P(r)icking Therapy

As a doctor, if you treat a patient exactly as per the guidelines given in the text books and journals, what will be the result? Well, it may not be exactly positive as you predict. As we all know that a disease does not present or behave in the same way in all patients. Hence the therapy also must suit individual needs. I am going to narrate such an incident which happened in my life.

She was a 29 years old pregnant lady,  working in a private college in Chennai as an associate professor. She was seen by my friend and a working colleague, a gynecologist for her pregnancy. During the second trimester, the patient was found to have gestational diabetes. Hence my friend referred her to a popular ‘American Board certified’ endocrinologist in the city to manage the diabetic part. After a thorough evaluation, he started her on short acting insulin thrice a day with a guideline to adjust each dose according to the capillary glucose level. That meant, the patient had to check her blood glucose level with a glucometer by pricking her finger thrice daily and self-administer insulin accordingly. I won’t blame the consultant for prescribing such a treatment as her blood sugar was significantly high, which warranted such a therapy as per the international guidelines. She sincerely tried that treatment for about 3 weeks, but the result was not encouraging. During her review, the consultant added an intermediate acting insulin shot at bedtime, in addition to the existing therapy. After a month, the lady got frustrated with the pricking therapy and went back to her gynecologist to express her dissatisfaction with the endocrine consultant. It is the human tendency to try age old methods when a modern method fails. Sometimes the result may be surprising! My gynecology friend suddenly remembered me. (Before the era of so-called super specialists, she used to refer medical problems, to me only). She rang up and told me about the patient and sent her to me.

When the patient entered my consultation room with her husband, I could smell a whiff of anxiety in both of them. After an interaction for a few minutes, related to their family and other history, I could make them do away with that and talk freely with me. I told them that the consultant had prescribed the therapy as per the standard guidelines and his sole aim was to keep her blood sugar under tight control. She asked me a pertinent question.

She: If it is so, then why my blood sugar is not getting controlled?

Me: Before I could answer that, may I know your problem with the current treatment?

She: Doctor, I am a working woman in a college. I have to take class almost every day. I cannot hold the chalk-piece and write on the blackboard, as my fingers are very sore by pricking them thrice daily. (In those days there were no power point presentations). Moreover I feel like a sick patient, carrying my glucometer and pricking my fingers in front of my colleagues in our room. They look at me very pitifully and console me, which annoys me more. I feel like throwing away everything and leave my child to fate. Whenever meal time comes, the fear of pricking my finger makes me very anxious that I don’t even relish my food. Why should diabetes treatment be so cruel?

Me: Did you express these feelings to your previous consultant?

She: Yes. But his reply was very blunt. He asked whether my child’s health is important or my feelings! He asked me to bear with the therapy and continue, for my own good and my unborn child’s health.

Well, I did know how important is to control blood sugar very tight during pregnancy. I also knew the guidelines given by International societies such as American Diabetic Association (whose words were Gospel truth for endocrinologists)! I went through her diary of events and evaluated her blood sugar patterns. After deciding what to do, I started the talk.

Me: OK. I shall treat you in a painless way, so that your blood sugar will be controlled. You must agree on two conditions. First, you must follow my instructions strictly. Second, you must ensure that you take the remaining treatment with me, till the delivery of your child. Then only it will be easy for me to formulate and manage your therapy. Of course, if you are unhappy with my therapy, you can tell me and quit. Are you ready for these?

She and her husband readily agreed as long as there are no more pricking of her painful finger pulps.

I prescribed her, an intermediate acting insulin twice a day before food, to be taken for two weeks. I asked her to meet me with fasting and post-breakfast venous sugar report taken in a laboratory. She asked me whether it was fine to contact me after two weeks, as the previous doctor asked her to talk to him on alternate days about her sugar levels. I assured her that there was no need to do so. I told her to forget that she had diabetes, asked her to carry on her job normally, but just take insulin twice a day. She happily agreed and went. She met me after 2 weeks promptly. She was looking more cheerful and told me that she felt much better. I saw her sugar report which was far better than her previous ones, and increased her night insulin dose slightly higher. I requested her to repeat the blood sugar after a month and report to me. I advised her about hypoglycemia warnings and precautions.

The next sugar report was perfect and I asked her to continue the same till delivery. She was hospitalized for delivery, in the institution where I worked. I met her and adjusted the dose finally as per the needs. She delivered a healthy female baby after a day.

After three days she was discharged. Her whole family met me in my out-patient office and profusely thanked me for taking care of her problem.

She: Doctor, many thanks for understanding my painful situation before I met you. You never wanted me to prick my fingers so many times daily, for sugar testing, but still you could control my sugar effectively. If that was possible, then why doctors advise us this painful pricking therapy?

Me: See, I am a conservative physician. I see every aspect of the patient before therapy and decide, as I always treat a whole human being and not her disease alone. Do you know that all hormones in the body are villains to one hormone-insulin? When you are anxious or afraid, your hormones called catecholamines increase very much, which can counteract your insulin and make it ineffective. That was the reason, your blood sugar was never under control as you were always under stress and fear. I removed the element of fear and anxiety in you about the tests and therapy, and you responded in a beautiful way to the treatment. You helped your own therapy and not me.

She: Doctor, thank you so much. I wish that I should have met you earlier in this issue. However I will certainly recommend your name for my colleagues.

Whatever the scientific evidence says and gives us guidelines, it is for the physician to use his/her expertise in evaluating a patient wholesome and customize the therapy according to the needs of the individual. The success or failure of therapy depends on that. After all the gist of “Evidence Based Medicine” is a perfect balance between the scientific evidence, physician’s expertise and the patient’s beliefs. If some doctor treats with only one or two of  these three elements alone, he may not be able to succeed.