Dr. Karla Espinosa De Los Monteros discusses how to promote self-management interventions and multicomponent behavioral strategies that emphasize the monitoring and regulation of behaviors and reinforcements.
Back to Symposium Page » Welcome back. We have a very exciting afternoon of speakers lined up, and I'd like to remind you to please go ahead and put your questions in as you think of them, and those will be addressed at the end. So I'm very honored to welcome our first speaker. We know that living with diabetes is hard work, and finding the right support can make a huge difference in a person, uh, management and overall care with diabetes. We heard a lot this morning about the challenges that people may have, and it's often difficult for physicians. Toe have adequate amount of time to really address their challenges and needs. Dr. Carla Espinosa Delos Montero's is passionate about supporting patients living with diabetes who are feeling overwhelmed by the day to day demands of diabetes management or who find that work, family, emotional factors and other outside forces, especially in this time of co. But I'm sure, um, impact their ability to safely take care of their diabetes. Dr. Espinosa received her PhD in clinical psychology with an emphasis and health psychology from UCSD, San Diego State and a joint doctoral program in clinical psychology. She has a masters of health and psychology and our master's degree in public health in the area of health promotion, also from San Diego State. She is over 11 years of experience working with the treatment teams and with patients with diabetes, and we're very, very happy to have her here as part of our scripts team. She's been invaluable in the management across all the different types of patients that we see on a regular basis. And so I welcome Carla. Thank you so much, Mara, for that wonderful introduction. And, um, you know, I'm really excited to be here to talk to all of you about something that I'm incredibly passionate about, which is what we can do as healthcare providers to help support our patients on their journey to improving your diabetes self care. I know that there was a few talks people today that have addressed some of the things that I'm gonna be talking about, so I'll try my best. It's just kind of add to it so that you can keep learning and, you know, learn new tricks that you can use to help support your patients. So okay, so I have no conflicts of interest to this close today. Okay, so I have three main learning objectives for today's talk. First of all, I'd like to start off by just talking a bit about how we can foster empathy for patients and their journey with diabetes. Aan den. Following that, I'll go through some little tricks that you can use in your interactions with your patients to help move them in the direction of change. And a lot of these come right out of motivational interviewing on Ben. Finally, I'll end with some tips of strategies you can use toe help. Set your patients up for success when they leave your visit because, as you know, all the stuff that really matters happens outside of the clinic. So how do we help set them up for success? Okay, but I will be starting off by really focusing on what I feel is the most important piece of everything that I'm going to talk about, which is really the heart of what we do. And that is how do we help foster empathy for our patients and their journey? And I say this not because I think that you don't have this already. I know for a fact that all of you do the work that you do because you care deeply for your patients. But I bring this up because I also know how hard your job iss um it is not easy to do what you do every day. I see you all running around during the day from patient to patient, oftentimes not getting a lunch break or even a moment to go to the bathroom on. Do you still do this? And you show up every day. But it can be hard, especially when you have benchmarks you need to meet in regards to, you know, patient outcomes and so forth. And so sometimes when you're working under this pressure and you're working with a patient who for one reason or other, is not as engaged in treatment as you would like, it could certainly be easy. Thio, I think in that moment maybe air on the side of maybe labeling the patient as non compliant or non adherent or difficult. And unfortunately, even though I know all of you, even if you're thinking this would never try toe, treat your patients in a way that they would know that that's what you're thinking I think our patients, you know, they pick up on a lot more than we realize. And you don't know how many times I hear from patients who tell me, you know, You know, I know that my doctor is frustrated with me. I know that you know, my doctors still being difficult or even worse. I didn't want to tell my patients my doctor, because I didn't want them to think I wasn't difficult on DSO. Our patients do notice this and it does make a difference. And so whenever you can try in those moments, which, of course, you're gonna have because we're all human. But when you have these moments, when you're really struggling with this to just have an extra moment where you can sit back and really try to connect with your patient and try to understand why somebody might be making the choices they're making over and over again, and I'll give you a quick example of how this can work out. So I had ah, patient who I've been working with recently, and this patient was connected to me a little bit before Covert started, and, um, he was new to our clinic and are endocrinologist was actually meeting with this patient for the first time. And during that session, our patient, he was