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January 5, 2004

Behavior

Question from Seattle, Washington, USA:

I am 34 years old and have had type 1 diabetes for 13 years. My glycemic control is very poor. (Last A1c was 14.9%.) Although I know the risks and dangers of poor control, I seem to continually play games with my insulin. When I need to lose a few pounds, I skip a couple of shots or when I know I am having blood taken I taken a little extra so my blood sugar is lower. I tell my doctors that I check my blood sugars, but I rarely do. I have frequent highs and lows, and have ended up in the hospital on numerous occasions. I started seeing a counselor lately to help me, but I haven't come clean with my doctors yet. I know I am playing Russian roulette with my life, but I can't seem to get motivated to really try. What and/or how should I bring this up with my doctor? What would you do with a patient that hasn't been completely honest with you regarding their own home care? Your thoughts and ideas are greatly appreciated!

Answer:

If a person I was seeing in therapy was willing to share his or her deepest fears and worries, I would feel flattered and honored that they felt safe enough with me to discuss these concerns. The role of a therapist is to support and guide an individual, and to teach that person new ways of looking at things and new strategies for managing them. A therapist should never judge a person they are working with. Therefore, I encourage you to share your struggles with your therapist.

It may be that you have already experienced some diabetes-care specialists who have used fear and criticism as a way to encourage you to make healthier choices with your diabetes care. Many adults who have experienced this type of diabetes care can become extremely afraid of being honest and straightforward about their own struggles with the demanding and exhausting nature of living with diabetes. However, there are many excellent diabetes clinicians out there, and in addition to sharing your struggles with your therapist, I encourage you to share your struggles with your diabetes team. If you are not happy with their response, look for another team.

Good luck – you can not do this on your own, but you can do it with some help from others.

JWB
Additional comments from Dr. Jim Lane:

Actually, this is a common problem with a chronic disease. Treatment and results are related to the ability of the patient to carry out a treatment plan. First, you have to tell your physician what you have indicated. This will allow your physician to potentially use local resources to help you. If you try to fake out your physician, you are cheating yourself. You need a treatment plan that you regularly follow. Variation from the plan requires input from your physician. You need checks and balances on your behavior. This may require you send sugars to your physician or the diabetes educator you work with locally. Finally, you may need to see a mental health professional that can work with you to change your behavior.

JTL
Additional comments from Dr. David Schwartz:

Given what you have said with an extremely high HbA1c and recurrent hospitalizations for wide glucose fluctuations, I suspect that your physician well understands that you have not been completely forthcoming during your clinic visits. And if your diabetologist has the capacity to download your glucose meter, which is now almost standard, then your physician can really see just how often you truly check your blood glucose.

You may have pulled the wool over the eyes of your doctor, but probably not. And even if so, probably not completely. I think your physician would see your “fessing-up” as a genuine attempt on your part to try to turn your situation around. Paraphrasing something often stated in other situations, “the first step to fixing the problem is acknowledging that a problem exists.”

DS