Going the extra mile.

Today I’m a very good doctor.  Not that I’m ever a bad doctor.  Mostly I really care, but there are times, I confess, when I just go though the motions.  Conversely, on days like today, I take my usual care factor up a notch or two.  I take thorough social histories, address all of those important preventative health issues, explore my patient’s concerns deeply and end up running an hour or more late, to the chagrin of the receptionists.

Madison is next on my list; the usually sullen teenager whose last HbA1c was nearly the same as her age. First impressions are surprisingly favourable. Her skin’s glowing and she’s actually smiling at me! Not only has she brought in her recent blood sugar readings, but they’re actually pretty good.  She admits to having had purposely taken her insulin incorrectly in the past but proudly tells me that she’s been taking it perfectly for several weeks now, and that she’s never felt better.

insulin pen“So what made you change your mind about taking your insulin?”

“I don’t know. Just happened I ‘spose.”

“Please try to think carefully about possible factors. I’d really like to know.”

I’m very interested in finding out which of my warnings carried the most sway. I don’t ask for self congratulatory purposes; seeing her looking so well and happy fulfils this already.  It is for intellectual interest and self improvement.  I want to use the feedback from Madison to help me with future non-compliant teenage diabetics; to make me a better doctor.  It is one of my “very good doctor day” quests; on a less engaging day I would just be grateful that Madison was looking after herself at last and not feel the need to delve deeply into the reasons.

As Madison ponders, I mentally try to predict what she will say. I often play this game when seeing patients.  In Madison’s case, I reckon my emphasis on the short term results of skipping insulin last visit would have been the trigger for change.  The prospect of long term risks, such as developing kidney failure in middle age, does little to scare most teenagers.

“Come to think of it, there was something that, like, changed my mind.   Do you watch (name of badly acted Aussie soap)?”

“No, I don’t get much time to watch TV.”

“It has lots of medical stuff in it. You’d like it.”

Not likely.  I smile at Madison indulgently. I wonder where she is going with this.  A doctor character who reminds her of me?

“There was this epileptic girl on the show. She didn’t take her medication properly and she ended up having a fit when she was out surfing and she, like, died.”

“That’s sad.  And?”

“And what?”

“I’m a little confused. How does this story relate to your diabetes?”

“It made me see that if you don’t, like, take your medication properly, it can be really dangerous. So I started back on my proper insulin doses.”

“It had nothing to do with what I told you last visit? Nothing at all?”

It is Madison’s turn to smile indulgently.  “I know you tried to help me but, to be honest, all I heard was, like, ‘blah blah blah’.”

Going the extra mile today suddenly seems overrated.  I think I’ll take the usual route to lunch.   The receptionists will be pleased.

(names and identifying details have been changed to protect patient privacy)