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.