A professional view: Dr Meera Ladwa, MRCP PhD is a diabetes speciality doctor and Honorary Senior Clinical Lecturer at the Queen Mary University of London who leads the Young Adult Diabetes team at Newham University Hospital, a multidisciplinary service providing structured education, technology and psychological support for 16–25-year-olds with diabetes.
Warning: This story talks about suicide.
A typical day
It’s Monday morning and the medical student sitting with me in the clinic has raised an eyebrow. I am talking to my patient about football. I don’t actually know very much about football. I don’t even like football.
“See, with your bolus insulin, the timing is everything,” I’m saying. “A good football player anticipates the movement of the ball, right?” I move my coffee mug and my tuning fork across the desk into formation. “They get themselves into position before the ball is played, so they are in just the right place to intercept. If they are late – if they wait until after the ball is in play – they are going to have too far to run and they are never going to make it.”
Josh
Josh smiles politely at me. He has been listening patiently. “I get it, doctor,” he says. “You want me to start taking the insulin before meals.” Josh is 22 and has type 1 diabetes. He hasn’t seen a healthcare professional for seven years and his sugars have been running sky-high. His eyes and kidneys are already damaged. In his own words, he “went off the rails.” But now he has a job, a girlfriend and a baby.
“I thought, you know, I’m a dad now,” he tells me when he first sits down. “I need to look after myself. But I don’t really know what I’m doing.”
He’s embarrassed, thinking he’s about to be told off. I tell him what I tell everyone – that coming to see me is not a test for you to pass or fail. We are a stone’s throw from a premiership club, where he played for the juniors, so this is how I end up trying to explain to him the importance of pre-meal bolusing through the medium of football.
The medical student says afterwards: “But why did he leave it so long...?”
I know what they are trying to say. But the student doesn’t yet know how cruel diabetes can be, how its overwhelming demands means that some people can only cope by ignoring their condition and pushing it away, trying to pretend it doesn’t exist.
Miriam
Next we have Miriam, smartly dressed and articulate.
She has never forgotten that when she was diagnosed with type 1 aged 11, her mother told her she must never tell anyone she had diabetes, or nobody would ever want to marry her.
It was only a couple of months ago that Miriam finally admitted something; that for years, she has not taken her insulin because she is terrified of gaining weight.
“I don’t know why I’m doing something so stupid,” she says, with tears of frustration, not understanding how she could be so capable in every other aspect of her life and yet unable to figure this out.
Saima
In the afternoon, the student is surprised to meet Saima, a nurse in her 20s with type 2 diabetes and a BMI of 21.0kg/m2.
"About 25% of my patients between 16-25 have type 2 diabetes and often it does not look anything like the textbooks."
I arrange investigations to ensure we are not missing anything; here we see the more unusual causes of diabetes, such as fibrocalculous pancreatopathy and mitochondrial diabetes, on a regular basis.
Mohamed
I’m almost finished when Rita, our specialist nurse (and second mother to so many of our patients), puts her head around the door.
“I’ve just been talking to Mohamed on the phone. He says he wants to kill himself.”
The team is quickly rallied. We have an ad hoc meeting and agree on a plan. Our youth worker, Omar, is already on the case.
Inequality
When I speak to other doctors about my job, I find that they do not envy my role. Working with teenagers and millennials? No thank you. In this part of London, with one of the most ethnically diverse and most socioeconomically deprived populations in the UK, it can be especially challenging.
"Here, inequality is not just a lecture or a workshop. I see affluent young professionals from the City as well as girls trafficked here with no English, no GP and no mobile phone."
One moment I’m perfecting the settings on someone’s hybrid closed loop system, the next moment I’m trying to explain the importance of contraception using pictures and signs.
The day is over. As I make my journey home, I think of all the young lives I have seen scarred by deprivation and addiction and abuse. And then there are the more mundane but grinding aspects of modern life for young people under the shadow of this pandemic, the isolation, the boredom, the lack of opportunities.
There is so much we would like to do to help, but the NHS has been under huge pressure for months. We keep losing precious staff, while at the same time, demand continues to rise.
Bright spots
There will be some bright spots amid the gloom. In a few weeks, Miriam will start psychotherapy at a specialist centre for diabetes and eating disorders. Josh will be beaming when he comes to see me again, as his time in range has more than doubled.
And when I’m almost home, I get a message from Omar. He’s spoken to Mohamed, reassured him and made sure he has the support he needs.
It is rare that a day goes by without our team making a difference to some young person’s life. The next morning, my medical student is ready and waiting, eager to see what surprises the day will bring. I tell them that I hope they go into diabetes care and become a colleague of mine one day.
“Do you know something?” they reply. “I never thought about it before, but maybe I will.”
Names and details have been changed to protect confidentiality. The views and opinions expressed in this article and do not reflect the position of Barts Health NHS Trust or Diabetes UK as a charity or any of its staff members.
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