Friday, May 25, 2012

So...What EXACTLY do you do?


It's an odd conundrum being in the healthcare system nowadays. On the one hand you have the regular grind, the perennial pressure to do just that bit better at work, work that bit harder, start even earlier, finish later...all in the cause of trying to make someone better. You keep hearing the lack of finances and the buzzword of innovation zings all around you. Cynics say it's about doing the same thing at a cheaper cost, proponents haughtily claim to have discovered something no one else has even thought about. In short, work is damn hard...what the heck happened to those rounds on the golf courses, the Aston Martin DB7 I was supposed to have....sorry I digress...but shattering of those utopian lifestyle Consultants led or at least one heard about whilst a house officer has been bemusing to say the least. Anyhow, thats what you have on one hand..
On the other side of the coin lies damning statistics. Newspapers scream out headlines as to how poor diabetes care is in this country, how people are losing feet due to poor care, primary care are not fulfilling their responsibilities, specialist teams are failing patients within hospitals and you know what? Sometimes even the best get a bit weary, don't they?I am not sure I have met anyone yet in this business who doesn't give 2 hoots about the patients, everyone is working hard, the practice nurses, the GPs, specialist nurses,Consultants, podiatrists...they are trying..working hard, fighting the fight...and then you get damn statistics which just says...not good enough.

Problem is you can challenge statistics, rail against it...but at the end of the day, it does suggest we don't do as well as we would like to. Interestingly, inside the confines of a hospital, the problem squarely does lie with us Diabetologists. Yep, I blame no one, but ourselves. For once, we cant use the usual scape goat of GPs..no siree...this one is totally our doing. For decades, we have allowed to be ridden roughshod over. We have managed to give a perception to the external world that all we do is "tweak a bit of insulin"and isn't most of the Consultant job do-able by a nurse anyway? Take any other colleague within the hospital....the refrain is "What EXACTLY do you do?" Surely we are there to look after patients who don't fit into a niche, who isn't a pure cardiology case, a pure respiratory case, a pure Gastroenterology case....isn't that your job? We are in a bizarre world where the refrain from others is that they function better when they concentrate on their specialist areas but oh no, that rule doesn't extend to diabetes specialists. We are the ones who take who others don't want. A recent example? " 82 year old lady..smells of urine...admit under Diabetes"... Does she have diabetes? Nope. Does she have anything that any other specialty will take? Nope. Default position? Admit to diabetes. And frankly, we have sat and let that happen. Mortality data suggests that people admitted due to any cause with a background of diabetes are suffering from poor care, some Trusts have shocking mortality data...but what are their diabetes specialists doing? They are mostly working as a peri-geriatric firm. Specialists have to be allowed to do what they do best, what they have been trained to do ergo concentrate on their specialty areas and if that rule is applicable to Gastroenterology, then it certainly is applicable to Diabetes too.

I can also appreciate the caring physician side which says "but we are generalists too"....and who IS going to look after that 82 year old lady if we don't? So she doesn't have diabetes, but we are a physician, aren't we? The rebellious lot will say "Not my problem...I am going to ape a Cardiologist and just concentrate on the heart"....but then again, if that's what my ethos was, I wouldn't have been in this specialty which is built on the bedrock of caring.  I say..we will but so should everyone else, every other physician. We cannot have different rules for different specialties and we, as a specialty, refuse to be a poor cousin anymore. My first and primary responsibility is towards any patients admitted to hospital who also has diabetes and then a shared responsibility with ALL other co-specialties to look after patients who don't fit into a niche. We are not the only ones who trained in General Medicine, every single other physician did too. The tax payer paid a lot of money to train all physicians to do general medicine, so why can the Gastroenterologist shirk that responsibility? That 82 year old lady should be the responsibility of the ward doctors where she is admitted, irrespective of what the ward specialty is. That is what makes us a physician, the ability and desire to heal, to care...not to pick and choose who we want to see.Locally, we are somewhat fortunate to have argued our case to a certain extent, but have no doubt, the battle to stick to that is daily, is regular, is..jarring.

So to NHS Diabetes and Diabetes UK, those powerhouses who are trying to raise the profile of diabetes, showcasing poor inpatient diabetes care....why not put some pressure on acute Trusts to think differently? Why not ask them to free Diabetologists from the tag of "accepting whatever is given to them"....and get them to do what they do best? Maybe that way a few less errors could happen, a few more Type 1 patients can actually get their insulin, a few more foot ulcers can be picked up in time...a few more lives saved. Maybe, just maybe it isn't just about asking for more resources, maybe it's about using what we already have, a bit more innovatively.

 Diabetes specialists are a funny breed...maybe it's just the subject which draws the mid mannered individuals towards it. Look around and the prototype of a diabetes specialist is a genteel, humble , soft spoken individual. Unfortunately in this world where the one who shouts loudest wins...we have been left far behind the macho snarl of the prototype Cardiologist. From a personal perspective, I am always in a hurry..a hurry to make things better. For me, when patient care isn't  as good as it can be, then I have little time for egos, little time for pacifying.....frankly I am not sure I would be able to explain to a patient that his/her diabetes care was compromised as I was more worried about how not to bruise the sensitivities of my Gastroenterology colleague. 

I have heard the refrain that we need to keep "our footprint" in general medicine to "ensure our existence"... please..do...give..me...a ..break. We have national statistics showing that people with diabetes are getting poor care and we need to do something else to "justify our existence"?! Guys, stand up and make the case of what we are, what we can do, how we can help hospitals with their diabetes patients, how we can help primary care with the avalanche...if diabetes was that simple...why do we spend 5 to 7 years training in this?? Stop worrying about your job...the problems with diabetes are huge and we have a big role to play if we want to make things better. Humble acceptance of a "step-brother status" is certainly not going to do it!
We are specialists and we should be proud of it. This is not a trivial disease, this isn't something to smirk at and no ..we are not the "sugar boys".. we are diabetes specialists....and there is no harm in saying that loudly and clearly. I also do however accept that not everyone is like me...not everyone is comfortable with the snap, growl and thunder approach.And I also do accept that there are different ways to achieve resolution. All I am saying is whatever your approach..do it..now.Patient care is suffering..now...so let's stand up and in whatever way works, be vocal about our specialty...and let's do it...now.

"Men do less than they ought; unless they do all they can"...so said Thomas Carlyle...lets not come to the end of our lives as diabetes specialists, look back and think we didn't do all that we could....just because we were more worried about upsetting our fellow physicians rather than fighting the good fight for the patient.

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