having a panic attack like a legitimate panic attack in session. And this is long before she even had said anything. She walked in and he was already in this panic mode. And so luckily for this patient, we have a psychologist in the office who can go in and work with him on Dwan. Of the things that I learned when I was able to talk to him about what was going on is that he had a few weeks ago met with his primary care doctor and his primary care doctor had really scared him on. Did you know that the patient was honest and said, You know, I have just been a difficult patient. I know. And he went on to tell me that for the last 10 years, his blood sugar's had been really unsafe and his, you know, and not only that, but, you know, he admits that he often would not show up for his doctor visits or would keep canceling and postponing them and postponing them. Um, he rarely ever checked his blood sugar. And so he didn't really know how food was impacting his blood sugar because he wasn't checking them and then even sometimes wouldn't even take his medications. And so, of course, the primary care doctor who had been working with him for so many years was very concerned. And on this particular day, when this patient showed up and his A one c had shot up a few points on the primary care doctor, very worried, said to the patient, You know why? I just don't know what more I could do for you. I have kind of run out of ideas here. You're heading in a direction that's really scary. I'm worried about your future. I'm worried about your health. I'm gonna have to run a whole bunch of test to make sure that things are OK now. And I'm going to send you to a technologist because at this point there's not much more I can dio and s. Oh, my patient left that visit and what he heard his doctors say, was that he was terminally ill. So he really truly thought that he was dying. And when he went to that appointment with under technology. That's why he was having a panic attack in the middle of the session. She didn't even said anything. He was already writing to hear, like the worst news of his life. And so I bring the story up because what would have been really helpful in that moment? I think it's for that doctor who, understandably, I mean, was responding in a way that makes sense. But if he would have taken a moment to really try to understand why this patient was responding, the way they were over and over again, and what it turned out that was happening for this patient is that they were completely terrified of diabetes. And in fact, it wasn't that they didn't care enough about their diabetes. It's that they care probably too much. And so every time that they would check their blood sugar to them, it was a reminder that they were going to die one day of this disease and because they would see off the numbers that were not ideal, they eventually decided that was better, just not to check because they would make them feel really anxious. And then it was hard to focus on the things that they needed to do, and this person had a very demanding job. And so it was so much easier for them. Just not look at those numbers at all. And then every time they went to the doctor again, they would get that news. And again, he was avoiding because it just was too hard to go through his life worrying all the time about his diabetes. And so when this provider, in an attempt to try to help him try to scare him straight, what they did was exactly the opposite of what that patient needed. So this is again why I really emphasize that it's really important to take a moment and try to walk in our patients shoes and, you know, again, E No, all of you know what diabetes is? I mean, this is what you do every day in, day out. You work with people living with diabetes, but I just want Thio talk a little bit about what living with diabetes is like from our patients perspective. So we asked them to take medications, oftentimes multiple times a day, right, and these medications might have side effects on Did you know, even for metformin, something that seems pretty benign. You know, it can have some pretty uncomfortable side effects. And so we're asking people to do this, and on top of that, you know, they can read and they see those, like a little printouts that gets from the pharmacist that go over all the warnings and things that could go wrong. And then they see on the news and commercials about all the things that could go wrong when you take these medications. And so we're asking them to, you know, really trust us that, you know, they're gonna be safe taking these medications even though they're seeing this stuff all the time and then, you know, on top of that, we have them check their blood sugar. For many of them, it's multiple times a day. And while you know, obviously it's not something convenient. It could be quite inconvenient. And it could be painful for many people on top of that, I think. More importantly, it could be really hard to motivate yourself to check your blood sugar when you know that what you're going to get often is some bad news, right? For many people, you know, especially people who've been really struggling every time they check their blood sugar, it's, uh it's a moment to remember that they're failing and their diabetes, And you think about, you know, maybe the person doesn't want Oh, I feel bad that they maybe they're already having a bad day. Maybe it's their birthday and they don't want something to bring them down. There are many reasons why somebody would want to avoid this. And in fact, this is the number one recent people give me for why they don't check their blood sugar. Then we asked them to go to the doctor multiple times a year. Again, these