BY
Danielle Ofri is the author of: What Doctors Feel; Medicine in Translation; Incidental Findings; and Singular Intimacies:
Becoming a Doctor at Bellevue Just the other day I took care of an older woman who had been struggling to keep her weight and her glycated hemoglobin (HbA1c) on this side of pathology. Her daughter recently lost her job, though, and the plummeting of the household income had an instant eff ect on her health. Fresh produce was too costly to be a regular part of her diet, which now slid back to the staples of potatoes and white rice. Like clockwork, her blood glucose spiralled upward. It’s not all bleak, of course. Some of my patients have great success with treatment. A few have completely turned their lives around, singing the praises of quinoa, kale, and physical activity. Their successes are inspirational to me, and often to other patients. But most of my patients dwell in the frustrating middle zone. They’ve made sacrifi ces and changes. They’ve put in the eff ort, but the results are slight. The last 30 pounds are intractable. The HbA1c hovers stubbornly above 8%. The insulin dose creeps relentlessly upward. The pill count for the associated hypertension, hyperlipidaemia, and cardiac disease edges into the double digits. I try to stay optimistic, to keep encouraging the incremental changes my patients are making. But it’s hard not to feel defeated. The latest and greatest medications don’t off er appreciable changes. Each new one on the market seems like little more than a costly rearrangement of deck chairs. The main developments that have delivered signifi cant improvements in glycaemic control to some of my patients have come in the area of plumbing, be it of their insulin syringe or their gastrointestinal tract. The insulin syringe, with its frightening needles and complicated mechanics of loading, routinely scares off my patients. They’d gladly suffer the side-eff ects and pill burden of multiple oral agents rather than venture anywhere near a syringe. But the insulin pen, with its hardly feelable needle, has changed this. It doesn’t require a nursing degree to use and doesn’t look like drug paraphernalia. Plus all those patients with retinopathy can now set the dose correctly.
But then in waltzes Mr Hokama. At his fi rst visit, his blood glucose was in the high 300s and he could have earned frequent fl ier miles with the number of trips he was making to the bathroom to urinate. He was reluctant to start insulin, but with my cajoling, pleading, and negotiating, fi nally consented. Around this time he also took up ballroom dancing and now dances for 2 hours nearly every day. Between the rhumba and the insulin, he has handily corralled his glucose into a manageable zone, and each time he comes in for an appointment, I am duly impressed. White rice, though, hasn’t disappeared from his diet. “I’m Japanese”, he reminds me with a gentle smile. “Sushi does not work with brown rice.” I concede the point. It’s easy to become nihilistic about diabetes, so overwhelming is the burden of medical care for these patients. My old professor was right, and even prescient— as old professors so often and so annoyingly turn out to be. Diabetes has come to defi ne the working lives of many doctors today. It can seem as though the tide will never turn. But perhaps thinking about the tide is simply too much for the individual doctor. Those in the clinical trenches can really only think in terms of individual patients. Mr Hokama keeps me inspired. As do my other patients, whose fortitude can be impressive, especially in light of the daunting odds. HIV infection eventually evolved from a sprint to a marathon. Diabetes always was a marathon, however the incline of the track steepens noticeably by the day. Doctors and patients press up that incline together, panting, often daunted, but ever striving. Danielle Ofri Bellevue Hospital, New York University School of Medicine, New York, NY 10016, USA danielle.ofri@nyumc.org
www.thelancet.com Vol 385 May 23, 2015
Danielle Ofri is the author of: What Doctors Feel; Medicine in Translation; Incidental Findings; and Singular Intimacies:
