medicine · MS-3

Non-compliance

I just finished a write-up for a patient of mine whom I discharged on Friday.  Nice guy. Middle-aged diabetic man, recently out of work, who had been denied Medicaid because he had saved too much money.  Yet he could not afford to pay for private health insurance (diabetes is a doozy of a “pre-existing condition”) and he won’t be eligible for Medicare for over a decade.

His glucose on admission was sky-high.  Turns out he doesn’t take his metformin and glipizide regularly.  Why?  Can’t afford them.  Doesn’t check his fingersticks.  Why?  Can’t afford the test strips.

This is not just some lazy patient, or someone with their priorities screwed up.  When I asked about foot ulcers, he gave me the lecture on the importance of foot care for diabetics.  He made sure to go to his optometrist appointment.  (It was last year; he can’t afford one this year.)  He could use some help quitting smoking, but that’s not unusual around these parts.

We fixed him up, ruled out some of worse sequelae of diabetes, and tried to get him on his way.  We tried to maximize his compliance by putting him on a combined formulation of his home meds.  He needs insulin, but if he can’t afford the fingerstick test strips, insulin is a BAD idea. (Mmmm coma!)  What’s going to happen is this: he’s going to take fewer of the pills to make them last longer.  He’s going to end up in hyperglycemic hyperosmolar state.  And he’s going to end up in the hospital again, maybe with retinopathy or nephropathy or neuropathy (he’s already got numbness and tingling, so it’s just a matter of time).

It’s screwed up.  This guy’s real problem isn’t the diabetes.  It’s the fact that his diabetes can’t be managed because of money and insurance issues.  It really irritates and upsets me that something as peripheral as that — something that I never think about it for myself — is what’s really going to kill this guy.

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