Endocrinologists’ Perspectives on Early Screening for Diabetic Peripheral Neuropathy: A Phenomenological Study in Four Chinese Based Hospitals

Abstract

Purpose

This study aims to explore endocrinologists’ awareness and current practices regarding early screening for diabetic peripheral neuropathy (DPN), and to further analyze their experiences, barriers, and potential optimization strategies in implementing DPN screening within clinical practice.

Patients and Methods

Methods: A qualitative study based on Husserl’s phenomenological framework was conducted. Twelve endocrinologists (3 male, 9 female; age range 29–47 years; clinical experience 3–23 years) from four tertiary hospitals in China were recruited via purposive sampling. Semi-structured in-depth interviews were used. This phenomenological approach was chosen to explore the lived experiences and subjective perceptions of physicians regarding DPN screening, as quantitative methods cannot capture such contextual richness. Data were analyzed using NVivo 20.0 with Colaizzi’s seven-step method.

Results

Five major themes and 11 sub-themes were identified: The most predominant finding was that, despite endocrinologists’ recognition of the necessity and urgency of early DPN screening, its implementation is critically limited by three interrelated barriers: insufficient physician training and heavy workloads, limitations of screening tools (eg subjectivity of physical exams and high cost of electromyography), and poor patient compliance due to lack of awareness and financial constraints.Other themes included current screening practices and optimization strategies.

Conclusion

This study indicates that despite the critical role of early DPN screening in diabetes management, its implementation remains constrained by limited healthcare resources, limitations of screening tools, and patient-related barriers, such as awareness and affordability. Therefore, it is recommended to enhance physician training, standardize screening protocols, and improve patient adherence through policy support and health education to promote the widespread adoption of DPN screening.

Introduction

Diabetic peripheral neuropathy (DPN) is a common chronic complication of diabetes, with high prevalence and substantial clinical and economic burden.¹ It results from long-term hyperglycemia, dyslipidemia, and insulin resistance, manifesting as distal symmetrical numbness and sensory loss. Epidemiological studies show DPN prevalence among Asian type 2 diabetes patients ranges from 44.4% to 67.6%, with over three-quarters experiencing diagnostic delays.^2–4 DPN causes gait disturbances, increased fall and fracture risks, and advanced-stage diabetic foot ulcers or amputations; medical costs are significantly higher than those diabetic patients without neuropathy.^2,5,6 Therefore, effective DPN management is an unavoidable public health challenge for endocrinology.

Early screening and intervention for DPN are key to improving patient outcomes, yet multiple challenges persist in clinical practice. Epidemiological data vary significantly due to a high proportion of asymptomatic patients, limited research, differing neuropathy burdens across subtypes, and a lack of standardized screening methods.⁷ According to guidelines from the American Diabetes Association (ADA) and the Chinese Medical Association Diabetes Division, screening should be performed regularly after diagnosis or disease progression, combining history taking with at least two testing methods to enhance sensitivity and specificity. Thus, while early screening is essential, current inconsistencies must be addressed through standardized protocols.^8,9

Nerve conduction testing is the gold standard for DPN diagnosis¹⁰ but its cost, time, and complexity limit widespread screening, leaving a need for simple, reliable early examinations.^11,12 Furthermore, physicians and patients differ in perceiving painful DPN: physicians prioritize pain after glucose and renal management, while patients face poor awareness, financial pressure, and limited time.^13,14 Screening procedures vary greatly due to lack of standardization, risking diagnostic bias.¹⁵ In resource-limited settings, multi-factorial strategies can reduce DPN incidence and progression.^7,11 Thus, DPN screening implementation depends not only on technical specifications but also on healthcare system operations and doctor-patient interaction patterns.

Despite clear policy consensus on DPN screening, implementation obstacles persist, and literature on clinical physicians’ perspectives remains scarce—making it essential to reveal their real experiences. Current research is largely limited to Europe, America, or Southeast Asia^14,15 China’s healthcare system faces unique challenges due to its hierarchical structure, resource concentration in tertiary hospitals, and imperfect referral mechanisms. Using phenomenological methods can capture physicians’ implicit knowledge and judgment logic beyond quantitative surveys, identifying context-specific barriers and facilitators. Therefore, exploring Chinese endocrinologists’ perspectives is not only regionally representative but also holds irreplaceable clinical value for optimizing localized screening pathways.

In summary, this study aims to explore the understanding and attitudes of Chinese endocrinologists regarding early DPN screening, focusing on their judgment of screening necessity, weighing potential pros and cons, and real-world obstacles encountered in daily implementation. Through semi-structured in-depth interviews and Colaizzi phenomenological analysis, this study aims to reveal the promoting and barrier factors of DPN screening in the context of tertiary hospitals in China from the perspective of clinical practitioners, and to provide empirical evidence for developing more targeted and actionable early screening strategies.

