Noncompliance Versus Diabetes Self Care: Are We Still Playing a Blame Game?

Jane Jeffrie Seeley asks: Whose regimen is it anyway? Are we taking the time to ask patients how they choose to manage their diabetes? What are their goals? Have we presented both the benefits and the costs (in time, money, and energy) of the treatment we are recommending?

| Feb 3, 2009

Back in 1993, I published an article titled "Is Noncompliance a Dirty Word?" in which I expressed sadness that people with diabetes were being blamed by their healthcare providers for not following treatment advice (1). I suggested that the patient's "failure" might really be a failure of the partnership (or lack thereof) between patient and provider.  Fifteen long years ago, I challenged diabetes educators to work with medical practitioners to change noncompliance from a dirty word to a rare occurrence. So, how are we doing today?

From noncompliance to self care

Well, the diabetes lingo has evolved from "noncompliance" to "nonadherence," and then to "the inability to perform self-care," but they all describe a patient with diabetes who is not following the prescribed regimen. No matter what we call it, the outcome is the same. Patients are not doing what we tell them to do. 

The result can be the onset and progression of the complications of diabetes that we all know and dread, but the consequences all belong to the patient, not to us. My question to my fellow diabetes educators is: Whose regimen is it anyway? Are we taking the time to ask patients how they choose to manage their diabetes? What are their goals? Have we presented both the benefits and the costs (in time, money, and energy) of the treatment we are recommending? Does the patient know how to follow the regimen safely and comfortably? Until we do this, the patient is not ready to be independent and perform self care. 

Frank's story

Several years ago, I was asked to see a new patient as a favor to a former colleague. She was in tears as she told me that her husband, Frank, was not taking care of his type 2 diabetes and related her fears that he would develop serious complications, or worse.  Both she and his primary care physician labeled Frank as noncompliant and blamed him for his poor glycemic control and A1c of 8.8%. 

On his first visit, I asked Frank to bring in all his medications so that I could review them with him. I was sad to learn that he was taking sub-therapeutic doses of three oral agents and had stopped taking exenatide because it "didn't do a thing." When I questioned him further, I learned that he had been taking the exenatide at the starting (non-therapeutic) dose at the wrong time (post-meals) and in the wrong place (injecting in his forearm) because he had received instructions from an office "nurse" who very likely was not a nurse at all. He had stopped monitoring his blood glucose because the numbers never improved, despite intensifying therapy.

Lessons learned

As you read Frank's story, you are probably filled with anger at Frank's physician for not properly managing Frank's diabetes. To make this story even more heart-wrenching, let me add that Frank was in his early forties, had young children, and worked at a blue-collar job that required physical labor. He needed to be healthy to support his family. 

Over time, I worked closely with Frank to develop a partnership with him, and he learned how to manage his diabetes through lifestyle changes and optimal pharmacological interventions. I am happy to say that Frank keeps in touch to let me know how he is doing, and he is filled with pride that his hard work is finally paying off. 

Why am I telling you all this? For this reason: We are all taking care of many "Franks" who are getting substandard treatment because they've been labeled noncompliant. How can we turn this around? I have made it my personal mission to react whenever the term noncompliant or nonadherent is used to describe a patient referred to me. I take the time to explain that a breakdown in the partnership between patient and provider has led to the point that the patient is not capable of safely and comfortably performing self care. I share with the provider the secret to my successes, and I try to help them do better, one intervention at a time. I hope that you will take the time to do the same.

References

1) Seley, JJ (1993). Is Noncompliance a Dirty Word? The Diabetes Educator; 19; 386-391

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Categories: A1c Test, Beginners, Blood Glucose, Complications & Care, Diabetes, Diabetes, Hospital Care, Professional Issues, Type 2 Issues


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Comments

Posted by Anonymous on 3 February 2009

They also say people are noncompliant when they do exactly what they are told and it doesn't work. A guy following the diet, meds, etc to the letter is called noncompliant and a liar but it turns out he had pancreatic cancer that wasn't diagnosed until too late for any treatment to work. All because he was obviously lying and was really noncompliant.

Posted by Anonymous on 9 February 2009

I was told that I was noncompliant when I suddenly lost my vision. I was told to keep a careful log for 2 months of my blood sugar (fasting, before & after each meal and at bedtime). When I showed my log, the doctors still didn't believe that my diabetes was in perfect control. When I was finally diagnosed, it had nothing to do with my diabetes. No one ever apologized to me. It still infuriates me.

