Control Freak

I have a very non-compliant patient. 

  • He is a type 1 diabetic on an insulin pump and does not come in but once every 12 to 18 months to be seen. 
  • He makes his own decisions about changing the basal rate, never consulting me.
  • The only way I can get him in to the office is to limit the amount of medication I give him.

His control is excellent.

  • Despite having diabetes since he was a child, he has no kidney or eye damage.
  • His Hemoglobin A1c is always below 7% and usually below 6.5%
  • He has minimal hypoglycemia.

Given the fact that the recommendations are to see these patients at least every 6 months, I somehow feel he should be coming in more often.  He acts apologetic whenever he does come to see me, not following \”the rules\” like he should.  If I am measured for my \”performance\” regarding diabetes care, he will be flagged as a \”bad\” patient in several areas because of the infrequency of his care.

So what?

Isn\’t the point that he has good control?  Isn\’t our goal the prevention of the complication of diabetes?  Why should I care if I see him often enough if he does a better job than I ever could with his diabetes?

This is a good argument for appropriate measures of care quality.  If I am to be paid bonuses based on my quality, shouldn\’t it consider patients like this one to be appropriately controlled?  He is a perfect candidate for e-visits, given that he could just e-mail me his sugar readings and I could send him lab slips.  I still need to do foot exams and blood pressure checks, but why can\’t a reliable patient do this from home as well?

I know he cares about his diabetes.  Why can\’t he just care for himself with me as a consultant only when he needs me?  Of course, right now the only way I can get paid is if he sets foot in my office. 

So that is what we do.  I ask him how he is doing, check his feet and blood pressure, give him a lab slip, and we talk about baseball, politics, and his son.  We have to do this.  It\’s in the rules somewhere.

6 thoughts on “Control Freak”

  1. A recent study looked at diabetes control with and without open-access schedules. The end points were objective measures of diabetes control (eg A1c) rather than frequency of visits. They found that patients with more frequent visits (but not lower wait times) had better control.
    If there is research that more frequent visits = better control is that a good standard to compare your performance to other practitioners? What is the alternative? If you use A1c, severity of illness comes into play and will vary between practitioners. Patient satisfaction? Frequency of hospitalizations? Complication rates? Assuming you don’t want to do more paperwork to measure your performance than you do to treat the patient what is the alternative?

    Personnally, I think they should use an objective measure of the patients condition as the yardstick, not a measure of your offices organization. Severity of illness will be a variable factor but it probably correlates to practitioner training too. Eg, the more fragile the DM the greater the likelihood the patient is managed by an endocrinologist. Based on the complaints of Dr. Wes the reporting agencies are much more interested in the doctors than the patients — so I’m guessing your screwed. Sorry.

    http://www.waittimes.blogspot.com

  2. A recent study looked at diabetes control with and without open-access schedules. The end points were objective measures of diabetes control (eg A1c) rather than frequency of visits. They found that patients with more frequent visits (but not lower wait times) had better control.
    If there is research that more frequent visits = better control is that a good standard to compare your performance to other practitioners? What is the alternative? If you use A1c, severity of illness comes into play and will vary between practitioners. Patient satisfaction? Frequency of hospitalizations? Complication rates? Assuming you don’t want to do more paperwork to measure your performance than you do to treat the patient what is the alternative?

    Personnally, I think they should use an objective measure of the patients condition as the yardstick, not a measure of your offices organization. Severity of illness will be a variable factor but it probably correlates to practitioner training too. Eg, the more fragile the DM the greater the likelihood the patient is managed by an endocrinologist. Based on the complaints of Dr. Wes the reporting agencies are much more interested in the doctors than the patients — so I’m guessing your screwed. Sorry.

    http://www.waittimes.blogspot.com

  3. I’ve got a good friend who was diagnosed Type 1 at the same sort of age as your patient Dr Rob. Her control is exemplary, apart from she occasionally likes to drink more than she really should (but compensates her insulin to control her GI).
    I know someone else who’s GI, and indeed medication generally, control frankly sucks and blows at the same time! Typical comment “chocolate eaten in bed doesn’t affect your GI”!!!! I’ll not describe her medication control, to avoid causing nightmares! 😉

    On this basis, and purely as a lay opinion, I’d agree that patient condition and GI control are better metrics than “how often do they visit a clinic?”

  4. I’ve got a good friend who was diagnosed Type 1 at the same sort of age as your patient Dr Rob. Her control is exemplary, apart from she occasionally likes to drink more than she really should (but compensates her insulin to control her GI).
    I know someone else who’s GI, and indeed medication generally, control frankly sucks and blows at the same time! Typical comment “chocolate eaten in bed doesn’t affect your GI”!!!! I’ll not describe her medication control, to avoid causing nightmares! 😉

    On this basis, and purely as a lay opinion, I’d agree that patient condition and GI control are better metrics than “how often do they visit a clinic?”

  5. y’know, I think this is harder for doctors than for anyone else to understand, but people do very often KNOW their bodies. So when someone shows up rarely, even with something fairly serious and warranting frequent medical visits (like this fellow with his diabetes) — well, good thing you two have good rapport. Then if he does sense something as being “off” and outside his control, good chance he will be seeing you ASAP.
    Conversely, have you ever had a patient who is fretting about something “out of synch” with themself, but no clear problem? Look hard!

  6. y’know, I think this is harder for doctors than for anyone else to understand, but people do very often KNOW their bodies. So when someone shows up rarely, even with something fairly serious and warranting frequent medical visits (like this fellow with his diabetes) — well, good thing you two have good rapport. Then if he does sense something as being “off” and outside his control, good chance he will be seeing you ASAP.
    Conversely, have you ever had a patient who is fretting about something “out of synch” with themself, but no clear problem? Look hard!

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