Starting insulin — the needle-phobic patient

PLAB 2 & PRES 3 · prescribing / endocrine · medium · 8 minutes

Candidate brief

You are an FY2 doctor in a GP surgery diabetes clinic. Mr Stephen Doyle, 61, has type 2 diabetes for 11 years. Despite maximal oral therapy and a recent GLP-1 trial that he could not tolerate (severe nausea), his HbA1c is 78 mmol/mol and rising. The diabetes team has recommended starting a once-daily basal insulin (insulin glargine) alongside his metformin. Mr Doyle has been told the headline already and has come to you very anxious: he has a lifelong fear of needles. Please explain the insulin start, address his concerns, and agree a practical plan for his first weeks.

What examiners look for

Starting insulin is three consultations wearing one coat: a pharmacology lesson, a grief conversation (the diagnosis just changed meaning for him), and — for a vocational driver — an occupational negotiation. Candidates who teach only the injection fail the man. Needle phobia is clinical data, not colour. He faints; he has never self-injected; his wife does his finger-pricks. The plan must be built from those facts: demo pen in hand today, first injection supervised in clinic, wife recruited, tiny 4 mm needle technology explained truthfully. "You'll be fine" is not a plan; it is why he has avoided blood tests for years. Reframe what insulin means with his own evidence: his uncle's story is the old pattern of insulin started a decade too late. His background retinopathy is the reason to start NOW — insulin is the intervention that stops the complications he fears, not their herald. That reversal, delivered kindly, is the consult's turning point. Driving is the non-negotiable honesty: Group 2 on insulin means DVLA notification, conditional licensing, monitoring standards and a period off the buses while assessed. Concealment is uninsured, illegal and — with forty passengers — unconscionable. The candidate's job is to make the lawful path feel survivable: occupational health, union, a team that manages the paperwork with him. And the hypoglycaemia teaching is the licence to leave the room: symptoms, four-is-the-floor, treatment carried on his person, never drive below five, wife briefed. A man starting insulin without hypo education has not been started on insulin — he has been handed a risk.

Guideline references

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