This is a case commentary about a diabetic patient, in regards to the patient interviewed in a clinic setting. The case is studied in a holistic manner, where medical and non-medical aspects were fully covered. A detailed account of the people involved and thoughts are also included.
Ms Linda Mogen*, 76, is a retired school teacher who currently lives with her husband in the town area. She pays a visit to the clinic every 3 months for an overall checkup as well as to obtain her medications, which is mainly insulin. Her family is doing fairly well and there is no financial burden, although she prefers to visit this particular clinic although it is relatively further from her house because there are no charges for her as an ex-government employee. She appears as a contented lady who is well-read about her condition.
Aside from that, she also suffered from hypertension, chiefly due to stress from her previous work as a teacher. In the past, Ms Mogen had been diagnosed with a thyroid nodule in the throat, and a cyst in the breast, which were both benign and removed 5 and 8 years ago respectively. As a baby, she used suffer from asthma, but as time passed it became less apparent.
Ms Mogen discovered her condition because her father and two sisters had diabetes too, which appeared to be a hereditary disease in her family. She was strongly recommended by her sister – who is a nurse- to have a checkup. Apart from her course of insulin (pill form), Ms Mogen also consumes alternative medicine, such as Barley Green Herb, as well as other supplements. There are rashes resulting as an allergy to insect bites as well, possibly related to her diabetes.
*Names changed to maintain confidentiality
Diabetes mellitus (DM) consists of a cluster of metabolic disorders that presents high unusual levels of blood sugar, analogous to hyperglycemia (Kumar, 2009). Type 1 DM is caused by destruction of pancreatic islet B cell primarily by an autoimmune process, leading to insulin deficiency, where the patient becomes prone to developing ketoacidosis, whereas type 2 DM results from insulin resistance and weakened insulin secretion, aside from disproportionate hepatic glucose production. Some common presenting symptoms of DM are polyuria, polydipsia, weight loss, fatigue, weakness, blurred vision, frequent superficial infections and poor wound healing (Kasper, 2008). From urine testing, patient would also present with glycosuria and ketonuria. Insulin is responsible in stimulating bone formation, thus there might be significant bone loss in untreated diabetes mellitus (Saladin, 2010). In relation to diet, starchy food has to be reduced, i.e. rice, bread, pastries, potatoes and sugar. Ms Mogen had to significantly cut down on her intake of rice, as rice contains complex carbohydrates and the body has a limit of converting the glucose to energy.
Risk factors for type 2 DM includes a family history of diabetes, race or ethnicity, polycystic ovary syndrome or acanthosis nigricans, habitual physical inactivity, obesity and hypertension (Kasper, 2008). In Ms Mogen’s case, she had a family history of diabetes, where her father and siblings were also affected and also she had hypertension, which is now under control. Optimal treatment for diabetes is not merely balancing the plasma glucose, but DM-specific complications and risk factors for DM-associated diseases ought to be identified and handled with a wide-range diabetes care. Generally, treatment for type 1 DM is 0.5-1.0 U/kg per day of insulin partitioned into several doses. Mixtures of insulin preparation with variable times of commencement and duration of action should be utilized. Type 2 DM can be controlled with diet and exercise alone or alongside oral-glucose-lowering agents, insulin, or a combination of oral mediators and insulin (Kasper, 2008).
Hypertension is a chronic elevation in blood pressure (>140/90). Most patients are asymptomatic; however, severe hypertension leads to headache, epistaxis or blurred vision. Investigation includes urinalysis for blood, protein and glucose, plasma urea and electrolytes, plasma creatinine, plasma cholesterol and ECG (Haslett, 2006). Optimal goal in controlling hypertension is using a single drug if possible, while maintaining minimal side effects. First line agents include diuretics, beta blockers, ACE inhibitors, angiotensin receptor antagonists and calcium antagonists (Kasper, 2008).