interactions are often not pleasant for patients, and then every single day we're having them make choices about what they eat. And these choices are things that people generally wouldn't choose if they didn't have diabetes. They can be inconvenient, they take more work, they take more planning. And for people who are living in areas where it's hard to come by healthy food, it can actually be really hard to eat this way and then on top of that, you know, we're asking them to exercise and do diabetes, education and they're doing all these things within the context of their own lives and all the things that they're already juggling. Just think about how busy you are. Eso We're asking them to take on this job because diabetes really is a job. But it's a job that nobody asks for. And not only that, but you don't get to take breaks. You don't get time off. You get, you don't get paid, you get no benefits from it, right? So this is incredibly hard. What we ask of our patients is a lot. And then add to this that while we all know that there are many long term benefits to good diabetes care, and believe me, our patients are more than aware of this. There are, unfortunately, very few immediate benefits to it, and so particularly for people living with type two who can actually feel quite healthy. We're asking them to make a lot of sacrifices now for a promise of a future that you know is really out, out in the distance. And, um, you know, if we're all honest with ourselves and how many of us are willing to make choices right now that are gonna maybe make a difference to our future, right? Like it's really hard, because, remember, it's one behavior at a time, right? And every it's very easy to say. Well, this one doughnut is probably not gonna make a difference. This one time I didn't check my blood sugar is not gonna make a difference, but then those add up right. But in that moment, that person's not thinking in that way. And then, of course, to add to that there are many immediate benefits to ignoring diabetes. Just think about all the things that we love and enjoy. I mean, we've got the holidays coming, and what we love about the holidays is the food and hanging out with their friends and family being carefree, maybe having some alcohol and just lounging around. And these are all the things that bring joy in our lives. And that's the same stuff that were often asking for. People with diabetes are patients with diabetes to make compromises on a regular basis, and again, you might be able to do this every once in a while. But if you had to do this every day, I mean, how difficult is that? And so I bring this up just to help remind you in those moments when you may be tempted and again completely understandably so to label your patients as unmotivated or non compliant or difficult to just take a moment and step by. Step back. And remember how hard this is. Just think about all the times in your life when you have set out to Maybe you had a New Year's resolution, that you decided you were gonna exercise and run a marathon or whatever it is that you decided you were going to do and how many times you were actually successful with that, right? We all struggle with this, and so if we can connect with that, we're gonna be in a much better place to help support our patients. Okay, Okay, so then moving on from there, the next part of the talk, I'm gonna be focusing on a few strategies you can use in your sessions with your patients toe. Help promote interactions that will foster change right with moving that patient in the direction of change. And I'm first going to start by going over some of the things that I'd like people to do less of and I bring this up because they're really, really common and again, no judgment. I myself I'm at fault for this. You can ask my husband. I do some of these all the time, and I'm a psychologist, and I know I shouldn't, but the first one that I'm going to go over is something called the Writing Reef Life. And basically, what this is is that it is very it's actually very hard not to do this. So when we see somebody doing something and we recognize the problem, we have this urge to just jump in and immediately correct the person and tell them what they're doing and how they should fix it. Right? This is something that we all do. And if you're married and if you have kids, you know this well, so But what happens is let's say you have a patient that's coming in, and they tell you, you know, Okay, I'm not taking my medication. I haven't really been taking my medication. Now, you know, you might want to jump in right away and say, Oh, well, did you know that you know, this medication is really important that you take it because if you don't take it, then you know it's gonna be really hard to get your diabetes in a safe place. And if we can't get in a safe place and imagine what's gonna happen if you can't see well or you end up having to go to the hospital, what's gonna happen? Your kids and we're gonna jump in and give them all these reasons, which might be perfectly rational. But what's happening in that moment when we're doing this is that our patient is feeling like they need to explain themselves to you, right, because they're going to feel a little bit defensive, and they're gonna feel like I got explain to them why I'm doing this and so they'll jump in and they'll tell you, Yeah, I know, doctor, but it's because I have a really difficult job or my husband doesn't help me out through my kids or really whatever it is. And they'll just go on and on to tell you all the reasons why they haven't been able to do it. And at the end of the day, when that session is done, what that patients going to remember