Material and Methods

Research Design

This study was based on Husserl’s descriptive phenomenological framework,¹⁶ focusing on the principles of “returning to the things themselves” and “suspension”,¹⁷ with the aim of deeply exploring endocrinologists’ true experiences, perspectives, and the essential structure regarding early screening for DPN.

Research Participants and Sample Selection

This study was conducted between January 2026 and February 2026 at four tertiary hospitals in Hunan province of China. Purposeful sampling combined with maximum variation sampling was employed,¹⁸ with the sample size determined according to the principle of information saturation,¹⁹ A total of 23 specialists were contacted for recruitment. Four did not respond, four were excluded for failing to meet the inclusion criteria, and another three declined participation due to the audio-recording requirement. We respected their decisions, resulting in 12 participants. The inclusion criteria were as follows: (1) Practicing physicians working in endocrine wards or diabetes specialty outpatient clinics with ≥3years of clinical experience; (2) Have participated in DPN screening, are familiar with DPN screening tools, and can accurately describe operational methods and interpretation standards; (3) Willing to participate in the study and able to clearly express personal opinions. Exclusion criteria: (1) Interns or short-term trainees; (2) Individuals with language or communication barriers who cannot be interviewed smoothly.

Ethical Considerations

We confirm that this study was conducted in accordance with the Declaration of Helsinki. This study was approved by the Ethics Committee of the Affiliated Hospital of Hunan Academy of Traditional Chinese Medicine (Ethics Approval No. 202602),It has also received approval from three other hospitals (The Second Xiangya Hospital of Central South University, Changsha Hospital of Traditional Chinese Medicine (Changsha 8^th Hospital),The Second Affiliated Hospital of Hunan University of Chinese Medicine). The confidentiality of the collected data and anonymity of personal information were ensured, along with the participants’ ability to withdraw at any time. Written informed consent was obtained from all participants. The participants were informed that anonymized clinical details related to them would be published and that they had the right to withdraw their consent at any time prior to publication. The participants’ names were not used within the research ethics framework, and the encodings in the interview texts were made as “N1, N2, N3 … ”.

Data Collection

Data were collected through semi-structured in-depth interviews conducted via a combination of face-to-face (hospital conference room) and online formats. Each interview lasted 20–30 minutes. Two female researchers (Haili.Zhu. and Qing.Yuan.) conducted the interviews. Haili.Zhu. (PHD candidate in integrated Chinese and Western medicine) currently works in the same hospital as five participants (in different departments), with only professional interactions; Qing.Yuan. (Master’s candidate in nursing) had no prior contact with any participant. Both received phenomenological training and used suspension memos, reflexive journals, and peer debriefing (including a third researcher, Xueqin Zeng, without clinical ties) to manage potential bias from Haili.Zhu’.s prior relationship. Such backgrounds enabled them to acquire solid knowledge of diabetic peripheral neuropathy (DPN), relevant treatment procedures and clinical contexts, as well as to accurately comprehend the professional terminology and clinical experiences described by the participants. To ensure consistency and depth across all interviews, the two interviewers jointly developed and revised the semi-structured interview outline. Prior to formal data collection, two randomly selected participants took part in pilot interviews, based on which the interview outline was further refined. Each interview was carried out by the two researchers simultaneously: one facilitated the conversation, while the other took field notes. Upon completion of each interview, the audio recordings were transcribed and double-checked carefully by both researchers to guarantee the accuracy of the transcribed content.

Based on the literature review and research objectives, a semi-structured interview outline was developed, including the following questions: (1) What is your understanding of DPN? What do you think is the significance of early screening? (2) What DPN early screening methods do you currently know of or use? How do you view the effectiveness and necessity of these methods? (3) In your daily work, do you routinely or actively conduct early screening for DPN? Could you briefly introduce your specific practices or practical experience? (4) What facilitating or hindering factors do you think exist in the current process of early DPN screening? (5) How do you think the implementation of early DPN screening could be improved? (6) Do you have any other thoughts or suggestions regarding early DPN screening?

The interviews used the interview outline as the core, with relatively open-ended questions. Techniques such as repetition, counter-questions, and follow-up questions were used to encourage participants to elaborate further.²⁰ Data saturation was attained when all questions were answered, responses were completed and no further new information was obtained from many participants. In this study, the total sample size was 12, the data saturation was achieved in tenth interview and the additional two interviews were conducted for confirmation of data saturation.

Data Analysis

The interview recordings were transcribed into text within 24 hours of each session. After line-by-line verification, the transcripts were returned to the participants for validation. Using NVivo 20.0 software, Colaizzi’s seven-step phenomenological analysis was conducted,²¹ followed by meaningful coding. (1) Repeated reading and suspension of preconceptions; (2) Extraction of meaningful statements; (3) Coding extracted statements to derive preliminary meanings, resulting in 32 initial meaning units; (4) Using NVivo 20.0 software to cluster similar meanings into 11 preliminary themes; (5) Developing detailed descriptive statements for each preliminary theme, accompanied by typical quotations, and subjected them to third-party review; (6) Through collaborative discussion among the research team, the 11 themes were further consolidated into four core dimensions; (7) Selected participants were invited to validate the analytical findings, with adjustments made based on their feedback.

