Irvine, California, United States
Fifteen years old, Jane sat in the exam room innocently denying that large doses of insulin were causing her severely low blood sugars. Living with type 1 diabetes, she had been prescribed daily insulin injections, which she herself administered at meals. Though she denied injecting more than the prescribed amount, the evidence to the contrary could not be ignored. Naturally I was concerned for her safety, as insulin overdosing is potentially fatal. She had already been admitted to the hospital a few times with hypoglycemic seizures. I racked my brain, “Why wouldn’t she follow my instructions on insulin dosing?” Excusing myself from the room for a moment, I realized how aghast and upset I was that she had not only ignored my advice, but also had compounded the disrespect by lying about it. How could she watch me diligently investigating the cause of her hypoglycemia all the while defying my instructions? The situation challenged my identity as a successful physician and my feeling of self worth. When my patients do poorly, my credibility becomes questionable. But while she ignored my recommendations and threatened my identity as a doctor, much more was at stake: if she could not be truthful, we could not have a productive partnership. I imagined storming into the exam room and, laying bare the scientific data, shaming her into a confession. But a tiny voice inside me told me: “go to the balcony.” Perhaps I had contributed to the situation?
Most patients hate taking insulin injections, which made her overdosing even more baffling. It was clear to me that she was defying my authority. But why? Maybe I had failed to ask how Jane felt about her treatment plan? In order to get to the root of the problem, I clearly needed to listen attentively and avoid accusation so that she would not withdraw even further.
Returning to the exam room, I discovered through a series of creatively-phrased questions that she was angry with me about her restricted meal plan and resented having to take insulin with her meals. She was embarrassed to be different from her peers and longed to be carefree like the others. She admitted to devising her alternate insulin regimen following an inadvertent overdose that we had treated with food. If she injected large doses of long-acting insulin, she realized, she could “treat” the resulting low blood sugars with her favorite food and eliminate the need for insulin injections at school. Jane then began to inject extra insulin before leaving home for school. Eliminating embarrassing visits to the nurse’s office to get her insulin injections, she could now spend more time with her friends during lunch.
Acknowledging how frustrated she must have been feeling, I admitted that I had not considered how her treatment plan would affect time spent with her school friends or how she would cope with “being different.” Our differing priorities had obviously created a problem: I was focused on regulating her blood sugar while Jane was contriving ways of appearing normal. With the issue out in the open, Jane was much more receptive! We discussed how she could include more of her favorite food in her diet—for instance, an occasional scoop of ice cream instead of crackers. Further working with the dietician, she incorporated her favorite snacks into her meal plan. Though I had to establish ground rules on appropriate diet and accurate insulin dosing, we were able to jointly explore options such as the controlled delivery of insulin and use of the dietary exchange list. We also worked on how to “fit in” and include her friends in creating a support system at school.
Having this conversation changed the way I looked at the situation. Jane’s lack of adherence was neither about me nor a violation of my authority. I had failed to engage Jane in the management of her own health. Only by taking the vantage point of a neutral observer was I able to gain insights and see the “third story,” a story that delved into the patient’s perspective, her needs, desires and wishes—exposing my contribution to her behavior. Initial attempts failed because I was focused on my own position; however, when I shifted my attention to her perspective, I realized that building trust would allow Jane to express her needs to me. Through effective communication, Jane and I became partners in improving her health.