Thread by @medicalaxioms

Common Doctor Error:

If the plan isn’t working, replace it with a more complicated plan.

I saw a lady who had been admitted repeatedly over the last year for DKA.

Each next resident team tried to develop an increasingly complicated sliding scale for her.

I said, “There is only one medicine you need to take for right now. Take one single injection of long acting insulin every day.”

Nothing else really matters. She just needed enough circulating insulin to stay out of DKA.

Other things matter. ACE inhibitor, statin, aspirin, blood pressure control. Tight blood sugar control.

The issue here is PRIORITIES.

When working together with a person of limited health literacy (and probably literacy in general), the doctor must learn to be simple. Simple and clear. “Take this injection every morning.”

Over time, in the light of success from this single treatment, and no longer missing outpatient appointments due to another stay in the MICU, you can add ONE MORE MEDICINE.

Be ready to abandon it if it damages the success you were having with THE SINGLE MOST IMPORTANT MEDICINE which is once daily long acting insulin.

Somewhere hiding in all this is a fear we teach residents of looking like a “bad doctor.”

“You sent a lady with DM1 home on ONE MEDICINE? That’s malpractice!!”

I disagree. Having her try to manage even a second medicine when she can’t get the first one right is malpractice.

We spent a long time trying to figure out why she couldn’t get the first one right. Then the intern figured out at discharge she had never picked up her long acting insulin because everyone before had ordered the wrong one that wasn’t covered by insurance. >$100 instead of free.

Kaplan-Meier curves are long. Therapeutic alliances are built on trust developed over time. Simplify. Start with the top priority. Build over time. Add less important things in later. First, prevent readmission if possible. The best medicine is done in the clinic.