Helping them accept their diagnosis

Helping them accept their diagnosis

Vijay Gopichandran

Good evening! Today was a very long day at the clinic. We had an annual diabetes screening camp. This is a routine annual ritual that we perform year after year, in which we collaborate with a local organization who funds us, to organize a camp for screening our routine patients for complications. If we find any complications or early indications of them, we initiate appropriate preventive strategies. Often these camps are very disheartening to us from a clinical point of view because we unravel very serious problems that our patients develop silently. Many of our patients who have a well-controlled blood sugar level in a routine fasting and post-meal blood glucose test, show up as having abnormally poor sugar control over the past 3 months on the glycosylated hemoglobin test. This often slaps us hard on the face and wakes us up to the realities of practicing diabetes care in a setting with limited resources. On one hand, we have patients who do not have an enabling physical or social environment to adopt healthy lifestyles and on the other, we have limited access to cutting edge technology and medicines. We scramble to do the best given the circumstances, which is often not enough. I am narrating here the interaction with a young man who came to the camp to see us today.

I was given a table and chair at the far end of the room where the camp was happening. As I was seeing one of the early patients in the camp, my colleague came and showed me a paper on which were scribbled, “the next patient’s brother is standing outside the camp and requesting that we convince his brother for marriage. He is looking for brides for him, but he is refusing as he has diabetes”. My colleague told me that this note was passed on to her by the field health worker. I nodded to her that I will take care of it and continued seeing my patients.


The man was 32 years old, thin built, with a rough beard and a small thin moustache. His beard had a few areas of grey in it. His eyes appeared unengaged as he sat in front of me.

“please tell me, how are you today? Are you taking your medicines regularly?” I asked as a conversation starter.


“Sir, actually, I am not taking medicines for the past 4 months” was his reply. His face lacked any expression when he said this.

“ok, may I ask why you did not take your diabetes medicines?”


He was silent and did not give me a response. His eyes were drifting, and he was seeing behind him and to his sides. He was very conscious of himself and the environment. I have to say here that the campsite lacked privacy. It was an open room where many patients were gathered to have their blood test reports, ECG and other tests reviewed. It was not meant to be a private doctor-patient encounter. In this setting, I had to now initiate and maintain a conversation about diabetes, marriage, eligibility to marry, etc. I requested the other patients standing nearby to kindly give us some privacy and then asked him,

“I understand that your family is trying to get you married. Do you have any concerns regarding that?”


‘yes, sir, I mainly want to talk to you about that. I do not know how to make this decision. Nowadays I have several problems with my body. My feet are constantly burning. Moreover, I am also having dimness of vision. I feel that my body is being affected by my diabetes. So, I don’t want to marry an innocent girl and spoil her life” he said.


I was not sure what he meant by spoil the life of an innocent girl? Is he worried that diabetes somehow makes him ineligible to marry? Is he worried about his sexual capabilities? Is he worried about the prospect of having children? Is he worried about premature death due to diabetes? Is he worried about giving diabetes to his wife and children? I was not sure which of these was his worry or was it something else that I didn’t even think of. So, I asked him,

“are your sexual functions normal? Do you have sexual problems?”


He hesitated for a bit, looked around, ensured that no-one was in earshot and said, “Not at all. All that is perfectly fine” I am not sure if he was completely honest about it. But at that point, there was no choice for me but to believe him.


“are you worried that you will die early?” I asked next.


“yes, sir. I think so. I think I am worried about that. How can I marry a girl after knowing that I have diabetes and it is affecting my body?”


This was a tough question. I was in no position to give him a certificate of perfect health. This man had an HbA1c of 14 (even one unit above 7 is considered as high sugars). Diabetes seemed to have started influencing his vision, and nerves. He had also started having early kidney problems because of diabetes. It was not inaccurate to say that diabetes had started impacting his life significantly. Therefore, I could not tell him there is no possibility of premature mortality. But the question is whether the probability of premature mortality precludes one from marriage? I was not convinced that having poorly controlled and complicated diabetes is a reason not to marry.


