Monthly Archives: January 2024

My Hero List Grew by One That Night

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It was early during residency. I was still adjusting to primary care clinic which included learning how the computer system worked. I still didn’t have home access to the electronic medical records so I couldn’t review my patients ahead of their appointments. I also couldn’t write my patient notes at home. All my patients were new to me. Between the challenge of learning new patients and the computer system, I fell behind in clinic one day.

My patient appointments stacked up like logs against a dam before it bursts. And, with my appointments running behind and my slowness with the computer system, the notes I had to write for each patient appointment were pushed to the end of the day.  My last appointment ended an hour late because it started an hour late.

There I was, already after closing time and just starting to fight the computer system to write my notes as fast as I could. Everyone else in the clinic had left an hour or so earlier. I was hungry because I hadn’t thought I’d need to bring dinner.  I’d already eaten breakfast and lunch at the clinic. I was startled when I heard someone in the hall. The janitor walked by my office, “Late night?” he asked pausing outside my open office door.

“Yeah. I’m new here and I’m still slow with the computer,” I said.

“And they just left you?” he asked.

“It’s okay. Hopefully my notes will be done soon,” I said.

“Well, thanks for your work,” he said.

Hours passed. One note at a time, like small footsteps, my pile of remaining work dwindled. The janitor stopped by my door again. “I got you these. It’s not much but it’s all I could find,” he said. He handed me a bag of BBQ potato chips and a mini-Fanta orange soda.

“Thank you so much! You’re so kind,” I said. I was too tired to be giddy but in better circumstances I would have been gleeful for the snacks.

“Have a good night. Hope you can leave soon,” he said and walked away, back to his own work.  

I don’t think he’ll ever know how much he saved me that night. When I was finally done with my work and as I walked through the empty clinic and then the empty parking lot to my car, I thought about how much I appreciated the janitor. I’ve often thought it odd that society focuses so much on big names and money. In my experience, heroes are always humble strangers acting out of kindness and with no motive or expectation of recognition.  

That night I was reminded that all it takes is pausing to offer a little help to transform a person’s night. The janitor clearly had already ingrained that knowledge into his existence. And like the heroes who came before him, I added the janitor to my life’s hall of fame as I walked to my car to drive home. My hall of fame isn’t a hall of fame like those for baseball players but, to me, it’s a lot more important. And, in case you’re wondering, I’ve never had a more delicious bag of chips and can of soda.

Today We Start Insulin

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“Today we are going to start you on insulin. Given your high A1C level (a lab that shows your average blood sugar over 3 months), it is recommended so that we can better lower your blood sugar. Lowering your blood sugar is important because when your blood sugar is this high it can affect many aspects of your health including severely increasing your risk of heart disease and stroke,” I said. It was the second time I’d seen this patient in my clinic. They were quick to laugh and had a full life.

The patient hung their head. This was the first time I had started someone on insulin as a primary care doctor (we use insulin exclusively to manage diabetes in the hospital, but in the outpatient setting it’s reserved for specific indications). Starting insulin isn’t supposed to be punitive but some patients feel as though it is because of the stigma associated with diabetes.

There are numerous medical diseases and conditions that are stigmatized. Among the most common I see are diabetes, obesity, psychiatric diseases, and sexually transmitted diseases. People with diabetes are often blamed for having the disease. If or when they require insulin, the patient may feel like their need for insulin is a failure because their blood sugar was not controlled with other treatment measures. People with diabetes can be labeled as “weak” and “lacking self-control.” This labeling is out-of-place and unproductive. While lifestyle (such as diet and exercise) does contribute to the development and progression of diabetes, lifestyle is only part of the story.

In addition to individual choices, other parts of life like genetics, environment, and the social determinants of health have an important impact on health outcomes including the development of chronic diseases like diabetes. Further, it is critical to be able to have open and respectful conversations about patients’ individual situations and how their lives might be optimized to manage their diabetes and to reduce their likelihood of developing complications from diabetes. Stigma gets in the way of having these open, respectful conversations. When people have diabetes, the disease can severely increase their risk of death by heart disease and complications such as vision loss, nerve damage, kidney damage, and infection. This makes management of diabetes with a multimodal approach – including lifestyle optimization and medications – essential. Judgement has no place in developing a therapeutic plan.

When I recommended insulin to my patient, it was not as punishment. It was without judgement. It was out of concern for their health. The strategies we had tried to lower their blood sugar to that point weren’t working. The patient was doing so well otherwise. They didn’t have kidney problems. Their feet still had feeling. They hadn’t had a heart attack. I wanted them to live without these complications for as long as possible.

As the patient left the appointment, I was hopeful that our new strategy would help them lower their blood sugar. I also hoped that this patient felt respected even if they were unhappy about starting insulin. I’d see how they did with the insulin at our next visit. Time would tell if insulin at the dose we started would work for them or if we would need to make further adjustments. Chronic conditions require long-term (often life-long) treatment plans. Flexibility to adjust the plan as life develops is critical for success. This patient with diabetes was no exception. I looked forward to working together to lower their blood sugar in the months and years ahead.