Becoming a Doctor at Bellevue Just the other day I took care of an older woman who had been struggling to keep her weight and her glycated hemoglobin (HbA1c) on this side of pathology. Her daughter recently lost her job, though, and the plummeting of the household income had an instant eff ect on her health. Fresh produce was too costly to be a regular part of her diet, which now slid back to the staples of potatoes and white rice. Like clockwork, her blood glucose spiralled upward. It’s not all bleak, of course. Some of my patients have great success with treatment. A few have completely turned their lives around, singing the praises of quinoa, kale, and physical activity. Their successes are inspirational to me, and often to other patients. But most of my patients dwell in the frustrating middle zone. They’ve made sacrifi ces and changes. They’ve put in the eff ort, but the results are slight. The last 30 pounds are intractable. The HbA1c hovers stubbornly above 8%. The insulin dose creeps relentlessly upward. The pill count for the associated hypertension, hyperlipidaemia, and cardiac disease edges into the double digits. I try to stay optimistic, to keep encouraging the incremental changes my patients are making. But it’s hard not to feel defeated. The latest and greatest medications don’t off er appreciable changes. Each new one on the market seems like little more than a costly rearrangement of deck chairs. The main developments that have delivered signifi cant improvements in glycaemic control to some of my patients have come in the area of plumbing, be it of their insulin syringe or their gastrointestinal tract. The insulin syringe, with its frightening needles and complicated mechanics of loading, routinely scares off my patients. They’d gladly suffer the side-eff ects and pill burden of multiple oral agents rather than venture anywhere near a syringe. But the insulin pen, with its hardly feelable needle, has changed this. It doesn’t require a nursing degree to use and doesn’t look like drug paraphernalia. Plus all those patients with retinopathy can now set the dose correctly.
The other salutary plumbing adjustment, of course, is bariatric surgery. For years I was a sceptic. The absurdity of surgically correcting our societal pressure to overeat all the wrong foods rubbed me the wrong way. I couldn’t decide if the bariatric tune-up was worthy of Franz Kafka or of Oscar Wilde. But now that I’ve seen the lives of some of my patients dramatically turned around, I’ve come to accept bariatric surgery as a legitimate tool in the armamentarium, though certainly not the fi rst one I grab for. But bariatrics and insulin pens aside, diabetes remains a frustrating slog for both doctors and patients. It can sometimes seem as if the world is conspiring against us, between the ubiquitous presence of super size, super cheap, super lousy food and the even more ubiquitous sloth-inducing technology that limits our muscular fi tness to the fl exor carpi radialis. There are days when I consider the idea that we’d have more success with diabetes if we simply exterminated white rice and soda vending machines from the face of the earth.
But then in waltzes Mr Hokama. At his fi rst visit, his blood glucose was in the high 300s and he could have earned frequent fl ier miles with the number of trips he was making to the bathroom to urinate. He was reluctant to start insulin, but with my cajoling, pleading, and negotiating, fi nally consented. Around this time he also took up ballroom dancing and now dances for 2 hours nearly every day. Between the rhumba and the insulin, he has handily corralled his glucose into a manageable zone, and each time he comes in for an appointment, I am duly impressed. White rice, though, hasn’t disappeared from his diet. “I’m Japanese”, he reminds me with a gentle smile. “Sushi does not work with brown rice.” I concede the point. It’s easy to become nihilistic about diabetes, so overwhelming is the burden of medical care for these patients. My old professor was right, and even prescient— as old professors so often and so annoyingly turn out to be. Diabetes has come to defi ne the working lives of many doctors today. It can seem as though the tide will never turn. But perhaps thinking about the tide is simply too much for the individual doctor. Those in the clinical trenches can really only think in terms of individual patients. Mr Hokama keeps me inspired. As do my other patients, whose fortitude can be impressive, especially in light of the daunting odds. HIV infection eventually evolved from a sprint to a marathon. Diabetes always was a marathon, however the incline of the track steepens noticeably by the day. Doctors and patients press up that incline together, panting, often daunted, but ever striving. Danielle Ofri Bellevue Hospital, New York University School of Medicine, New York, NY 10016, USA danielle.ofri@nyumc.org
www.thelancet.com Vol 385 May 23, 2015
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