The Case
He was 60 years old, neat and quiet, and half-bowed to me as he shuffled into the room. He made his way to a chair and sat rigidly, with his hands in his lap, nodding earnestly whenever I spoke. It had been four months since the last time we met, when we had spent nearly 30 minutes going through his diabetes medicines, but his blood pressure and sugars were still terrible.
After 10 exasperating minutes, I flicked back through his notes, skim-reading several years of doomed attempts to get some grip on his disease. Over time the tone of the notes had changed from puzzlement at his lack of improvement, through frustration, to outright suspicion. We had thought of non-compliance, of course, and a previous doctor had taken the trouble of reviewing all his prescriptions, looking for telltale gaps – but there were none; he had always collected his medicines exactly on time. Yet his HbA1c had continued to climb with his burgeoning polypharmacy. He had always come for his annual reviews, and ‘yes doctor’, he said, he did understand it was important to get this under control.
The outcome
With nowhere else to turn, I told him that we were going to have to consider starting insulin. He became oddly animated and asked ‘are there no other tablets we could try instead?’ And then, suddenly, he began to cry.
He was scared that insulin might be dangerous for a man who lived alone, with no family nearby, and who couldn’t read the instructions.
None of us had thought of illiteracy, and he had been too ashamed to tell us. And so, for years, he had collected his medicines, not telling us that he had been unable to read the instructions on the bottles and packets. He had simply stored them away at home. And tragically, with each escalation of treatment, it became harder for him to tell us.
This time, he and I decided to start again. Despite his initial reluctance, he brought a neighbour to his next appointment, who listened carefully and guided him through the first few weeks of his treatment, until it became routine for him.
What I learned
There are many reasons for treatment failure, and not every failure to comply with treatment is because of apathy or carelessness.
We had collectively failed this man for years, missing the point in each and every consultation.
How this changed my practice
Whenever treatment isn’t working for one of my patients, this case sticks in my mind, reminding me that there may be a simple solution – if we are humble and receptive enough to find it.
Dr Nick Ramscar is a GP in Bracknell, Berkshire
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