most is the things that they said to you, right? So if they sat there the whole time explaining why they can't do it, they're gonna leave that session and what they're going to remember and what's been reinforces why they can't do it. That's exactly the opposite of what we want toe happen, right? And so again, this is really hard to do because it just is kind of a reflex for all of us. But if you can just try your best not to do this, I will go over some tips of other things that you can do to address problem behaviors that are a lot more effective. Mhm. Okay, okay. The other one that does not work is fear tactics. So I know a lot of times people don't believe me when I say this, but they really mostly don't help. There are very few exceptions to this. For the most part, they don't help and often times they will backfire. Just like that story I said earlier on DSO if you can avoid doing this, there are many more ways to get a point across the patients that are gonna be a lot more effective. So you might be sitting, going, They're going. Okay, so then what am I supposed to dio? And so let's go over some of the things that you can do. So first of all, look for strength, And I know Dr Santos did a really great job of going over this. So I just will add that there are times when you will be working with someone where you might say, Well, you know, it's really hard to find any strength here. This person is just basically doing everything opposite of what I would want them to dio. And even in those situations, I would say that it's always possible to find a strength, even if it's a simple a saying, Hey, Mr Jones, I know that it's not easy for you to be here today. I know that it's hard to come, and I just want to thank you for taking the time to come and being willing to sit here with me. Because now that you're here, then we can work together on this, and as long as you're here, I'm going to do whatever I can help you get to a safer place, right? You can make it a simple as that. And even in that situation here you are pointing out something positive and you're setting the tone for the rest of that visit because unfortunately for most of our patients, what happens is that when they go in to see us, they feel like this. They feel this small because the whole time there in the session, their doctors pointing out to them right, belief, so all the things that they're concerned with. But what it feels like to be on the receiving end of that is something that is not pleasant for anyone, right? And in fact, it's not uncommon for my patients and tell me, you know, I know I should be coming in more often, but it's just that it's just every time I go in, I just feel so horrible about myself, or I feel so hopeless or I feel so ashamed or angry. And so again, if people are having all these negative emotions when they're coming in to see us, chances are that the next time they have to come in, they're gonna be dreading it, or maybe they're gonna postpone it and try to reschedule it. Or maybe they're just not going to tell you all the things that they're doing because they just don't want to feel bad. Mhm. So if instead we focus on the good, then that person is going to have a completely different experience. So I had a patient that adjustment with last week, who I've been working with for a whole year on trying to get her diabetes into a safer place. She has type one diabetes, and this has been a struggle for her for a long as she's been living with the disease, and we started off with her a one c of 13, and the day that I met with her, she had just met with the endocrinologist, and she had gotten the news that her agency was down to eight. Now, to me, this was amazing. But to her, this was so discouraging because she was hoping for an agency of seven, which was her target. And so she came in and she was just so discouraged. And she was like, You know, I just I don't know that I could do this. It just seems so impossible. And so instead of sitting there and just kind of talking about how awful it is and how hard diabetes is. What I did was like, pulled out her labs and we started to look at the chart and I said, Look, you know, you started off a 13 and then about a few months later you went down to 10 and then a few months, months later, you went down to, you know, the nine, and then now you're at eight. That's amazing. Look at that trajectory. You're going exactly where we need you to be. You're headed in the right direction. And for her to be able to see that it was a completely different way of thinking about it. And I didn't show her anything she didn't know, but it really changed that conversation. And so instead of having a whole session where we just focus on how hard diabetes was, we had a whole session where she was sitting there thinking about Okay, what more can I do? Or how can I tweet this or How can I change that or this really worked? And so now I'm going to do a little bit of a bit more of this, and we made this into a very empowering conversation. So again. If we emphasize the good, our patients are gonna leave our sessions feeling empowered. If we Onley focus on the bad, they're gonna leave feeling terrible. And that's gonna lead them to feel, do a lot of things among them, Just avoid altogether and which is exactly what we don't want. Okay, so the next thing that I want to focus on is just this idea that we really want to spend more time trying to understand. Why are patients behave the way they dio? And the only way we're gonna know is if we ask. So I always say, you know, one of the first things you should tell ask your patients is you know, simple. You just say living with diabetes is really hard. Tell me what to you