Sunday, February 11, 2018

Being there

I have been asked this question a fair times now in the diabetes world- more so recently- and I suspect bar those close to me, most folks won't know the answer- and opinions are formed based on what they see in the public persona, social media, blogs etc.

The question has been simple (or in some cases, its been more of a statement..well ya know what the world is like nowadays…the smorgasbord of instant opinions and all that!) -"Are you a Libre-Man or a CGM-man?" Forgetting the basic fact that nowadays they are deemed to be the same thing-yet on a paradigm (not by me, I MUST stress!) its  silly question to start with- but I suspect warranted to an extent by my very public and open support for getting this technology to people with diabetes. Its also come with the usual conspiracy theories…"He must have been paid, No?" / "Does he have shares in Abbott?" / "He must be lining up a job with them"…I won't rehash all the reasons here- but it maybe worth all those characters taking off their tin foil hats for a moment. Nope- not paid, didn't have any of my research or MD/PhD work funded by them, nor do I have shares or taking up a job.

Do also please give me some credit and don't insult my intelligence to that extent- if I wanted to make money off this, I wouldn't really be so public about my support for it, would I? I have even had some clever clogs whispering "he is close to industry"- it makes me chuckle when you see that view from even within NHS circles- someone must have forgotten to pass them the memo about the  "NHS drive to work closer to industry" or even the role of AHSNs to work with industry to accelerate innovation". Ah well- a blog on that some time soon too.

So the answer to the question is….well..neither. I couldn't care less about whether its a Roche CGM or a Medtronic super-pump or a Dexcom whiz-product- or for that matter Libre. I don't think any of them are the panacea or something I must favour..if I believe in 1 thing- its about something that is more ethereal- its funnily enough, not a product.
Its something I was taught by some of my best tutors in life…and it ain't a super tech. Not some fancy insulin either…so let me share a personal view. I have been a Consultant now for nearly 10 years now- and I have had a few "success stories"- none, I repeat, NONE of them down to me or a whiz-tech. A fair few of my patients are active on social media- they can verify- but I have never done a clinic in my life offering someone a Libre or a CGM as a panacea. On the contrary I have only 1 simple rule of doing diabetes care..whatever be the type. It goes as follows:

"You don't have diabetes; You don't live their lives; You don't have the same socio-economic situation. Thus, you have no right to judge them"

Thats pretty much is it, to be honest. I talk a lot about Type 1 diabetes- but am equally passionate about Type 2 diabetes- about working for the population (Super Six Model-remember that?), about treating the individual, de-prescribing where needed, keeping the frail elderly safe, using the appropriate drug or diet what suits the individual- not my personal preference. Its stood me well- and I plan to continue to do so. Its not about the Libre or the CGM- its about being a guide in the persons life- providing them with the tools they need- whether that be education, peer support, just a kind word- or sometimes? Just keeping quiet.

The reason for championing Libre has been the principle of moving the paradigm from finger pricking to the next phase of innovation. I couldn't care less if it was called "Mickey Mouse"- or produced by a start-up company. For me, its the principle of shifting the care paradigm to the next phase- and that extends to every part of diabetes care. If we genuinely want to improve diabetes care. we need to be nimble, flexible, accept that what controlled setting such as trials tell us is not the gospel- but guides at best to help us. That we may need to rethink our strategies such as providing education only by face to face means -is the only way or that it an only be given after 6-12 months after diagnosis in type 1 diabetes. Lets face it, beyond a few chosen centres of excellence, diabetes care in the main is about "You have diabetes; sorry thats a bit shite; here are some leaflets; An education programme on a set day: see you in 6-12 months". The person is left with their diabetes…alone, looking for direction, friends, support- but we as a system resist change…because? Evidence says we must do it in only 1 set way- damn the fact that not many are coming to the protocolised versions of education sessions or clinics.

So- no- I aint in any camps- fact of the matter is- past the Libre- I am also starting to spearhead the CGM work (I bet the next query would be why I am supporting CGMs and not education!)- as much as working on individualised targets in the elderly- or championing different style of education programmes. They ALL matter to me- they all mean improving self management for those living with diabetes, keeping them safe….its not that tricky - we don't need to fit ourselves into boxes, we just need to see ourselves as support for those on their journey with diabetes.
I appreciate how tough that is as a professional, how tricky it is to let go of that control (thats not what our training teaches us)- but all I can say? That is what brings the best results- for what its worth- 10 years of being a Consultant has taught me that- as have my patients.

Go on- do give it a try. Just try and be there. It makes for much better diabetes care. And oh- easy on the conspiracy theories. Much better time spent on improving diabetes care. Honest.

3 comments:

  1. Thanks for this, a refreshing perspective. So often Drs tell people with diabetes what they need, when they have very little idea of our lifestyle or the everyday struggles to achieve those a1c targets. Surely whatever helps should be championed.

    ReplyDelete
  2. Hi Partha,

    Thank you again for the great blog and all your work with promoting the use of CGMs.

    CGMs are a fantastic educational tool, and we need to encourage Type 1s to be enquiring about how they self manage. There's a lot of emphasis on carb counting and getting the rapid acting insulin dose right, but we don't emphasise the variability of day-to-day insulin sensitivity enough. This is where CGMs come into their own. The effects of exercise (or lack of it), stress, sleep, caffeine etc. are all quite difficult to quantify but they account for much of this variation in insulin sensitivity. I've seen fellow Type 1s get exasperated when they have varying responses to the same meals and insulin does on different days - and wondering if they've got something wrong. It's a recipe for diabetes burnout if you don't understand it.

    It's very much easier to develop an intuition for good self management using the instant feedback of the CGM.

    I do hope we are able to incorporate CGMs into the educational courses that we offer as soon as is practicable.

    With very best wishes,

    Ian

    Dr Ian Paterson
    Sheffield

    ReplyDelete
  3. Quite right Partha, it's about the right kit for the individual. Whatever works for you. But we do need access, and we do need to know what's out there! Sensors (all of them) are really improving diabetes care. Any quibbles about cost are easily out-argued by the reduction in complications due to improved control. That's where the savings (both in cash an in terms of physical and emotional pain) will be made. Thanks for being part of pushing this forward. Sue

    ReplyDelete