“you have diabetes that is poorly controlled. If you start taking your medicines regularly, it is highly likely that you won’t worsen. You can win several years of complication-free healthy life if you follow regular medicines and lifestyle.” I said.


“ok, sir. I can take regular medicines.” He replied.


“in addition, you should also manage your diet and do regular exercise. Do you drink alcohol?”


“Yes, I drink every Sunday and whenever there is a festival and when I meet my friends”


“you must reduce and stop consuming alcohol. That will also help.” I said.


“Sir, I cannot stop drinking alcohol with my friends. If I suddenly stop, they will get suspicious and start asking me many questions” he sounded very much concerned when he said this. I understood now that the issue was far deeper than just a patient with diabetes getting married. This young man had not yet accepted his diagnosis of diabetes and was not yet ready to embrace the life of a patient with diabetes.


I then asked him, “tell me about your visual problem. Are you able to see distant objects clearly?”

“Sir, that problem I have for many years. I saw an eye doctor and he told me that I must wear spectacles. I started wearing them. But then I don’t wear it in public places. I wear it only in my home and when I am alone”


“Why is that? Why don’t you wear your spectacles outside of your home?” I was very much intrigued.

“I feel ashamed to wear spectacles.”


I am a person who has been wearing spectacles from my 13^th year of life. So, I was amused when he said that he felt ashamed to wear spectacles. I pointed to my own spectacles and told him, “I am not at all ashamed. Why are you?”


He smiled shyly but did not answer the question. Now it was clear to me that this young man had serious problems accepting his limitations and adapting his life to them. Just like how he was not accepting his refractory error in the eye, he was also denying the diagnosis of diabetes. The non-acceptance of diabetes was preventing him from adopting healthy lifestyles that are required for diabetes. The non-acceptance was also probably the reason for irregular medication intake and a reason for why he is unable to see a life in which he is comfortable with a diagnosis of diabetes, comfortable enough to share it with another person and make them a life partner.


I realized that my most important role in that situation was to help him accept the fact that he has diabetes and his life will have to be different from before the diagnosis. Non-acceptance of a diabetes diagnosis is a common affliction for many young patients whom we diagnose in our clinic. They go through a very long denial phase. Some of the common misbeliefs that people harbor during this denial phase are – “diabetes is a temporary illness like a fever and will go away after a few months of tablets”, “If one blood test shows high sugar levels, I can repeat it as many times as needed till I get a normal value and then I won't have diabetes anymore”, “after starting medicines, I can test my blood sugar, if it is low, then I can stop the medicines”. Therefore, it is very important for the physician to help patients with diabetes accept their diagnosis in the first place. In our experience, this acceptance is very difficult to achieve. For some patients, it takes a serious complication or a catastrophic health event for them to enter the acceptance phase.


“Brother, the first thing you must do is accept the idea that you have diabetes. Please tell me the following sentence aloud – ‘I have diabetes. It is a lifelong disease. I need to take treatment throughout my life’.”


He said the sentences once and I could immediately sense a change in his voice and his general demeanor. His voice became lower and his face became more serious. I could visibly see him moving from denial to anger phase. In the next few weeks, I plan to take him through a step by step process of helping him accept his illness. I plan to help him know more about the disease and plan to make him repeat the statements that I made him say earlier. A gradual increase in awareness about the disease and acceptance that he has the disease will help him seek out and accept behavior changes required to handle the disease. I think that will be a good start to build his confidence and then discuss the possibility of marriage and a family. When he has accepted his illness, he will be more comfortable talking about it and revealing it to others. When he does that, the chances are greater that he will find a good bride to marry and share a life with.


In primary care, especially while treating chronic diseases like diabetes, it is very important to help patients accept their diagnosis, accept the limitations and restrictions that the disease will impose on them and adopt changes to their life that will help them. This was a very important lesson I learned today during the camp, especially while treating this young man.