Imminent Threat
Not sure how many people remember the old TV show Lost in Space, but we just loved the robot. Although the robot didn’t officially have a name it did have jobs one of which was to protect the family and warn them when danger approached. For those of us who go that far back one of the best scenes is the robot swinging his arms stating loudly “Danger Will Robinson” (hey it’s on YouTube if you want to check it out). The robot was warning Will of an imminent threat, something that was going to harm him immediately.
Now just in case you’re thinking OK what the heck does this old TV show have to do with diabetes we’ll tell you; as it’s a big reason why patients with Type 2 diabetes aren’t engaged with their diabetes management as most would like them to be. It also points to a major reason why many of the companies in the interconnected diabetes management (IDM) will fail. The reality is Type 2 diabetes does NOT pose an imminent or immediate threat to a patient.
We can speak from experience as when you walk into a doctor’s office and that doctor says you have cancer that is a very real and imminent threat. The patient immediately becomes engaged as their life has been threatened. This is not the case with diabetes as it takes years for complications to develop, diabetes is a killer but it’s a very slow killer.
Think for a moment what it’s like when a patient is told they have diabetes. After the initial shock wears off the patient listens patiently as their physician begins to outline what their new life will be like. They are told to test their glucose levels regularly, more than likely told to change their diet and of course assigned a regimen of drugs to take. Most are told to seek the help of a diabetes educator, but few do.
In the early stages the patient follows this outline, testing their glucose, eating differently and taking their meds. However, the patient quickly learns two things, first managing diabetes is a big pain in the rear and second even after doing all this stuff they don’t “feel” any better. Slowly they lose the zeal and begin testing less frequently and while they take their meds they begin missing doses. From the patient’s perspective its no big deal if they miss their afternoon dose of metformin as there are no imminent consequences from missing the dose.
It doesn’t take too long before they stop testing their glucose altogether as these numbers become meaningless. No matter what the numbers are there are no changes to the meds they take or when they take them. This is one reason we have believed that a non-invasive glucose monitor would do nothing to change diabetes management. So, what if that meaningless numbers comes as result of a finger stick or non-invasively it’s still a meaningless number.
To make matters worse most physicians use guilt or threats so that the patient stays adherent to their therapy regimen. If we had a dollar for every time a physician said; “Hey if you don’t take your meds I’ll have to put you on the needle” we’d be retired already. We understand why physicians do this, but this use of guilt or threats creates another problem, as the patient begins to develop a fear of insulin. That it if they are put on insulin it’s a personal failure. See patients aren’t afraid of needles they see insulin therapy as a personal failure. This is unfortunate as insulin when used properly is very effective.
Next the patient must deal with the public’s ignorance when it comes to diabetes. Something that has gotten worse over the years thanks to social media. I will never forget shortly after my own diagnoses being out with my wife for dinner. As we waited for our table at the bar we naturally discussed this new disease I had just been diagnosed with. Some guy sitting next to us who obviously overheard our discussion comes over holding a glass of scotch and states unequivocally; “Hey my best friend has had diabetes for years its no big deal you got nothing to worry about. No big deal at all.” Just ask any patient with diabetes and we can almost guarantee they have had a similar experience of this ignorance.
If we’ve said it once we’ve said it a thousand times if chronic pain was associated with poorly controlled diabetes you can bet the ranch patients would pay attention. The fact is once this pain does arrive its too late. The genie cannot be put back in the bottle.
It also does not help matters much that there is very real bias towards insulin using patients. We see this everywhere. Many insulin using patients themselves look down upon non-insulin users as second-class citizens as if they really don’t have diabetes. Well they have the same disease they just treat it differently. Yet this bias towards insulin patients adversely impacts non-insulin patients.
Right now, you can’t swing that very dead cat without hitting one company or another working on some way cool whiz bang cloud enabled system that is supposed to help patients more effectively manage their diabetes. Systems which are clearly targeted at insulin using patients but marketed as if they work for ALL patients. Now we understand the business rational for targeting insulin using patients, but the real money would come from less intensively managed patients for the simple reason they vastly outnumber intensively managed patients. And these patients need just as much help they just need help in a different way.
Again, if we’ve said it once we’ve said it a thousand times it’s not that difficult to give the patient the how to manage their diabetes, but it is extraordinarily difficult to get them to want to manage their diabetes. A major factor here is the lack of an imminent threat, there is no sense of urgency. Hence therefore we believe other motivational tools are needed.
We have spoken with several companies whose business model is built upon the false premise that patients want to “feel” better. Sure, in a focus group patients say feeling better is their goal as this is the politically correct response. However out in the real world outside of this controlled setting life is much different. As the facts tells us, yes, those pesky facts again, most patients aren’t managing their diabetes as they should.
The bottom line here is without an imminent threat with no sense of urgency patients will follow the path of least resistance, this is human nature. These patients aren’t stupid or ignorant they understand diabetes is serious and needs to be managed. However, they receive no immediate tangible reward something they can see touch or feel for managing their diabetes well. There is little if any constant positive reinforcement for doing all the work. Human nature being what it is why would anyone do anything when they don’t get anything back from all this effort.
We use this example all the time when a person goes on a diet and begins to lose weight they receive lots of positive reinforcement. Friends, family members and co-workers notice and say things like “Hey you look great.” These compliments just reinforce the person’s resolve it helps motivate them it makes all the effort worth it. A patient with diabetes does not walk into a room and have a person blurt out “Hey Dave your A1c looks great today.”
Now one just might think the companies in our wacky world would get this, but they don’t. Rather than understand human nature they focus on the toys in the toy chest. They believe way cool whiz bang somehow overrules human nature. They seem to forget that all these toys even when they are played with does not necessarily make the patient’s life easier. That the use of the toy is just one more reminder to the patient that they have a chronic disease they do not understand, didn’t want in the first place and requires work to manage.
This is the reason we have always favored any system or toy that is elegantly stupid. Systems or toys that eliminate steps that really do make the patient’s life easier. Look at the FreeStyle Libre a toy that owes a great deal of its success to the fact that it does not require calibration and has rather simple insertion process. Or think about the Intarcia exenatide micro-pump, once inserted the patient does nothing. The coming slap it on turn it on CGM from Dexcom (NASDAQ: DXCM) is another example.
What all these toys have in common is they ELIMINATE steps, they make life EASIER for the patient. The fact is the less interaction any patient has with their diabetes management the better. Theoretically IDM can do this however none of the toys we have seen so far have done so.
For the past 21 years we’ve been watching companies fumble about like the Keystone Cops inventing new toys that while way cool and whiz bang ultimately have little or no impact. Fundamentally what these companies have forgotten is patients are humans and not computers that just follow commands. Human’s who in addition to all the other things they do daily have the added burden of managing their diabetes. Since there is no imminent threat no sense of urgency little in the way of constant positive reinforcement it’s understandable why so many patients choose the path of least resistance.
