Three A.M. Thoughts: ‘Doctor’s Orders’

IMG_2657_3It is a cultural artifact that we regard medical professionals as authority figures. We expect them to command us and we are expected to obey. Hence the phrase: ‘doctor’s orders’. This relationship does not work for Type 1 Diabetes. It infantilizes the patient, which is the worst possible outcome. A person living with Type 1 needs a team of professional health care providers (endocrinologists, opthamologists, general practitioners, nurses, dietitions, psychologists, social workers, diabetes educators) to help with management of the condition. But the patient needs to be the Captain of that team. Healthcare providers should be trusted advisors, not authority figures.

Healthcare providers may have relevant and necessary training and expertise in the science of the condition. I say ‘may have’ because in my experience not every healthcare provider who purports to understand T1D actually does. And a little knowledge, as they say…

Many conflate it with Type 2, and seem to think that all diabetes — and all diabetics — are the same. This is one of the things that irritates me the most. As far as I am concerned, Type 2 is a whole different medical condition that is not relevant to my life or my chronic medical condition. The two diseases share a name. They should not. This has created dangerous confusion in both the public and certain healthcare providers, who insist on speaking to and treating individuals with Type 1 the same as those with Type 2. So I’m asking all of us who understand Type 1 and ‘get’ that it is not the same as Type 2 to join me in a campaign to rename the condition. I’m not sure what the new name should be. But it should not have the words ‘type’ or ‘diabetes’ in it.

My body does not make insulin. No matter what I do, that is not going to change. I can diet and exercise till the cows come home, but I will still need insulin. We all need to deal with that. Putting me in a room with a bunch of Type 2 patients does not help me. All of the programing, public information and educational initiatives that are concerned with ‘Diabetes’ are, in my experience, primarily focused on Type 2 and we are just an afterthought. There may be some focus in the paediatric system on Type 1, but once we turn 18, we are abandoned.

Some of us are trying to change that.

Anyway, back to being the Captain of my healthcare team. A Type 1 patient needs to be in charge of her own healthcare management, because it requires effort and attention 24 hours a day, 7 days a week, and my healthcare providers are not available to me on that basis. Notice that I did not conflate that into 24/7. That’s because I want to convey to you just how specific, comprehensive and overwhelming that effort is. It is a tremendous amount of work. I am thinking about my condition all the time, every waking moment, no matter what else I am doing. I’m balancing my blood sugar against my food intake and my exercise level, plus the effects of my stress level, climate, altitude, etc. , all of which have an impact on blood sugar.

When I’m walking my dog, I’m managing my diabetes, calculating whether exploring that new path in the park is going to require a lower basal rate or some carbs to keep me balanced, wondering whether my perspiration is caused by exertion or low blood sugar.

When I’m in a business meeting, I’m managing my diabetes, calculating how much time I have before I need to make some adjustment in order to maintain my cognitive acuity. Stress makes my blood sugar rise, so does prolonged inactivity. Did I adjust my insulin dosages appropriately and is it still working properly?

When I wake up in the middle of the night, I have to manage my diabetes, directing my foggy night-time brain to get up and test my blood sugar to figure out if I woke up because it’s too high and I need insulin or if it’s too low and I need sugar. Then I need to be mentally clear enough to take the right corrective action, if indeed one is required. An error in either direction can have nasty consequences. Ignoring it and going back to sleep is just not an option.

When I’m performing on stage with my band, I’m listening not just to my voice and the music, but also to my body, looking for signs of low or high blood sugar. For a whole 45 or 60 minute set, I’m stuck there, not able to test my blood or bolus insulin – and people are watching me. At least I hope they are.

When I’m making love, I’m managing my diabetes, calculating how long I can stay disconnected from my pump before my sugar will start to glide upwards, in spite of my increased activity level, keeping track of the passage of time and whether I feel like my sugar is high or low, which I hope I don’t have to tell you, can interfere with one’s enjoyment of an experience which by its nature, takes us outside of time, space and our awareness of the self as an individual.

The point is I am managing my condition constantly. It’s not like I just give my medication and then forget it and get on with my day. So a Type 1 patient soon gains more intimate and comprehensive experience of her condition than any medical professional can match.

You need both in order to succeed: the medical expertise and the intimate experience of the condition.You need a collaboration between trained medical experts who are current with all the latest scientific data and studies, treatments, therapies and theories and the you need the expertise of the individual who is living with the condition and managing it 24/7.

Healthcare practitioners seldom treat just one type of patient. Typically, they see a range of medical conditions, even if they specialize. T1D is only one of the medical areas an endocrinologist or a nurse or a dietitian will need to stay current with. T1D is extremely complex and not entirely understood. There is no cure, and we still are not sure why some people acquire T1D and others don’t. Also, each case is unique and what works for one individual doesn’t necessarily work for another. And in case that isn’t complicated enough, the condition in a state of almost constant flux. What worked for me a year ago (or a month or even a day ago) doesn’t necessarily work today.

The T1D individual, on the other hand, lives and breathes T1D, but in the context of their whole life. It is not the only thing I’m doing. So I need you, healthcare providers, to help me understand the big picture – the broader implications of the studies of hundreds, perhaps thousands of individuals over time and in varying circumstances. I need you to help me understand the possible implications of the things that are happening to me, as well as the things I do or don’t do to manage my condition. I need you to present me with alternatives and possibilities. But in the end, I need to be the one ultimately responsible for managing it. I need to make the decisions, after appropriate input from the experts on my team. Because I am the Captain. I need to be the Captain, because ultimately I am the one living with the consequences of the decisions made in the management of my condition.

So I don’t accept ‘doctor’s orders’. I expect consultation, communication and collaboration. I think we all want the same thing: better health outcomes, fewer hospitalizations, and lower long term costs (physical, psychological and financial) of managing chronic illness. I believe – no, I know — that this is the only way to get there. We all need to be team players, and I need to be Captain of my T1D management team. Go Team!

 

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