Methodological Rigor

To ensure research rigor, the following measures were implemented: All researchers held graduate degrees or higher, underwent systematic training in qualitative phenomenological research methods, and maintained weekly discussions throughout the analysis process; participant authenticity was fostered through member checking, peer review, and encouraging genuine expression during interviews; and a detailed audit trail was established. NVivo 20.0 software was used to document all analytical steps, decision-making processes, and team discussions, ensuring the traceability of the research process. Before the interview, the researchers signed a suspension agreements, suspension (epoché) is the methodological practice of bracketing one’s everyday beliefs and theoretical presuppositions to focus purely on lived experience. To operationalize this concept, the researchers signed a suspension agreement before the interviews. Recorded their own understanding and possible bias of DPN screening, and continued to write a reflection log in the process of data collection and analysis to minimize the impact of personal experience and theoretical presupposition on data interpretation. Double independent coding was used to compare the coding results. For the inconsistencies, the two coders first discussed them. If they still could not reach an agreement, they were submitted to the research team meeting for further discussion, and the third-party researchers with qualitative research experience participated in the review to ensure the objectivity of the analysis.^22,23

Results

Respondent Characteristics

Table 1 summarizes the demographic characteristics of the 12 participating endocrinologists. The respondents ranged in age from 29 to 47 years (mean 37.1 years) and comprised three males (25%) and nine females (75%). Their professional titles ranged from physician to chief physician, with years of experience ranging from 3 to 23 years (mean 10.6 years). Specific details are presented in Table 1.

Table 1.

General Characteristics of Study Participants (N=12)

Participant No.	Gender	Age	Marital Status	Level of Education	Length of Service	Professional Title
N1	F	46	Divorced	Master’s Degree	23	Chief Physician
N2	F	30	Unmarried	Master’s Degree	3	Physician
N3	M	42	Married	Master’s Degree	16	Attending Physician
N4	F	29	Married	Master’s Degree	3	Physician
N5	F	36	Married	Master’s Degree	9	Attending Physician
N6	F	47	Unmarried	Master’s Degree	20	Associate Chief Physician
N7	M	36	Married	Master’s Degree	9	Attending Physician
N8	F	38	Married	Master’s Degree	13	Attending Physician
N9	M	38	Married	Master’s Degree	10	Associate Chief Physician
N10	F	38	Married	Master’s Degree	10	Associate Chief Physician
N11	F	29	Unmarried	Master’s Degree	3	Physician
N12	F	36	Married	Master’s Degree	8	Attending Physician

Notes: Participant No. = participant identification number; M = male; F = female; Physician = Resident physician; Attending Physician; Associate Chief Physician; Chief Physician.

Research Findings

Theme 1: Necessity and Urgency of Early DPN Screening

Overcoming the Limitations of Symptoms to Achieve Early Warning

Early screening helps identify the risk of diabetic peripheral neuropathy (DPN), providing early warning and supporting clinical decision-making. As diabetes and its neurological complications often develop insidiously, some patients may have undetected hyperglycemia for a long period before diagnosis, and early DPN symptoms are frequently atypical. Screening enables timely detection of potential nerve damage, facilitating disease assessment and intervention planning.

N10: I believe that early DPN screening is highly meaningful. It enables earlier problem detection and timely medication intervention, which can also mitigate or delay subsequent complications.

N4: Because some patients have elevated blood glucose levels before diabetes is detected, although they remain unaware, the actual disease history for most patients is longer than the documented history. Therefore, we typically perform DPN screening during the patient’s initial visit.

N5: A patient’s perceived onset date does not reflect their true disease history. Clinicians should not assume early onset based solely on a one-month diagnosis and neglect early DPN screening. For diabetic patients, screening must be initiated promptly and early.

N6: Patients with DPN may not exhibit textbook-typical peripheral sensory disturbances. Without early screening and annual preventive examinations during follow-ups, early-stage cases are often missed.

Improving Quality of Life

As diabetes management shifts from glucose control to overall health benefits, early identification of DPN enables comprehensive interventions. Early screening facilitates timely health education, pharmacological treatment, and systematic follow-up, thereby improving patients’ long-term quality of life and disease outcomes.

N5: Diabetes management now emphasizes enhancing the quality of life of patients, requiring a holistic assessment of the overall benefits. Early DPN screening enables us to intervene promptly, provide health education, and conduct follow-up care.

N7: The role of DPN screening extends beyond the early detection of lesions. It fundamentally reduces the risk of severe diabetes complications and improves patients’ quality of life, making it a core component of diabetes management.

In conclusion, endocrinologists agree that early DPN screening holds value for early warning, improving prognosis, and detecting occult progression. However, this clinical consensus contrasts sharply with practical implementation—when integrated into routine outpatient practice, physicians face challenges regarding tool selection and standardized frequency protocols, representing the second core finding of this study.

