Diabetes: big problem, little confidence

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By Rowan Hillson

The first time I increased a patient’s insulin dose I lay awake all night worrying that his blood sugar might fall too low. I was a house officer, and insulin was scary! The patient slept well and safely.

Diabetes is common, chronic and complicated. A recent nationwide audit of 12,191 people with diabetes in 206 English acute hospitals found that 15% of beds were occupied by people with diabetes. Worryingly, 37% of these patients experienced at least one error with their diabetes medications (the full results can be read here).

The National Patient Safety Agency (NPSA) has had over 16,000 reports of insulin incidents. In 2010 the NPSA issued an alert requiring action for all health care professionals to improve prescribing and administration of insulin, which was linked to a “Safe use of insulin” e-learning course.

I trained over 30 years ago. Are junior doctors more confident now? Apparently not. A study of 2149 junior doctors by George et al provides worrying evidence that UK trainees lack confidence in managing diabetes. Just 27% were fully confident in diagnosing diabetes, 55% in diagnosing and managing dangerous low glucose and 27% in managing intravenous insulin. Regarding management of diabetes, 24% of respondents would “not often, rarely or never” take the initiative to improve diabetes control. 43% would not adjust insulin in patients with poor glucose control.

Confidence is a combination of knowing what to do and believing you can do it. Experience helps. Also, we all need to know what we don’t know and when to ask for help. An unconfident doctor may make the patient anxious. Galen believed that in the 2^nd Century: “Confidence and hope do more good than physic”.

Trainee doctors receive varying amounts of diabetes training and variable supervised experience of looking after people with diabetes. With too little training, trainees may rightly be worried about managing diabetes. Inadequate care of people with diabetes in hospital could worsen virtually every clinical outcome regardless of the main reason for admission. It also worsens patient experience. Diabetes is a common, potentially dangerous but eminently treatable condition. All units in all hospitals should have access to a specialist diabetes team. And trainee doctors should have training and support in diabetes management until they each feel confident in looking after people with diabetes under their care.

Table from the paper ‘Lack of confidence among trainee doctors in the management of diabetes: the Trainees Own Perception of Delivery of Care (TOPDOC) Diabetes Study’, QJM: An International Medical Journal, Advanced Access, 21 April 2011

Read on for an excerpt from Dr Hillson’s commentary ‘Diabetes – big problem, little confidence’, which is published in QJM: An International Journal of Medicine, Advanced Access, 21 April 2011. You can read the original paper and the commentary for free on the journal’s website.

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The management of diabetes requires expertise and precision. Diabetes care has become increasingly complex. Mistakes are made not only with insulin, but with the increasing number of non-insulin hypoglycaemic drugs. Most trainees are unfamiliar with exenatide, or pioglitazone, for example. They may not realise that the latter can precipitate cardiac failure and increase fracture risk. They may not realise that warfarin may increase the hypoglycaemic effect of sulphonylureas. But trainees are only too aware of the complexity of diabetes care…

Regarding management of diabetes, asked whether they would act, 24% of respondents would ‘not often, rarely or never’ take the initiative to improve diabetes control, 64% said this for adjusting oral hypoglycaemic therapy and 43% for adjusting insulin. The fact that 57% would adjust insulin is worrying, bearing in mind their admitted lack of confidence about this drug. Questionnaire studies are, by definition subjective, but so is self-confidence! This is not solely a British problem. An American questionnaire study of 52 resident physicians found that 48% were ‘not at all comfort- able’ with intravenous administration of insulin.

Doctors need appropriate confidence in their knowledge and how to apply it to the care of each patient. Obviously one has to have acquired the knowledge in the first place! And recognizing the varied presentations of particular diseases and how to individualize treatment requires experience. There has been concern that reduced trainee hours limits opportunities for experiential learning. Awareness of the boundaries of one’s knowledge and that there is more to know is a key factor in maintaining patient safety. Over confidence is dangerous. Lack of confidence may be safer, but only if it triggers a request for advice and stimulates learning. Lack of confidence may mean that nothing is done—‘I’ll wait until the ward round tomorrow – I don’t want to trouble Professor Hippocrates in clinic and I had better not refer the patient to the diabetes team without his permission.’ An unconfident doctor may transmit his or her unease to the patient and impede recovery…

It is not just the patient who suffers; unconfident doctors may feel anxious and inadequate.

Dr Rowan Hillson is National Clinical Director for Diabetes at the Department of Health, and a consultant diabetologist at Hillingdon Hospital. Her commentary to this paper is to be published in QJM: An International Journal of Medicine.