Posted by Anonymous on 9 February 2009

If noncompliance is a significant issue in the population, perhaps it is another symptom of the disease, and not just the voluntary behavior of the patient.

Posted by Green Lantern on 9 February 2009

Excellent article! Western medicine is based on an acute model that is a poor fit for chronic disease. The "job" of someone with a chronic disease is to self-manage, NOT comply. Self-management includes tasks like noticing and reporting symptoms, maintaining safety, and dealing with the day-to-day decisions about what to eat and what dose of medication to take at what time, given your exercise level... (See the Chronic Care Model: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2).

Having gone to a number of professional diabetes meetings, it's always astounding to hear diabetes professionals taking full credit for their patients' management successes. Excuse me? How often are they on hand to offer advice--an hour a month?

The author is absolutely, completely right about the value of a working partnership between patients and professionals to produce good health outcomes.

Posted by Anonymous on 9 February 2009

You assume that some people actually care about their diabetes management. There are so many phychological problems involved, that providers just aren't getting it and don't have time to sort them out. Low-self esteem, eating disorders, depression and so on, are real factors in considering non-compliance and mostly aren't being taken into account or treated. Providers simply don't have time in a 10 minute appointment to address these issues. When it comes down to the almighty dollar, people mostly come second.

Posted by Anonymous on 9 February 2009

I have been using an insulin pump for about two years now and it has literally saved my life. I had been scheduled for a kidney and possible pancreas transplant.The daily routine that all of us have to do is second nature to me now.But then there are those days when you are tired, your sugars are not what they should be and you just want to throw in the towel. I am very lucky that I have a wonderful supportive husband as there are no diabetes support groups where we live.

Posted by Maria Weber on 9 February 2009

Two years ago I was put on an insulin pump This has literally saved my life and kept me off dialysis. Because at that time I was scheduled to have a kidney transplant with possible pancreas transplant.
Its not easy at all to do the same things over and over agin every day of the week for the rest of your life .And then there are those days when your sugar levels ar not good, you are tired and dread doing the fifth finger prick of the day you want to just throw in the towel. I am so fortunate to have a wonderful understanding husband who understands and helps me every day......even though I know its not easy for him either. Self dicipline is a very hard thing to do on a daily basis but the alternative is really lousy!

Posted by Anonymous on 10 February 2009

Oh the joys of "non-compliance". As you say, if the results aren't what the doctor says he assumes you're screwing up. When we first went on Lantus it had fierce peak that nearly killed my husband on several occassions. This may have been because he was still using regular (none of the fast actings were available) and the overlap was too great. Whatever the reason, the doctors just said "IT'S 24 HOURS - NO PEAK". A few years later the standard graph shows a definate peak and doctors are admitting that different insulins act differently in different people. How about listening to the patient in the first place?

Another technique of doctors is what I call information hiding. One of the dirty little secrets of diabetes is the long list of complications that don't make the "Major Hits" list but affect so many of us -- cataracts, digestive problems, gall stones, and gall bladder damage, low testosterone. You don't find out they are complications until the symptoms are well advanced and even if you COULD have done something earlier it's too late now.

And our latest "why the hell didn't they say something sooner" story is that my husband's blood sugar has been difficult to control (despite multiple tests and multiple injections and careful counting of carbs) and the doctors have given little help. Until we brought in a carefully built graph from our CGMS, our doctors just waved us off. This time, we came graph in hand and armed with the question "can the amount of fat at an injection site affect the rate and amount of insulin absorption"? So, turns out the standard issue "always use the abdomen" may really be "unless you've got a big gut then go around the sides where there's less fat". Thanks for telling us that ten years ago. Naturally, if you search the web that information's out there ... it just hadn't been forthcoming from a string of endos.

I think the doctors are well meaning but unless they've lived with this up close and personal they have no idea how hard it is, even for the most compliant patient with the best attitude to manage the roller coaster that is diabetes.

Posted by Anonymous on 10 February 2009

So, I am a type 2 diabetic and my health care provider has excellent education classes for patients and also offer those classes to the general populace of our county. If I need something or have a questions it is just a phone call away. I would say they listen to you .

Posted by pfrank on 10 February 2009

As a Type 1 for 44 years, the author is completely right. You need to develop a good relationship with your doctor and his/her staff. The key is TIME. Diabetics need their doctors to listen to them. As my doctor once told me, "I want to listen to you. You have diabetes, not me!"