is the hardest part about living with diabetes or what part of diabetes drives you most crazy? You can imagine if my patient, who I talked about earlier had their doctor asked them, You know what aspect of living diabetes is hardest? That patient would probably told them, is that I'm always worried that I'm going to die from diabetes and then that doctor would have known okay, fear tactics are not gonna work with this person, right? So if we take a moment to try to ask our patients to understand what they're struggling with or what their struggles are when it comes to diabetes, we're gonna be able Thio, meet them where they need us to be. On DSO there are many, many reasons why somebody would struggle with their blood sugar management. I'm not going to go over all these because I know Dr Santos did a pretty good job of addressing these. But I will say that you know, the key here is just asking just simply asking. And for people who don't know how to ask about mental illness, Um, you don't have to be shy about it. You could just straight out ask someone. You know, it's not uncommon for people living with diabetes to feel really burned out. It's just true for you. Or, you know, sometimes when people are feeling really depressed or anxious, it can be really hard to focus on. Their diabetes is just something that is happening for you, because this is pretty common, and people will be more willing than you think to disclose this information if that is indeed something they're struggling with. Mhm. Okay, so I said earlier that we really want to avoid telling people what to dio. But what we do want to do is to encourage people to tell us what they're going to dio in motivational interviewing. We refer to this this change talk. So anytime someone talks about what they're going to do, how they're going to do it, why they're going to do it, what they've already been doing to change that is all examples of change talk. And we know that the most persuasive arguments that people will ever have that will help encourage them to change are going to come from the patient. They're not going to come from you, and so are goal is to really get people to tell us why they need to make these changes. And we also know from the literature on him I got the more patients talk about change, the more likely it is that they will be able to make these changes. And again, like we said earlier, you know, if a person spends the whole session trying to convince you why they can't do something, that's what they're going to remember, and that's going to just further reinforce the fact that they can't do it. But if instead they're spending the whole session telling you why this is important to them and why they want to do this, then when they leave, they're going to be much more likely to do it. And so there are many strategies you can use to get people to engage in change. Talk s I'm just going to go over to that are just really simple to use and e think anyone with even somebody without any site background can dio And the first one is something called the change ruler. And it goes a little something like this. So let's say you're working with someone and they have been working on trying to be more active, and so you might ask the person. Okay, so on a scale 1 to 10, how important is it to you to be more active and the person might tell you 10 and then you can say, Oh, wonderful. Tell me why. And then they'll spend the next few minutes telling you why being more active is really important to them. Um or they might give you a four, and then you can say Oh, okay, Affordable. Why not a one or a two? And then now you've tricked them into spending the next couple minutes telling you why it is important to them. Um, you can use the same ruler to assess confidence so you can ask them, you know, not a scale of 1 to 10. How confident are you that you can go for a walk every day after work? And then again, if they give you a high number, you follow up on that, and if they give you a low number, you follow up with an even lower number. So you said for Well, what about why not a one? And now they have to tell you all the reasons why they think they could do it. And that's exactly what we want them to be thinking about when they leave our sessions. Another great question is the miracle question. It actually comes right out of problem solving therapy. And so you ask the person, you know, if you could be 100% successful in making the change you want, so if you could be 100% successful in going for a walk every day for the next month. How would your life change? How would you feel? And now you're forcing the person to think about the benefits of engaging in this behavior. And now this person is going to be thinking about it. And they're gonna because we know that the most persuasive argument they're going to come from your patient. Now we're doing, you know, a really good job of really getting your person ready and set to make these big changes. And then finally, and I'm not going to spend too much time on this because Dr Santos did a really good job here. But I do want to emphasize that it's really important to create hope for patients because we have done a marvelous job scaring our patients about diabetes, unfortunately, but what many of them don't here enough or don't really even know is that it's perfectly possible toe live a long, healthy life with diabetes, right? And so, um, Susan Guzman and Bill Polanski, who are wonderful Diaby psychologists, have the saying, and it is well, Mattis. Diabetes is the leading costs of nothing, and I love saying this to my patients and I Honestly, it's like I see the brains like explode when I say this because they're just like, Oh, I have