Misunderstood & Oversimplified - The Complicated Nature of Diabetes

One doctor’s realization that a lot of thought and effort goes into managing this disease well

My name is Calvin Wu, and I’m an endocrinologist — a physician that specializes in hormone-related diseases including diabetes. I’ve been on the front lines of the diabetes epidemic for years and am convinced that we’re not getting anywhere with our current approach to this disease. That’s why I joined Steady Health, and together we’re on a mission to revolutionize the patient-provider experience and deliver diabetes care in a more thoughtful and meaningful way. The following story is about my personal journey towards embracing the complexity of a disease that I had once underestimated.

Despite ongoing efforts and major advances in drug therapy, diabetes care remains suboptimal and largely unchanged between 2005 and 2016. Adapted from Kazemian P et al.

I’m embarrassed to say that I used to think that managing diabetes was easy.

Some of my earliest experiences managing blood glucose revolved around using formulas to derive a starting insulin regimen for hospitalized patients with diabetes, followed by continual dose adjustments to try and keep their blood glucose within a reasonable range. The process was generally straightforward — a high glucose reading by lunchtime probably meant I should give more insulin the next morning to cover for breakfast, whereas a drop in blood glucose overnight probably meant I should reduce their evening dose of long-acting insulin. For something so seemingly menial, I enjoyed being able to see the positive impact of my efforts by the next day, and found it inherently gratifying to work out a regimen that reliably maintained blood glucose at goal.

A limited point of view

I didn’t fully appreciate back then how narrow a view I was getting of diabetes management. Many physicians like myself learn to practice medicine by primarily taking care of sick, hospitalized patients during our residency training, but the experience of managing diabetes in the hospital setting is controlled and decidedly artificial — treatment is limited to insulin, we specify the meals patients can and can’t have, patients are generally confined to their beds, and nurses (not patients themselves) collect the glucose measurements and administer each dose of insulin. Not surprisingly, people’s diets and lifestyles start to look very different after they leave the hospital, and one can only imagine how well an insulin regimen tailored to their hospital stay fares in the real world. When patients came back for follow-up, they often were not giving their insulin or checking their blood glucose on a regular basis, leaving me with little data with which to make an informed clinical decision. If blood tests suggested that glucose levels were high, the knee jerk response was to increase their doses of insulin overall, when in reality that might not be the appropriate intervention.

I didn’t fully appreciate back then how narrow a view I was getting of diabetes management.

Although I empathized with my patients, I didn’t really know what they were going through either. I didn’t have any personal experience with diabetes, nor did any of my close relatives or friends. Up until that point, I had never poked my finger to measure my blood glucose level, nor had I ever given myself an injection — these were tasks that nurses (not doctors) taught patients to perform. Meanwhile, I would routinely advise patients to exercise regularly and to adhere to a healthy low-carb diet, without a concrete understanding of what that actually meant. When that didn’t work, I didn’t ask enough about or appreciate the importance of their lifestyle choices or management strategies. Instead, my medical training had largely emphasized medications as the answer, and managing type 2 diabetes in particular (for which more treatment options exist besides insulin) became an exercise of “choosing the next medication” when others had failed. In truth, I chose to pursue endocrinology because I was fascinated by the elegance of the body’s hormonal feedback loops, not because I was especially interested in diabetes.

More than meets the eye

Imagine, then, how baffled I was when my senior co-fellow told me at the start of my endocrinology fellowship that “managing diabetes is hard.” To be fair, I had always been tasked with managing all of a patient’s medical problems in primary care — diabetes was typically only one of many concerns I had to address during a 15–20 minute visit, so I only had time to graze the surface of a multifaceted disease. Having made the decision to subspecialize, however, I could now focus my entire attention on diabetes and a small handful of other endocrine disorders, and it became readily apparent why my co-fellow felt the way he did.

Imagine, then, how baffled I was when my senior co-fellow told me at the start of my endocrinology fellowship that “managing diabetes is hard.”

I became very aware of how misguided the practice of blindly increasing long-acting/basal insulin to counteract high fasting morning glucose levels could be, after uncovering that patients were routinely struggling with dangerously low blood glucose levels (hypoglycemia) or compensating with maladaptive behaviors (such as eating not due to hunger, but to prevent their blood glucose from dropping too low). I learned to inquire very specifically about what patients were actually eating, realizing that giving a set dose of insulin for every lunch, for example, didn’t make any sense if people weren’t eating similar meals day after day.

