Two years out of his residency, over a Thanksgiving weekend in the early 1980s, Dr. Alan Glaseroff stared at his ceiling and considered how his life had just changed. “I was overwhelmed by a series of disturbing possibilities: blindness, heart attacks, amputations, kidney failure – the end of life as I knew it.”
Glaseroff had just been diagnosed with diabetes, and he recalls that moment in a superb new essay, “Why Burn Out? A Personal and Professional Journey” (Diabetes Spectrum, Winter 2007 - this is a superb physician journal). For both patient and clinician, burn out is one of the most common pitfalls in this disease, but Glaseroff argues that it can be avoided through a combination of self-empowerment and empathy – and he makes his point with some candid self-criticism.
Glaseroff developed diabetes some years before publication of the DCCT results, which proved that tight glycemic control can reduce the risks of complications. In fact, when he was in medical school, he had been taught that “tight control was dangerous, that preventing hypoglycemia was the most important part, and that glucose levels of >200 mg/dl were OK ‘as long as the patient isn’t symptomatic.’” Nonetheless, after his diagnosis he chose to believe in the benefits of tight control for psychological reasons as much as anything else: it gave him hope, and he conveyed that message to his patients. (He is chief medical officer at the Humboldt-Del Nortre Independent Practice Association in Eureka, Calif.)
“I focused on the A1C as an actual measure of the damage process, which meant that if I could keep it in the normal range, I could prevent complications,” he writes. “I needed to believe that to simply go on. I spread that hope to my patients, frequently adopting an ‘us versus the world’ attitude that turned us into a membership club of sorts . . . It was a message of personal power, the same message that had pulled me up from the depths that first November night. I didn’t have to end up a victim, and neither did my patients.”
But his approach didn’t work for all patients, including a “divorced retiree” who smoked cigarettes, ate pancakes with syrup, had A1C’s over 14 percent, and probably never “took a shot of insulin that I didn’t witness.” But during office visits, Glaseroff didn’t probe what underlying issues were preventing him from taking better care of himself. Instead, he would ask, “Are you trying to commit suicide? Which body part do you think will fall off first?”
In May of 2005, the patient suffered multi-organ system failure. In the hospital, shortly before he died, he thanked Glaseroff for doing all that he could for him. In a bizarre twist, the very next day Glaseroff hosted a large conference on diabetes self-management, but as he headed to the conference, “I felt tired and burned out . . . I felt that I had failed my patient in some profound way. It would have been easy to say that he had made his choice and that all I could have done was make sure his was an informed decision. But it wasn’t true. I had contributed to his demise in my own special way by showing my frustration and trying to scare him.”
He could barely perform his own duties at the conference before introducing Dr. William Polonsky, author of Diabetes Burnout, who talked of patients needing to believe that self-management was worthwhile and achievable. He suggested that doctors ask patients how they felt about their disease and practice “motivational interviewing.” It suddenly made sense to Glaseroff.
“I began to see what might have gone differently with my patient had I altered my approach and listened instead of delivering stern lectures. I have little idea what he really thought about his disease, largely because I had never asked.” Glaseroff concludes that his patient was in denial, but “rather than explore it, I had repeatedly attacked his defenses with my threats of doom and gloom. Whatever it was he was truly thinking and feeling, what I had tried hadn’t worked.”
The episode highlights a central shortcoming of our health care system for diabetes: the disease resists simple fixes. It has emotional and psychological dimensions that can only be resolved through careful, probing discussions, but most health care providers, and certainly physicians, cannot offer that time for financial reasons. They get a set fee per patient visit, so they must keep churning through patients to make ends meet.
We have no quick solutions for our health care system, but we believe that Glaseroff’s essay sheds light on an important problem. For patients to avoid burn out, they have to believe they can influence their own destiny, and the same is true for doctors and diabetes educators. They have to believe in the merit, indeed the essentialness, of their work. For Alan Glaseroff, as both patient and clinician, we know that’s true.
James S. Hirsch
Is there any way we can read the essay online? I've been diabetic for 10 years now, practicing tight control with no complications so far. But it's getting old, very old. My most recent A1C was 6.4, high for me. I'm worried about burning out.
Posted by: vicki | 02/28/2007 at 09:12 PM