My guess is you never wanted to be an internist, or else you’d have pursued that calling. But more and more, optometrists need to be up to date on general wellness standards and be willing to bring them up with patients. Inevitably, this means having awkward conversations with people who might look askance at comments on obesity or smoking that come from the person they go to “for glasses.”

Nowhere is this more acute, or more common, than when seeing diabetes patients. It’s acute because these patients have the best chance of improving their long-term health through lifestyle modification. It’s commonplace because the footprint of diabetes is vast—about one third of the US population either has the disease or circumstances that qualify as “pre-diabetes.” 

The medical need and urgency put you smack in the middle of the diabetes epidemic, like it or not.

To make matters worse, it’s happening in an environment that extends so much deference to patients that it only makes a tough conversation even harder. We hear a lot these days about how important it is to treat patients like customers, rolling out the red carpet for them in every conceivable way to keep them loyal to you, as a hedge against losing them to online providers of cut-rate care. People today and millennials especially—the mantra goes—will hold you to the same standards as their other retail experiences. If you can’t be as convenient as Amazon or as unctuous as Apple, you’ll lose out.

You know what? Too bad. A lot of diabetes and pre-diabetes patients need a wake-up call about their health. If you don’t put your foot down, they may lose theirs. 

Not much good can come from an interaction where patients are inclined to treat doctors like a maître d’ and the doctors themselves are ill at ease discussing lifestyle modification for fear of offending them. That’s two people looking for an easy out to a difficult situation. Skipping a conversation about weight loss or letting a diabetes patient take a pass on a dilated eye exam helps no one. 

That means you’re going to lose some patients. So be it. Movie buffs (and Guns N’ Roses fans) know the line, “What we’ve got here is failure to communicate. Some men you just can’t reach.” Same goes with patients. Many will genuinely welcome advice and be grateful for your concern, but there will always be a few who chafe at it. If a diabetes patient refuses a dilated exam, or acts defensive about following up with their GP to discuss weight loss, note it in the record and send them on their way. But it’s your responsibility to bring those issues up.

The customer isn’t always right. Sometimes, they aren’t even a customer at all. In your dispensary? Sure. But in the exam room, they’re a patient and you’re an authority.

This month’s feature article on diabetes, plus a thoughtful column on billing do’s and don’ts for the diabetic eye exam, can help keep you connected to standards of care. Now all you have to do is enforce them.