Posted by Anonymous on 10 February 2009

Green Lantern stated "Western medicine is based on an acute model that is a poor fit for chronic disease." That hits the nail on the head. I have one diabetic educator that does have diabetes, and is on a pump, and completly understands the problems ... those who do not, and simply look at the 'model', have no understanding of the problems diabetics face daily, and therefore label us noncompliant. I wish it were that easy to follow the "model", but the "model" does not come close to covering everyday experiences.

Posted by Anonymous on 10 February 2009

Reading the other comments, it looks to me like it's all been said, but I would add my voice to the "psychological problems" comment. The way the individual perceives having diabetes is HUGE! I think many, if not most, at some point early on just give up. I know I did at first. I was diagnosed as type 1 in 1970 and at first just gave up because I ran into so many hypoglycemic problems while at work that I just made sure I ate enough so it couldn't happen. Of course at that time glucose monitoring on a frequent basis was impossible too. I developed serious depression; I felt I could no longer consider myself a healthy person, instead I was a "sickee." Oh it was miserable, and over time I got therapy and antidepressant meds and my attitude improved, as did means of treating type 1. But at no time did any M.D. even consider my emotional problems. Now I see it all around me, diabetics obviously following no kind of healthy diet at all, lying to themselves and making excuses that it's really not so bad to have drinks with high fructose corn syrup in them, etc. And others just come out and say, "I don't care, I can't win anyway." I am so sorry for them. I really believe more comprehensive healthcare, which includes emotional healthcare and therapy as needed, should be offered. But that's not going to happen in our current society and the current economic times.

Posted by Anonymous on 10 February 2009

I've been treating my diabetes very successfully for 10 years with insulin. I count carbs, adjust my insulin based on carb intake using a formula developed with me by my diabetic educator. My A1c is consistently 6.0 to 6.3. I see my doctor every 3 months and bring my daily blood sugar readings and insulin dosage records.

Still I get labled by some doctors and office nurses as being "non compliant". The problem lies in the fact that they like to give "orders" that only they can change. The fact that I change my insulin dosages based on my blood sugar readings and carb intake means that I, the patient, am in control of my diabetes and I am responsible. Physicians and nurses are control freaks and they lable anyone who takes charge of their own health and medication dosages as "non compliant" or even worse "self-medicators". They operate on the assumption that only they are smart enough to know how to administer meds. Its not just diabetes meds but blood pressure or any other meds that with a little education, the patient can manage better than the doctor on a day to day basis. The doctors and nurses should view themselves as teachers, not preachers and dictators.

Until doctors and nurses see the patient as the control agent and vest responsibility in the patient the problem of so called non compliance will continue. I teach patient advocacy. I tell students (mostly nurses who object) that there is no such thing as a non compliant patient, only one who doesn't understand the advice (not directions) they were given or didn't agree with it in the first place but would not challenge/negotiate or debate with a doctor or nurse over the treatment regimine. Until doctors and nurses abandon their contempt for informed patient decision making, their actions will disenfranchise patients and rob them from their own responsibility and actions to achieve good health.

Imagine, a doctor or nurse having to "negotiate" with a patient over treatment that the patient will agree to. Doctors and nurses will call this blasphemy. Patients will recoginze it as the only solution to the best healthcare.

I've posted as anonymous because I've acutally been asked to leave a doctors practice for suggesting these things. The doctor told me "I don't want a patient like you who questions my 'orders'". So I choose to remain anonymous rather than subject myself to losing medical care because of my belief that I am responsible for my health.

Posted by DAR on 10 February 2009

My endo probably sees me as "noncompliant" because when I first saw him about 5 years ago, he told me to eat more carbs and double my meds. Instead, I lowered my carbs and stopped taking the meds because I didn't need them.

My last A1c was 4.9 and instead of telling me it couldn't be done and wouldn't do any good even if I did keep my BGLs low (as he usually does), this time the endo warned me that having low (i.e. normal, nondiabetic) BGLs is not healthy.

All those poor nondiabetics! Having normal BGLs must be harming them! Yeah, right...

