Sadly, this week, we have heard of the death of Emeritus Professor Robert Tattersall, who had a stellar career as a diabetologist, clinician researcher, and medical editor in the UK in the final quarter of the 20th century. Following what some regard as an unexpected and early retirement in 1998, Robert spent the early part of the 21st century investigating the history of diabetes, which he published in two volumes: Diabetes: The Biography (2009) and The Pissing Evil: A Comprehensive History of Diabetes Mellitus (2017). There are so many credits to Robert’s name that cannot be covered in a blog. So, I refer you to a very interesting and enjoyable profile published in Diabetes Care last year by Prof Simon Heller (one of Robert’s mentees), and to his legacy of published research.
Why, you might ask, am I profiling a diabetes physician in a blog that is usually focused on psychosocial aspects of diabetes? Well, it is because he was, as Prof Heller describes, “ahead of his time”. Robert’s parents were both psychiatrists and his wife was a child psychiatrist. Pre-dating most research into the psychological aspects of diabetes, in 1981, Robert Tattersall published “Psychiatric aspects of diabetes – a physician’s view”. This is a fascinating read, and while much is ‘of its time’, some insights are as true today as they ever were. For example, “the emotional problems of the insulin-dependent diabetic have been recognised since the 1920s and will not go away. This has tended to be neglected as an area of psychiatric research and any attempt to link psychiatry more closely to general medicine could well start with diabetes, which … is a useful paradigm of the interactions of the emotions with a physical illness”.
Robert is duly credited with being one of the pioneers of self-monitoring of blood glucose in the 1970s. As Simon Heller writes, “…in parallel articles published in The Lancet, Sönksen and Tattersall showed clearly that self-monitoring of glucose was not only feasible but led to improved levels of blood glucose and patient satisfaction (5,6). Interestingly, when their ideas were discussed at a British Diabetic Association (BDA) professional meeting, the proposal that patients should both measure their own glucose and adjust insulin doses on the basis of the results was regarded as incredible and even potentially dangerous! In a prophetic comment in the article in The Lancet (6), Robert and colleagues included in the abstract the following understatement: “Smaller and more portable machines will make the technique more widely applicable”.” We live in an age where smaller and more portable machines are now more widely available (and their use ‘in the home’ is accepted by diabetes physicians!). The technology is revered and the diabetes knowledge, skills, diligence, stoicism and support applied by people with diabetes remains under-recognised. Furthermore, as we move into pioneering era of user-led developments (Looping, DIYAPS, OpenAPS), this extract reminds us that history has a habit of repeating itself. So, we need to do more to embrace the enthusiasm, innovation and generosity of the #WeAreNotWaiting movement. Importantly, we should remember that innovations in diabetes have always been initially regarded as “incredible and even potentially dangerous”.
Later in Simon Heller’s profile, there is an insightful comment by Robert Tattersall referring to the now outdated concept of “brittle diabetes”: “In a thoughtful and perceptive editorial published in the British Medical Journal in 1985 (10), Robert wrote, “…diabetologists commonly miss factitious disease, …partly from a deep seated reluctance to believe that patients would deceive us wilfully… and… because we have a stereotyped picture of the sort of patient we would expect to ‘cheat,’ which often excludes those considered to be ‘normal and nice’”.“ A key concern of people with diabetes remains, as we published here only last year, that they are often judged harshly by clinicians who do not appreciate them as experts in their own condition. Thirty-five years after Robert’s comment in the BMJ, much of our work at the ACBRD is focused on eliminating stereotypes, and encouraging health professionals in the use of open communication in diabetes consultations.
We have just celebrated World Diabetes Day by honouring the central role of nurses in diabetes care: #NursesMakeTheDifference. So, it is interesting also to note comments by Professor Peter Watkins in his book review of Diabetes: The Biography. He writes, Robert Tattersall “observed that the innovation making the greatest difference to the lives of patients was not so much the introduction of human insulin, but the spread of diabetes specialist nurses. Diabetes led the way in the evolution of the specialist nurse as early as the 1950s, and most other specialties have followed suit since that time. Nurses both listen and provide ample consultation time which doctors might try to emulate and, indeed, Tattersall writes ‘that the doctor must have close acquaintance with his patient and give ample time to his problems’.”
In the Final Thoughts of his profile of Robert Tattersall, Simon Heller offers a powerful reminder to us of what is truly person-centred clinical care: “During his career, Robert had recognized that diabetes is an almost-unique disease in that the success of the treatment depends not on the professional carers but on the person with the condition. He encouraged those who worked with him to listen to their patients and ensure that those with the condition were equipped with the complex skills to manage it themselves. Thus, the role of the professional was to support patients in the daunting task of implementing and sustaining these skills on a day-to-day basis.”
Unfortunately, I never had the pleasure to work with Robert Tattersall, but I have long admired a diabetologist who so clearly appreciated the importance of understanding the person with diabetes. Emeritus Professor Robert Tattersall inspired so many of the clinician researchers who have inspired me. His work and words are so insightful, and so progressive, that they can still give us pause for thought, even today.
Heller SR. Robert Tattersall, a diabetes physician ahead of his time. Diabetes Care, 2019; 42(6): 1005-1008