 I have always been interested in issues of social justice and health disparities. I have a number of family members who've become ill. And so caring for them and sort of co-managing some of their illnesses and watching them from when I was young, I knew that I was going to try and find a way to impact social determinants that tend to disproportionately affect African Americans. My grandmother was born and raised in the South, so we're all Southern African Americans. My grandmother has always been an excellent cook, but it hasn't always been things that the doctor would have prescribed about her diabetes, her blood pressure, those kinds of things. How we cook is so much part of our culture and our familial tradition, and she learned to cook from her grandmother, and it's hard to change habits. She has hypertension. She has diabetes. She has a thyroid problem, which is unrelated. She has been overweight, and her cholesterol is high. I would sometimes go with my grandmother to the doctor in the clinic. And then that's that, and then there's home, you know, and there's not always cross-talk between the two. And, you know, people were not talking about the ways, specifically the ways that she was preparing her food. You know, it's always like, oh, you have to eat healthy, you have to have vegetables, you have to have sorts of it. Well, we had lots of vegetables, like real vegetables, not just potatoes, but there are things, but in those vegetables, that weren't entirely healthy. She has limited health literacy. She only finished the eighth grade, so her ability to understand doctor's shorthand, she doesn't want to say, hey, wait, can you slow down and give me another 10 minutes? I really want to understand what's going on. Then they would sort of give her a prescription, and off we would go, thank you, doctor. And she would not have any idea about what just happened, because she didn't want to offend the physician. And so all of this misunderstanding that we would then have to try and clarify after the doctor visit, because during that time was sacred doctor time. And so they were really informative to me, growing up, thinking this seems kind of crazy. Hello, Mrs. Robinson. How are you doing today? I'm fine, thank you and you? Well, thanks. How have you been? Well, I've been pretty good. Good, good. Have you noticed anything unusual or different about how you've been feeling? No, everything's about the same. And have you been taking your medication and checking your diet? Well, yes. I've been pretty good. I've been eating all my vegetables, I know you said that was important, and I've been taking all my medications to every day. Okay, that's great. That's really important, Mrs. Robinson. Are you experiencing any fatigue or other symptoms? No, sir, I feel about the same. Well, okay, if everything's the same, let's keep you in your current medication, and you can come back and see me in three months. Okay. Grandma, did you tell him about the sore in your foot? It's just a little sore, and I don't think it should be anything to worry about. She has a sore in her foot, doctor, she says it hurts, and she's tired all the time. You have a sore in your foot? Mm-hmm. Well, have you been wearing proper shoes and checking your feet every day? Yes, I have. Okay, then, let's take a look, okay? Well, it's just a little sore, but it don't even hurt that much, but it's on my right foot. Well, I do see some redness and some signs of infection, but I believe that's a result of your diabetic condition. Now, the infection is still in its early stages, but it's important that we address this because some serious problems could occur as a result. Okay, doctor, I understand. There are two ways to handle the problem with your foot. I can give you some antibiotics, which should clear up the problem, or we can have you see a foot specialist. Mm. You know, I think I'm going to have you see the foot specialist. Whatever you think is best, doctor, what's... I've got a referral slip for you to see the foot specialist, call his office, make an appointment, and they should take care of you. Oh, I can't see the foot specialist today. I have to make an appointment? Yes, I'm afraid so. But I have to work all weekend. I don't think I can take off another day so soon. This is Robinson. I'm sorry for the inconvenience, but we don't have a pediatrist in this office, so you're going to have to make an appointment to call. Okay, I will call as soon as I get home. Great, glad to hear that. You know, it's also time for you flu shot, so I'm going to send the nurse in and she can take care of that for you. Okay, doctor, thank you. Heaven, you have a nice day. You're welcome. This is Robinson. Grandma never made that appointment. Seeing people who I knew were smart, engaged at home and in community, and still not being able to transfer that same sort of skills and confidence when they were communicating with the physician made me decide that I wanted to focus my interest in health disparities, specifically on that patient-doctor communication dynamic. Hi, Mr. Taylor. How are you doing today? I've been okay, but just really fatigued lately. But this is an