Posted by Anonymous on 11 February 2009

As a diabetic educator in a large teaching hospital I see the damage in labeling a diabetic patient "noncompliant". The medical residents may not prescribe the best insulin regimen, nurses stop teaching the patient, and the patient ends up with substandard care. If healthcare professionals spent more time talking with their pts they would find that often the "noncompliance" is based on mental health, financial burdens, food issues (no food in the house means not taking insulin to avoid dangerous hypoglycemia), poor family support, lack of diabetic self management education (such as what is an A1C) and the list goes on. I always find a reason, valid for that person, of why they might not be following their medication/lifestyle regimen. With careful and compassionate teaching many of those issues can be addressed. I loved this article and think it should be required reading for the medical community. We need to be careful in labels, and really not use them at all, or risk being labeled ourselves as incompetent healthcare providers!

Posted by Anonymous on 11 February 2009

I was also considered noncompliant for years after I was diagnosed with diabetes. Before my diagnosis I was told my symptoms were all in my head. It took me 5 years and a number of doctors before I was correctly diagnosed as a type 1. If it had not been for a couple of good diabetic nurses who got me some education I could have died- my Ac1 was 18 and remained close to 9 for years. I am now on a pump (Ac1 6.6) and have great communication with the team at the office I go to but this is because I was willing to keep search for the right care. I still get angry some times when I remember how the doctor would tell me that I was lying in my food diary and that I must be eating other things that were causing my blood sugar was so high over 150 before meals. (I am 5'7" and dropped to 120 lbs )

Posted by danbrown on 12 February 2009

The author makes a good point, but is using the wrong weapon and is aiming at the wrong target. By 2002, at age 61, I had been a morbidly obese (375 pound), T2 for 16 years. I was in denial, fitting perfectly the “noncompliant” definition used by the author.
Of course, during this period my doctor and his dietician tried many times to get me to lose weight. They used the usual “lifestyle changes” prescription: the balanced starvation diet and exercise routine, still prescribed by virtually the entire medical and public health establishment. And, of course, because starvation diets and exercise, when I tried them, both made me hungry, I failed over and over again to permanently lose weight.
My doctor’s primary target for the self-care component of my treatment to forestall the ravages of the disease was weight loss; meanwhile, for his part, he was prescribing progressively more pharmacological solutions to forestall the “inevitable” complications of my noncompliance. Sound familiar?
True, I did not get the scare lecture about complications, but that seems like a desperation tactic to me. That is a tactic a failed therapy might result in, to be used by the frustrated therapist to shock an unconscious patient into “compliance.” But, is it right to blame the patient, or terrify him, when the wrong prescription fails? Is the medical establishment unwilling to look at what it is asking for – what it means by “compliance”? If the end – the target -- is weight loss (for all its benefits), and good glucose control, and great lipids, is there no willingness to look at what works for all of these?
Pharmacologically, because on a balanced diet T2 diabetes is without doubt a “progressive disease,” I was by 2002 maxed out on 2,000 mg Metformin and 20mg Glyburide and starting Avandia, and still had out-of-control A1c’s. Then, one day my doctor suggested another way for me to lose weight (the part of my self-care for which I was responsible, and noncompliant). He suggested low carb. As an internist and cardiologist, he had just tried it himself before suggesting it to me. This was 1 month after Gary Taubes’ seminal July 2002 cover story in the NYT Sunday magazine, “What If It’s All Been a Big Fat Lie?”
Within 9 months on Atkins Induction (20 net carbs a day) I had lost 60 pounds. More importantly, I was down to just 500 Metformin and 5 Glyburide. I kept it all off for 3 years, then gained back 12 (after cheating, not counting carbs and not testing daily). So, I switched to Richard K. Bernstein’s “Diabetes Diet” (30 net carbs a day: 6,12,12) and lost 96 pounds in 50 weeks. This time, to avoid hypos, I titrated off the Glyburide completely.
I do not exercise. I am never hungry. My FBG is now usually in the 80’s and 90’s. My A1c’s are now always in the low to mid 5’s (most recent 5.4). I now take just 500 Metformin, and eat a VLCKD diet. My dietary, of just 15 to 20 net carbs a day, limited protein, high fat, and restricted calories, allows the fat I ingest (65% of my diet) and then my body fat to nourish me.
Today, 6 1/2 years after starting this regimen, I am lighter by more than 150 pounds. I intend to lose another 25 in the coming year, and perhaps another 25 in the year after that.
The weapon: a VLCKD, period.
The targets: My total cholesterol, at 188, is down from 214 in August 2002. My HDL, at 67, is up nicely from 48, my LDL, at 111, is down nicely from 170, and my triglycerides, at 52, are way down from 144, my BP, 110/70 (with the same meds), is also way down from 140/90. I do not take a statin, and I do not restrict saturated fats or cholesterol.
The right weapon: the right diet – a very low carb ketogenic diet. Effective self-care made simple and easy: No hunger, no sweating, easy weight loss, and great glucose control, blood lipids and BP’s.

