This post is inspired by The Job of the Modern Doctor is to Convince on kevinmd.com. Written by TireDoc, I was struck by this paragraph –
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.
Reference:
M Kortykowski. When oral agents fail: practical barriers to starting insulin. Int J Obes Relat Metab Disord 2002 Sep;26 Suppl 3:S18-24.
The worries a physician feels at this time come from past experiences of these. A degree of patient resistance is inevitable occasionally but if this is all the negativity that you are getting, it shows really good communication skills, particularly that you have been preparing the patients well as the control is slowly lost.
There is one suggestion that you could try that might contribute to this already highly competent care and communication in cases where you have particular concerns.
It sounds like the problem is the local presence of doctors who do not have the same outcome based criteria as you but will tell the patients what they want to hear to the detriment of their health, especially for their feet. I would suggest finding a local endocrinologist who works to your criteria and is trustworthy in terms of not poaching patients in order to develop a mutual understanding in which you can use each other for second opinions. If the patient’s reaction suggests that they may go off shopping for somebody to tell them what they want to hear, beat them too it and suggest that they may like a second opinion for such a major life decision.
For many that offer will be enough. It is an exceptional acknowledgement and shows understanding of how they feel. It also shows your confidence in making the right decision. They will trust you more and will be less likely to seek that opinion. I suspect you could relax a little more on the worries regarding compliance.
If they do seek the second opinion, they will go to a doctor who receives the complete story from you, including any exceptional concerns, and then confirms everything you have said, telling the patient that they have a wonderful doctor (which is also what you tell their patients). Worst case scenario, you each occasionally get each other patients in tit for tat but neither of you end up attending to their feet during a hospital admission caused by a failure to use insulin when indicated.
And if I were forced to have a tiger loose in my living room, I’d sure as hell want it sedating too. If it started to get tolerant to the tablets in its food and starts getting restless, I’m injecting it!
Thanks for your comment. I am fortunate that there are many endocrinologist-colleagues in my area who I am confident will not “poach” my patients. I must admit though that I rarely offer to patients that they seek a second opinion – I will try this suggestion!
It is a commonly used strategy in UK for major decisions when patient has doubts and works well. Communication is essential to ensure the other doctor understands all the background to your decision.
Easy in UK because treatment is basically standardised to protocols of best practice and nobody wants to poach. So this is taken as read. If your system has a more competitive tradition, you probably do need to make an informal arrangement. They need to be conscious of saying right thing.
So good luck with it!
Thank you!
Thank you for this, Dr. Iris – love the Dubois excerpt about the baby tiger analogy. My ex-hubby was one of your non-compliant patients with diabetes (there’s that C-word again!). Last summer, he managed to walk our only daughter down the aisle on her wedding day before being rushed to hospital with advanced sepsis, untreated open foot wounds, and imminent amputation. Talk about ruining those wedding festivities! Our poor daughter and her brand new husband then spent the next 2 1/2 weeks sitting vigil at her Dad’s bedside in ICU – instead of on their honeymoon.
That’s what happens when you starve/turn your back on that baby tiger in the living room…
Denial, from the patient’s perspective, is often what oncologist Dr. James Salwitz once called “just wanting to be a person, and not a patient anymore”. Sounds so simple, but may explain a lot. I wrote more about Dr. Salwitz’s comments at http://myheartsisters.org/2013/06/08/i-dont-want-to-be-ill/
regards,
C.