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03/05/2013

The Diabetes Challenge

Jennifer Chevinsky, B.S.

A recent study found a strong association between the number of test strips covered by insurance and better medical care in type 1 diabetics. Test strips are impregnated with chemicals that react with glucose when sensed within a drop of blood. Strips are disposable and cost from 40 cents to $1 each, although this cost is often defrayed to some extent by insurance.

Type 1 diabetes, previously called ‘juvenile onset,’ is a chronic illness that affects over three million Americans.  It was previously referred to as ‘juvenile diabetes’ because it was believed that this condition only developed in childhood, a theory that has been disproven.  Individuals of all ages can and do develop type 1 diabetes.

In type 1 diabetes, individuals do not make enough insulin, a substance that helps mobilize glucose, or sugars, from the blood stream into the cells.  The underlying concept behind treating patients with type 1 diabetes is to provide enough insulin to allow the proper amount of glucose to enter the cells – without making the blood glucose drop too low or raise too high. If a patient’s sugar is too high, then he may experience diabetic ketoacidosis and if it is too low, he can fall into a hypoglycemic coma. Glucose level is dependent on multiple factors including a patient’s weight, body type, metabolism, diet, exercise, etc. To maintain a safe or healthy glucose level, type 1 diabetics must test their blood sugar multiple times a day.

At the University of South Florida’s Morsani College of Medicine, I was recently exposed to an innovative approach to learning about the experience of an individual with type 1 diabetes.  Nicole Johnson, a former Miss America, advocate for type 1 diabetes awareness and founder of ‘Bringing Science Home,’ brought in a panel of patients to speak with us about their experiences with diabetes.  The speakers ranged from affected children and teenagers to caregivers and relatives. After the session, we were asked to participate in the diabetes challenge, an experience built to simulate a day in the life of an individual with type 1 diabetes.

Because of the nature of the condition, individuals with type 1 diabetes are encouraged to check their blood sugar multiple times each day – when they wake up in the morning, before each meal, before going to sleep, and when they feel their sugars might be rising or dropping.  Likewise, we were loaned a glucometer and were encouraged to test our blood sugar throughout the following day.

I soon learned that this process is not as simple as the instructions would suggest.  The procedure of testing blood sugar typically involves pricking one’s finger and squeezing out the blood on to a disposable test strip (not an exciting process for the trypanophobics or hemophobics among us).   There was confusion about how to assemble the glucometer, where to put the test strip, and when to load it with blood.

Additionally, I received multiple error messages on the glucometer – when I did not fill the strip with enough blood, if I fumbled with the glucometer and didn’t proceed quickly enough, or sometimes even when I thought I did everything correctly. I then had to use another one of the test strips, of which I only had about 10 for the day.  I noticed myself deciding whether it was ‘worth it’ to waste another test strip on the occasion that I received another error message.  Throughout the day, my fingers began to feel sore, not only from the needle pricks, but from squeezing my fingertips to milk out the blood.

Continuing with my normal routine, I recognized the bulkiness of the glucometer pouch, as I brought it with me to my daily activities.  I couldn’t help but feel as if people were watching me when I pulled out the glucometer to check my blood. I suppose if it is not something one has seen before, the process and machine might look quite strange.  I even thought about just checking my sugar in the car, so as to not make any kind of public statement or scene.

Every medical practitioner is likely to interact with an individual who has type 1 diabetes, thus it is important to recognize the barriers these individuals might face that could prevent them from following prescribed treatments.  Although this mode of learning might not be new, with medical students or physicians taking on the role of patients with particular illnesses, it has been my first experience with this type of learning.  I think it is a great way to fully immerse in a particular culture and recognize first-hand some of the legitimate concerns and struggles of the population.

Going forward with my clinical education, I hope this experience will help me become a better practitioner, knowing the right questions and concerns to ask my future patients with type 1 diabetes. Although this simulated experience was not designed to address the new study on the correlation between insurance coverage for test strips and patient compliance, it raised important ethical issues about how I can best help my patients care for their health. Patients may only be able to afford a certain number of strips, meaning that a strip that does not work is a choice of whether to spend a precious resource of health care dollars or to forgo testing at that time.

Decisions such as how many strips are covered by insurance carry real world implications for patients and their health. As a future physician, it will be my job to advocate for my patients and to do so in a system where economic and political forces are not necessarily arrayed with the patient’s best interest in mind. I can share the latest scientific evidence with my patients, but without support from our society, there is not much that either of us can do to ensure best health outcomes.

 

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