Posted by Anonymous on 12 February 2009

Dan Brown proved, once again, two important things. 1) If you take control, things happen. and 2)It's about carbs, stupid. (The medical "researchers" are just starting to admit this.) Thanks Dan!

Posted by Anonymous on 23 June 2009

Personally I think a lot of what has been said is a crock of shit.

I have had this stupid life sucking condition for a year. For a start, I work out that there are about three types of diabetes sufferers. The "Goody 2 shoes" brigade that plaster their wonderful blood sugar levels and HBA1 fucking C levels all over the internet as well as how they have "Low carbed" and measured all their calories and lose lots of weight and test their capillary blood 20 times a day. They are like the boozers who get addicted to "Recovery" rather rhan the booze. If you are one of these people, well I rake my non-existent hat off to you! you live to please all these nice phsicians who will dearly love you cos you tick all their little boxes and-guess what- you will live until your brains turn to mush, your teeth drop out and you end up stuck in some lousy old folks home where you won't even recognize your offspring as you attempt to chew your liquefied food.

There are those that just give up.

There are those like me who tried hard then gave up and are likely to seek a happy medium between smug diabetic obsesives and those who really struggle as recently I have been.

Part of the problem is medical support that literallay "Bombards" someone with what they need to do. Consequently the average working Joe just gets overwhelmed cos working Joes have to work and cannot be full time crazy diaberic obsesives. When I came out of hospital with high pre coma sugars, well what a honeymoon wehen I was off work as ill. When I rejoined the real uk work world things got more tricky.Diabetes is like loading a huge cumbersome computer programme
that takes up loads of disk space. It slows you down but people just expect you to be as before.

On top of this you have dieticians expecting you to reach impossible weight targets so they can tick their little box. Nurses bluntly describing how your former "Obesity" contributed and saying that your kidney function, tryglicerides LDL and HD fucking L cholersterol need to be constantly assessed and by the way -have you thought of taking statins as well as the 4 shots of shitty insulin a day that half the chemists that you visit do not stock when you need them. Don't get me wrong-the shots are the easy part-a nettle sting gives more pain.

Also-have you written down your blood sugars tested 4 times a day as well as trying to actually hold down a job?

And always the reminder, like the threat of eternal damnation that hellfire priests used to use for "Sinners" "Whoooooo" your feet will be chopped off with gangrene "Whoooooo" you will go blind "Whooooooo" you will have a stroke or hearrt attack or "Whooooooo" you will be impotent cos of neuropathy.At every fucking lousy turn you diabetic industry hangers on tell us what will happen if we don't stick to your path of nice "Compliant" righterousness and all the time there is the specte of blame-like it really is all our fault.

If this is the case then every racing driver-soldier, football player, climber and many more should be refused medical help because after all "They knew the risks"

You may think me ranting and unfair bur a medical systemn that starts by making a person feel. like a piece of crap unless they treat each day as a "Battle" against diabetes does not work, do this to a number of people and they will just not bother. After being bombarded with all the dire medical consequences at the same timeof hearing that my firm could close and put us our of work I just did not bother getting a HBA1C-even though my average pin prick level was around 5.0 millimoles per litre (UK measurement) despite also having a normal eye screen I have not had a HBA1C since. I am just sick of the possibility of bad news. You medics listen up-stop treating us as your own personal tock box project and stop spooking us-after all you could crash your fancy car tommorow even though my advice would be that it is too fast for you. Don't take this post the wrong way but I am sick of smug diabetes sufferers granstanding how wonderful they are whilst some of us are eating shit right now BUT guess what my blood
sugar, though higher os still normal range re pin prick tests