Theme 2: Current Practices in Early DPN Screening

The Selection of Screening Tools Prioritizes Objectivity and Efficiency

In early DPN screening under high workload and limited diagnostic time, efficiency and objectivity are key factors influencing clinical decisions. Compared to complex, time-consuming, or highly subjective methods, healthcare professionals prefer rapid tests with objective results. Neuromyography provides intuitive, reproducible assessments of neurological function, making it a key objective tool for DPN diagnosis.

N3: Ultimately, we still rely on objective indicators. EMG is an excellent choice because there is no clear scoring standard for sensations such as numbness. We prefer quantifiable testing methods.

N7: When performing early screening in outpatient settings, we generally prioritize more efficient and objective tools.

N8: If I only perform electromyography (EMG), it’s very convenient—it allows me to focus solely on assessing nerve issues.

N8: Many elderly patients have comorbidities, such as diabetes or cerebral infarction, leading to significant variability in subjective reports. Therefore, we currently prioritize nerve conduction studies and EMG.

There is Insufficient Standardization in the Frequency and Procedures of Screening

In clinical practice, although DPN screening protocols show standardization in content (from history-taking to treatment planning), no unified standard exists for screening intervals. Frequency is adjusted flexibly based on patient characteristics and follow-up schedules. While this flexibility enables personalization, it may compromise the consistency and systematic nature of screening.

N9: The basic process involves three steps: first, inquiring about relevant symptoms; second, conducting the corresponding physical examination; and third, ordering auxiliary tests such as EMG.

N2: We generally require all newly diagnosed patients to undergo one EMG test and advise them to have at least one annual follow-up, ideally one to two times per year.

N5: We remind patients to return for outpatient follow-ups every three to six months. If they are readmitted after this interval, we typically reassess complication progression or medication-induced improvements.

N12: We generally recommend that diabetic patients undergo annual systematic blood glucose adjustments during hospitalization, combined with routine screening. High-risk patients are advised to screen every six months.

Thus, while physicians follow similar screening protocols, significant variations exist in tool preferences (favoring objective electromyography) and screening frequency (ranging from every six months to annually). This “standardized procedures with inconsistent implementation” reflects the tension between individualized needs and standardized management. Deeper constraints—including physician competence, instrument limitations, patient compliance, and systemic barriers—will be examined in Theme 3.

Theme 3: Multifaceted Barriers to Early DPN Screening

At the Physician Level: Insufficient Professional Competence and Training

The level of clinical experience and professional competence directly impacts the quality of DPN screening. Experienced physicians tend to conduct comprehensive evaluations, whereas some practitioners may, due to workload or lack of experience, overrely on instrumental examinations at the expense of basic physical examinations.

N1: Experienced physicians who know that the patient has diabetes will generally arrange a comprehensive examination. However, if the physician isn’t thorough, they might skip the detailed physical exam and directly order tests like EMG.

N9: EMG is not difficult to perform, but doing it well is challenging. Training needs to be improved. After doing it for a while, it feels relatively simple, but performing it thoroughly and ruling out other issues remains difficult.

At the Technical Tool Level: Highly Subjective, Time-Consuming, and Subject to Potential Limitations

Physical examinations and scale assessments suffer from significant subjectivity and lack of objective quantitative standards, which may lead to biased results. Additionally, scale evaluations are time-consuming, imposing an additional burden on clinical practice. Furthermore, some elderly patients or those with severe underlying diseases may find electromyography (EMG) examinations intolerable, limiting their application.

N3: One issue with physical examination is excessive subjectivity. Sensations like pain and numbness rely entirely on patient self-reports.

N7: The scales mentioned in the guidelines are useful, but why do many hospitals not adopt them as definitive diagnostic criteria? Because they’re too subjective, yielding too many false positives and false negatives—that’s a major issue.

N8: Why do not we routinely use scales? Honestly, the workload is too heavy; administering scales to patients takes too much time.

N3: EMG is not suitable for certain patients, such as those with coronary heart disease or pacemakers. There are restrictions for these individuals—not everyone can undergo this test.

Patient-Level Factors: Insufficient Awareness, Financial Burden, and Misunderstanding of Diagnostic Procedures

Many patients lack adequate awareness of the importance of DPN and its screening, particularly when there are no obvious symptoms, often leading to reluctance in undergoing relevant examinations. Economic factors also constitute a significant barrier, with some patients abandoning screening due to high costs. Furthermore, fear or misconceptions regarding electromyography further reduce screening compliance.

N1: EMG testing is indeed expensive, costing several hundred yuan. Some patients undergo this procedure solely to qualify for specialized outpatient services. Without that requirement, many would decline due to cost concerns.

N7: Many patients completely misunderstand the purpose of disease screening. For instance, if their blood sugar is well-controlled and they experience no numbness or pain in their feet, they feel that testing is unnecessary. Some even question whether doctors are seeking to charge extra fees and outright refuse the examination.

