Integrating Multidisciplinary Results to Produce New Knowledge About the Physician-Patient Relationship: A Methodology Applied to the INTERMEDE Project

From a critique of the principle of autonomy to an ethic of heteronomy

Etymologically, autonomy is the ability to give oneself rules and follow them. It is an important principle of medical ethics, which can sometimes raise some tensions in the care relationship. We propose a new definition of ethics, the ethics of heteronomy: a self-normative, discursive and responsible autonomy. Autonomy cannot be considered without the responsibility each person must have towards others. In the care relationship, autonomy would be more the ability of each person to reach out to others than the ability to decide alone. The care relationship must be seen as an accompaniment of equals where each person allows the other to be rephrased. Autonomy would then no longer be absolute but relative to each situation. Being autonomous would become an ability for adaptation of the patient-doctor pair. The accompaniment allows the birth of a relationship of trust, giving the patient and the doctor the ability to touch and let themselves be touched, thus making each one progress in this reciprocal dialectic. The care relationship becomes the possibility of considering autonomy as a collective and not as an individual notion only. Paradoxically, by promoting the autonomy of the patient-doctor pair, they both develop their own autonomy.

Effect of a Mobile Phone-Based Glucose-Monitoring and Feedback System for Type 2 Diabetes Management in Multiple Primary Care Clinic Settings: Cluster Randomized Controlled Trial

Background

Recent evidence of the effectiveness of mobile phone–based diabetes management systems is generally based on studies conducted in tertiary hospitals or professional diabetes clinics.

Objective

This study aimed to evaluate the clinical efficacy and applicability of a mobile phone–based glucose-monitoring and feedback system for the management of type 2 diabetes mellitus (T2DM) in multiple primary care clinic settings.

Methods

In this multicenter, cluster-randomized controlled, open trial, 13 primary care clinics in Seoul and other large cities in South Korea were voluntarily recruited. Overall, 150 (9 clinics) and 97 (4 clinics) participants with T2DM were assigned to the intervention and control groups, respectively (2:1 allocation). Every month, participants in both groups attended face-to-face physicians’ consultation for the management of diabetes in the clinic. For the intervention group, participants were required to upload their daily self-monitoring of blood glucose (SMBG) results using the mobile phone app in addition to outpatient care for 3 months. The results were automatically transmitted to the main server. Physicians had to check their patients’ SMBG results through an administrator’s website and send a short feedback message at least once a week. At baseline and 3 months, both groups had anthropometry and blood tests, including hemoglobin A_1c (HbA_1c), and responded to questionnaires about treatment satisfaction and compliance.

Results

At 3 months, participants in the intervention group showed significantly more improvement in HbA_1c (adjusted mean difference to control −0.30%, 95% CI −0.50 to −0.11; P=.003) and fasting plasma glucose (−17.29 mg/dL, 95% CI −29.33 to −5.26; P=.005) than those in the control group. In addition, there was significantly more reduction in blood pressure, and the score regarding treatment satisfaction and motivation for medication adherence increased more in the intervention group than in the control group. In the subgroup analyses, the effect on glycemic control was more significant among younger patients and higher baseline HbA_1c levels.

Conclusions

The mobile phone–based glucose-monitoring and feedback system was effective in glycemic control when applied in primary care clinic settings. This system could be utilized effectively with diverse institutions and patients.

Trial Registration

Clinical Research Information Service (CRIS) https://tinyurl.com/tgqawbz