I recently saw three new patients with type 2 diabetes, two referred by their PCPs and one came on the recommendation of an existing patient who had brought his HbA1c down from 9.7% to 6.4% in the past 15 months.
The three new patients had much in common:
- They were in their 50s and each had senior management positions in their respective jobs.
- They were all aware of their diagnosis of diabetes for 3 years or more.
- BMI was 30 or higher.
- HbA1c was between 10% and 12%.
- They did not bring either a glucose meter or any information about their blood glucose.
- None of them checked their blood glucose more than once or twice a week, if that.
- All claimed to be in good health and systematic review of symptoms confirmed that.
- Two of them had a family history of diabetes.
Who is at fault for their disregard of their diabetes? Does it really matter? I believe all of you who read this will acknowledge that it really does matter. The bigger issue is not only do these gentlemen need fairly intensive instruction about diabetes and its management, but how do we get to the PCP who let their patient get to this point? Yes, I do send a polite letter back to the referring physician — dictated in front of the patient — as well as provide the patient with a copy, but I am not convinced that has any effect. (NB: The PCP has a much tougher job than the endocrinologist or other sub-specialist!)
Clearly the most difficult task of getting and maintaining glycemic control, at least to me, is to have the patient develop the habit of checking their blood glucose at least once a day, preferably more often if insulin is prescribed. However, if that is all I can get the patient to do, I request that they check CBG every other morning before breakfast and every other night at bed time. Not ideal but better than nothing.
Most blood glucose meters have the capability of downloading blood glucose values to a PC and the three gentlemen briefly discussed have access to PCs and are familiar with using them. I invite patients to email the data to me every 2 weeks or so with the main purpose to have them appreciate the often marked changes in CBG. The graphs so generated do get patients’ attention, probably more than I can hope to accomplish any other way — a “picture” is worth a thousand words. Tweaking insulin dosing based on the data is straightforward.
This leaves unanswered the question of what to do with patients who aren’t PC savvy and/or won’t follow instructions about diabetes management — lifestyle, diet, therapy. Ideally a certified diabetes educator on hand will take care of this but a CDE is not always available where we practice.
How many newspaper articles have you read this year concerning the increasing prevalence of diabetes? I would not find that so bad if I were more confident that I could convince more of my patients to take charge of their diabetes — every patient who does achieve and maintain glycemic control can’t wait to tell family and friends.