Letting Go of Diabetic Patients

I have had to dismiss patients because of unacceptable behavior towards either my staff or me. I have also had to let patients go because of failure to comply with the financial policies of the office. And I have had to ask patients not to follow up unless they are ready and willing to participate in a specialist's care.

Technically, these patients are not dismissed from the practice. And, no, I do not “fire” every diabetic patient whose Hba1c is above goal, or patients who experiment with their medication doses, or those who claim they don’t eat yet gain 10 pounds between each visit. I understand that lifestyle changes are hard, and that diabetes in particular is a labor-intensive disease to have. People get frustrated and burned out trying to manage it, and from time to time, even the most compliant patients have periods of pretending they don’t have the disease.

I am talking about the patients who won’t even try, or pretend to try, for that matter. The ones who will not check their blood sugars, refuse to have their meds changed, and won’t get their labs done. OK, before you start typing feedback about looking into the psychological, mental, and financial reasons why people do or don’t do what they do or don’t do, I get that. I ask patients why. I talk about complications and the avoidance thereof. I talk about their fears – fear of needles, fear of the results, fear of pain, fear of side effects. We discuss their concerns about cost, their perceptions about food, exercise, and meds. I do understand the barriers to good diabetic control.

I have one patient who smokes 2 packs of cigarettes a day, yet has to ration her insulin and skip some of her other meds because she can’t afford it. She doesn’t check her blood sugars because she can’t afford the testing supplies either. She knows how ridiculous that is. I have told her that I will help her as much as I can with samples, but she is too proud to ask except during her visits. I have given her the contact information for some patient assistance programs, but I don’t know if she has actually attempted to apply. However, I keep seeing her because I know that, despite her non-adherence, she is doing the best she can with a physical and psychological addiction to nicotine. 

On the other hand, I have another patient who has been on the same 2 oral agents for the 3 years I saw her -- the same 2 meds she was on when I started seeing her. I told her numerous times that she either needed to lose a significant amount of weight and/or go on additional medications. “Oh, honey, I’m not going to change how I eat.” And that was a roll with butter for breakfast for example. Not, even a pretend, “I’m gonna try, doc” or the more common, “but I don’t even eat.” Just a definitive statement of unwillingness to even attempt a change. She also refused to try any other meds. We discussed the potential complications of uncontrolled diabetes. We discussed the potential barriers. It wasn’t fear of side effects. The issue wasn’t cost. She just wanted to keep doing what she was doing. Well, after 3 years of just watching her Hba1c stay firmly around 8, I told her that I really wasn’t doing anything that her primary care physician (PCP) couldn’t do. As a matter of fact, I was doing exactly what her PCP was doing before she came to me. I had run out of suggestions and had exhausted my repertoire of patient education. And while she is welcome to come back any time she decides she wants to do something more, I told her there was no need for her to see me. Save yourself your time and copay. And save an appointment slot for someone I can hopefully help. It was not an unpleasant conversation and we parted ways amicably. I still hope that she comes around and does something to help herself, whether she does so under my care or not.

There are too few endocrinologists and too many people with diabetes and other endocrine disorders to spend time with those whom we cannot help. We should certainly continue to try to reach those we can and to work through the issues that prevent good healthcare, but sometimes, for the greater good, we have to let some patients go.