The risks allied with a specified blood pressure depends on a combination of risk factors in the specific individual, which includes age, gender, ethnic origin, diet, smoking, family history, blood cholesterol, diabetes mellitus and pre-existing vascular disease. There are certain special circumstances to be considered when prescribing drugs. For example, in diabetic patients like Ms Mogen, the goal blood pressure to be achieved is <130/85. First-line therapy should include ACE inhibitors and angiotensin receptor blockers to control blood pressure and slow renal deterioration (Kasper, 2008).
According to Kumar & Clark (2009), doctors have a clinical responsibility for patients, where the rights of patients may be outlined by the three duties of clinical care: Protect life and health; respect autonomy; protect life and health and respect autonomy with fairness and justice. As such, there are ethical issues that come in association with this.
As a patient has his/her own rights of speaking or providing information, it is of utmost importance to acquire consent prior to any interviews. As a patient’s given consent is strongly interrelated to legal issues, it must be also noted that the consent is given voluntarily. The circumstances accompanying the obtaining of consent should be pondered upon.
For example, the moment Ms Mogen sees a person in white coat approaching her; it might not have suggested itself to her that we are medical students instead of doctors. At that point, this may have inadvertently created a state of mind that she is compelled to answer our questions. Also, she may not have wanted to appear as an unfriendly individual, hence allowed us to approach her. If this is true, then it would be unethical to have proposed such a pressure, even if unintentionally.
While building a rapport between the doctor and the patient, it is observed that when the doctor can gain the patient’s trust e.g. patient fully acknowledges that the information they provide is kept secure, an unwavering patient-doctor relationship is successfully built, and this consecutively encourages the patient to offer helpful information without hesitation. Lack of trust prompts a defensive and impersonal approach to medicine by the clinician and patient, leading to the deterioration of the quality of patient care and professional life (Kumar, 2009).
Ms Mogen mentioned that she desires to consult her usual GP whenever possible, as she finds him amicable and feels free to consult his advice while offering her progress on the illness. This is seemingly attributable to a stable foundation of trust that has been built since the past few years.
Duty of Care
Once a patient consults the doctor, the doctor has the duty to cure the patient with the best efforts. He must be empathetic, talk courteously and perform his responsibilities towards the patients. In Ms Mogen’s opinion, she think that a good doctor is one who puts themselves in patients’ shoes and tries to understand the patient. He must also provide the patient with related information when the patient requires it because this aids in the wellbeing of the patient.
In addition of providing help and treatments to the patient, it is essential that a doctor abides closely to legal aspects. The two fundamental aspects that cannot be overlooked are those related to consent and confidentiality.
Consent can be obtained in two ways: either verbally or in black and white, typically by signing a consent form; or be implied when the patient accepts the treatment without question, objection or other physical signs that illustrates rejection (Kumar, 2009).
For consent to be legally acknowledged, there are three important requirements, which includes:
1) The patient must be competent i.e. has capacity to consent e.g. is capable mentally and in terms of age.
2) The patient must be adequately informed concerning the risk, benefits, procedures and other matters they are consenting for.
3) The patient has to consent voluntarily, and not be coerced into accepting treatment against their wishes.
Under certain circumstances, such as life saving emergency procedures, there may be exceptions to these rules. However, most or all of the procedures taken has the need of obtaining legal consent, as this serves as”insurance” for further matters. Consequence of failure to do so includes being charged in court.
Ms Mogen is of legal age to grant consent, was mentally competent, fully understood the purpose of the interview and was not under any form of pressure by a third party. She was keen to share her personal experience and information for educational purposes as well.
Information gathered from a patient is not to be violated without the patient’s consent, except under obligatory use as evidence in court. As a medical student, I have appropriately de-identified the subject or information by replacing any possible identifiers with pseudonyms and thus have the right to discuss the elements of this case with my peers.
Every single patient has a distinctive personality or feature, based on different aspects. It is therefore practical for us to view the sociological aspect of different patients based on a particularly useful model, CHESS-C:
S Social support
Within the adaptable CHESS-C mnemonic (Aroni 2009), [history] is one of the sociological aspects that may possibly explain Ms Mogen’s attitude towards her condition, and how she accepts it as part of her life. Seeing that Ms Mogen’s father and two sisters had been diagnosed with diabetes mellitus, she felt the necessity to have a medical checkup as advised by her sister. She recognized that this may be a hereditary disease in the family.
