Caring for Patients with Diabetes: Risk Management Strategies

Randy Linde, MD, a practicing endocrinologist in Palo Alto, California; updated by Howard Marcus, MD, FACP, Chairman, Texas Alliance for Patient Access

Diabetic patients pose unique risk management concerns for physicians. Many patients simply refuse to accept that they have diabetes, while others may not recognize the seriousness of the associated complications. This article provides insights on eliciting patient compliance with a complex set of self-care requirements. The article also demonstrates the importance of carefully documenting every patient encounter in order to deflect potential litigation.

Patient Denial

A 30-year-old male with severe retinopathy was referred to me by an ophthalmologist for diabetes management. A lab test confirmed hyperglycemia. The patient denied that he had been informed of having diabetes and said that in the last few years, he had been told only that his blood sugar was mildly elevated on several occasions. Further evaluation confirmed significant neuropathy and renal insufficiency. I explained to the patient that he had clear-cut diabetes with multiple complications, and I described the ominous potential of the disease. I suggested that he have his previous medical records forwarded and made a number of diagnostic and treatment recommendations. All of this was documented in the medical record.

I did not see or hear from the patient until nine months later when he reappeared with a persistent flu. He provided no explanation for having disregarded my previous advice. I reiterated my concerns and somehow convinced him to undergo laboratory studies that morning. Later in the day, I called him with the unfortunate news that he had developed renal failure. I arranged for him to be hospitalized by a nephrologist, who subsequently took over his care.

One year later, I received a letter from the patient’s attorney alleging that I had not warned his client of the possibility of developing renal failure and that he intended to file suit. Nervously, I reviewed the patient’s chart and found that my consultation note was quite clear—I had warned the patient of the risks. A request from his attorney for a copy of the records soon followed, and that was the last I ever heard of the matter.

While some degree of patient denial is common with diabetics, this particular patient was one of the most extreme examples I’d seen in my years of endocrinology practice. I certainly understand why denial occurs: A diagnosis of diabetes is frightening. Diabetes is the nation’s leading cause of blindness, kidney failure, and amputation, and it significantly increases the risk of heart disease and stroke.

No one reacts favorably when advised that he or she will have to live a structured lifestyle that includes a regimented diet and daily blood sugar monitoring. Some people live in abject terror of having to self-inject insulin. Others fear losing their jobs and keep coworkers unaware of their diabetes.

Diabetes Education as Risk Management

At our clinic, we use a multidisciplinary approach to diabetes management. Patients referred for an endocrine opinion are also seen by the diabetes educator, and we refer many patients to an ophthalmologist, podiatrist, or other specialist when indicated.

Many patients referred to us are either recently diagnosed or poorly educated about their diabetes. Initially, patients may be overwhelmed by the team of consultants and the scope of information we give them, but our goal is to overcome each patient’s fears by providing information and support. Accomplishing this goal is like teaching someone how to walk all over again: It is painstaking and repetitive. The desired result is for patients to do well because they assume personal responsibility for their health—perhaps the ultimate goal of risk management.

Patient education often requires multiple teaching methods and repetition. We provide four main sources of knowledge for our patients:

• The diabetes educator meets with each patient, both alone and with a family member or close friend in attendance.
• We recommend reading material with the level of difficulty matched to each patient’s motivation and background.
• We organize regular meetings of small support groups for diabetic patients.
• We review patients’ progress and new self-care skills at periodic follow-up appointments.

The Diabetes Educator

Our diabetes educator is a registered dietitian who designs an individual diet plan to fit each patient’s special needs. The plan includes directions for grocery shopping and eating out. The educator teaches patients how to monitor their blood glucose, evaluates patients’ techniques regularly, and calibrates their equipment.

Sessions focus on instructions for self-administration of insulin, including insulin kinetics, and emphasize the importance of timing meals and exercise. A spouse or other partner participates as much as possible, especially during the discussion of management of acute illness, hyperglycemia, and hypoglycemia. We send every insulin-dependent patient home with a prescription for a glucagon emergency kit in case of hypoglycemic coma. We periodically remind the patient’s partner of how, when, and why the glucagon is administered. We also sponsor advanced classes in diabetes management with our local diabetes society.

The diabetes educator and I have developed a good-cop, bad-cop routine that evolved from the educator’s sympathetic and accepting nature and my tendency to push hard for results. Invariably, patients who need reinforcement will call her, and she comes through for them.

During my sessions with patients, I look for opportunities to test what they’ve learned. I might ask, "When should you check for urinary ketones, and how would you act on the result?” Anticipating a common error, I often ask, “What would you do if you accidentally took your morning insulin dose at bedtime?” This approach may seem harsh for people coming to terms with a new disease, but it is intended to create self-confidence—which is critical to the diabetic patient.