appointment that I definitely didn't want to miss. I'm glad to see you. It's good to see you. It's been a couple months. Tell me how things are going. Well, I'm a little fatigued, worried that my tiredness is starting to affect my life. Just got a promotion, so now I'm even busier than ever. Well, congratulations on the new job. Thank you. Thank you. I do want to do well, but I'm worried that my tiredness is going to affect my performance, and I just really want to get on top of this doctor. I totally understand. There are a lot of different reasons why people who have diabetes can be tired. You could have a thyroid problem. You could be a little anemic. You're not sleeping as well because of the new job. It could be that your blood pressure's a little low. Remember at the last visit, we adjusted your blood pressure medication. Let me go ahead and check your blood pressure now. Are you having any side effects? Problems with lightheadedness or dizziness? No. Great. Well, for people who have diabetes, the most common cause of fatigue is that their sugars are not well controlled. Have you been doing all the things we've talked about as far as keeping an eye on your sugars, taking your medications like you're supposed to? No, doctor. I have missed some of my pills. It's kind of hard to remember to take so many pills at different times of the day. And when I get home, I'm so exhausted that I'm just too tired and I forget to take my sugar at night. So no, I have not been doing the things that I'm supposed to do, doctor. Okay. Well, I appreciate you being honest with me. Your blood pressure's normal, by the way. It's not at all uncommon when people have a lot of new things in their life to have some difficulty keeping track of all their diabetes responsibilities. So I appreciate you letting me know. How's your diet going? Good. I've actually made some progress, I think. I've definitely been eating better since the last appointment I had. The nutritionist that you introduced me to has really taught me a lot. My wife and I, now we cook enough food so now I can take something to work. We're eating healthier. And it's also making it a little bit easier for me at work because I don't have to go out during the busy time at work. Great, great. So you're doing some things better. Having a few steps back in some other areas. Well, it does sound though like your sugars are part of the problems with making you so tired. There are a couple of ways we can try and address to get on top of this. One would be to keep the medications the same, but we just try and figure out ways that you can remember to take them. Another would be to switch your medications all together to a different kind of pill. And then the third would be to try something that's all together different, like insulin. Insulin? Oh. See, my family, they deal with insulin a lot. Honestly, doctor, it's kind of scary to use a needle every day. Right. A lot of people are scared of the needle. But it really, they're just tiny little things and people really, once they start they find there's not that much of a problem. And insulin is probably the most effective way in getting your sugars under control. Well, let's explore some of the options and get some details. Because it's really important to me that I make a decision that's right for me. Sure. I think that's important, too. There are a lot of options that are out there, but us finding the one that works best for you is the one that's going to be best for us. Because what that means is that you're going to be able to stick with it over time. And so we need to find one that's going to work best with your lifestyle that you think you can actually do. So the first choice, again, would be to keep with what you're already doing, but just trying to find a way that you can remember to take them. Because they had worked better for you in the past, but now with a new job you're having problems forgetting. One of the things you could do is buy one of those pill counters that people have sometimes. You put all the pills at the beginning of the week, take it with you to work, leave it in your desk, and then take it home on Fridays. Or you could maybe set your watch so that it goes off twice a day during the day to remind you to take your medications. Do you think that might work for you? Sounds good, but with the promotion and being busier, I'm in the field a lot. I'm in meetings. Sometimes I'm not at my desk when I keep my medication and then I can't really take them discreetly where I am. What's some other options? The next thing is we could change you to a different kind of pill. So maybe there's a new kind of pill that is once a day. So you could take that and not have to worry about being at work and remembering to take them to your job, but it does have a few side effects. A lot of people who take this medication have some complaints initially of some loose stool or some abdominal discomfort. So it's something you should be aware of. Yeah, I already have irritable bowel problems. I'm worried that the side effects from that may be a little bit too much for me. And again, I'm in the field a lot, so I'm not really sure if I can get