard to diagnose, such as metabolic disorders and often heart disease, that we are also on the lookout for, aren`t we? So it's not just diabetes that we are looking for in our daily work, it's just one of many.' (GP specialist, urban)
Among the experienced GPs there was consensus that the patients had an increased awareness of the disease and that patients increasingly wanted a general assessment of their own health condition, with measurement of HbA1c as a natural part of this package.
Many of the GPs reported that they were sometimes surprised to see which patients had an elevated level, since these included some who did not 'look like' typical type 2 diabetes patients. Usually, most doctors themselves took the initiative to measure HbA1c in overweight patients.
'So why [did you measure] long-term blood sugar in him then, since he was healthy?' (GP specialist, urban)
'He is a little chubby.' (GP specialist, urban)
Many of the doctors were aware of the FINDRISC (Finnish Diabetes Risk Score), but the form was not used as a diagnostic tool during the consultations, because it contains questions that would naturally come up in a consultation anyway. The overall clinical assessment was more important than a strategic identification of patients at risk. One of the doctors argued that the form should be integrated into the patient record and remuneration systems to persuade the doctors to use it. For patients with an HbA1c level in the pre-diabetes range, the doctors described their task at the time of diagnosis as providing sufficient information about the disease and encouraging lifestyle change. Here the focus was on provision of general lifestyle advice and identification of areas in which the patient was able to cope well. Many of the doctors pointed to the importance of portioning the information over several consultations, since they had found that patients are rarely able to absorb more than three items after a consultation.
'Okay, now you have the diagnosis, we will not do anything acute. We have time. So let's use that time. And they receive information, and they receive it repeatedly.' (GP specialist, urban).
In addition, the intensification of the consultations served as a tool to maintain the motivation and lifestyle change. One of the GPs drew a parallel with a visit to the dentist:
'Just think of yourself, when did you have your last appointment with a dentist, right? Afterwards, you're a little better with the dental floss, right. [...] So really, the frequency we're looking at is a lot more effective than a large training course. (GP specialist, urban)
In cases where more than simple measures were considered necessary to achieve a lifestyle change, patients were referred to a diabetes patient education course. Many of the GPs from rural areas pointed out long travel distances and low availability of such courses as possible barriers to referral and participation.