Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Reality bites 


I constructed what I thought was a great care plan for my patient with diabetes. I later learned that he wasn’t allowed lunch breaks and had nowhere to store his insulin. I now ask the patient about their daily routine to create a realistic plan. 

I was a second-year internal medicine specialist from Brazil, meeting with a patient for the fifth time in the outpatient clinic. He was a middle-aged with long-standing diabetes that was poorly controlled, despite being on the available anti-diabetic medications. I’d been adjusting his insulin regimen for five months without success.  


The first thing I felt when realizing once again the failure of treatment was frustration. I felt like I wasn’t going to be able to achieve my goals of care. Finally, I asked what a typical day for him was like. He was a construction worker. It took him two hours to get to work, and he didn’t always get a lunch break. He often didn’t take his insulin to work because he couldn’t store it properlythere was no fridge. 


Immediately, a rush of guilt. I felt terrible for having felt like he’d been failing me, when truly I was the one who had been failing him. I’d made what I thought was a great management plan, but it was a plan for a hypothetical patient, not for the real one in front of me. That day, we talked about alternatives for treatment that would actually fit his reality and routine.  


My training in Brazil taught me to fit my knowledge into the context of the patient as a person. Here are a few things that I learned: 


1. Help patients set their own health goals.  

As physicians, we know how diseases work and what treatments are indicated. But patients are the ones who know what they actually can and will do for a treatment regimen. Keep that in mind when creating a plan together. 


2. Ask the obvious, don’t assume. 

It’s easy to assume what another person’s reality is. Always ask. Patients often come from different social, cultural, and religious backgrounds, and that may not be immediately evident.  


3. Understand their routine. 

Before suggesting specific treatments, especially ones that involve lifestyle changes, go through a patient’s daily and weekly routine. This will make it easier to create a more practical and realistic plan together. 


4. Remember that change, especially lifestyle change, takes time. 










This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.