to a bathroom. I'm not sure if that will work well for me. What are some other options? What about insulin? Okay, so the insulin is something you could take just once a day and it really mimics what your body naturally does when it makes its own insulin. So it's a really nice alternative. It's the best way of keeping your sugars under control and it's a lot easier to give than it used to be. You would have to do two things. One, learn how to give yourself the injection, something you don't know how to do now, and two, you'd still have to make sure that you check your sugars at least once a day. One tiny shot at home. And I could take my sugars at lunch. It worked. Good idea. And like I said, my family already have history of diabetes and I'm sure they helped me with taking this shot. And it's important that I make the right decision, Doc. So if insulin is going to do that, then let's do it. Okay. I'm really glad to hear that. I think insulin probably is the best choice for you. Particularly long-term. Not only will it make you feel less tired, which is what brought you in today, but it also helps prevent complications from diabetes. So having good sugar control means you're less likely to go blind, less likely to have to be on dialysis, less likely to have a heart attack, all those things that we're really trying to avoid. So I think it's a good choice for you. And I do understand you're concerned about the needles. That's not at all a new problem or a concern that people have. And so I'm going to have a nurse come in here, go over it all with you, ask her any questions. And if you get home or forget anything, you can always just give me a call. You know what? I'm excited. I'm ready. With all the information you've given me and, of course, with my family helping me out, I think I can do this. And if it's going to stop me from being so tired and help me out, then I'm definitely here. Wonderful. I'm so glad you came in. Thank you, Doctor. Good to see you. I'll see you back in a month. All right, bye. We don't go shopping and then the sales clerk says, here's your address. You go home when you take it and think this doesn't fit. Well, I guess this is what I have. We don't buy a car that someone pushes off on us. We don't do that in any other aspect of our life. But when it comes to coming to the physician, we lose a lot of our autonomy and sense of self-efficacy, our sense of confidence in being able to make intelligent decisions and choices about how things may affect our life. I tell people that my job is to be their coach, their informant. But it's their job to sort of live their life. And so I give them advice. I give them all the information. I can help make recommendations. But this is a choice that we have to make together. I'm the expert in what I know. You're the expert in what you know. Together, we can make a decision that's best for you. Shared decision-making is really just a really basic concept. It's where patients and physicians come together to share in the decision-making process about a treatment for that patient. So ordinarily, the physician makes most of the decisions about what's going to happen for the patients. This concept is that the patients would also be actively involved and through all phases of the clinical encounter. So they would share in the discussion about symptoms. They would share in the discussion about pros and cons of all the treatment options. And ideally, they would share in the actual decision about what's going to happen when they leave the room. Once people really know all the facts, then they can incorporate those and say, okay, this one is really best for me. But without that information, it's impossible for patients to feel like they can make an accurate decision. And it really is true. If you want open heart surgery versus a balloon angioplasty, if you don't really understand what those even mean, so really getting the information on the table from both parties and then sort of mixing it all up and then everyone at the end of the day saying, okay, this is what's going to work. This is like a great thing to do, but it's also important because people do better. People have better control of their diabetes. Their blood pressure is better controlled. They're less likely to be hospitalized. They feel better. They're more likely to get their preventive care. All of these things that are really tangible, hard health outcomes can be traced back to this kind of communication between doctors and patients. Come prepared. So have a good sense of the things that you want to discuss and all of the symptoms that you're having sort of have them down in advance. I would say ask good questions so that you make sure that you're getting all the information so you can make those decisions. And I would be very clear with your provider that you're interested in participating and making those choices. The three D's that we want to remember when we go into the doctor's office are discuss, debate, and decide. You want to discuss all the symptoms. You want to debate, have a friendly conversation with your doctor about all the options, and then decide on the treatment that is best for you.