Thursday, May 19, 2016

The Healthcare Experience: A Clash of Experts

Throughout my time with diabetes visits to the doctor have undeniably improved.  As a teen I used to cry and scream in the car at my mother after every consult (God bless all the parents of diabetics).  I committed all the biggest sins: made up my numbers, told any lie to appease my doctor, and pretended to commit to new plans without the slightest consideration. 

I feel like I’m in a good place now: I like my doctor, feel like I can be honest with him, and sometimes actually don’t want to wait for three months until the next visit.  Crazy, I know.  After 15 years I finally established a doctor/patient relationship that worked like it was supposed to: as a team.  The post-doc dirty martini tradition I started a couple years ago is a reward, sometimes a celebration, and rarely a somber distraction.

But there are still troubling issues I can’t figure out.

The last doctor visit was one of the best I’ve ever had.  He used words like “tight control” and said my A1C didn’t need to be lower—probably the closest I’ve ever come to a compliment from a doc.

More prevalent though were words like “safety.”    The theme of this visit seemed to be lows even though they were far outnumbered by highs, and I hadn’t had more than a few or any severe ones.  My A1C had been steady for a year, and the last result had actually gone up a smidge.  But the conversation and according medication adjustments hinged on safety and lows, in my belief, because the student/resident doctor’s “focus du jour” was on lows. (She had asked me with incredulity during our one-on-one consult if I drove.  I was, and still am, irked by that question.  Does diabetes mean you’re supposed to be relegated to taking public transit and cabs?)

The most lasting effect of this visit was an increased paranoia of going low, “cheating” more, and higher BS.

In conjunction with the talk about lows I was also gently pushed to consider a pump and/or CGM and set up a meeting with a diabetes educator to learn more about the products available, which I balked at but pretended to consider in the future, kicking the can down the road.  I am profoundly averse to change; I refuse to use the bank drive thru, still use a typewriter on occasion, and was a late adopter of smartphones. 

Both of these recommendations—the medication adjustment to err on the side of highs instead of lows, and the consideration of switching from MDI/insulin pens to a pump—are absolutely legitimate.  One hundred percent.  I just didn’t know if they were right for me.  I kept asking myself: if things are going good, why do we have to change anything?  I didn't have a problem with using pens or having the occasional low because I over-corrected from a high; why did they?

On the other hand, what if I was just being stubborn?  I challenged my reluctance to embrace what I knew could be a very positive change.  I likened the switch from multiple daily injections to a pump as the same hesitation I felt when going from pills to insulin—a change I wished I’d made sooner.  I have an inkling I’ll feel the same about a pump when I try it.  I’m trying to figure out what’s right for me and if it’s personal preference or fear that holds me back from switching.

That’s the hard place I can’t seem to escape in the doctor/patient relationship: there are two experts in the room with often differing views on the best course of treatment.  The doctor has formal education and vast knowledge on the disease, and you have an intimate understanding of your body and its day-to-day management.  It’s good for one to challenge the other with ideas, but hopefully the ending place is not so far apart.  

In the end, patients should leave with plans that are actionable and leave them empowered.  We should feel we have the agency to chew, and not just swallow, our doctor’s orders.


  1. It should absolutely be your decision, and what you are comfortable with. But it is great to hear that they are suggesting alternatives for you and trying to be helpful. I really had to speak up for what I wanted, because my clinic just never had the time for me.

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