N12: Some patients have misconceptions about EMG, believing it to be painful or involving electric shocks or discomfort. This leads to psychological resistance among certain patients.

System Level: Restrictions Imposed by Healthcare Insurance Policies and Uneven Distribution of Medical Resources

Medical insurance reimbursement significantly affects DPN screening implementation, as asymptomatic screening may pose compliance risks. Furthermore, healthcare resource allocation is imbalanced: primary care institutions lack specialized equipment and personnel, requiring patient referrals to higher-level hospitals, while tertiary hospitals face tight schedules and high operational costs.

N6: Early screening is not fully implemented yet, and it still involves medical insurance issues. If patients undergo screening without symptoms, it might violate regulations.

N3: In some community hospitals, screening capabilities are very limited. They can only perform basic blood glucose monitoring and cannot conduct EMG tests. Many patients need to go to tertiary hospitals for accurate diagnosis because community hospitals lack the equipment—they do not even have CT scanners, so screening cannot be completed.

N4: I hope EMG examinations can be scheduled more reasonably, with more doctors assigned to reduce patient wait times. This would also lessen patients’ reluctance toward the tests, as they wouldn’t feel the wait is too long.

N5: The EMG equipment is bulky and requires manual operation. There are also economic considerations, and personnel must be assigned to operate it.

These four-dimensional barriers are interwoven and mutually reinforcing. For example, inadequate physician training increases reliance on electromyography, whose costs and accessibility constraints stem from primary care resource limits and insurance policies. Meanwhile, patient misconceptions and financial concerns reduce screening acceptance, leading physicians to favor time-saving objective tests in busy clinical settings. Together, these barriers constitute the “last mile” challenge in early DPN screening—from awareness to implementation—and inform the optimization strategies in Theme 4.

Theme 4: Optimized Strategies for Early DPN Screening

In response to the aforementioned multi-level barriers, the interviewed physicians proposed a progressive set of improvement recommendations ranging from patient education and procedural standardization to policy support. These strategies correspond one-to-one with the barriers identified in Theme 3, forming a complete closed loop of “problem–solution”. The following discussion is presented under three sub-themes.

Strengthening Patient Health Education

Medical professionals generally agree that patient awareness should be enhanced through diverse forms and channels of health education, including screening educational videos in waiting areas, organizing free medical consultation events, and effectively utilizing new media platforms and short-video platforms for outreach.

N7: Some patients genuinely struggle to understand, especially those with lower levels of education. We typically show them a science popularization video. In fact, these early screening-related science popularization videos are continuously looped in the waiting area.

N12: Science communication is crucial. Currently, virtually every hospital and doctor engages in this process. Short-video platforms like TikTok are immensely popular, and with rapid AI advancements, many patients’ first instinct upon noticing symptoms isn’t to see a doctor—it’s to scroll through videos or ask AI how to handle it.

Standardizing Screening Procedures and Strengthening Grassroots Management

It is recommended to standardize DPN screening and incorporate it into the routine diabetes assessment system, while enhancing chronic disease management capabilities at primary healthcare institutions. Measures such as assigning dedicated community physicians, establishing specialized collaboration mechanisms, and utilizing chronic disease management platforms should be implemented to improve the accessibility and continuity of screening.

N1: Improving early DPN screening implementation hinges on standardization. Even if patients aren’t admitted to the diabetes ward, any diabetic patient should have neuropathy screening included in their assessment forms.

N5: I believe primary care facilities, such as community clinics, need to further strengthen chronic disease management—not just for diabetes. There are already quite a few chronic disease management platforms available today. Our hospital and departments are actively promoting the integration of conditions such as diabetes, cardiovascular diseases, and respiratory disorders into comprehensive management programs.

N8: Could community centers assign relatively permanent doctors to liaise with specialists and dedicated personnel responsible for health education? That way, someone would actually follow through on these tasks.

Strengthen Institutional and Policy Support

Enhancing supportive policies and medical insurance coverage is crucial for promoting the long-term standardized implementation of DPN early screening. It is recommended to establish coordinated guidance between the national authorities and healthcare institutions to standardize and promote complication screening protocols, while alleviating patients’ financial burdens and providing institutional safeguards for screening efforts.

N2: We could strengthen public awareness campaigns about relevant medical knowledge and complication screening procedures through national platforms, medical institutions, or public channels.

N5: Of course, we also hope the government can provide more support through medical insurance or policy measures. Many patients aren’t unwilling to seek treatment; it’s just that the financial pressure is significant now, and costs are indeed a problem.

N7: Actually, the government has already begun to prioritize this area. Policy initiatives are driving progress, and societal awareness is increasing. Both policies and guidelines are continuously emphasizing and advancing this effort.

