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[IP] (Fwd) Dr. Ponder's thoughts

I received this very thoughtful reply from Dr. Ponder and thought it 
appropriate to share it with those of you interested in the "dog" 

From: Steve Ponder MD, CDE <email @ redacted>

I've been heartened by many of the supportive comments made by the
group over the past few days. I'm a very positive person and want to
see all my children and teens with diabetes succeed. In fact, what I
tell all my new patients is that living a fulfilling life is my first
goal for them, diabetes should be secondary to that. I do use
analogies and metaphor to attempt to explain not only pumping, but
also a variety of other endocrine disorders to children and their
parents. I have chalkboards in each exam room so I can make (feeble as
they may be) drawings to illustrate concepts. My next step is to use
the power of computers and digital imagery to do the same. Children
are taught moral values and other critical life skills by stories,
fables, metaphor and hyperbole. As I reflected on the stir that I
created, I realized how much I really rely on this in my day to day

To restate the analogy attributed to me in the new "Pumping Insulin"
text, it goes like this: imagine the pump like you would your favorite
pet dog (I don't use this unless the child has a dog), now imagine
tying the dog by a leash around your waist and taking him/her
everywhere you went: to church, to the store, at school, sleeping with
you at night, and so on... After a while, you might start having a
different opinion about the pet, who, after a long day you would often
put in the back yard after a full day of companionship. The pet may
never issue a peep and be the best behaved creature around, but it is
always THERE. Yes, it will protect and comfort you, but it still
always THERE. Yes, the pump is a wonderful device, almost beyond
compare, but it comes with inherent duties and responsibilities as
well as attachment issues. I get annoyed at my beeper and can at least
turn it off when I'm not on call or put it up on a shelf at night (not
a luxury I have with my pump). 

I must portray these issue to the child in a way they can attempt to
understand and compare to something in their daily lives. Remember,
kids come in with a lot of pre-conceptions about pump therapy. Often,
these are shared by parents. Unfortunately, the "readers digest"
condensation of my analogy wasn't able to portray my intent, or the
full analogy itself. Had I had the opportunity to know it was going to
be used, I might have made some suggestions in it's editing. But, it's
out there and I will defend its proper use.

Regarding pump therapy and children. I have gone out on limbs many a
time to advocate a pump for a patient that no other doc would dream of
suggesting it to. In almost every case, I've been pleasantly surprised
how well they have done and how the first impression would not have
been the best one. I understand and share the concerns that many have
about the eagerness of some in the endocrine medical profession to
discourage pump use. Often not based on a rational reason, but due to
a lack of understanding of what it can do for the patient and their
lifestyle. At a prior practice location, the director of the adult
endocrine unit (an MD, PhD) advised a pharmaceutical rep (who has type
1 dm and was interested in the pump) that her lifestyle as a traveling
rep was "too erratic" for the pump. I was floored! But, I'm happy to
report, this doc has since "come around" after she began to "inheret"
my teen pumpers who graduated to being "young adult" pumpers. I like
to think that the number of short-sighted health professionals who
work in the diabetes area is declining, but I'm constantly surprised
by the stories I hear, many on this site.

I don't know if we will ever reach a point where the pump will be
started on most (if not all) children within a couple of months of
diagnosis (or even at the time of diagnosis). I was not prepared to
start Dr. Morgan's daughter on the pump within that 2-3 month time. I
realize her daugher does well with it and was started within the first
year of diagnosis by my former partner. But I have still not yet
crossed that threshold yet. The "analogy" I used with Dr. Morgan's
daughter is the "walk before you run" analogy exemplified by the
"learn to ride a bike first before you purchase a race car"
comparison. I does not surprise me that her daughter is speeding
around now in her "race car " and doing well. I would have started her
on the pump when the time arrived. But I moved on before her daughter
had diabetes for 3-4 months. 

I would be interested in knowing who out there feels that way. My
current opinion is that the child and teen (plus the family) needs
time to absorb the diagnosis and master basic insulin usage and carb
counting before starting a pump. The webmaster feels that starting a
pump during the "honeymoon" is advantageous since it serves to protect
the child against the inevitable mistakes that have a tendency to
occur in the child (and even the adult) starting on the pump. Again, I
must advise patients "starting up" during the honeymoon (or in the
first couple of years after diagnosis) that great control is going to
be part pump and part honeymoon influenced, and that the honeymoon
component will eventually fade away. I just want there to be a
balanced view on what it will and can do for the patient. If I come
across as "raining on your parade" , then so be it. Still, I will
always agree that CSII is far better than MDI as a therapy. But,
travelling the Concorde is far preferable to a 727, but I can more
easily afford the latter than the former.

Until a system is developed that takes out any need for the person
with diabetes to make choices in their daily care, then serious
attention will need to be placed on the psychology of diabetes. I
wonder if Dr. Morgan would have felt me to be presumptuous had I
suggested a pump for her daughter right after her ketones had cleared
after diagnosis. If I were to strip away all other factors, then
clearly the best way to deliver insulin for everyone is by the
pump...and from the onset of disease! But I can't strip away "all the
other factors": such as attitudinal issues, financial issues, social
factors, and how a human being (child or adult) reacts to an illness.
The choice to "use or not to use" and "when to use" will always be
caught up in this human equation that cannot be set aside. 

I've really enjoyed having the opportunity that the mini-controversy
this Pumping Insulin chapter has created to confront some of these
issues head-on. I want to work together with persons with your level
of commitment (and Dr. Morgan) to raise standards and raise
conciousness to the issue of better pumping for all (at any age). I
most of all want to improve standards for how children and teens are
taught the pump and how they are follow-up from an educational

Again, thanks!

Steve Ponder MD, CDE

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