This guide provides a step-by-step approach to explaining a diagnosis of type 1 diabetes. You should also read our overview of how to effectively communicate information to patients.
Structuring your explanation
Explaining a diagnosis requires structure and adequate background knowledge of the disease. Whether the information being shared is about a procedure, a new drug or a disease, the BUCES structure (shown below) can be used.
Opening the consultation
Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
BUCES can be used to remember how to structure a consultation in which providing information is the primary focus. Before explaining the various aspects of a disease, it is fundamental to have a common starting point with your patient. This helps to establish rapport and creates an open environment in which the patient can raise concerns, ask questions and gain a better understanding of their problem. After introducing yourself, it is important to take a brief history (this is the first part of the BUCES structure):
- What has brought the patient in to see you today?
- What are their symptoms?
- Are there any risk factors that can be identified? (e.g. lifestyle/family history)
Tip: Practice taking concise histories to get the timing right. In OSCE stations, timing is crucial and you do not want to spend all your time taking a history when you are meant to be explaining a diagnosis! A rough guide would be to keep the introduction and brief history between 1-2 minutes maximum.
What does the patient understand?
Following a brief history, it is important to gauge the patient’s knowledge of their condition. Patients may know someone with the condition, or this may be their first encounter with the disease. Be open with the patient and work to identify any misconceptions they may have. The patient sitting before you may not even know at this point that they have diabetes – you may be the first person to inform them of the diagnosis.
Due to these reasons, it is important to start with open questioning. Good examples include:
- “What do you think is causing your symptoms?”
- “What do you know about type 1 diabetes?”
- “What has been explained to you about type 1 diabetes so far?”
Open questioning should help you to determine what the patient currently understands, allowing you to tailor your explanation at an appropriate level.
At this stage, primarily focus on listening to the patient. It may also be helpful to give positive feedback as the patient talks (i.e. should a patient demonstrate some understanding, reinforce this knowledge with encouraging words and non-verbal communication such as nodding).
Checking the patient’s understanding should not be solely confined to this point of the consultation but should be done throughout by repeatedly ‘chunking and checking’.
Tip: Try using phrases such as: “Just to check that I am explaining what type 1 diabetes is clearly, can you repeat back to me what you understand so far?”. This is far better than only saying “What do you understand so far?” as the onus is placed upon the quality of your explanation rather than there being an issue with the patient’s ability to understand.
What are the patient’s concerns?
The patient’s concerns should never be overlooked. A diagnosis of type 1 diabetes can be a significant life event and provoke a variety of worries. Asking the patient if they have any concerns before beginning your explanation allows you to specifically tailor what is most relevant to the patient, placing them at the centre of the explanation. The ICE (ideas, concerns and expectations) format can provide a useful structure for exploring this area further.
ICE
Ideas
- What does the patient think is causing their symptoms?
- What is their understanding of type 1 diabetes?
Concerns
- What are the patient’s concerns regarding their diagnosis?
Expectations
- What is the patient hoping to get out of the consultation today?
Explanation
After determining the patient’s current level of understanding and concerns, you should be able to explain their condition clearly.
You should begin by signposting what you are going to explain to give the patient an idea of what to expect.
“I’m going to begin by talking about how your body controls blood sugar, then move on to discuss what type 1 diabetes is, why it is important to address and how we can manage it together.”
In preparation for your OSCE, practice your explanation in patient-friendly terms. Consider using visual aids such as diagrams or drawings to help understanding.
Tip: Use the mnemonic “Normally We Can Probably Manage” to help you remember the structure of explaining a disease.
Normal anatomy/physiology
The control of blood sugar can be explained by using an analogy of insulin as a key to the cell.
“Carbohydrates that we eat are broken down into sugar and released into our blood. This sugar is the fuel for all the cells that make up our body, and it needs to get from the blood into the cells for them to function properly.”
“A chemical called insulin acts like a key to unlock the cell and let the sugar in. This chemical is produced in an organ called the pancreas.”
What is type 1 diabetes?
“In type 1 diabetes, the pancreas stops producing insulin. This means that sugar is no longer able to enter the cells of the body and builds up in the blood.”
For further information, see the Geeky Medics guide to type 1 diabetes.
What are the causes of type 1 diabetes?
Type 1 diabetes is an autoimmune condition in which beta cells of the pancreas, which produce insulin, are destroyed. Both genetics and environmental factors are implicated in the pathogenesis, however the exact cause is unclear.1-2
“Type 1 diabetes is an autoimmune condition, meaning the body attacks its own healthy tissues. In this condition, cells in the pancreas are destroyed, meaning the body is no longer able to make its own insulin. There is nothing you could have done to prevent this, as the cause is thought to be related to a combination of genetics and environmental triggers.”
Problems/complications of type 1 diabetes
It is critical to explain the significance of type 1 diabetes, as without treatment, it will lead to both acute and chronic complications and ultimately be fatal. A good initial explanation will encourage patients to attend structured screening and monitoring, enabling them to identify problems early and seek medical advice.
It is important not to scare the patient but to explain that you are outlining the potential complications so that they are aware of them. A clear explanation is essential so that the patient is informed on how to reduce the likelihood of complications and improve adherence to lifestyle and pharmacological interventions.