Theme 5: Cross-Topic Observation: Differences in Perspectives Among Physicians with Different Professional Titles

Analysis revealed that physician rank may influence their cognitive orientation toward DPN screening. Participants were categorized into two groups based on professional rank: junior and intermediate-rank physicians (physicians and attending physicians, N2, N3, N4, N5, N7, N8, N11, N12) focused more on the accessibility of screening procedures and outpatient efficiency; senior-rank physicians (associate chief physicians and chief physicians, N1, N6, N9, N10) tended to offer suggestions from the perspectives of whole-course disease management, disciplinary norms, or institutional optimization. Given the small sample size, these differences are presented as observational trends in the data.

Discussion

Current Status of Early Screening for DPN

This study revealed that diabetes and its peripheral neuropathy exhibit slow progression and an insidious course characterized by atypical early symptoms.²⁴ Some patients remain in an undiagnosed hyperglycemic state for extended periods before diabetes diagnosis,²⁵ while early DPN symptoms are often nonspecific or even absent. Relying solely on the timing of diagnosis or clinical symptoms may lead to missed diagnoses and delayed interventions.²⁴ Selvarajah et al²⁶ noted that early DPN symptoms are often subtle or atypical, making them easily overlooked, and emphasized the importance of early screening to prevent complications. Given this, endocrinologists should enhance awareness of DPN’s insidious progression of DPN in clinical practice, incorporate peripheral neuropathy screening as a routine component of diabetes management, and proactively implement systematic screening at the earliest opportunity to improve early detection rates and optimize subsequent management.

Concurrently, this study indicated that endocrinologists believed that early DPN screening could help identify patients with early-stage neuropathy and inform clinical decision-making. Related research has also demonstrated that early screening not only aids in diagnosis but also significantly improves long-term outcomes for patients with diabetes and reduces the incidence of complications.²⁷ With the evolving concept of diabetes management, shifting from a sole focus on glycemic control to holistic health and quality of life improvement, early DPN detection has become a critical strategy for enhancing patients’ long-term quality of life and preventing complications.²⁸

Against the backdrop of recognizing the importance of early screening, the current frequency of DPN screening in China roughly aligns with guideline recommendations,²⁴ however, this study found that in clinical practice, there remained variations in the use of screening tools and screening frequency, which is consistent with the report by Malik et al.²⁹ Some clinicians prefer objective, reproducible tests, such as EMG, as primary tools for early DPN screening. Owing to its ability to provide a direct assessment of nerve function, EMG is the preferred choice for most physicians, consistent with the findings of Zhou et al.³⁰

Regarding screening frequency, clinicians often adjust their schedules flexibly based on patient variability, follow-up needs, and hospital arrangements. This flexibility reflects the individualized nature of clinical practices. However, variations in screening frequency and tool selection may compromise the comprehensiveness and consistency of screening, potentially affecting the accuracy of early diagnosis.³¹ Despite differences among physicians in screening tool selection and frequency, research indicates that most endocrinologists follow a relatively standardized screening process for DPN. This process typically begins with symptom assessment and medical history collection, progresses to physical examination and ancillary tests, and culminates in treatment plan formulation based on a comprehensive evaluation. This screening workflow demonstrates the professionalism and logical approach of endocrinologists in DPN screening, effectively identifying potential neuropathic risks.

The heterogeneity in screening tools and frequencies across different hospitals is not unique to China. Borson et al³² found in a primary care cognitive screening study in the United States that physicians’ choice of screening tools was highly individualized, with only 17% of screening-positive patients receiving subsequent action. Radhakrishnan et al³³ also noted that even physicians who trusted conservative guidelines still over-recommended screening, revealing a gap between guideline recommendations and actual implementation. Previous studies sometimes attributed this heterogeneity to physicians’ inadequate cognition or insufficient training. However, the present study’s interviews revealed a more specific operational reason: electromyography became the preferred choice for most physicians not because it was diagnostically superior to other tools, but because scale assessments were practically infeasible in busy outpatient settings. Although Tilson et al³⁴ affirmed the instrumental value of asymptomatic screening, they did not explore why other tools were abandoned. The present study demonstrated that when scale assessments and electromyography were both available, time pressure inevitably drove the choice toward the latter. This raises a practical issue: if the ideal workflow recommended by guidelines cannot be implemented in primary care or time-constrained outpatient settings, standardized protocols should perhaps not pursue “full-package examinations” but instead define a minimum effective combination, such as symptom inquiry plus simplified physical examination, with electromyography added only when necessary. The suggestion by senior-rank physicians in this study to incorporate DPN screening directly into routine diabetes assessment forms reflects precisely this pragmatic approach.

Junior and intermediate-rank physicians (N2, N3, N4, N5, N7, N8, N11, N12) more frequently mentioned operational efficiency pressures and patient communication difficulties, and were more likely to rely on electromyography while neglecting basic physical examinations; senior-rank physicians (N1, N6, N9, N10) tended to offer systemic suggestions from institutional or process optimization perspectives. This difference suggests that professional rank may moderate physicians’ perception of and response to screening barriers. Based on these findings, future efforts should focus on further standardizing screening protocols to ensure that all patients receive screening services of equivalent quality, thereby enhancing early DPN diagnosis rates.

