The patient has some responsibility as well!

I was asked to see in consultation a 49-year-old senior management executive to discuss the use of an insulin pump for his type 2 diabetes. The specific question was whether he would be a candidate for pump therapy instead of glargine plus pre-meal insulin which had been his regimen for several years.

This very busy man was interested in a pump because his meal times were erratic. Despite a 15-year history of type 2 diabetes his knowledge base for the disease was about as minimal as I have seen for awhile. Regular glucose checking was not part of his routine, and business-related dinners meant that he could not be seen to have to worry about his diet. He was so embarrassed by his disease that he “admitted” that he had become quite adept at surreptiously injecting himself through his clothing so no one would notice. He was relieved to learn that this is a safe way to take insulin.*

I began our conversation by indicating that insulin pumps are an expensive way to care for diabetes but he quickly assured me that he had excellent insurance coverage and he was sure his needs would be covered. For now he was using syringes and needles and had no idea that insulin pens are available. I left him with some websites to visit to learn about the availability of pens, pumps and continuous glucose monitors. Since he was getting bored in hospital waiting for surgical care of a diabetes-related foot ulcer and had his laptop with him he was pleased to have something to help him while away the time. We then discussed the relationship between meal content and post-meal blood glucose, and the effect of physical activity on his glucose levels.

I saw him again today a week later to discuss what he thought about the several options available to him for insulin delivery and glucose monitoring. He had absorbed not one word of that 45 minute first encounter — no doubt as much my fault as his. He had not gone to any of the websites but instead he and his wife excitedly showed me the 2-inch thick paperback on diabetes that had been recommended to them by a neighbor. They hadn’t started reading it yet!

*Fleming DR, Jacober SJ, Vandenberg MA, et al. The safety of injecting insulin through clothing. Diabetes Care. 1997;20:244-247.