The process of learning to deal with diabetes often involves major lifestyle changes that can be quite discouraging. While patients may leave each session feeling mental fatigue, it is important to find a way to end each session on a positive note.

Support Groups

Patients who join support groups benefit not only from hearing about the personal experiences of other members, but also from having the chance to share their emotional responses to being diabetic. Health professionals are not encouraged to attend these meetings unless invited to speak on a topic of interest to the group. This provides the opportunity for patients to blow off steam about us—the cops. Patients who participate in groups tend to take criticism more constructively, and they usually achieve better diabetic control. Our diabetes educator initially organizes the groups, which are generally self-sustaining.

Difficult Patients

Clearly, these techniques do not work for everyone. When managing a patient with longstanding obesity, a sedentary lifestyle, and type II diabetes, we make it clear from the outset that this type of patient usually does poorly due to lack of compliance. We also emphasize that developing diabetes late in life doesn’t provide protection from complications. We walk a fine line with those patients, who often need a great deal of reinforcement as well as a rude awakening to reality. Playing hardball is sometimes effective. Our former diabetes educator observed that our successful type II diabetics were the ones who were afraid of me.

For those who remain in denial, we are left with the ethical and medico-legal responsibilities of giving detailed explanations of the long-term hazards of untreated diabetes, including death. Since our common goal in practicing medicine is to alleviate pain and suffering, that kind of interaction is most unsatisfying.

Risks to Family Members

We remind our patients that diabetes poses risks to others as well as to themselves. A poorly controlled diabetic can be emotionally labile and a burden to family members. While we encourage family support and feedback, our goal is to make each diabetic patient personally responsible for achieving good self-control.

The most flagrant example I’ve seen of a patient personally failing to assume accountability for his diabetes was a 50-year-old man who had worked as a salesman in a variety of industries. Unfortunately, he had mastered the art of selling a lie.

For years, the patient had been a closet drinker, a fact his wife made known to me shortly after I assumed his care. Although his only long-term complication after more than 20 years of diabetes had been mild retinopathy, he suffered frequent insulin reactions, during which he physically abused his wife. The insulin reactions persisted despite repeated efforts to provide diet and insulin dosage advice that should have been effective. Periodically, his wife would find an empty whiskey bottle in his car, for which he would find some excuse, never admitting his problem with alcohol. Paramedics were regularly called to his home to administer intravenous glucose to him and first aid to his wife. Finally, after a number of warnings, his health insurer revoked his coverage.

Risks of Diabetics Driving

There are more than 25 million diabetics in the United States, many of whom take insulin and drive a car. Driving is undoubtedly the greatest day-to-day liability this disease presents to the general public, since a severe insulin reaction may cause a sudden loss of consciousness. Most people with diabetes can drive safely, but we periodically review the issue of driving with all patients.

Specific rules vary among states, but we emphasize the responsibility of all patients who drive to be certain that their state department of motor vehicles (DMV) is aware of their diabetes. When we learn of a patient who is not complying with our advice or who fails to sense the warning symptoms of hypoglycemia before losing consciousness, we inform the patient that we are obligated to disclose this information to the DMV as a public safety measure. This is done by sending a confidential morbidity report form to the local public health department or directly to the DMV. The DMV then sends a physician’s form to be completed before a patient is interviewed by the DMV. Thus, it is ultimately the responsibility of the DMV to determine whether an individual with diabetes should drive.

No Easy Answers, Just Precautions

There is no vacation from diabetes. Dealing with the disease means stabbing a finger to test a drop of blood several times each day, eating three carefully considered meals and snacks, fitting in an exercise session among life’s routine demands, and often taking multiple daily doses of insulin. A variety of issues can arise that will prompt a call or visit to a primary care physician, endocrinologist, or diabetes educator. Most foot problems require a visit to a podiatrist. An annual eye exam is mandatory, even without ocular disease. Diabetics must be regularly screened for renal disease and lipid abnormalities. Being a diabetic can be a full-time job.

Managing the myriad risks of diabetes means looking out for the well-being of patients, their families, and the public. Our principal goal is to make patients as expert as possible in handling diabetes—ideally, making good self-care second nature. Our system of diabetic management is structured to reinforce important information by ensuring that it is provided and documented by more than one caregiver. Our robust approach to diabetes management has allowed us to achieve unusual success in compliance and diabetes control.

It Takes a Village

The African proverb “it takes a village to raise a child” means that an entire community of people is needed to help a child grow in a safe and healthy environment. The proverb also applies to the many healthcare professionals—the “village”—that help our diabetic patients manage their own disease and decrease the occurrence of diabetes-associated complications.