“The build-up of sugar within the blood, when sustained over time, can lead to damage to many parts of the body by affecting the blood vessels and nerves. Without treatment, this damage is inevitable and would ultimately lead to death.”
The complications of type 1 diabetes can be divided into metabolic, microvascular and macrovascular complications.
- Metabolic: diabetic ketoacidosis, hypoglycaemia (as an adverse effect of insulin treatment)
- Macrovascular: atherosclerotic cardiovascular disease, peripheral arterial disease
- Microvascular: nephropathy, retinopathy, neuropathy
Diabetic ketoacidosis
“When the body cannot get energy from sugar in the diet, it starts to make it from other sources, such as fat. This leads to the buildup of dangerous byproducts that make the blood very acidic. This can make you very unwell, very quickly and requires treatment in hospital.”
For further information, see the Geeky Medics guide to diabetic ketoacidosis.
Cardiovascular and peripheral vascular disease
“High blood sugar levels cause thickening and narrowing of large blood vessels that can eventually lead to heart attacks or strokes. This also reduces blood supply to the legs, which can lead to the development of ulcers, infection, and possibly require amputation.”
Nephropathy
“The damage to blood vessels can also affect the kidneys, impacting their ability to filter waste. If this progresses significantly, end-stage kidney disease requiring dialysis can develop.”
Retinopathy
“Circulation to the eye can be damaged in a similar way, leading to irreversible effects that may progress to blindness.”
Neuropathy
“Nerves anywhere in the body can be affected. Symptoms such as reduced sensation, pain, poor blood pressure control and delayed stomach emptying, amongst many others, can result from this.”
Management
Pharmacological
The treatment for type 1 diabetes is with lifelong insulin. At diagnosis, an individual care plan will be set up by the diabetes specialist team and reviewed regularly to titrate doses to target blood sugar readings. As part of this, the patient is trained to measure their own blood glucose and administer insulin via subcutaneous injection.
A referral to a structured education programme, such as DAFNE, can support type 1 diabetic patients in adjusting their own insulin doses independently.
In certain circumstances, monitoring and administration can be achieved through continuous glucose monitors and insulin pumps, respectively.
“The only treatment for type 1 diabetes is with insulin, which you will be trained to administer via an injection under the skin. Safe use of this requires regular monitoring of your blood sugar levels with a finger-prick blood test. A specialist team will support you in finding the right doses for you, and you can also be trained in learning how to adjust these yourself.”
For further information, see the Geeky Medics guide to insulin prescribing.
Non-pharmacological
Due to the possible complications of the disease, all patients with type 1 diabetes should be encouraged to adopt several lifestyle changes.
“In addition to using insulin, it is also important to follow a healthy lifestyle to reduce the risk of complications.”
Start by explaining what the patient can do to reduce long-term complications, including:
- Eating a diet low in fat and salt
- Weight loss if the patient is overweight or obese
- Undertaking at least 150 minutes of moderate physical activity a week
- Limiting alcohol intake and smoking cessation 1-2
It can be useful to signpost patients to resources such as NHS Better Health, which provides information and support for lifestyle interventions.
Sick day rules
During a period of intercurrent illness, a person with type 1 diabetes is at higher risk of acute complications such as diabetic ketoacidosis. It is important that the patient is aware of how to manage during these times and seek urgent medical advice if not improving, as hospital admission may be required. Self-treatment includes:
- Never stopping or omitting insulin
- Checking blood glucose more frequently
- Consider checking blood/urine ketones
- Maintaining normal meals
- Drinking at least 3L of water per day 2
“Illnesses and infection can dangerously increase your blood sugar levels. It is important that you are more aware of your diabetes management during these times. It is crucial to continue taking your insulin and eating meals as normal, as well as staying well hydrated. You also need to monitor your blood sugar levels more frequently. If you are not getting better, you should seek urgent medical attention.”
Monitoring
Routine reviews form a very crucial part of diabetes care, through blood monitoring and screening for complications. This includes:
- HbA1c monitoring: measured every 3-6 months until stable on unchanging treatment, then every 6 months
- Cardiovascular monitoring: annual blood pressure, BMI, renal function, lipid profile and urine albumin
- Vaccination: influenza and pneumococcal
- Foot checks: annually
- Retinopathy screening: at diagnosis, then yearly 2
“It is very important that we work together to manage your diabetes, and part of this involves attending regular reviews. To check blood sugar control and reduce complications from diabetes, we will arrange regular monitoring blood tests in addition to screening for any complications with your feet, eyes and kidneys.”
Closing the consultation
Summarise the key points back to the patient.
“We have discussed quite a lot today about what type 1 diabetes is, how the condition is managed and the possible complications. I realise this is a lot of information to take in, so I have a leaflet summarising everything we’ve discussed. I will also refer you to a structured education programme to learn even more about managing your diabetes.”
Ask the patient if they have any questions or concerns that have not been addressed.
“Is there anything I have explained that you’d like me to go over again?”
“Do you have any other questions before we finish?”
Offer the patient some leaflets on type 1 diabetes and its management and direct them to reliable websites to gather more information (examples include Diabetes UK and NHS conditions).
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Editor
Dr Jamie Scriven
References
- Lucier J, Mathias PM. Type 1 Diabetes. StatPearls. 2024. Available from: [LINK].
- NICE CKS. Diabetes – type 1. 2024. Available from: [LINK].
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