I learned the hard way to ask about injection site rotation, after several patients developed severe hypoglycemia as a result of my continuing their home doses of insulin in the hospital. Repeated injections into the same exact location had created scar tissue from overuse, which prevented the injected insulin from absorbing properly. However, the proper administration of insulin into another unaffected site by the nurse would then subject these patients to the full unbridled glucose-lowering effects of that dose, resulting in seizures or loss of consciousness.

I encountered insulin resistance at its most extreme while quite literally managing diabetes “on steroids” at a cancer hospital. It was routine here for patients to receive massive courses of corticosteroids as part of their chemotherapy regimens, which could transiently but dramatically increase insulin resistance and cause glucose levels to skyrocket. Trying to keep up with the ensuing glucose fluctuations required frequent and astonishingly large-scale medication adjustments that had me second-guessing myself at every turn.

Putting myself in my patients’ shoes

As my naïve perspective on diabetes management matured, so did my understanding of the patient’s experience. I made a dedicated effort to put myself in my patients’ shoes and learn everything I could, from pricking my finger and injecting myself with saline, to trying out every diabetes device on the market I could get my hands on. I had always had a vague understanding of carbohydrate counting, but forcing myself to practice it with my own meals helped me realize how difficult and intensive the process truly was. Meanwhile, my patients taught me to appreciate the nuanced effects of differing meal compositions, varying forms of physical activity, and emotional states on blood glucose.

An example of the multiple factors a person with diabetes is juggling at any given moment. From: Adam Brown, https://diatribe.org/42factors

But by far the most eye-opening was the experience I gained from attending diabetes camp at Camp Conrad Chinnock as part of the volunteer medical staff. Seeing kids between the ages of 7 to 12 have to check their blood glucose before and after every snack or activity, double-checking their insulin dose calculations before meals, waking them up in the middle of the night to check their blood glucose and giving them something to raise it if it was too low — it all finally hit me how omnipresent their disease was in nearly every aspect of their lives. I was deeply humbled by the layer of complexity it added to doing all the things that I took for granted in daily life, but also by how these kids did not let their disease slow them down. I began to re-evaluate the burdens it places on others as well — be it the pregnant woman with gestational diabetes worried about her unborn child, or the gentleman intent on avoiding the horrible complications of type 2 diabetes that all of his relatives have suffered.

Finding a new direction

Now, more than ever, I understand that managing diabetes is complicated. And for the patients who have it, managing diabetes is relentless, and sometimes just plain hard. I feel blessed that I don’t personally struggle with this disease day in and day out, and I know better than to judge a patient with diabetes for not taking perfect care of themselves. Coming to these realizations has made managing diabetes as a physician more meaningful and relatable, and far from being bored by this subset of endocrinology, I now find the unique challenges it poses to each individual incredibly interesting and rewarding to tackle. With the number of US adults with diabetes projected to nearly triple to over 60 million by 2060 and little question as to where I can have the greatest impact, I even made the conscious decision earlier this year to make diabetes the primary focus of my career.

Our consultations at Steady Health are designed to be collaborative and focused on the individual’s data and goals

As I strive to hone my craft, I have come to realize that diabetes care has to be personalized to be truly effective. In the past, this often took a lot of time and effort outside of a traditional visit and wasn’t always possible, but the ambitious care model we have developed at Steady enables me to spend a full hour getting to know my patients at their first visit, build on that relationship over messaging and video, access and monitor their data remotely, and use that data to make informed clinical decisions and collaborate on goals tailored to the individual. These days, I find that I am more often advising patients on how to better manage their meals, lifestyle, and strategies around blood glucose levels than I am writing a new prescription for them, and it’s satisfying to see that that’s actually having a greater impact. Looking back to a time when I used to find diabetes formulaic and one-dimensional, I think I’ve come a long way. For that, I have my patients to thank — because they have been, and always will be, my greatest teachers.

A special thanks to Henrik Berggren, Aimée José, Sid Ghodke, & Karin Wu for their feedback and suggestions.

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