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The path to the dark side

My day job is as a pediatric endocrinologist ("peds endo" in the diabetes on line community vernacular). In our current health care system, primary care “providers” (doctors, physician’s assistants and nurse practitioners) evaluate and examine patients, determine if their patient needs more assistance or care than what they can provide, and then get referred on to specialists as needed. I am one of those “specialists”.

Here is a referral note from a primary care provider I got a few months ago:

"Patient needs to be seen by peds endo and [patient] needs new monitor for home and for school. Lectured [patient] regarding health and taking charge and to stop depending on other people to take care of [the patient] and discussed risks of DM such as blindness, amputation, dialysis..."

In really this note says more about the “refer-er” than the “refer-ee”. I wish I could say this attitude is rare, but it’s not. Good cop-bad cop roles aside, this reflects a prevailing attitude about "diabetics" held by many primary care providers. Remember that 80% of all persons with diabetes are followed by primary care doctors without much in-depth diabetes training. For them, it's mostly experiential learning after medical school and residency training. And much of what they do learn is imprinted from their mentors biases.

Guilty until proven innocent” might come to mind here. Is this paternalistic attitude a consequence of how we train (or don't train might be the better way to view this) our doctors and nurses? Or is it all simply borne out of one’s clinical experiences? Is it assumed that a child or teen with diabetes must be lectured and threatened with long term risks of their disease? The path to the dark side of using fear as a motivator is quite seductive.

Or is it just another version of "tough love"? I suppose it depends on the circumstances. Shock therapy does have its role in clinical care, but very sparingly. But in my opinion it rarely works in the long term to effect lasting change and is much overused. Some of you might argue the provider is frustrated and at a loss of what to do next. And that would be a fair point.

The problem is, lecturing (talking down) is easy. It might even make the lecturer feel better that they've done their job properly and they can then get on to the next clinic room. But the patient may be left in smoldering pile of hopelessness, or might dig their heels in deeper that they are not going to listen to all that baloney they heard and do nothing they were told. For many, its the final straw and they find a new doc.

Who's to say that these moves aren't intentional? After all, doctors are now being paid by their employers (the doc's employer, not the patient's) based on percentage of patients with elevated A1C values. Why would the doc want to fight a constant battle with a patient not ready to change (for whatever legitimate reason) and simply find a way to push them out of the practice. In the doc's mind, that patient can be some other docs problem.

I know few persons with diabetes, certainly children, who are not part of some kind of family unit. Depending on others is human. It's just a matter of how it's shared. Diabetes can create a tremendous dependency challenge for some patients, parents and kids. Balancing those responsibilities is the provider’s greatest challenge.

Getting the child some new devices was the first matter discussed in the above scenario. I don't know if that implies a greater focus on technology than on choices. But the focus on the 'objective' (things) over the 'subjective' (knowledge, understanding, behaviors) is really at the heart of this matter. Modern medical training is excessively objective in its focus. It tends to be tech-driven. Face to face contact (developing therapeutic relationships) with patients grows shorter and more hurried all the time.

Focusing on technical solutions, numerical results or laboratory outcomes is a trap that ensnares many health care providers. They might actually feel that to ask "how are you feeling about your diabetes" could be a time trap they wish to stay far, far away from.

I feel that how we approach patients with diabetes has more to do with outcomes themselves than how we arrive at them: in other words the choices we make. Choices are influenced by beliefs and attitudes. Sadly, there are not as many options to develop those skills in medical training as there should or could be. These skills are usually developed on the battlefield of clinical care.

Medicine used to revolve around providing care, concern and attention to other's stated or perceived needs. Science and technology have ripped us away from that focus and into a test tube/high tech mentality where all one’s ills can be measured, scanned and categorized, and then followed by an algorithm or sliding scale which tells us what we must do or prescribe next. That scares me.

Medical practice becomes more and more of a commodity item each day. The thought that we may “package” it and sell it as a product is disturbing. We all lose when the art of medicine is overtaken by the science of medicine. We can't ever lose sight of the fact that diabetes management is, and always has been, about people making CHOICES in their care.

Diabetes is a condition managed by people. It’s a series of hundreds of daily considerations, decisions and choices. The provider really does not manage the condition: the patient does.

I’m afraid I will continue to receive referrals like the one above until I retire. As such, patients and families must be aware of these not so subliminal practices and make sure they question and challenge the care they get when much of it is laced with heavy doses of judgment, condemnation, and fear.

Feel free to share this freely with others who you feel might benefit.

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