A recent reminder of the limits of diabetes technology

As excited as I am, and many people are, about making major strides in improving the capabilities of diabetes technology, we have to keep in mind the limitations of technology.  There is often a time and a place where innovations can improve the daily life and “workflow” of a person with diabetes, but there are situations where face-to-face human encounters will never be replaced.  I had a recent reminder of this.

At one of the locations where I work, I do regular video-chat appointments with people with diabetes who live in remote areas.  At one such visit recently, I spoke with a patient, Gloria, who was using hundreds of units of basal insulin a day and hundreds of units of bolus insulin a day.  Gloria lamented the fact that this amount used to control her diabetes well but no longer was doing the trick and her hemoglobin A1c was now over 14%.  There are many considerations in a situation like this, including ruling out an infection as the cause of her high insulin doses “no longer working,” and after thinking this through, I was tempted to proclaim her situation due to worsening diabetes and insulin resistance.  I was ready to switch Gloria over to U500 insulin (five times the concentration of “normal” U100 insulin… think about the new forms of laundry detergent where you need less fluid to do the job).  This is a somewhat drastic step because of the risks of confusion on the part of the patient but especially the rest of the medical community over her insulin doses, since U500 is relatively infrequently used.

Before switching Gloria over to U500, I asked her to make the multi-hour drive to come see us in clinic, in person, face-to-face.  I wanted to make sure she was actually using her insulin properly before ramping up her dose.  She met with our excellent diabetes educator, who discovered that, in fact, Gloria was making several errors in how she was injecting her insulin.  Over the next two weeks, without any changes in insulin dose, Gloria’s blood sugars came down from 300s and 400s to 100s and 200s, and we avoided needing to switch to U500.

Sitting together with the patient and diabetes educator, watching the patient go through the end-to-end process of injecting her insulin was not something we could do over a video-chat from hundreds of miles away.  There was nothing that could have replaced this in-person, and personal, interaction.  Even as a technology proponent, I smile at that simple fact, because it is the human interaction that led me and many others to become physicians.  When designing new technologies, or thinking about how to implement existing ones into practice, it is important to remember that human interaction cannot be replaced in every situation, nor should we strive to do so.  Technology should serve to augment and enhance these interactions.

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About Aaron Neinstein, MD
I'm an Assistant Professor in Endocrinology and Director of Clinical Informatics at the University of California, San Francisco.

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