Once the patient and I agree on a diagnosis, the doctoring begins. Based on nothing other than my words, I have to convince the patient to take poison, do something that may hurt a lot, or go see another doctor who will cut them with sharp objects. Based on a single conversation, I expect strangers to change their lives, expose themselves to unknown dangers, and then usually not see me again for a month.
It reminded me of those (somewhat) dreaded occasions when I had to tell my patient in the clinic – You need to be on insulin. Those with type 2 diabetes are often on oral medications but insulin becomes a necessity when despite these drugs, the blood sugar levels are not at goal. I worry about these occasions not because I am afraid to start a patient on insulin (because after all I am an endocrinologist!), but because it’s a rare patient who would willingly submit to daily injections. I now have to, as Tiredoc says, CONVINCE the patient.
It is interesting how M Korytkowski talks about psychological insulin resistance in When Oral Agents Fail: Practical Barriers to Starting Insulin. Both healthcare professionals and patients share concerns in initiating insulin therapy. Korytkowski enumerates the following for healthcare professionals –
- Fear of patient’s anger
- Fear of patient compliance
- Resentment of extra burden of patient crises during initial stages of insulin therapy
- Anger and irritation of oral antidiabetic drug failure
- Fear of losing or alienating a patient
- Inadequate time or personnel to teach insulin therapy
- Concerns regarding hypoglycemia and weight gain
I have examined my conscience 🙂 and can truthfully say, I have experienced only #2 fear of patient compliance and #5 fear of losing or alienating a patient.
To repeat from TireDoc –
Based on a single conversation, I expect strangers to change their lives, expose themselves to unknown dangers, and then usually not see me again for a month.
I fear for patient compliance. Have I explained insulin therapy thoroughly? Did the patient understand my instructions? I write down my instructions, but what if the patient loses my prescription? And that has happened often enough. I ask them to monitor blood sugar with a glucometer. Will the patient follow the schedule? If the patient injects insulin without checking his blood sugar, what would happen if he goes into hypoglycemia? TireDoc is right – this will change their lives and it might expose them to danger. When I start insulin, I ask the patients to follow up after two weeks or if possible after a week. They can call the clinic if they have problems. But that leads to my fear of losing or alienating the patient. I wonder how they are doing when they miss that next appointment. Are they ok so they don’t feel the need to follow up? Or did they not follow my advice and are now hesitant to follow up since they didn’t start on the insulin? My hands are more than full with many patients at my clinic but I fear losing patients (as has previously happened over the issue of insulin), because more often than not, it has meant meeting them again at a hospital confinement for a diabetic foot infection (or other complication) because having refused insulin, the blood sugar remain uncontrolled.
William “Lee” Dubois wrote a no-nonsense book Taming the Tiger: Your First Year with Diabetes. He begins the first chapter by saying – It’s going to be OK. You’re going to be OK. I say this to my patients to reassure them but I have also used Dubois’ tiger analogy often enough at clinic –
Can you have a pet tiger? Sure. As long as you feed it well, groom it, and never turn your back on it, you can co-exist with a tiger in your living room. But if you neglect the tiger, starve it, turn your back on it – the tiger will pounce on you and tear you to shreds.
What do you think? I’d like to hear from you – maybe I can do with another analogy.
M Kortykowski. When oral agents fail: practical barriers to starting insulin. Int J Obes Relat Metab Disord 2002 Sep;26 Suppl 3:S18-24.