As quoted by Jerry Maguire and our diabetes educator "help me help you", this directive could summarize many of our diabetes follow-up visits in our practice. I am currently on service and have once again admitted several patients with recurrent diabetic ketoacidosis as a result of missed insulin. Omission of insulin is a very common problem in the adolescent population due to behavioral challenges. Our goal as diabetes care providers is to attempt to negotiate behavioral change.
Question: How do diabetes clinicians, educators, and people with diabetes walk through this “mine field” unscathed?
Answer: Very Delicately.
To make clinical assessments, it is essential for our patients and families to bring the appropriate information or data to the appointment so the physician can make any changes in treatment. Required data for every visit should include information on insulin regimen and doses, blood glucose results with the availability of a glucose meter(s), and written or downloaded hard copy records. It would be helpful to provide, in writing, concerns or problems that have occurred since the last visit interval. Our diabetes team makes every effort to download blood glucose meters at every visit. However, if there is no meter(s) available, there is little clinical intervention that can be done safely. It is clear that data must be available to make decisions about insulin management. It is not unusual for patients (particularly adolescents) to “forget” to bring their meters. Parents consistently remind their teens to remember to bring everything to the visit.
What are the underlying factors behind forgetting blood glucose meters and /or logs? It has been my experience that in many situations, meters are intentionally forgotten as they are simply not being used. Lack of utilization may be translated into “not checking blood sugars.” Most teens who have forgotten their meters will simply state they are checking blood sugars the desired amount (4-6 times/day). Simply bringing a log book with blood sugars written in same color ink or ending in the same number (digits with a majority ending in 2) is not always reliable. I also know that our teens really do not want to disappoint so they often bring something to the visit even if the accuracy is suspect.
Question: How do we allow our teens to help us to help them?
Answer: By providing honest responses.
If a patient does not bring the information necessary for our team to make changes in the treatment plan, I honestly state that I could try to make some changes based on the information I do have (height, weight, blood pressure, hb A1c, etc.), but I truly require blood glucose data to evaluate trends and fluctuations. There are some visits where I do not change any insulin doses due to the fact that there is not enough data. However, this also provides an opportunity to discuss the barriers to self-blood glucose monitoring, which is often of even more import to overall management. Once again, we emphasize that medical suggestions do not always translate into action. Negotiation of behavioral change is paramount and there must be “buy-in” by both the family and child/teen with diabetes to move toward glycemic improvement. Thus, the expression, “help me, help you” takes on a very different meaning in the context of providing care in the clinical setting. It is essential for the diabetes team to work very closely with the family and child/teen to help each other provide the best possible care.
This is the first of the ongoing series of “help me, help you” blogs. Please send in any specific topics that you would like me to further address.
(I would like to thank SR for originating the idea for this blog).
Published On: February 21, 2013