never thought about it this way This is such an important message to get across to our patients and particularly these days with co vid. I will say that our patients living with diabetes are living through a particularly stressful time because the only are they dealing with all the stresses were dealing with their also constantly being singled out as the population most at risk of Cove in. And so I often tell my patients who are really worried about Cove it You know what, did you know that it is really diabetes that's unsafe? That is what's gonna put you at most risk with covitz. So if we can get your diabetes into a safe place and chances are that your risk is not gonna be that much higher than someone who doesn't have diabetes, and when you say this to your patients like again, it's like completely changes the whole feelings about it. And not only that, but it helps to motivate them to want to do something about it. Like now you're telling me there's something I can do. I can control this, and thus it's gonna be a lot more empowering. Okay, Um, I also like to emphasize that perfection is not necessary, so you don't need to be perfect to be safe with diabetes. And this is particularly important to get across to many of our patients who have type one because they have these wonderful devices that help, you know, tell them every day, all the time where the blood sugars are and these air wonderful. But at the same time, they can also be very discouraging for someone who is struggling to keep their diabetes safe. And I will tell you that when I talk to people living with type one, and I asked him what the hardest part of living with diabetes is. The most common answer I get is that I could be doing everything right and yet still have bad days. And so I often I want to emphasize to people you know, you don't need to be perfect. All we need is for you to be safe the majority of the time, right? We need to maximize your days in range so that when you have a day where you're not in range, whether it's because you who knows some fluke or maybe because it was your birthday or whatever it might have been that those won't matter as much because for the rest of the time, you're mostly safe. And I think this is such an important message because it makes it seem so much more attainable to our patients. Uh huh. Okay. And so finally, I'm just gonna end with going over some strategies that you can use with your patients to help set them up for success because, as you know, the big important stuff happens when the person leaves the office. Um, and first of all, I just want to emphasize that we really want to keep our message a simple as possible, Um, in sessions with me, my patients are often shocked that, you know, they think they're going to come in and they have to tell me that they're gonna 10 things and they're gonna change everything in their lives. And I always tell No, no, no. I just want you to focus on one thing. Just one thing. And the reason why I do this is because I know that it's very important, particularly early on, for people. Toe have experiences of success with behavior change. And so in order for them to have this experience of success, it's my job to make sure that I make it attainable. And if I make giving them five things that they need to change, then you know the chances that they're gonna have success with those fire things is going to be pretty small. But if I choose one and I make it realistic, then the likelihood that they'll be able to achieve that is going to be much higher. And once they feel encouraged because they see that what they do matters, they're gonna have a lot easier time adopting other health behaviors. So if you can focus on one recommendation at a time, I would highly encourage that. If that's not possible, then even saying, You know, I'd like you to work on a B, C and D. But if you're only gonna be able to do one thing, focus on it, that it might be another way to approach it, um, to I really encourage you to get people to write down what you're asking them to do so because we're always talking about the importance of giving people information and multiple formats like verbal and written. And I know that we all have these great printouts we get, you know, automatically with Epic, you know, just print out instructions. But believe me, those just end up in the trash. So what I have my patients to in session is I have to pull out of paper and a pencil, and at the end, I say, Okay, so let's write down what you're going to dio. And then I have the patient themselves write down what they're going to dio, and this gives me the opportunity to also do point number three here, which is to use the teach back method, which basically is just asking people to repeat to you what they're going to dio. And so I have them write it down. And at the end, I said, Okay, can you read to me what you wrote down? And then the person will then read me the instructions and that gives me the opportunity to then make any corrections I need to make, because sometimes no matter how clear we think we're being our patients, you know, they hear something else, and so that's my opportunity to check to make sure that we're both on the same page. Um, setting goals is also really, really important. And again, I'm not going to spend too much time here because I know Dr Santa's talked about this, but I will say that one of my favorite frameworks for setting goals is the smart goal framework, and it basically goes like a little bit like this. So smart goals. It stands for specific, measurable, attainable, realistic and time bound. And here's an example of a goal. So I might say, Okay, I'm going to start exercising more, and that is