During your busy day in clinic, you allow yourself to look away for a few moments from your computer monitor, and notice a smile forming on your patient’s face. Even in the face of the myriad challenges that threaten to send you over the threshold of burnout, you’ve felt that you’ve helped your patients.
As usual, this week is a blur—of prior authorizations; the seemingly limitless clicks you have to make to clear those clinical reminders on EHR; and running behind 30 minutes or more, as you see your 20 patients. Many of these visits stretch way beyond the 15 to 20 minutes each is allotted. But, once again, you’ve made it. You preview that last chart. Your last patient of the week, Ms M, is a 52-year-old woman with type 2 diabetes (T2DM) diagnosed 3 years ago. She’s had her struggles, and had been in denial after being diagnosed. But she’s been earnest, and has been thriving since selecting 1 aspect of her lifestyle to change—her exercise. She’s on metformin 1000 mg BID, has worked with the dietitian and lost 4 pounds, and is walking, biking, or swimming a total of 150-200 minutes a week, often significantly more.
So, you ready yourself to congratulate her, convey how proud you are of her, review her SMBGs, renew her meds, and return to that EHR, maybe get home in time for dinner with the family, right?
But (and haven’t you noticed, there’s always seems to be a wrinkle, especially in a blog post like this?) you see her hemoglobin A1c has gradually inched upward. She had been between 6.2 and 7.0% since being inspired to turn around. Now it’s 8.8%. She wonders, aloud, if she’s the source.
What would you advise?
I can sum up in 3 words: it’s complicated.
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2. Garber AJ, Abrahamson MJ, Barzilay JI, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm - 2018 Executive Summary. Endocrine Practice. 2018;24(1):91-120.
3. Handelsman Y, Bloomgarden ZT, Grunberger G, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Clinical Practice Guidelines for Developing a Diabetes Mellitus Comprehensive Care Plan - 2015. Endocrine Practice. 2015;21(Suppl1):1-87.
4. Nathan DM, Buse JB, Kahn SE, et al. GRADE Study Research Group. Rationale and design of the Glycemia Reduction Approaches in Diabetes: a comparative effective study (GRADE). Diabetes Care. 2013;36:2254-2261.