Stories from the Stethoscope: February 2021

Sheila was a community patient of mine who had poorly controlled Diabetes Mellitus. She was quiet and nervous but had tremendous warmth in her personality she would occasionally share. Her blood sugars were never ideal. Her housing situation and dietary choices did not provide the ideal situation to succeed. One day she came into the office with blood sugars in the 400’s. We spent time discussing her food choices and the new dose of her insulin. I asked her to come back in one week. One week later the blood sugars had not changed. We talked about exercise, stress, food, and drink choices. I increased her insulin again and asked her to return in a week. She returned the next week and her blood sugars were still in the 400’s. I could not believe it. I did a thorough exam and checked her urine for an infection. I spent more time teaching and going over everything we discussed last week. I increased her insulin again. I was off the next week, but I wanted her to be seen. I put her on my colleague’s schedule and gave her some background information about Sheila.

When I returned from vacation, I began to catch up with the staff. Dr. Gleda mentioned that she saw Sheila for me. I said, “How did it go?” She replied, “Well, I read your notes and I asked her the one question that you never did. I asked her if she was taking her insulin. Guess what? She hasn’t taken her insulin in weeks.” I was dumbfounded. I could not believe that I was increasing a medication that she was not taking. I was not upset with the patient. I was disappointed with myself. Prescribing a medication, picking up the medication, and then taking the medication are three separate steps in the healthcare delivery process. In the early stages of my career, I just assumed that because I prescribe a medication all the other steps just fall into place. Boy was I wrong. Over time you learn that some patients only take their pills a few times a week. Some patients feel they do not need them or only take them when they don’t feel well. Many patients don’t have easy access to the pharmacy or cannot afford the therapy we order. Providers are quick to increase and change medications without asking about the other steps in the process. I now ask the following: Are you taking your medication? What is stopping you from taking your medication every day? How can we work together to make it easier for you to take your medication every day? Health care delivery continues to improve. Many of us use programs such as chronic care management, remote patient monitoring, and artificial intelligence. They can really bridge the message and the value of a provider’s services between visits. We just have to remember to ask the right questions when we have our patients in front of our eyes.