The Doctor-Patient Relationship Isn't Always Smooth

I recently saw a patient who had changed her insulin doses on her own since her last visit. I may not have minded (well, I would have, but I might not have said anything negative) if her blood sugars were good, but they were not. I pointed it out to her, and she said "Well, if take all that I'll drop too low."

I told her that it had been two months since she sent her readings in for insulin adjustments. Her reply: "I work 60 hours a week. I didn't have time." I tried to show her what the consequences were of her under-dosing herself. "I don't understand how to do this," she said. So I said that's what I'm for, I'd like to guide her but I can't without the data I need and I can't adjust her doses if she isn't taking them.

I suggested a nutritionist -"stupid."

A diabetes education class -"useless."

She had something negative to say about every suggestion I had, and then had the cojones to say she doesn't understand why I get frustrated with her. I lost it. I said I get frustrated because I care. I said it would be so much easier if I just didn't give a s--t. Yes, I said it. I could just sit back, let her do what she wants, not try to help her, and sleep well at night. Instead, I made one more suggestion: I was going to have a diabetes educator call her and try to help her. I told her not to try to go this alone. Today, I got a message from said educator, who called the patient's home and was abruptly told that she (the patient) was not available.

Then, I recently had another patient, one whom I have been seeing for several years. She had refused for several years to start insulin. She finally agreed one day, then didn't take it for months. Then stopped it because it made her "stagger." Not that her blood sugar was too low; it was just a "side effect" of that particular insulin. We tried another one that made her nauseous. The last time I saw her, which was over four months ago, we made an adjustment in the dose of one of her medications as a concession. Well, she came in today stating that her sugars were still high (surprise!). I asked her if she has been taking the higher dose, and she said that she has - for the last three weeks. So I asked her what she did for the three months before that, and she said she had been taking her old dose.

I couldn't do it anymore. For years, I have tried to encourage, educate, and cajole this woman into taking care of herself. I have told her of the consequences of her decisions. Her husband is a living example of success.

I have tried being nice, and have lost my temper with her like I do when my kids do something stupid and dangerous. I finally gave up. When she told me what she did, I did not reprimand. I did not correct her. I did not ask her why. I went through the obligatory questions, I got a thorough review of symptoms, and I performed a physical exam. Then I asked her what she wanted.

Now, I should have prefaced this by saying she was recently in the ER for dehydration and the ER doc told her that it was because her DM is not controlled (I disagree - it was probably the diarrhea she had, but that's neither here nor there). She said she knows she needs something. I said, OK. She said maybe she does need insulin. I said that's fine. I started computing how much she needs when she interrupted to tell me she wants to start at a small dose. OK, that's fine. That's when she asked me if I want her to find another doctor. I said no, I'm not asking her to leave, but she's a big girl and can go where she would like. She said she didn't want me to be upset with her. I almost found that funny. It was the first time in a long time that I didn't get upset with her. I had conceded. I was beaten down. I was throwing up the white flag. I figured I couldn't make her do what I thought was right, so I was going to let her do things her way. She said she didn't want to do things her way. Well, she didn't want to follow my recommendations either.

I know I can't help everybody. I can't save the world one patient at a time. I would love it if I could. But there are some people who just won't let you. And I'm finally coming to terms with that. Oh, I will keep trying. I will probably break out my angry mommy voice from time to time, but I am going to have to learn when to take a step back, take a deep breath, and cut those apron strings.

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