For an upcoming Medscape article, I’m seeking US-based primary care physicians to discuss “The Good Patient Problem”—why some patients appear fully adherent yet continue to have poor glycemic control. The piece will explore how PCPs set realistic goals, adjust care plans, and keep patients engaged when lab results don’t tell the full story. Questions: Some patients follow every recommendation yet still struggle with glycemic control. From your perspective, what are the most common reasons for this disconnect between adherence and outcomes in primary care? When a motivated patient’s numbers don’t improve despite strong effort, how do you frame that discussion? What helps you balance being honest about the data while keeping the patient engaged and encouraged? How do you decide when it’s time to adjust the care plan—such as changing medications, monitoring frequency, or lifestyle goals—versus giving more time for current interventions to take effect? What tools, systems, or team-based supports within primary care have you found most helpful for patients who are doing “everything right” but still not meeting glycemic targets? Requirements for participation: • Must be US-based • Must have verified physician credentials (MD or DO) • Conflict of interest disclosure required if relevant • Responses are considered permission to quote with attribution; may be lightly edited for clarity and flow

It's common for patients to feel discouraged when they're diligent but still struggle with glycemic control. In primary care, this disconnect often stems from complex, multifactorial influences such as genetics, stress, sleep, hormonal changes, hidden dietary factors, medication timing, or conditions like thyroid disease or insulin resistance. Even small variations in carbohydrate absorption, physical activity, or gut microbiome can affect the glucose response. When discussing this with patients, I like to be transparent and have empathy by acknowledging their effort first, then reframe the goal to use their numbers to learn, not judge. This preserves patient trust and motivation. Deciding when to adjust the healthcare plan depends on patient trajectory and time frame, if there's no measurable change after several weeks of consistent adherence, or if glucose levels remain high despite appropriate lifestyle changes, that's a cue to reassess and review medications, add or switch agents, and evaluate sleep, stress, or possible comorbidities. Some helpful supports include continuous glucose monitoring to track patient patterns, involving a pharmacist or diabetes educator to help with medication optimization, consulting a nutritionist to fine-tune diet, and seeking behavioral health support for stress and burnout management. Team-based care where nurses, dietitians, and educators help track progress keeps patients engaged and helps clinicians focus on root causes. Overall, when patients do everything right but results still lag, it's rarely about their effort and is more indicative of hidden variables, adjusting the plan thoughtfully, and maintaining hope and motivation through partnership.