Those Darn Diabetics!
Do you ever wish difficult type 2 diabetics weren't your headache? Your wish has been granted. They aren't your problem anymore.
You read that right. They are not your problem. They are your patients who have a particular problem. Such a distinction may seem fussy, but it actually represents a pivot point for changing old attitudes and responses toward people who are used to feeling like perennial problem children.
Under the established system, as soon as tests confirm the diagnosis of type 2 diabetes, we lead patients to a conveyor belt. Most hop on by themselves. If they don't, we're happy to give them a nudge (or even a shove). Members of the healthcare assembly line then outfit the patients with armloads of widgets, gadgets and instructions.
But what about the ones who don't go peaceably? You've seen them. They test once a day (if that) when the order is for four times. They don't get their prescriptions filled, or if they do, they don't take the meds. They think they're dieting when they settle for a two-scoop cone instead of a banana split. They lie, even when their HA1c levels rat them out. And some of them simply leave and don't come back for years.
We often fuss about having to respect patient autonomy, but with this crowd we're secretly thankful for such a broad and convenient excuse to hide behind. If they choose to be noncompliant, we can't very well arm wrestle them, can we?
If this stubborn bunch were a tiny percentage of all the diagnosed type 2 diabetics out there, we might have a non-amputated leg to stand on. But it's not a small group, by weight or by numbers. And even among the "good" patients, there can be serious gaps and lapses. We can throw in the towel and continue to absolve ourselves of responsibility, or we can take a look at how we as healthcare providers might be influencing--or even provoking--these less than satisfactory outcomes.
For starters, we need to change the amount of time patients are given to process such a life-changing diagnosis. Many patients will want to begin treatment immediately, and by all means, we should help them to do just that. But some will need a couple of weeks, or even a couple of months, to deal with their shock, anger, grief and resistance.
But isn't waiting dangerous?
For all but the handful who wake up in the hospital after a diabetic coma, the risk of delaying has to be measured against the drawbacks of pushing people who simply aren't ready to make momentous changes in their lives in the blink of an eye. Remember, we're talking type 2 diabetes here--a glacier rather than an avalanche. Some of these folks have been diabetic (without their knowledge) for years. Giving them enough time to become invested in their own health care could avert far lengthier periods of "noncompliance" down the road.
Assessing our patients to see if they're eager or reluctant is a crucial step in deciding what comes next. Those in the "teacher's pet" group will need little more than guidance, tools and affirmation as they follow the program laid out for them. But if treated prematurely, the heel-draggers will see guidance as imposition. Tools will feel like shackles. And there probably won't be a whole lot to affirm.
Why? Because they won't have had a chance to willingly board the good ship, "Sugar-free Lollipop."
Think about a cardiac patient who needs serious but non-emergent surgery. If we give him the diagnosis and then whisk him off to the OR a few hours later, without ever asking what he wants and without obtaining his consent, he could very well end up feeling assaulted. Should this resentment carry over into his recovery period, we can expect him to rebel every chance he gets. He'll complain about having to ambulate in the hallways, fuss about the tasteless new diet, and rail at having to take meds--some right now for the pain and others for the rest of his life. And who can blame him?
If unnecessarily rushing a patient into surgery seems absurd, why can't we see the similarities in our treatment of diabetics? We may not use the general anesthesia implied in the above scenario, but after we lay out the bad news, do we give the patient time to think about the information? Do we ask what his goals and priorities are? Do we present our resources and our knowledge as an offer with the clear recognition (both in us and in the patient) that he is free to walk out the door to seek a second opinion or even do nothing at all? Let's be honest--our sense of urgency on the patient's behalf hardly ever allows that to happen.
Speaking of second opinions, surgical patients are often encouraged (and sometimes required by insurance companies) to obtain a validating (or dissenting) assessment. Not so much with diabetes. After all, the numbers don't lie. And the treatment is pretty straightforward. So, why not skip that option and quick-march those rascally diabetics into treatment?
What do you think would happen if we went at a slightly slower pace? What if we did encourage a second opinion or at least a second appointment a month or so after the initial diagnosis so that the patient could work through the bad news and figure out what he wants? What if we sent him home with factual, non-emotional information about the systemic nature of the disease and explanations of the different treatment choices? We know that patients (and their family members) Google every ache and sniffle, so why not provide a list of trustworthy websites to help them see the big picture. We could even give him a couple of down-to-earth questionnaires to help him organize his priorities, identify areas of struggle, and zero in on where he wants to direct his energy.
When we jump the gun and bypass the patient's the need to internalize this knowledge, we communicate that we don't trust him with his own life. But if we give him solid information and offer our resources as consultants, we ditch the typical tug-of-war rope and make ourselves available to collaborate against a common foe.
If we demonstrate this much respect--nothing more than a potential surgical patient is routinely accorded--we'll appear more like allies rather than enemies to be lied to and avoided. The glucometer, the meds, the exercise and even the diet will look like ammunition to fight a disease rather than punishments from the mean medical folks.
Once we're willing to see our patients as people who need our help with their problem, they won't be our problem anymore.
