Why is diabetology such a good speciality?

If you are reading this publication, I imagine you have already committed yourself to a career in diabetes. Perhaps you are ground down by the manager’s demands to run one stop clinics, do endless annual reviews, read yet more protocols, produce mind numbingly boring cardiovascular risk factor assessments, keep the computerised register running, etc.? Perhaps you are regretting your choice of specialty and thinking you would be able to make more money with a cardio- or gastroscope? It is interesting to look back and see what some of the doyens of diabetes have had to say.

Twenty years ago, the Belgian physician, Jean Pirart (born 1922) wrote an inspiring article ‘What I have to say to a young diabetes specialist after 35 years of experience’ (Pirart, 1983). Among his aphoristic gems were the following:

• Remain realistic. Do not try to normalise all parameters. Keep in mind a list of priorities in decreasing order.
• Do not overburden a new diabetic with too many exams (or too much education in my opinion).
• When you talk, never look at your hospital record. Look at the patient. Watch him or her carefully.
• Do not talk in a scholarly way. ‘High blood sugar’ is as good as ‘hyperglycaemia’. Speak to be understood, not to be admired.
• Be cautious in taking any decision to change something that is 
• running well, however odd a treatment it may seem to be.
• Do not trust schemas and classifications too much. After all the patient has a right to be himself.

John Malins (1915–1992), who ran the diabetic clinic at Birmingham General Hospital from 1955 to 1979, suggested that diabetology was the last bastion of the general physician. In the preface to his diabetes textbook (Malins, 1968) he wrote:

“The more diabetic patients one sees the more difficult it becomes to present the simple picture that so many readers like. Diabetes is a disorder of such infinite variety that it becomes impossible to say that this always occurs or that never happens. We do see thin children with mild diabetes that can be controlled by dieting and fat women who develop severe ketosis… today a diabetic clinic provides the widest clinical range of any speciality in medicine with metabolic, vascular, neurological and psychiatric problems outstanding. In addition there is a chance to enjoy some of the pleasures of general practice which arise from long acquaintance with many of the patients. The chance, all too frequent, to ease the last years of those whose health is slowly failing calls for all the resources of the general physician”.

Despite Malins’ comments about the extraordinary variety of diabetes practice, it has sometimes been put to me that diabetic clinics are boring because the patients are stereotypes of one another. It may sometimes seem like this but the solution is to follow the advice of Frank Davidoff who, in 1996 wrote:

“It is one thing to see twenty different cases of diabetes in the course of a week; it is quite another to see twenty different people as patients, all of whom happen to have diabetes. In every case, the very same biological disease ‘lives’ in a different person, and the disease expresses itself differently in every one of them. Learning about what makes these individual patients ‘tick’ biologically and psychologically; figuring out how best to interact with each of them; deciding how best to negotiate, to develop therapeutic alliances, to use language effectively – all provide potentially endless sources of interest”.

There are plenty of guidelines and algorithms which indicate that treatment of diabetes is essentially simple. It is management of the patient that is so difficult and this is what distinguishes the expert diabetologist. Yes, you have made the right choice – sticking wires and tubes into people is infinitely less interesting and satisfying.