I never like to use the word “perfect” when it comes to diabetes. Far less when it comes to being a “perfect” diabetic, although so many of us, including this recovering “perfectionist,” share this impossible desire.

So when I first saw this article,Seeking the Perfect Diabetic Day,” my face immediately turned into Munch’s painting “The Scream” and I was completely ready to condemn whatever the article said. 

Then I read the article and realized “the perfect diabetic day” is a measurement for hospital administrators to quickly see how well their institution is managing the glycemic control of patients. 

Seemingly a step in the right direction as we know hospitals tend to be monoliths with a hundred heads, silos that don’t cross, and filled with overworked providers and staff who need you to write on your body which arm should be operated on. And since practical wisdom says, “no one should be in a hospital without an advocate,” I’ll take all the help we can get.

According to Kalman Holdy, MD of Sharp Memorial Hospital in San Diego, the measure simply looks at the proportion of days during which every blood glucose measurement for every diabetic patient is within the recommended range for hospitalized patients — 70 to 180 mg/dL. 

In an informal poll of 51 nurses, doctors, and pharmacists, the vast majority (98%) said they preferred using perfect diabetic days over average blood glucose values as a performance metric. Personally, I’m all for doing what providers prefer provided it’s not life-threatening to me.

The benefit of using this measure Holdy says is that each hospital unit can improve their glycemic control. Tracking their performance, the percentage of perfect diabetic days increased overall from 33% in 2002 to 43.8% in 2010. 

That’s good, however this next statement seems irresponsible. In terms of a bottom threshold, says Holdy, values lower than 35% should require that some action is taken to improve the quality of institutional glycemic management. Well, that’s kind of scary – 36% glycemic control is considered good enough not to do anything?

I applaud any institution trying to make improvements and when I looked at Sharps a little more closely they do seem to stand out from the pack. They’re making lots of improvements to improve care: lowering noise to increase calm and redesigning the flow of the hospital for greater efficiencies. Not unlike an amazing hospital in Singapore I visited a few years ago.

That said, I do know one other way that better glycemic control can happen in the hospital setting. Let educated patients control their own blood sugar, provided they’re conscious and know their name. I’ve heard way too many stories of one’s insulin and syringes being taken away by a nurse who knows diddly about blood sugar management.

An engrossing and humane read by a doctor/patient

 

I’m reading a book I love – After the Diagnosis written by kidney specialist, MD Julian Seifter.

Doctor Seifter has diabetes himself, and so shares his own actions, or rather inactions, (he’s a notoriously bad patient the first several years) but it’s really in the background of this book. 

The book’s focus is the stories of his patients. Since all his patients live with kidney disease and generally face the unpleasant, yet only life-saving measure of dialysis, they each face life-altering decisions and are in different stages of their conditions. Seifter relates their stories, their journeys and how they prevail.

It is a fascinating look at the human spirit, and for me made all the more interesting told by a physician whose first orientation is clinical. Yet, he is deeply human and not afraid to share that side of himself with his patients; this often becomes the key for his patients to take the next step they might not otherwise. 

Here is a short bit from the book

Dr. Seifter meets Lyla, a young West Indian woman, who has end stage renal disease, diabetes and AIDs. Lyla went missing after her first dialysis appointment where she was prepped for future treatment. When Seifter next sees her he asks how her blood sugars are. She doesn’t know. They take out her meter and he helps her test, which she doesn’t know how to do. 183, “That’s not so bad,” he says. And then he realizes he has not put on gloves and this is probably the first time in years Lyla has had blood taken without someone wearing gloves. Seifter thinks of referring her to the dietitian, but does not when he thinks how culturally-insensitive she is. She will only hand Lyla the same standard diet she hands everyone. Instead he asks Lyla what she eats. When she tells him rice, beans and potato chips he asks her to match her carbohydrates with protein and make her portions a little smaller. He asks next how she’s feeling about dialysis, “I’ll try it,” she says.

Connecting with the patient, not the illness, is one of a physician’s greatest tool. Yet, it is not what’s emphasized in medical school In fact, I recently spoke with a physician who told me in a way humanity is trained out of  medical students. 

This book is written for patients and physicians alike. There are the stories and interwoven many of Dr. Seifter’s insights. For instance Seifter encourages doctors to help their patients be more imaginative and playful when considering treatment options. Doctors, he says, are instrumental in giving patients confidence, even permission, to keep going. If a doctor, for instance, doesn’t clearly encourage treatment a patient may hear, “Don’t do it!” 

If this is your cup of tea, as it is mine, you will take away a great deal fromAfter the Diagnosis.