Posted by Anonymous on 27 November 2009

I don't have diabetes, i just happened to catch a preview of a television news story that strongly implied diabetes was mainly just a burden on healthcare and likely the patient's fault. In that case: Should obese people be, based on their physical appearance, denied coverage for any treatment of high blood pressure, cholestoral, back pain, leg pain, poor circulation, etc.? Can workaholics take the blame for high blood pressure, hypertension, and weakened immune systems? and therefore, are they to develope any conditions that can be associated with these factors, shouldn't they be considered burdens whose conditions are their own fault? (Of course, what if they are a doctor, and changing their work habbits would mean less people would be treated? this is not directly related, just trying to demonstrate how acting out of greed without thinking can result in self-defeating consiquences) Or how about accusing workaholics in the field of data entry of being the sole cause of their carpel-tunnel syndrome, and therefore denying them healthcare coverage in the treatment of their condition? Oh, better yet, elderly people have obviously been trying to live as long as they can, therefore can't we say that any health issues associated with their age are their own fault? how about an accusatory denial of healthcare coverage for them? Medicine is medicine, the medical industry is first medical, then an industry. If you want to close the whole system down and let people only live as long as natural conditions will allow then fine. If you want to save lives, by all means do it. If I have to listen to another pinhead (believe me several other terms were denied based on self-censureship) gripe about how much someone else's medical condition is costing them I say hopefully someone in their family (preferrably they themselves) will come down with exactly that condition. Everyone wants to have enough money to live comfortably. Seeing to a person's ailment to insure that they can live at all comes first unless you people have lost your humanity entirely. I cannot claim a completely objective oppinion here, the assenine costs of medical services affect me as well. I may not have diabetes but i have a diagnosed condition that requires monthly prescriptions which, without insurance coverage, would cost more than 150 a month just to insure a normal standared of living. given the mass of material inside each perscription, some neccisary ingredients must come from the bottom of the Marianas Trench to justify the costs. If the costs of machinery and materials are really that great (and i have a feeling much of this cost is from mismanagment [nice word for extortion i think], not from the process of production or usage) Than it is up to the medical industry and the federal government to make these neccesities to the quality of life of our citizens affordable. I don't care if its a tough problem to solve, solve it or forgo your souls. Medicine should be an institution, not an industry. anyone who wants to put a dollar sign on human life is worth less than a penny to me, and even at that poor value should be exchanged for cash equivolent (then destroyed.. not murdered as that would imply that human life were more than simply an economic statistic) to help improve the economy they are so worried about (hope non of your kids come down with diabetes.. if you idiots are successful you'll be paying out the nose to treat it, and for your kid's sake I hope you can afford it). This loss of human perspecitive and de-valuing of human life has been a key indicator of the beginning of a society's downfall throughout history (Persia, Rome, Etc). When you see the impact this attitude has on the individuals within the influence of said culture, you almost start to look forward to it. It's usually not until the whole thing collapses that the people most responsible finally begin to suffer (though not nearly enough), rather than being able to hide behind the almighty dollar and push the consiquences of their greedy influence (maybe include the media for its eagerness to add fuel to this fire simply to improve ratings?) onto anyone else who happens to be more vulnerable. Its times like this that I wonder if human extinction can be avoided at all or if changing our rediculous attitudes will at this point only delay the inevitable. Dont say I didn't warn anybody. To those staring down the barrel of this idiocy, please use anything i have said that might be useful in order to protect your humanity from these money-puppets that have already destroyed their own... i mean, the irony that these people are talking about others who deserve to suffer from physical ailments when they should have been born mute, and yet they're walking around yapping their mouths off about how much it sucks to have to give something to insure the wellbeing of other members of their society. OOh! that just made me think of another one. Is your kid having trouble in school? Maybe its his/her own fault. If they aren't really trying, as indicated by their inablilty to complete assignments on time and to a standardized level of proficiency, I shouldn't have to pay any taxes to provide for education or transportation for the degenerate. Any parents outraged by what i just said? Good. Now we just need to force your child to drop out of school and ruin the rest of his/her life to show you idiots how your actions are affecting others. (and dont you dare mention attention deficite disorder. That is a medical condition requiring expensive appointments and often medication to correct. Since the little brat won't pay attention even though he/she has been told to by several teachers, it is the child's own fault and the full costs of education should be placed on the family if they want their child to continue in the public school system. In case anyone is thickheaded enough to not detect the sarcasm, I have ADD.)

Posted by Anonymous on 3 June 2014

I totally agree. The irony is that "care" of diabetes while in the hospital is atrocious. I am a type one diabetic and had a doctor who took away all my long-acting insulin as well as all of my standard meal insulin. Predictably, I was in DKA within two days. I complained and not a thing was done. If I had reduced my doses like that no doubt my endo would scream at me, and for good reason. Yet a medical professional does the same thing, and meh. Her actions were beyond "noncompliant."


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