the goal, right? But it's kind of this vague, fuzzy thing. I don't know exactly what and how I'm going to do it. So with the smart goal, you would have your patient make it sound like this. So I'm going to go for a walk Mondays and Wednesdays, Monday, Wednesday, Friday, after work at the park near my house. I'm gonna keep track of it on my phone, and I'm going to start off with just 10 minutes at a time. I can always add to it. If e feel like you know I'm doing well, I can always add more and I'm going to start on Friday. And so that has now gone from this fuzzy thing to something very tangible that our our patient can work on and keep track of. And again, we've also made sure to make it realistic so that the patient is not overwhelmed because we want those experiences of success at the beginning. And finally, I would take a moment at the end of your sessions to do some problem solving. And again, this doesn't have to be complicated. I promise. You don't have to come up with the solutions. They're going to come from your patient. All you have to do is ask the right questions. So, for example, if I have a patient who's working on being more active, I might follow that up by saying, Okay, so what ISS most likely to get in the way of you being able to go for a walk Mondays and Wednesdays and Fridays and the patient then is gonna have to tell me in their eyes what might get in the way so they might say, Oh, well, you know. I guess that after work, I'm always really tired, and I usually come home and then sit down and start watching TV. And once I sit down at the television, it's gonna be really hard to motivate myself to get back up. And so now that they thought about the barrier, then the next question would be okay. So then what's one action you could take today That would set you up for success? And now the patient can say, Okay, so maybe I probably should go straight to the park. I shouldn't come home, because if I come home is gonna be really hard to motivate to go back out. Or they might have to decide, You know, after work is not the best time, because I'm just not going to do it. So maybe I gotta do it during the day or at lunchtime, right? But again, you're making them think about what might get in the way so they can start setting themselves up for success on. And then the last question I always ask which is really important is to just follow up by saying, Okay, is there anything else that I could do to help support you, and you will be surprised at what your patients will say. And you know, the other day I had a patient who is going through chemo, and it's just overwhelmed with the amount of doctor visits she's going through. And so for me, I thought it made perfect, reasonable sense to try to spread out our appointments as much as possible so that she wouldn't, um, be so overwhelmed. And when I asked her this question, she actually told me, Oh, can we have sessions more frequently? Because it actually helps me to have more accountability, and I would have never thought of that myself, right? So again, it's really important to ask our patients. You'd be surprised at some of the things that they tell you. So in conclusion, patients will be more forthcoming and open to your message. If they feel understood, don't tell people what to do, get them to tell you what they need and how they will do it. Optimism and positive reinforcement are powerful, so use them often. Keep your message simple and help your patients set goals that are smart and remember that the best solutions to behavioral challenges will always come from your patient. So make sure you ask the right questions and that's it. And there's my references, and I have a whole bunch of resource is here for anyone who's interested in learning more about any of the topics that I covered. Then I have time for questions. I actually don't know. Hopefully have some time for questions. Thank you, Carla. Very important and very informative. We had heard from an earlier speaker this morning. The results off, um, stressed during Copan times. And how much would you say this has impacted your patients? Any things you particularly seen regarding stress and cope on impact on your practice? Yeah, that's a really great question, you know? Yes, this has been a very stressful time, I think for everyone I mean, including myself, certainly for our patients. And like I said earlier, I think the way it seems to present itself the most is that you know, people feel really vulnerable because they're constantly being told that their risk. And for some people, it has resulted in them just kind of being home and being I had a patient who was scared to even go outside her house right, Just even walk around right? Or it could also be that they have family members who are really worried. And so these family members are constantly arguing with the patient, trying to get them to do less because they don't want the patient to go to the doctor. They don't want the patient to go to the grocery store, and they don't want patient to go to the gym or whatever it is, because they're worried about them. And so the person living with diabetes is feeling really constrained and controlled. And so I think it really has affected people. Um, deeply. I mean, so many people. And my my suggestion for all of you is to take a moment to us to just ask people and say, You know, gosh, you know, living with diabetes is really hard and living diabetes during covert is particularly difficult. Can you tell me how it's been impacting you? And then that way you could get a sense of where the challenges are and you can help address them. But yeah, it's been tough. Thank you so much. I really appreciate your time. Thank you.