Sustainability
I admit, I'm not very smart when it comes to picking the right approach to my patients with uncontrolled diabetes. I'm still trying to figure things out.
It's a truth; how well a patient does depends in large part to compliance (with some exceptions), with glucometer checking, and proper usage of medications.
And so, from my end, I'm often left totally helpless when a patient comes in for his/her checkups and has an A1c of 14% but NO glucose readings in the past 2 weeks to review. And freely admits to missing 50% of the insulin.
On one hand, I try to tell myself: "They are informed adults- if they choose to not take care of themselves knowing the risks, it is their perogative..."
On the other hand, it makes me, the physician, feel like a failure and a fraud. It makes me feel guilty that they will get billed for this office visit and yet they get nothing out of it, aside from my encouraging them to do better.
And so, I've done things my colleagues have advised me not to. I have my patients email or fax me their logbooks in a couple of weeks so that we have some objective data to guide adjustments of doses. I've even been known to call patients to remind them to send me numbers. So, this inevitably leads to a torrent of emails and faxes weeks later; I sometimes spend hours a day going through these, advising changes. Except this is done in my own personal time; we don't charge for a telephone call.
Sometimes I request for a 2-4 week follow up. Except that my schedule is booked 2 months out, so whenever I ask for an urgent 'work-in' what this usually means is I see them over lunch. Which means the special diet of SpeedLunch+Dyspepsia®, or NoLunch+HungerPangs®.
Sometimes seeing the improved control is gratifying enough. Sometimes, things are no better. But consistently though, I come home exhausted and hungry. And so, I do wonder about the sustainability of this practice. It's not a smart or healthy way for the practitioner, but eventually to keep myself sane I suspect I'm going to have to back off, and accept that some patients just don't want to help themselves and if so, I shouldn't be trying to kill myself helping them.
posted by vagus at 6:59 AM
3 Comments:
Doc, at the end of the day, you know you have tried your best for your patient. Even though the patients are non compliant and not bothered with their health, I am sure their loved ones appreciate you checking on them regularly. Wish I have one caring doc like you to take care of my loved ones.
My endocrinologist has over the years, learnt to be "strict" with diabetic and chronically ill patients who don't comply with instructions on medications, monitoring, etc. Seems harsh to some, but he makes it clear that he will stop seeing a patient who perenially defaults; it's either the patient shapes up or ship out. He's an excellent and caring doc but is also well known among patients that he wouldn't tolerate patients who continue to be sloppy in keeping to their part of the bargain. Setting the ground rules upfront for patients, I guess, is useful for a fruitful long-term doc-patient relationship.
very few of my poorly controlled patients on insulin would want to come 2 weeks later. very few bother doing home glucose monitoring - most cite cost issues/can't be bothered/stigma.
even fewer with hba1c >9% want to start on insulin - i've heard them say they would rather die of complications/commit suicide than start!
i used to get very upset about these patients but now i just let them be after all they don't appreciate my concern/strictness. patients are also autonomous beings after all.
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