Last year, during the post-Thanksgiving Day sales, an Instant Pot I'd had my eye on became available at a bargain price. So I got one, took it home, and read the instruction manual so as to not violate the Gay-Lussac law of the mass, pressure, and temperature of gases—or at least not have the lid become a projectile. The instruction manual was 40 pages long, with three pages devoted to a table of instructions on what to do if the device underperforms. According to said table, some corrections can be made by the user; other error messages need the learned assistance of a service center.
In many years of fielding unanticipated patient calls, one of the elements of doctoring that probably could have gone a lot better (especially for patients with diabetes, but for others with chronic conditions as well) was how I conveyed self-management or even survival skills that patients need far more frequently than do Instant Pot users.
Some disorders are curable, but most patients with diabetes, adrenal insufficiency, or hypoparathyroidism will not only have their disorder forever but will inevitably find themselves in a predicament where they need to recall their doctor's advice—assuming they were advised at all. Although insulin reactions are anticipated and discussed, we don't often offer advice on what to do when patients leave their supply of insulin in the airport limo.
Sick day management, critical to those with diabetes and Addison disease, is among the subjects brought up early in the course of familiarizing patients with their condition. But this conversation often comes off as a scholarly exercise if the person is well at the time, and the discussion is mentally filed away as less urgent than the medication changes made at the same office visit.
Unfortunately, dire situations do arise. Pumps fail periodically. Emergency management to avoid ketoacidosis is part of pump training, but patients often take in this training with the idea that it won't really happen. Unlike our residency training, where someone has to attest that you do know how to do a paracentesis and take arterial blood, a simple quick signal from the patient that they understand and have no further questions gets accepted at face value.
As the number of medication options expands, adverse effects expand with it. Asking people to read the pharmacy dispensing printout could be counterproductive. Anyone who reads a printed form for a tricyclic antidepressant will wonder about the doctor's wisdom in prescribing it.
"Might the statin make me achy?" Definitely part of the discussion. "Will it make me demented?" Probably not part of the discussion. And that doesn't even pry open what some patients read on the Internet—largely correct in the right context, though a long way from universally applicable to every individual situation.
So, as an experienced specialty physician, why didn't I do better in getting patients to anticipate and react correctly to the inevitable downsides of managing a chronic, lifelong illness? Since I mostly received people referred by other worthy physicians, they didn't do any better. Each time a "what to do" inquiry came in, whether from the patient or the emergency department, with it came a reminder that maybe I spent too much time during the last office visit looking at glucose diaries and pedal pulses to the neglect of anticipating gaps in the patient's skills. These skills, after all, are as important to their ongoing care as insulin doses for diabetics or calcium and vitamin D replacement for those with hypoparathyroidism.
Let's Learn From the Instant Pot
We perhaps have a false sense of security about the diabetes classes our patients attend. I not only attended classes in anatomy, pharmacology, and neuroscience but also studied the material in anticipation of being tested—and I never scored 100%. Diabetes classes impart familiarity, which is a long way from expertise or the insight needed to create a solution out of basic principles at unexpected moments of crisis.
What would serve people better might be a readily available checklist: If "this" happens, do "that." If the meter says above 300, add 5 units of lispro. People with primary or secondary adrenal insufficiency know to double their steroid dose when they are sick, but what to do for the uncommon, serious glitches are what seem to whiz by.
I am among the majority of physicians who detest the electronic health record, but I admit that each one I have used has had a valuable but (at least in my hands) woefully underutilized feature. With a brief search for diabetes, the program developers have included many one-page guides for contingency situations. The level of sophistication varies. I've yet to see one that reminds patients that they can get certain insulins without a prescription if they run out unexpectedly, but most deal with sick days or injection site reactions, which are often very practical topics.
These guides seem to be placed in an inconvenient area, off to the side of the program, out of the mainstream of the office encounter work flow. Moreover, they come bundled with other disease-related education summaries that would fall more into the category of disease familiarity than crisis survival skills. This may be one area where a computerized nudge to the treating provider could make a difference. Perhaps when we click the box that says "hypoglycemia," we can be automatically directed to the brochure on this to print it for the patient, particularly if they have mismanaged the condition on their own.
We have the ability to address most problems that arise. What we don't seem to have, like the Instant Pot, is a coherent contingency list that is readily retrievable. This may be one opportunity to bring our contentious electronic health record systems closer to their true potential without irritating already skeptical users by automating some of the nudges that we need to redirect our attention to what may be needed most.
Richard M. Plotzker, MD, is a retired endocrinologist with 40 years of experience treating patients in both the private practice and hospital settings. He has been a Medscape contributor since 2012.
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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: A Lesson From the Instant Pot: How About a Troubleshooting Guide for Patients? - Medscape - Nov 27, 2019.
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