Doctor Priorities vs. Patient Priorities

by Danielle Ofri
New York Times

Not so long ago, a middle-aged patient came to my office for a checkup. He cheerfully admitted that he hadn’t been paying attention to his diabetes for the last few years. He’d stopped taking his medicine, stopped seeing his doctors, stopped thinking about the disease altogether. When I checked his blood sugar in the office, it wasn’t just a little elevated — it was four times the normal level.

For doctors, it is always a shocker to hear a case like this. How can a patient completely ignore a disease for so long? How can a life-threatening illness just disappear from someone’s consciousness?

The patient was not in denial; he knew he had diabetes. It just wasn’t on his priority list at this point in his life. For me, it was flashing neon at the top of my list with seven exclamation points.

It’s not surprising that doctors and patients have contrasting agendas. We come to illness from entirely different perspectives and backgrounds. Moreover, the angles of our respective lenses are mismatched.

For my patient, his wide-angle lens took in the whole of his life, of which diabetes was one small part. For me, in the 20 minutes allotted, my lens was narrowly focused on the disease that posed the gravest and most immediate risk to his health.

The challenge that lay ahead of us was to help each other adjust the angles of our respective lenses so that our visions could come into common focus. Otherwise, we’d slip into futile haranguing.

The diabetes algorithm taped to the wall could tell me exactly how much insulin to administer for his staggering high sugar level. But my patient didn’t need me to tell him; he was perfectly aware of the algorithm himself.

What the algorithm couldn’t tell us was how to understand the disease from different perspectives, how to tease apart the elements that had led up to the current situation, and how come up with a workable plan to prevent an otherwise healthy man from ending up blind, impotent, on dialysis and in a wheelchair from foot amputations.

That required extended discussions over the next few months that touched upon matters both practical and philosophical. We had to figure out how a taxi driver who relied on street-vendor food and whose only exercise was pressing the gas pedal could adhere to the diet and exercise requirements to control diabetes. We had to talk about the diarrhea that his diabetes pills caused. We had to discuss how his religious background influenced his approach to the future. And we had to talk bluntly about his life expectancy and the legacy he would — or would not — leave to his children.

It was fascinating to be in on the complicated, messy and individual way that people make decisions in real time. Both of us had to reconsider our assumptions about diabetes and how it should best be treated.

He flatly refused insulin, my opening bid for the most efficacious way to control his sugar. I had to fight back my clinical instincts to appreciate that bringing down his glucose level simply was not his top priority. He was most concerned about keeping his life “workable,” and needles were distinctly not part of that.

We had to compromise on a medical regimen that involved pills only, and agreed on an initial goal of getting his sugar just low enough to prevent the symptoms of excessive thirst and urination. Beyond that, it was negotiations that rivaled the Mideast peace process.

Was this a success? Well, his glucose did not get anywhere close to the normal range, as had been my initial goal. Certainly the scientific consensus is that getting glucose close to normal decreases the risk of many of the bad outcomes of diabetes. Letting go of this goal ran against all my training as a doctor.

But we did manage to get diabetes back onto his radar. While we both would have preferred that he didn’t have this disease at all, the reality was that it was there, like it or not. By being aware, he could now begin to think about how his food choices and activity level could sway the disease — for better or for worse.

His sugar is now lower than it was, and this should result in some harm reduction, even if the level never approaches normal. He is taking his meds and has made a few modest changes to his diet.

On my end, I’ve learned that there are times that I need to modify my own priorities and figure out with the patient what goals are achievable, at least at a given time. I’m also reminded how much more intriguing and challenging medicine is when we have the opportunity to delve in deep with a patient.

By the “quality measures” scorecard, this patient will count as a failure on my watch, since I have not succeeded in normalizing his glucose — or his cholesterol or his blood pressure, for that matter. The objective, outcome-driven data would rate me as a better-quality doctor if diabetes fell off his radar again and he dropped out of my practice.

Luckily for both of us, he continues to come to his appointments, and we both call that a success.    (from the New York Times)