She had been exceptionally optimistic about her condition when she first found out. This is because she was mentally prepared to get the news. It can also be seen that because there was a family member who was a nurse, and another was a surgeon, she obtained sufficient amount of information about diabetes, and therefore has established a brighter view of her diagnosis.
In terms of [culture], Ms Mogen had identified herself as a strong Catholic who is very into prayers and deems that by being contented and optimistic, life would change for the better. Along with this, her [emotions] helped her cope with her illness as she upholds herself a blissful mind, rid of any negative thoughts in everyday life. This notably lowers her stress levels, which helps her condition.
Besides that, Ms Mogen had a great deal of [social support] as she had a wide social circle – friends whom she knew from church and also her teaching days. Spending time with her friends once in a while kept herself occupied while having supportive companions, apart from her husband, whom she spends most of her time with.
Self Care, Lifestyle and stress
S Stress management
Ms Mogen’s approach and outlook regarding her health can be described using the wellness-based ESSENCE model. [Education] plays an important role in helping patients cope. Ms Mogen as a teacher is fully equipped with common knowledge and is well-educated. She took the initiative to understand and accept her illness by reading and researching as she realized that, by knowing the illness more, she lessened her fear and worry. The factor that she had acquired sufficient knowledge regarding her condition had greatly abridged her worry and subsequently helps her deal with her emotions.
Besides that, Ms Mogen fits a great deal of [exercise] in her daily life as she “feels good when carrying out housework or working out in the gym”. She does her own set of exercise, including bending, stretching, weight lifting and other self-improvised workouts 5 days a week for at least half an hour per session.
[Nutrition] is an especially vital factor for diabetic patients. Ms Mogen found herself adapting fairly well to eating minimal or no rice at all, compared to her old-self, who favored rice for her meals. She also became very conscious about what she feeds her stomach, which are now mainly green vegetables and fruits. This actually helps enhance immunity and increase life expectancy (Hassed 2009). This is accompanied by her minimal consumption of alcohol, only during occasions, and has never smoked.
After retirement, Ms Mogen generally thinks that she carries no more or minimal stress. Her hobbies are inclined towards the creative side as she likes to read, do flower arrangements and gardening. Being a “light sleeper” she gets “woken up easily and can sleep at any time of the day”, but this is not a problem to her.
As mentioned above, Ms Mogen was somewhat optimistic about her illness before and after having it confirmed. Her family was very supportive as well, especially her husband, who assists her in her everyday life. Although her life has undoubtedly been changed by the discovery of her condition, she accepts and tries to gather more information from her regular GP, whom she finds easy to communicate with and therefore finds herself comfortable sharing details with.
Having frequent visits to the clinic had become a routine for her thus she does not treat it as a heavy errand. The clinic basically provided her with the care she needs although certain areas can be improved e.g. the waiting time was relatively long and the clinic could open earlier, but overall the surrounding cleanliness was of satisfactory standard and she was happy with the service provided.
This clinical placement has generally motivated me to understand patients more, whether currently or in the near future. It was a pleasant interview with Ms Mogen and a good first exposure conversing with an actual patient. She advocates strongly for optimism and importance of knowledge, and was eager to share with us her life experience, which motivates me to keep a happy mind when facing difficulties.
It occurred to me that every patient has their own unique experience in the clinic, be it their interactions with their GP or service provided by the staff, therefore a comprehensive approach is required when dealing with a patient. I realized that as a medical staff, it is important to communicate well with patients and be sensitive to their emotions and concerns because every patient thinks differently. Moreover, establishing a good relationship with other colleagues increases work efficiency and build solid teamwork.
The interview with Ms Mogen provided remarkable insight to a patient’s experience whereas the whole visit generally enlightened our view on a patient’s perspective. As such, being given the chance to personally talk to the patients and staff had considerably widened my view in regards to the real life clinical settings and interactions. Basically this provided a vast area of discussion using a holistic approach, which is including a variety of aspects: biological, sociological, ethical, legal and lifestyle, none of which can stand alone.
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