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Treating chronic diseases such as diabetes requires a strong and open relationship between physician and patient.
In the last two years, I have worked intensively on improving our organization’s proportion of patients with diabetes who are poorly controlled. I’ve looked at the issues that contribute to uncontrolled diabetes from multiple angles and have reviewed hundreds of patients’ charts searching for the holy grail of diabetes control. To date, the battle has been waged uphill and we continue to lose ground.
There are certainly clinical issues at play, including physician inertia to advance treatment, but this is a small part of the larger problem. For many of our patients, financial issues play some role in their inability to successfully manage diabetes, even those with insurance coverage. However, as I delve more deeply into individual patient’s experiences, the situation becomes increasingly complex and confounding.
I thought of this recently as I met a new patient with poorly controlled diabetes. Mark (not his real name) is a middle-aged father of two rebellious teenagers. His elderly parents live with him and he is the go-to guy for friends struggling with addiction, mental illness, and poverty. He was fired by his previous physician for “non-compliance.” I have to admit that I didn’t exactly click my heels in delight when I saw his electronic chart come across my desktop. His hemoglobin A1C measurements are usually in the double digits. He no-shows or cancels appointments. He allows his medications to run out. He doesn’t prioritize his medical care.
So, I took the initiative. I knew that he may not come to see me for months if I didn’t reach out first. I asked my nursing staff to call him and schedule an office visit. About a month later, he came in. He is very likeable with an easy smile. I knew before I entered the exam room that we’d need to talk about starting insulin. However, I tried to channel all my learning from the last two years with this new patient, stepping out of my comfort zone and trying to approach his diabetes in a more patient-centered way.
While I was anxious to address his diabetes-his A1C was over 12-I held myself back and spent the first half of the visit on the various concerns he brought up (none related to diabetes). After we agreed on a plan for those issues, I broached the subject of diabetes.
“Do you understand why we care so much about the A1C, Mark?” I began.
We reviewed a risk chart that demonstrates how increasing A1C is associated with significant increases in risk of blindness, kidney failure and amputation. He took the information in stride, not fazed by my scare tactics. I moved on.
“Mark, what are your thoughts on insulin?”
“I don’t want to do that.”
I didn’t stop. I asked him about his specific concerns with insulin which included his assumption that he’d need to inject it into a vein and that he would be taking it multiple times each day. We were able to negotiate a once-a-day regimen that he thought was manageable for a three-month trial period.
Next, I broached the topic of self-glucose monitoring which he found difficult to do. I asked him if he could commit to checking just once per day.
“No, I don’t think I could do that.”
When I inquired about the challenges he had with this, we were able to problem-solve around his morning schedule. I knew we established rapport when he opened up about his struggles with his family and friends. It was clear that diabetes took a backseat to the more pressing issues he faced with his children and parents. My failure to understand this would prove disastrous to any future disease management I attempted on his behalf.
Next, we discussed insulin education. Instead of telling him how it would be arranged, I gave him the option to work with our clinic nursing staff, the diabetes educator, or the pharmacist to learn how to use it. I got a verbal agreement to call him at a certain time for follow-up and engaged him in the follow up plan.
I hope Mark felt as comfortable and hopeful as I did by the end of the visit. Only time will tell if my approach is successful.
Diabetes, especially when it is poorly-controlled, can become a full-time job. Just because our full-time job as physicians is disease and illness doesn’t mean our patients have the time, energy, or resources to successfully manage their diseases in a traditional medical model. Our healthcare system often makes patients with poorly controlled diabetes work harder than patients with well-controlled diseases.
For example, if a patient no-shows or cancels an office visit, it may be difficult to get medications refilled, especially for longer than one month. Some physicians may refuse to refill them altogether. The patient may be required to have fasting lab work, which limits the time frame in which he or she can attend a lab appointment.
Finally, many patients are managing not only diabetes but depression or anti-coagulation or chronic back pain as well. Multiply the frustration, medications, laboratory testing, specialty referrals by multiple diagnoses. It can be overwhelming and exhausting.
Our healthcare system is designed primarily to respond and react, not provide outreach and support. Getting diabetes care usually requires the patient to call to schedule the appointment or the lab, the patient to go to the appointment, the patient to drive to the pharmacy to pick up a medication, and the patient to remember to call back in three months to start the cycle all over again.
Often, we do a lousy job with all the in-between care–the touches that are needed between visits to make sure the treatment plan is on track.
Diabetes is also an expensive disease to manage, even with insurance. It is not just medications, but the testing supplies, the copays at the eye doctor, for diabetic education, for at least four medical visits, and for healthier foods at the grocery store. Most patients with diabetes also require medications for other conditions such as hypertension and hyperlipidemia.
The solution is neither easy nor clear, but as physicians working with patients with challenging diseases, it is important for us to remember how difficult it is to be a patient, especially with multiple diseases, disability and social stressors. We and our patients stand to gain much from eliminating or reducing the barriers to care, including those we’ve designed and implemented.
Jennifer Frank, MD, is a family physician practicing in Neenah, Wisconsin. This essay was an honorable mention in the 2014 Medical Economics Physician Writing Contest.