Henry, a 72-year-old patient, saw me for an initial consultation six months ago. He was diagnosed with type 2 diabetes 15 years ago, and not once had his A1c been under 9%. I was the 8th physician that Henry had seen during the past two years. I asked Henry, who was clearly frustrated, “Why are you unable to get your A1c below 9 %?” His answer astonished me. He fully extended his index finger, shaking it just inches from my face and said, “Ya know what, I am sick and tired of people like you and all of your buddies telling me the same thing…’Henry, you’ve got to eat less and exercise more!’ Heck, I’m still on the same meds, metformin and a sulfonylurea, that I was using back in 2008! I am sick and tired of being treated to failure. I don’t feel good, and I’m just about ready to give up!”
Understanding His Past
Turns out Henry is a Vietnam War vet. He spent two tours in Vietnam during the war and slept in areas exposed to Agent Orange for 18 months while on patrol. No one had ever asked him about his Agent Orange exposure, which is known to increase the risk of type 2 diabetes and increase insulin resistance.
Henry is an intelligent yet angry veteran who risked his life serving our country. He believes that we, as clinicians, have simply given up on him by continually referring to him as being “non-compliant.” Henry told me that his last physician even laughed out loud and accused him of not taking his medicines as directed.
Diabetes is a chronic and progressive disease that tends to get worse over time whether one is a Republican, Democrat, or Independent. We as clinicians should always strive to treat patients successfully toward their prescribed metabolic targets, rather than to failure.
Addressing His Fears
After performing a comprehensive history and physical exam, I asked Henry, “What scares you the most about having diabetes?” He replied, “I don’t want to lose my eyes, my kidneys, or a leg. And oh yeah, I want to see my granddaughter walk down the aisle someday.”
When was the last time your provider asked you this question? Obviously, Henry knows about the consequences of having poorly controlled diabetes. He knows that poorly controlled diabetes increases one’s risk of developing long-term complications. Rather than subject people to treatment failure, why not offer them hope and guidance towards successful management of their disease? After hearing Henry’s response, I reassured him by saying, “Henry, nothing is going to happen to you on MY watch. I will not allow you to fail!”
Cooking Up a Plan
I also needed to explain to Henry how we were going to fix him up within a period of weeks, not months…guaranteed.
“Henry, are you a good cook?” I asked.
“Yep, I can cook up a banquet if I had to.”
“Great news, Henry. You see, I’m a terrible cook. When I cook, people pray AFTER they eat! Now, let’s you and I cook some soup together. First we’re going to take some water, put it on a stove and turn on the burners. Then we’re going to add some metabolic ingredients. Let’s throw in some diabetes, a little hypertension, and some chronic kidney disease. Yep, you’ve got sleep apnea and a little PTSD. That goes in our soup as well. Look here, Henry, your LDL cholesterol is 134 mg/dL. That’s in the soup now along with your A1c of 9.2%. That diabetic retinopathy doesn’t smell good either. You see, our soup tastes terrible, but YOU, Henry, are going to make this concoction palatable. Let’s NOW add some “ingredients” such as CGM, high-intensity statins, aspirin, an ACE inhibitor, your CPAP machine (which has not been used for six months), a GLP-1 RA, and an SGLT2 inhibitor. Before long, Henry, everyone is raving about the smell of our soup. See, working together we can get this done and you’re going to feel great!”
Securing a CGM
Without giving him a chance to say no, our medical student applied a CGM sensor to Henry’s arm, after which we explained that he would no longer need to do finger sticks. The sensor would be monitoring his interstitial glucose values 20,160 times over the next two weeks. And I would be able to download the data remotely after a week and adjust medication doses at that time.
Henry smiled broadly and said, “Good, no one looks at my blood sugars anyway, and if they do they blame me for having good fasting glucose levels, yet terrible A1cs. It’s always MY fault.”
After seven days, Henry’s sensor was downloaded remotely and demonstrated persistently elevated interstitial glucose values with a time in range of just 18%. His labs showed evidence of stage 3B diabetic kidney disease and poorly controlled hyperlipidemia. His FibroScan demonstrated 67% fatty liver infiltration with F2 fibrosis. His office visits were also becoming more exciting and interactive. Within just four weeks of initiating a GLP-1 RA and SGLT-2 inhibitor, his time in range increased from, 18 to 55%.
After showing Henry how much he had improved since first seeing me four weeks prior, he stood up and gave me a hug.
“Henry, I am so proud of you. You know, I didn’t go to medical school to take care of runny noses, I went there to take care of YOU! I am honored to be your doctor.”
12 weeks after his initial consultation, Henry was back in the office with an A1c of 7.2% and time in range of 78%.
“Henry, how ya doing today, my friend,” I asked.
Henry replied, “Let me tell you Dr. I am feeling great and, uh, I’ve got some exciting news to share with you. Before I met you, my girlfriend of six years told me, ‘Henry, if you can get that A1c below 7.5% I will marry you.’ Guess what, we got married last Sunday thanks to YOU!”
Henry’s story is so very common within Primary Care where 90% of all diabetes is managed. I get it…we’ve got so much to cover in a 10-minute office visit. We’ve got to deal with prior authorizations and electronic medical records. We’re seeing 40+ patients a day and we are exhausted when we get home. Still, we as clinicians are the coaches, NOT the captains of Team Diabetes. The patient is in charge of his own destiny. If we expect our patients to “win the Super Bowl of Diabetes Management”, we need to become better and more motivating coaches. When we witness our patients leaving our office and turning around to say, “Thank you, Doctor”, we know our hard work and training have paid off. As clinicians we cannot always cure a chronic disease, but we certainly can and MUST do what we can to help our patients heal.