Factors Impeding the Implementation of Early DPN Screening

This study revealed that endocrinologists frequently faced heavy workloads, insufficient clinical experience, and inadequate professional training when conducting early DPN screening. Behind the aforementioned rank-related differences lay not merely knowledge deficits, but executive difficulties in clinical contexts. Junior and intermediate-rank physicians, under outpatient time pressures, struggled to translate guideline requirements into feasible operational procedures, ultimately needing to choose between screening completeness and efficiency. As N2 (rank: physician) stated: “If I only do electromyography, it’s very convenient”; while N11 (rank: physician) also noted: “I use tuning forks less often, and mostly use cotton swabs”. Both quotations pointed to the same dilemma: within limited time, physicians tend to choose less time-consuming tools. This “deficiency” manifested more as a lack of situational response capability—how to complete assessments and communicate with patients within constrained time. Therefore, training programs should not focus solely on knowledge transmission, but rather be differentiated: for junior and intermediate-rank physicians, simulated scenario-based training for rapid assessment and clinical reasoning is needed; while senior-rank physicians can leverage their experiential advantages to promote screening standard development and departmental workflow improvement. Less experienced physicians may neglect basic physical examinations during busy clinical periods and rely more heavily on instrument-based tests, such as nerve conduction studies.³⁵ Enhancing endocrinologists’ training and experience in DPN screening, particularly in improving physical examination and clinical assessment skills, is crucial for increasing screening comprehensiveness and accuracy.

Regarding screening tools, physical examinations and questionnaire assessments have limitations, such as high subjectivity and lack of standardized quantitative criteria, which can lead to biased results.³⁶ This study indicates that physicians commonly report that questionnaire assessments are time-consuming and increase their clinical workload. Simultaneously, the relatively low utilization of subjective assessment tools, such as questionnaires, may be related to their susceptibility to subjective factors and the risk of “false positives” or “false negatives”, thereby limiting their practical applicability.³⁷ The introduction of more standardized and quantifiable tools could reduce the reliance on subjective reporting and enhance screening effectiveness. Integrating screening steps into the electronic medical record’s follow-up template, with automatic prompts when physicians enter diabetes-related data, may be more feasible than adding extra paper-based checklists.

From the patient’s perspective, awareness of DPN and its screening is generally insufficient. Many individuals remain unaware of their personal risk, particularly during asymptomatic stages, which diminishes their willingness to participate in screening.³⁸ Some patients, due to limited understanding, perceive screening as unnecessary or even develop resistance, a finding consistent with Sadosky et al.³⁹ Misconceptions about EMG testing and cost concerns also diminish screening compliance.⁴⁰ Improving doctor-patient communication and strengthening health education are important steps to increase screening acceptance.

The impact of health insurance policies on screening is dual-faceted. On the one hand, the promotion of special outpatient policies has alleviated patients’ financial burdens to some extent;^41,42 on the other hand, physicians reported that the ambiguous positioning of asymptomatic screening within health insurance frameworks may introduce compliance risks. While Yang et al⁴² focused on the impact of reimbursement ratio adjustments on patient expenses, they did not address institutional concerns from the physician perspective. Abd-Elsayed et al¹³ and Nkonge et al⁷ discussed physician-patient cognitive differences and resource limitations, respectively, yet neither touched upon this issue. This implies that even when patient financial burdens are reduced, physicians may still avoid early screening due to institutional uncertainty. Therefore, policy improvement should not be limited to adjusting reimbursement ratios; it is more critical to clarify the health insurance coding for asymptomatic DPN screening to eliminate compliance concerns. For primary care institutions without electromyography equipment, there is no need to insist on independently completing full screening protocols; establishing referral pathways to higher-level hospitals, where screening-positive patients can undergo definitive diagnosis, better aligns with the reality of resource allocation.⁴³

This multilayered barrier structure is not unique to DPN screening. Ospelt et al⁴⁴ similarly identified workflow gaps, staffing limitations, high costs, and referral difficulties as major implementation barriers in a mixed-methods study of type 1 diabetes autoantibody screening, which is highly consistent with the physician-, patient-, and system-level barriers identified in the present study. This suggests that different disease screening programs may face common systemic bottlenecks at the implementation level.

Strengthening infrastructure at the primary care level, enhancing professional capabilities, and optimizing resource distribution remain key directions for alleviating referral pressures and reducing waiting times.⁴⁵

Support Requirements for Early DPN Screening

The optimized early DPN screening strategy proposed in this study encompassed improvements in multiple dimensions. Strengthening patient education is crucial for enhancing screening compliance.⁴⁶ Screening awareness could be increased by displaying science popularization videos in waiting areas, organizing free clinics, and leveraging new media platforms, such as short video platforms. This aligns with the findings of Wang.⁴⁷ Research has found that patients with lower educational attainment face challenges in comprehending relevant knowledge,⁴⁸ therefore, communication methods should be more intuitive and concise to enhance the acceptability of information.

