Power to the patient!

2009 has seen an increase in referrals for diabetes mellitus, both on the inpatient and outpatient service. One could make a strong case that this is a reflection of the economic troubles across the nation and particularly here in Michigan. Diabetes “friendly” food is more expensive than diabetes “unfriendly” fast food. I think a bigger factor might be the cost of capillary blood glucose testing. Testing is indeed expensive but there is a bigger issue I want to address — all too often it is wasteful.

The scenario goes something like this:

“How often do you check your blood sugar?”

The answers vary from every day to once per week or every two weeks or, “My doctor checks it when I go there for my three-month visit."

“And what do you do with the result when you have checked your sugar?”

“I write it down in my book.”

“And then what?”

“What do you mean, doctor?”

“You have checked your blood sugar, recorded the result in your blood sugar diary. That’s great! What do you do about the information you have just recorded?”

“Show it to my doctor when I go for my visit!”

It is tough for me to understand what benefit the patient gets from recording daily fasting blood glucose without having been given some indication about what to do with the result. Understand, those patients being referred to an endocrinologist for consultation are not those with an HbA1c of 7% or lower or fasting glucose consistently under 150 mg/dL — in itself not an ideal target. You and I have all seen patients carefully recording CBG of 180 mg/dL and higher for weeks at a time without any instruction about what to do with that data.

The time needed for a clinician to educate and empower the patient to take care of their own diabetes is more than most practitioners can spare, particularly because it really needs to be individualized. Certified diabetes educators are great, but for a number of very good reasons, too often this is group — not individual — teaching and training.

The web is full of resources for your patient with diabetes, but sending the patient there without direction may not be the best approach. Many professional organizations (www.aafp.org, www.diabetes.org, www.acponline.org, and www.webmd.com to name a few) have excellent material for patients and their families. Take the time to peruse some of these sites, download a copy of the material from some of the sites you find most helpful and user-friendly, and in a few minutes you can let your patient know that this is information you have reviewed and recommend. For patients who do not have access to the web, have a few copies on standby to distribute.

The oft-maligned pharmaceutical companies also have excellent teaching material which they willingly distribute for your use, but in today’s environment it is probably best to also have nonindustry sponsored material as well.

No matter what approach you choose to take, it is imperative that patients understand that in the long term, their best results will come when they better understand the disease and their personal involvement in their own care.