Psychiatrist reminds clinicians to blame the disease, not the patient. In the New York Times’s (10/21, D6) Mind Column, psychiatrist Richard A. Friedman, M.D., of Weill Cornell Medical College, writes that, in general, physicians and “psychotherapists generally don’t like it when their patients don’t get better.” Still, “lots of patients elude our clinical skill and therapeutic cleverness. That’s often when the trouble starts.” Dr. Friedman explains that “chronically ill, treatment-resistant patients can challenge the confidence of therapists themselves, who may be reluctant to question their treatment; it’s easier – and less painful – to view the patient as intentionally or unconsciously resistant.” While “it makes good medical sense for therapists to rethink the diagnosis and treatment of any patient who fails to improve,” Dr. Friedman observes that “this is a double-edged sword.” For example, “some patients really do want to be sick,” and “will go to extraordinary means to defeat doctors who try to ‘treat’ them.” But, the “vast majority of patients want to feel better, and for them the burden of illness is painful enough. Let’s keep the blame on the disease, not the patient,” Dr. Friedman concludes.
The discipline rate for some of my patients is not optimum by their parents.They have the money,mothers just let their children do whatever they like,giving them pocket money to buy any fast food,blood glucose is soaring…
On the other hand I have great parents who have very little but offer their kids optimum care.
For some families with very poor social circumstances,the kids are in danger for losing their lives.
Yesterday I had a 12 y girl,diagnosed 7 months ago.came to first visit,missing 3 appointments with me,but the mother is poor with 3 mentally handicapped boys at home and the father has no car.Life is very difficult.There is social allawance for every handicapped child or any one born with inherited condition,but not for diabetic children who have to buy diabetes supplies in most areas of the kingdom. I wrote and asked in higher rank,but nothing was done. I asked the parents to write and ask for free supplies or this allowance.
Happy today,finishing my round,I found a message to all staff from our young wonderful director asking us to list advantages and disadvantages of our administration. My poetry prompted democracy!! I love my colleagues…
Poetry is a beautiful way to deal with conflict. Well done for sending it out! I’m glad today is a better day for you.
I treat children, it means I deal with their parents, but I address all. We have to look after children till they come of age, even as patients. The difficult patient for me is the parent who has the understanding of the situation and the means to look after their child but still would not care as expected.
A mother, who is a teacher, with a 4 y old daughter with diabetes, never tell me the truth, high HbA1c,multiple visits to emergency but missing clinic appointment…This is a difficult mother
A small bribe:
I asked my kids who have HbA1c at 7 to lower it to make me happy.It was ah oh,they are doing great,but I want them to have the best control like many children in this community.Well I knew from their sweet faces the answer: No.
So I offered a bribe, 500 SR for every one who will make his or her old doctor happy.Wish if you saw the smiles…
LOL… I remember the first time I did something like this, I was 8 and told to help my younger sister with her math homework while Mom and Dad were out shopping. In order to (with a lot of coaxing) get her to do her problems herself, after exhausting the few alternatives I knew of, I offered her a Pez candy (small inexpensive candy that comes in little rolls or stacks) for each one she did herself. It cost me a roll of Pez, but she got her homework done without me doing it all for her…
(“Success!” I thought. When Dad asked me how I did it, I told him, and he chided me for taking the “carrot” approach: “You don’t have to bribe her – that’s my job,” he said. As a result, I was probably the only third grader who knew the word “bribery”…)
The moral? Greed often succeeds where enlightened self-interest fails. (Some moralists we are… <chuckle>)
Tmana,
When I brought my children back from boarding school in England, I wanted them to join Arabic schools, they did not know Arabic well, and my son would not do his Arabic classes at home with me until I offered him 100 SR /session. He collected 5000 in the summer and passed the set exam to join the proper class for his age then (12).My daughter refused, joined British school, then back to England for the rest of education. She studied law and back to Saudi, she cannot read Arabic well. My son studies in American College now in Dubai (engineering). Ok I will stop bribing my patients,I will change it to contest & reward ( anothe subtle name for bribery!!!).
The word doesn’t matter… it just brought back some childhood memories.
Which type of diabetes? on first presentation:
Family history
General Examination:
1-child presents in DKA:
antibodies( if available),thyroid function,celiac profile
2-child with symptoms of diabetes:
antibodies,c peptide,
3-Obese child with insulin resistance signs,acanthosis nigricans,and family history of type2 diabetes:
screen for components of metabolic syndrome is mandatory here( BP-lipid profile,BMI…)
4-Child with occassional hyperglycemia ( not on steroids):
Most interesting,fasting,postprandial BG,check blood glucose at home,follow closely!!
(4) OGTT, BMI, diet? May be reaction to processed foods (white flour, HFCS, trans fats) or a few large feedings rather than more frequent smaller feedings.
Also, since occasional… is it in relation to large feasts? Feasts after fast days?
The occasional hyperglycemia,I saw it in asthmatic children when receive hydrocortison,it disappears on follow up.But very few were MODY.
I have few with neonatal diabetes,amazing cases.( It is Friday morning.9:46 am) what is your time tmana?
It’s just after 3AM, The Other Half has just come in from work, and I’m about ready to turn in for the night… need to be up a bit earlier than usual for the next three days…
Good night
My endocrinologists wants kids to have an A1C of less than 8. After puberty, then they are expected to be below 7, but they worry about all of the lows and the dangers involved with that. I have a friend who keeps very close control over her son with an average of 100 and an A1C of 5.6. He has only been diagnosed about a year, but he has no clue about his lows and has had several seizures. this is not a good scenario!!! I work diligently with my son who is going through puberty, and I can barely get him below 8 - he is on the pump, we do delays, then adjust basal rates and I still have trouble with his numbers.
Nancy
Below five years of age, hypoglycemia can impair cognitive function, so we have to avoid it. Recent studies say good control from onset can prevent diabetes complications. But is it easy to accomplish that? No, especially during puberty which is a very difficult time for boys or girls to go through. For those above 7-8y who are doing well with HbA1c 7, I just encourage them by asking for less number
I do not have any child 12+ with A1C less than 8.Once they pass this terrible age they do get better.
Education is the answer!
More parents are keen to learn about diabetes,they go buy books,search the net for information and many come to the clinic with written questions,that make me happy,because other parents have no discpline at their house hold,with five children is the average for saudi family,some just are not doing better.It is education as number 1 in the path to control diabetes ,a disease that take over one"s life.
We decided to give our patients and their families an important message every clinic visit.After finishing basic education,every visit to clinic or to educator we have to single one message;
Today is : timing of insulin injection according to how high BG before meals
Last week: target numbers pre and post prandial
The week before: what is your HbA1c
Simple messages are remembered in such busy life for all,and they usually easy to follow!!
Sohair, so many sad stories. Your patients are very fortunate to have such a compassionate advocate.
When I was first diagnosed, (at 50,) a baby was crying in the next examining room and I said to the doctor that I couldn’t imagine dealing with a child’s diagnoses. She said that a huge percentage of couples divorce after having an infant diagnosed. Do you see that in your culture?
Hmm… you know, that could work as a daily or weekly SMS reminder to one’s cellphones. “Diabetes Nugget of the Day”, or something like that…