Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Wednesday, August 13, 2008

The Last Word on Diabetes

My, my, my, but didn't my little rant start a pissing contest!

Many thanks to all who commented. Obviously I appreciated those who agreed with me, but to those who didn't (specifically those who questioned my treatment of diabetes) let me say this about the disease in question:

Diabetes is the ultimate lifestyle disease. Despite the terminology of doctors "treating" or "managing" it, diabetes is a condition truly managed by the patient. Sure, doctors can prescribe and suggest (and cajole and persuade) but in the final analysis, diabetes control is pretty much completely in the patient's hands. (Which is why P4P measurements aimed at physicians are so unfair; but I digress.)

I have patients maxed out on three oral medications plus insulin who still run A1c's in the 8's, 9's and 10's. Every single visit includes treatises on the virtues of diet and exercise, along with the dangers, perils and hazards of non-compliance/uncontrolled diabetes. Sometimes it works, but -- NEWS FLASH! -- sometimes it doesn't.

I know how to teach patients to manage their own diabetes. How well they do it is up to them. It's just like a little secret I learned years ago: despite all the medical talk about "managing" pregnancy, women manage their own pregnancies. They listen to the doctors, then basically do what they want. (Don't get me wrong! I deplore it when they then refuse to take responsibility for their actions and blame the docs for anything they think went wrong.) Contrary to what the lawyers have everyone fooled into believing, medical "management" of most conditions doesn't amount to more than just a bunch of suggestions. Patients then do whatever they want.

(And yes, I'm quite aware that the title of this post is an oxymoron.)


At Wed Aug 13, 07:21:00 PM, Blogger rlbates said...

"I know how to teach patients to manage their own diabetes. How well they do it is up to them." -- AMEN! Both my mother and my brother are beginning to understand just that.

At Wed Aug 13, 08:08:00 PM, Blogger 'Ol Doc said...

As a recovering family doc I applaud your attitude, opinions, observations. You are "spot on." Great stuff. Keep it up!

At Wed Aug 13, 11:08:00 PM, Anonymous Anonymous said...

Wheres Wilford Brimley when you really need him? ,

Dudes got a handle on Diabeetus...

just call Liberty Medical

word out

At Thu Aug 14, 10:59:00 AM, Blogger Beach Bum said...

I was interested to read the comments in your first post. It seems, Dr. Dino, that you have misplaced your magic wand; the one you wave over your patients to make them do everything you suggest to them.

It's interesting to me to think about control; really, a doctor whose patient is conscious and competent is rarely in control of their patient. And when the patient walks out of the office, the doctor ceases to "manage" that patient.

And even had you tanked them to the gills with drugs, they still might have chosen not to take them.

It's really empowering to come to terms with the fact that we are, in fact, powerless. The patients have the power.

A think a slightly more useful metaphor to the doctor's role is one of guide or coach...

At Fri Aug 15, 09:16:00 PM, Anonymous Anonymous said...

If there's one thing I've learned in my first year in medical records, it's this: beach bum above is right can only do so much to help patients with the chronic "lifestyle" diseases that are so rampant in this country. Docs can beg and plead and lecture until they're blue in the face, but if the patient doesn't want to hear it, poor doc will get nowhere.

At the same time, I've also personally learned (as a patient) that it isn't easy to make the kinds of changes required to "manage" or prevent things like CAD, diabetes, and hypertension. So what has to happen is that doc and patient need to work together to make it a more viable plan. Numbers aren't everything, but helping each other out will push them in the right direction.


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