Of Diabetes and the Whale

Mr. Goldman was the last patient of a long and taxing day. He came in complaining of a painful foot, along with his ever present and smoldering, chronic diabetes. His right foot, which was red and swollen didn’t look good and the aura of his anxiety, tinged with fear, was palpable. 

“Doc, I’m hurting,” he said. “My foot really hurts, it tingles and feels numb. It never hurt like this before and that look on your face makes me worried. And you know I’m upset, so why are you trying to tell me this whale story?”

“Mr. Goldman,” I said, “I’m trying to help you understand how the poor control of your diabetes is causing your pain. The elevated blood sugar from your diabetes is probably the root cause of your foot pain. It can also cause you to have more foot problems, such as a diabetic foot ulcer, which might already be present. This is important because, if left untreated, the condition could result in the need to amputate your toes, maybe even your foot. And if the condition deteriorates and progresses maybe even your leg, like what happened in Moby Dick. What the white whale did to Captain Ahab’s leg, your diabetes could do to your leg. If you know the story, Mr. Goldman I’m trying to make an analogy with your diabetes. If your diabetes is like the whale it could, if left untreated, result in a similar fate.”

“Yes, I’m familiar with the story. You know Doc, I do read a fair amount, and stop being so formal with the ‘Mr. Goldman’.”

 “Ok,” I said, “sorry about that; it’s meant as a sign of respect for you as a patient.” 

“Thanks Doc, but it seems that time has passed, times do change.”

I continued. “I’m just trying to get you to appreciate the seriousness of your diabetic neuropathy and the possible beginnings of a diabetic foot ulcer. I know its complex and can be frightening but…”  

“Ok Doc,” he interrupted, “listen, I got some time, so please tell me again how you’re going to stop my foot pain and where the whale story fits in.”

I remebered reading about a technique called narrative medicine, which uses compelling stories to illustrate helpful insights for the patient. “Well, maybe we can use the Moby Dick story as a parable about…” 

 He interrupted me again, openly frustrated at the imprecision of my answer. “Parable, schmarable, Doc, tell me what to do about my foot pain.”

“All right” I said, “first we need to educate you in a more dramatic way, about your diabetes and how to better manage it for good blood sugar control. You need to treat your diabetes like Ahab did when he was hunting for the whale, with a vengeance: If you don’t attend to your diabetes with a diet to lose weight and take every day the medications that I prescribed for you, your diabetes will attack your body with a painful and lasting vengeance. This is exactly what is now happening to your toes and your foot. Sorry if I got carried away, but I’ve seen some bad results of poorly controlled diabetes, and I want you to realize how serious your diabetes could be. I’m going to add another different kind of medication to the others that will help keep your blood sugar in good control. And, I’ll give you some new medications for your pain.”

“Ok Doc,” he said with a faint smile, “but go easy on me. Now what’s the connection between my diabetes and the whale story?”

“It’s like this,” I began slowly. “The white whale represents your diabetes and the chronically elevated blood sugar that is associated with it. The whale is strong and dangerous because of its abundant fat blubber and it gets its strength and essence from its fat. In a similar fashion, Mr. Goldman, your type 2 diabetes, is to a large degree driven and made worse by the 45 pounds of excess abdominal fat that you carry. The powerful and destructive whale, or in your case your diabetes, has already taken off one of Ahab’s legs. Ahab is now in a vengeful fury to strike back and kill the whale. As so you should also strike back by losing your excess stomach fat and using your medications to control and prevent your diabetes from progressing.” 

 “Doc, I ain’t no whale, so don’t…” 

I cut in, “I know that, but unfortunately Ahab loses the fight and the whale sinks the ship, just as your diabetes could sink you. Hopefully, unlike Ahab, you will prevail. Let me explain how this could happen. Your diabetes is a condition where the body can’t regulate and control its blood sugar level. What elevated blood sugar does to the body’s blood vessels is like what salt water does to the fenders and metal body of a ’56 cherry Chevy that is parked at the beach for a couple of months. It corrodes, rusts, and destroys the metal. Eventually the salt water vapor literally destroys the car. Similarly, high blood sugar will tear-up, clog, and destroy your body’s blood vessels, so that your blood flow is reduced or even stopped. Without a good continuous blood flow to the eyes, kidneys, and nerves, as well as to your legs, they begin to wither and die. A frequent consequence of diabetes is the nerve damage that causes your foot pain and the loss of sensation in your feet. As diabetes progresses causing a reduction of blood flow in small blood vessels, it can lead to skin ulcers and infection, which when not aggressively treated can result in the need for amputation and other bad outcomes. With poorly controlled diabetes, as when Ahab’s ship sinks, so will your foot and the quality of your life sink”.

“I get it, Doc, but why the vengeance? It’s kind of a strong message for us mild-mannered patients who are not whalers.”

“Yes, I know” I responded. “I suppose it is strong and it probably reflects my frustration that most diabetic patients don’t deal with and respect their disease enough to prevent the unfortunate problems that develop until it’s too late. If diabetes is constantly attacking the blood vessels of your nerves, eyes, kidneys, and legs with a vengeance, don’t you think you should counter-attack with a vengeance to preserve your health? Don’t wait for the doctors to save you, or your legs. We can’t do it alone. We need the patient to be a part of the treatment, not as a passive victim but as an active partner working with their doctor. You have to adopt a new mindset for dealing with your diabetes, one with more active participation and less passive neglect. You have good tools: your diet, medications, and me. You’re a smart man, so why don’t you use them. Why not, Mr. Goldman, what’s holding you back?”

 There was a pause, something unusual for this patient who is seldom at a loss of words.

“Doc, you know that when I put my mind to something I usually can do it, but I’m distracted. You remember my wife, Joan. Well, she’s not doing so well with her cancer. You know we talked about her condition a while back. Well, now I’m kind of struggling with her care, especially at night when I have to get up and help her. My diabetes just doesn’t seem so important; it’s her I worry about. Yeah, I probably don’t eat right, and I do snack at night, and I know I forget to take my medications when I’m upset. I just haven’t been focused on myself. I know I’ve been more concerned about Joan than my diabetes.”

“I’m very sorry to hear about Joan’s condition, I remember her very well and I have always liked her,” I said. “I know how much you worry about her. But if you don’t take care of yourself, you can’t take care of her. You know, Mr. Goldman, in a sense you are the captain of her ship, and she needs you to be healthy, now more than ever.”

 He paused and averted his eyes, then continued, “Thanks for listening and caring, Doc. You know when you tell the story that way, I guess it makes sense. I’ll really take better care of my sugar levels. Thanks for your time and the new pills for my pain, but I need to go. I need to get home for Joan.”

As he got up and walked to the door, I said, “But please remember, Mr. Goldman, attack your diabetes with a vengeance.”

 “I will,” he said, “if you will stop with the formality, I’m your patient and you’re my doctor, so it’s OK.”

Flustered, I asked, “Then what do you want me to call you?”

He turned back from the door and met my eyes with a warm but penetrating look. He held his stare, then smiled and, with a slight nod of his head, said…

“Call me Ishmael.”  

Peter Vash, MD, MPH, is an internist, endocrinologist and an assistant clinical professor of medicine at the UCLA School of Medicine with a private practice in Los Angeles.