You're almost through the day. You've spent the day connecting with patients, and you feel somewhat spent. You still have notes to finish entering into the electronic record, and you know your last patient is an especially complex case. But first, you have to get through the second-to-last patient, a quiet middle-aged man sitting before you.
Based on labs, you surmised before the visit that this man is having problems with A1C control, which bodes poorly for his diabetes. You wonder what's going on with him.
You start the visit by asking, "What are you hoping I can do for you today?"
The patient stares blankly. "I don't know. You guys are the one that called me in. I was just told to come here."
[[Your A1C is too high.->A1C too high]]
[[We just wanted to check in with you.->Check In]] You turn to the computer and start pulling up the patient's records. "Well, it's your three-month checkup and your A1C has been too high for the last several visits." You tilt the screen towards the patient and show him the worrying trends. He simply responds, "Yeah..."
[[Recommend an increase in the patient's insulin injections.->Increase Your Insulin]]
[[Ask to see the patient's My Life My Health Care discussion aid.->Pull out ICAN]]You continue, "Based on the numbers, we should increase your insulin. That should bring you back within your targets."
You start typing out the script in the patient's record. "I'm going to increase all injections by two units. How does that sound?"
The patient is silent for a moment. They look as if they're deciding whether to say something. Eventually they just say, "Ok."
[[Remind the patient about their nutrition requirements and end the visit.->Education]]
[[Ask to see the My Life My Health Care Discussion Aid.->Pull out ICAN]]"We just wanted to check in on how things were. We noticed things weren't going exactly how we wanted. Is there anything going on that might be affecting your diabetes care?"
You pause to let the patient think. They sigh. "It's just been overwhelming, lately. I don't know where to begin."
[[Well, to start, we should probably increase your insulin.->Increase Your Insulin]]
[[Ask to see the patient's My Life My Health Care discussion aid.->Pull out ICAN]]"When you came in for your visit today, the nurse asked you to fill out a discussion aid. Is it OK if we take a look at it together?"
"Sure." The patient pulls out My Life My Health Care and lays it on the table. "Where should we start?"
[[Start with the back of the discussion aid.->Start with back]]"Let's start with the back, shall we?" You turn to the back of the My Life My Health Care Discussion Aid.
Under the question, "What are you doing to manage your stress?" the patient has written:
"Walk?"
Under the question, "What else is on your mind today?" the patient has written:
"Feeling overwhelmed"
[[Probe about the patient's stress management.->Managing stress]]
[[Probe about what's on the patient's mind.->Feeling overwhelmed]]The patient leaves with several pamphlets of information on proper diabetes nutrition and an increased insulin prescription. In their chart, you write a note:
-- Increase in insulin due
-- Keep injections at 4x/day
-- Referral to diabetes educator
3 months later, the patient returns for another routine follow-up visit. Their A1C remains the same.
END
[[Start over->Beginning. ]] Gesturing to the aid, you ask, "What stands out to you on here?"
"I don't know," the patient says. "I guess I've just been overwhelmed with work lately. I feel... I feel a little awkward about injecting at work. You see, I work in a customer-facing job without that many breaks. I probably don't get around to injecting more than two times per day."
He says the last bit reluctantly, with a note of guilt.
[[You need to keep up with your injections.->You need to keep up.]]
[[It sounds like you're having a hard time balancing work and healthcare.->Balancing work and care.]]
"It sounds like you're having a hard time balancing work and healthcare."
You pause. The patient nods.
"Okay," you say. "That's okay. A lot of people struggle with that, and we don't exactly make it easy for patients either. It's good for me to know that you're only injecting twice per day. Maybe we can adjust your dosing to account for that. How does that sound?"
The patient's face softens with relief. "Sure. That would help."
It's not an ideal solution, but then, the patient is not living in an ideal situation. "OK. If that's acceptable to both of us, then I'll write you a script and you can take it to the pharmacy."
