Eric was retired military and a first responder at the September 11th terrorist attacks in New York. He was also an uncontrolled diabetic and one of my favorite patients. He was just a regular guy trying to deal with life and kids, and had a Boston accent I like to poke fun at. That made him very relatable and easy to talk to. Diabetes was just one more burden that he carried with him at all times. I joke that we often fought about his chocolate milk addiction, but the one element that truly drove his treatment plan for managing this disease was the vivid and horrible memories that he gained working as a hero on that fateful day in 2001. He does not talk about that day except to say that he will “never go back there”.
Don’t misunderstand. There were times during the year that he did exceptionally well with reducing his need for medication and having very near normal blood sugars. He exercised, avoiding sugars and starch and even took his medication on a daily basis. He would say he wanted to give his sons an example because he knew that they were at risk for diabetes as well…and liked chocolate milk just as much as he did. He stuck to the plan we created together and things were good.
I don’t have the memories that Eric has. I don’t know if the slight chill and changes that arrive in September triggered his memories or just the date on the calendar, but I knew that come fall the treatment plan needed to be adjusted to meet his change in demeanor. The medicine needed to match the mindset. I remember several times seeing him stare at me in horror as tears rolled down his cheek. Horror at crying in front of me and horror at the images he tried desperately to keep locked away.
I did not try to say things like “Look on the bright side” or “mind over matter”.
I feel this would have only deepened the wound and destroyed the trust we had built between patient and provider. It would have only sounded patronizing and revealed my complete ignorance of his pain; a pain I still cannot imagine.
No, he needed understanding and compassion. During the months from September through December, we steered the plan toward taking some medication daily and avoiding liquid sugars. This was how he avoided complete physical break down and arrived in January with something workable and reversible.
This was the rhythm of his diabetes, although each September got a bit better.
My job was to work with Eric to keep his diabetes managed, but what is not discussed after earning all the degrees and letters that make you qualified to do this, is that without first treating the mind, your efforts will all fall short or even fail entirely.
You could even stretch this to say that providers and doctors work only as consultants to people with disease, because it is truly up to the patient to take action.
Eric is not the only case.
I work with over-stressed mothers that put partners, kids and pets ahead of them in all aspects of life. They skip medication doses to make sure the kids get to soccer on time or eat on the go at drive-thrus to avoid arguments. Years of battle on the home front has worn them down and they give up.
Caregivers avoid spending money on medications for themselves or healthy food in order to give comfort and love to a parent left with very little time. Ironically, this starts to close the door on their chance to extend their own lives. They have tried to stretch the resources, but it is too hard and they give up.
All of these people have a battle inside they are fighting, and as the thought of their own health comes roaring to the surface they quickly push it away. That thought alone causes pain and anxiety, because they know they should be doing more for themselves and they feel they can’t. The cycle keeps going.
The doctors see it, but treat their patients with logic. Reminding them of the damage, the risk and eventual end. This only serves to drive them deeper, and also discredit their feelings.
If you want to see patients flourish. If you want an end to worrying about your patients with diabetes. If you want progress, then you need to treat the mind of your patient, otherwise you are wasting your time and deepening their shame.
Start with what can be done and not with what should be done in an ideal world. We don’t live there. The most successful clients I’ve had were given a single action item to put in place at a time.
Take one pill of metformin each morning.
Inject your long acting insulin each night.
Switch your sweetener.
Check your blood sugar once a day…once a week.
Any start is a good start. As this one action becomes a habit, the effort of it falls away and they are ready for the next step, and slowly remember what it’s like to care for and about themselves.
Through this process, you’ve learned about avoiding their pitfalls and that they may respond differently at different parts of the year. You are ready for them when they have a relapse and adjust to keep them alive and engaged with your care.
I wished Eric did not succumb to his memories every fall, but he did and I was ready with the understanding and plan he needed to make it through his darkest hours.
I know if I had not had this approach, he would have simply avoided me and any medical care completely. This entirely defeats the point of being in a profession of healing.
I don’t think it is unrelated that the diabetes epidemic and the mental health problems are both seeing an equally terrifying rise year after year. They are related on some level that still needs to be revealed. Diabetes worsens mental health, mental health worsens diabetes or maybe a little of both.
I just know that diabetes, or any chronic disease, cannot be managed without seeing patients as people first. People have worries and fears that will obstruct their best efforts to be healthy and live fully.
If you want to be successful, treat their minds first and the body will follow.