I liked him instantly. There was something very refreshing about his willingness to be honest.
I hate my job. I’m 63 and I’m taking orders from men less than half my age. I had hoped that I could retire from my previous job but they privatised the company and a bunch of us were made redundant. So I took what was offered. So now I have to do all this physical work. On my breaks I eat chocolate. It helps me feel better and besides I like chocolate and milkshakes. I say to myself ‘ it has to be good for you its milk right’? Is Pizza OK doctor?
Several different colleagues had seen the patient over the years. He knew perfectly well that chocolate; milkshakes and pizza were a bad idea. A dietician and the practice nurse had seen him. His blood tests exhibited a worrying trend. Nothing that had happened in the intervening couple of years had changed. His job situation was much as it had been when he was first diagnosed with type 2 diabetes. He had been seen at least three times in the previous year and the picture was the same. If he had refused medication that decision was not recorded. I could imagine the conversation, focusing on diet and exercise. He described sleep apnoea and breathlessness on exertion. He struggled to get through each day. His cravings for comfort food and his sugar addiction were showing no signs of abating. For people like him we watch what plays out like a car crash in slow motion. Will he make it much beyond retirement? Will the vascular disease that appears in my crystal ball be averted?
A systematic review on the effectiveness of self-management training in type 2 diabetes concluded that
No studies demonstrated the effectiveness of self-management training on cardiovascular disease–related events or mortality; no economic analyses included indirect costs; few studies examined health-care utilization. Performance, selection, attrition, and detection bias were common in studies reviewed, and external generalizability was often limited. Norris and Narayan.
Our attempts to advise people like this man scarcely take account of their circumstances. Nowhere in his records did it tell me what this man did for a living, his hopes and dreams or his understanding of this unforgiving chronic condition. What was recorded was that he had received advice to lose weight (tick), to increase his exercise frequency (tick). His blood pressure had been measured at least three times in the past year (tick), lipids (tick), HbA1c (tick), renal function(tick), advised to see an optician(tick) and podiatrist (tick). According to our records he was receiving exemplary care. He was cast as ‘patient’ but not as a ‘person’. We knew nothing about where he lived, who lived with him, where he went on holiday, what he did at weekends, what he hoped to do when he retired. Nothing was noted about why he needs to do manual labour or whether he is in debt. In the fifteen minutes available this time we simply accepted that he was not going to change his lifestyle despite what I could tell him of the potential benefits. In return we shared a mutual concern for the risks he was harbouring. He would start medication and ramp up the doses until his risk for cardiovascular disease was reduced. Not a text book solution but then people are not cardboard cutouts. Our experience was supported by the results of research which reported that:
The core process of integrating lifestyle change in type 2 diabetes was multifaceted and complex. Challenges to the process of integrating lifestyle change included reconciling emotions, composing a structure, striving for satisfaction, exploring self and conflicts, discovering balance, and developing a new cadence to life. These challenges required acknowledgment in order for participants to progress toward integration. Whittemore et al.
Picture by Saxbald