[[Continue and conclude visit.->Continue visit]]"It looks as though you're managing a lot of stress," you say in a low voice. Then you pause.
The patient looks up at you. "Yeah."
"Do you want to talk about it?"
He sighs. "Work. Shifts are brutal, yeah. I guess I know I should be out walking more and eating healthy, but we don't get such long breaks. I work in a restaurant and food's all a bit greasy. So I feel, guilty, yeah, but there's also not a lot I can do."
You respond, "I hear you. Service work can be tough, and we often don't give food service workers a lot of opportunity to rest or eat well. If you'd like, I can set you up with one of our nutrition coaches here in clinic. Maybe they can help set you up with a plan for prepping meals that works for your situation."
The patient shrugs. "Sure, that wouldn't hurt."
[[Explore the inside of the discussion aid.->Look at Inside]]"You wrote here that you're feeling overwhelmed," you say in a low voice. "Do you want to tell me about that?"
The patient looks up at you. "I guess it's just work. Shifts are brutal, yeah."
You make a low, affirming sound. "Mm."
The patient continues, "I guess I know I should be out walking more and eating healthy, but we don't get such long breaks. I work in a restaurant and food's all a bit greasy. So I feel, guilty, yeah, but there's also not a lot I can do about it."
You respond, "I hear you. Service work can be tough, and we often don't give food service workers a lot of opportunity to rest or eat well. If you'd like, I can set you up with one of our nutrition coaches here in clinic. Maybe they can help set you up with a plan for prepping meals that works for your situation."
The patient shrugs. "Sure, that wouldn't hurt."
[[Explore the inside of the discussion aid.->Look at Inside]]You turn to the inside of the discussion aid.
Under the question, "Are these areas of your life a source of satisfaction, burden, or both?" the patient has marked:
My work: Burden
Being active: Burden
The food I eat: Satisfaction & Burden
Under the questions, "What are things that your doctors or clinic have asked you to do for your health? Do you feel that they are a help, a burden, or both?" he has marked:
Take medications: Help & Burden
Manage my diet & exercise: Burden
Manage stress: Burden
[[Ask, "What stands out to you?"->Patient Responds to Inside]]
[[Ask about "Take Medications: Help & Burden"->Patient responds to Medications]]You fold the discussion aid shut. "Well, thanks for sharing. I get that it's hard for you to do, but it's really important for you to keep your injections up."
As you talk, the patient folds his arms and sits back. His glance flickers away.
"You're still not well controlled," you continue, "so I think I'm going to have to have you increase your insulin doses and keep you at four shots per day. Do you think you can do that for me?"
He makes a small sound of assent.
[[Finish the visit with some patient education.->Education]]Over the course of the rest of the visit, the patient opens up about some additional pressures they have been struggling with. Together, you look up their route from home to work and identify some grocery stores providing fresh produce that they could stop by on their commute home.
The patient leaves with a look of relief, gripping your hand tightly.
In their chart, you write a note:
-- Change injections to 2x/day
-- Sent to pharmacy
-- Referral to nutrition coach
3 months later, the patient returns for another routine follow-up visit. Their A1C has lowered appreciably. You pick up the conversation where it left off, asking how they have been coping with work recently.
END
[[Start over->Beginning. ]] "It looks like you wrote here that taking medications is both helpful and a burden," you say. "Can you tell me about that?"
"Yeah, so..." The patient scratches his head. "I know that taking my medications is good for me but I just find it hard, uh, to fit it in. You know?"
"How so?"
"At my job, I work with customers. I don't get that many breaks and they're not that long. And to be honest, I don't feel comfortable injecting in front of people. They stare, I get ashamed. So I probably don't get around to injecting more than two times per day."
He says the last bit reluctantly, with a note of guilt.
[[You need to keep up with your injections.->You need to keep up.]]
[[It sounds like you're having a hard time balancing work and healthcare.->Balancing work and care.]]