Standardizing screening procedures and enhancing primary care facilities’ chronic disease management capabilities are equally vital.⁴⁹ Integrating DPN screening into routine diabetes assessment systems, supported by community physicians’ regular services, specialist collaboration mechanisms, and chronic disease management platforms, improves screening accessibility and continuity, making the process more systematic.⁷

Policy and medical insurance support are vital safeguards for implementing screening.⁵⁰ Refining medical insurance reimbursement policies to reduce patients’ financial burden, coupled with strengthened coordination between the state and healthcare institutions, can provide an institutional foundation for promoting screening.

Only through the combined efforts of healthcare institutions, primary communities, and policy support can early DPN screening be standardized and sustained in clinical practice, thereby realizing its value in early interventions.

This study offers a unique contribution by providing the first phenomenological insights into Chinese endocrinologists’ real-world decision-making on DPN screening within a stratified tertiary care system. It underscores that standardized and sustained implementation of early DPN screening requires the concerted efforts of medical institutions, primary care communities, and policy support. On a broader level, the resource-, tool-, and system-level barriers identified from the endocrinologists’ perspective hold global applicability—particularly for other low- and middle-income countries or health systems sharing similar hierarchical structures and resource constraints. These findings echo the global burden of DPN emphasized by Savelieff et al,⁵ where cross-country variations in disease prevalence, health infrastructure, and risk population coverage demand tailored public health policies and resource allocation. While the Chinese experience may offer valuable lessons for resource-limited settings, its applicability is limited by the specificity of specialized care models and health insurance systems, thus warranting cross-contextual validation in future research.

Conclusion

This study found that endocrinologists recognise the value of early DPN screening, yet their current practices favour efficient, objective tools (eg, EMG) with inconsistent frequency and protocols. Multiple barriers exist across physician, tool, patient and system levels, alongside proposed optimisation strategies.

Practical recommendations directly linked to these findings include: (a) mandatory physical exam training for junior physicians; (b) a standardized one-page DPN screening checklist in electronic records; (c) a short waiting-area video plus teach-back to address patient misconceptions; and (d) inclusion of asymptomatic screening in insurance schemes and referral pathways for primary care without EMG.

This study has several limitations. First, This study is geographically limited to Hunan Province. To mitigate this, we included four representative tertiary hospitals across ministerial-level comprehensive hospital, provincial teaching hospital, provincial integrated traditional Chinese and Western medicine hospital, municipal comprehensive hospital levels. Future research should involve primary care and other regions. Second, we combined online (WeChat video) and face-to-face interviews, which may introduce variability. To mitigate this, we used a standardized interview guide, trained all interviewers, maintained neutrality, encouraged camera use online, and found no systematic post-hoc differences in content or themes. Thus, although mode effects cannot be entirely excluded, our findings appear robust.

Future research should employ larger, more diverse samples and mixed methods to further investigate screening strategies in primary care, physician decision-making, and the impact of insurance policies. Additionally, future studies could integrate traditional Chinese medicine diagnostic approaches—such as inspection, auscultation and olfaction, inquiry, palpation (ie, “Wang, Wen, Wen, Qie”), tongue examination, and pulse diagnosis—with existing screening methods. This integration of modern and traditional medicine may lead to more convenient, cost-effective solutions.

Funding Statement

This work was Supported by [Department Joint Project of Hunan Provincial Natural Science Foundation] (2024JJ8200), [Research Project of Hunan Nursing Association](HNKY202407) and [Research project of Hunan Provincial Health Commission] (20257723).

Data Sharing Statement

The data that support the findings of this study are available on request from the corresponding author, Yan Chen. The data are not publicly available due to privacy restrictions.

Author Contributions

Haili Zhu: Writing – original draft, Writing – review & editing, Conceptualization, Investigation, Methodology, Formal analysis, Funding acquisition, Data curation, Supervision.

Yan Chen: Writing – original draft, Writing – review & editing, Investigation, Formal analysis, Data curation.

Wanting Xie: Writing – original draft, Writing – review & editing, Visualization, Validation, Investigation, Formal analysis, Data curation.

Xueqin Zeng: Writing – review & editing, Writing – original draft, Visualization, Validation, Formal analysis.

Qing Yuan: Writing – original draft, Writing – review & editing, Visualization, Methodology, Investigation, Validation, Data curation.

Dong Zhu: Writing – original draft, Writing – review & editing, Methodology, Validation, Formal analysis.

Ouying Chen: Writing –Writing – original draft, Writing – review & editing, Validation, Formal analysis, Methodology.

All authors gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

Haili Zhu reports support for the paper from Hunan Provincial Health Commission of China. The authors report no other conflicts of interest in this work.