Together, we will go our way

This is the 100th post on We Were Promised Hoverboards, and this time I'm handing over the reins to a couple of incredibly inspiring healthcare professionals.  

When Neil and Athinyaa spoke at DPC16 at the start of the month, everyone listened - it was a heartfelt, emotive talk about providing care to people, not patients.  This blog they've written continues that theme, and it's incredible.  Enjoy.

It'd been a few years since I attended Diabetes UK Annual Professional Conference. I used to find some of the sessions interesting and helpful, but really I preferred other conferences for technical content and it was foremost a networking event and somewhere to catch up with colleagues. Last year I had the chance to attend just one day after several year’s absence. This one was different and it tugged on a heartstring. You see, in the last several years, in the last years of my training and first years of being a consultant, I had also changed.

What was different about #APC2015? It was people, people with diabetes were there. How was I different? The answer is the same as why I thought the APC was different: the relationship with people living with diabetes. So, what changed in me? Had I been a bad doctor? Had I a bad attitude? The answer lies in a question. My colleague, Athinyaa Thiraviaraj and I were asked this question by Dani @danianddanzel a few weeks ago. The two of us had been working together for more than 3 years by this time. We'd been slowly bouncing thoughts and ideas past each other in reaction to the vagaries and trials of diabetes care, whether that was in the acute setting or clinic.

Dani asked what had motivated us to make changes. Was it our patients? She guessed that we wouldn't have made the change otherwise.  As we responded together, all the thoughts and ideas that we'd been talking over the last few years crystallised out.  Athinyaa said she thought it was both a difficult and easy question. She agreed that we both knew who had motivated us - people living with diabetes themselves. 

My first thought was about insight, or self-awareness, a sense that things weren't going right in what I was trying to do for people.  I'd chosen this life, spent years studying, doing exams and practicing medicine. Surely, if anyone, someone like me should know what is important in diabetes care and the medical risks involved. Why couldn't the people I saw in clinic see that these things were important? Why couldn't I get this across? Even at the end of my training I knew that sense of failure was inside me; I was already realising that I wasn't getting through to people like I thought I should. 

As I became established as a consultant, after a year or two, I gained something that I did not have as a trainee: continuity.  In seeing people again and again, relationships began to build as I got used to people and they got used to me. As that happened, I could see that people living with diabetes had needs that were different from what I was giving. I struggled with that knowledge. I had felt a failure. I had to admit that before I could change. That's the most difficult part. Nothing can change without admitting that there is a problem. Athinyaa has been really clear that where we were now in our careers was a factor; we were now consultants and so truly owned our decisions. It takes an empowered clinician to believe in empowerment.

So what were the actual changes? We started listening. It was as simple as that. We listened to the person sitting in front of us in clinic, the person in the ward and even in the high dependency unit. Listening was simply that: actually hearing what the person wanted to say, giving space, allowing them to say what they wanted.  In active listening we showed congruence, we were in the room with the person, not thinking about their numbers and risks.  It allowed us to express empathy. In accepting what they felt important at the time, understanding how people actually felt and what they wanted we learnt more about them, as a person. Yes, numbers and risks were important to us as clinicians and maybe to the person talking beside us, but maybe ‘the numbers’ weren't top of the agenda for the person themselves at that time. Looking back, we both had respected people with diabetes before, but now we had begun to demonstrate that respect better. 

Listening was a main factor in the other great catalyst, the diabetes online community. We listened there for weeks and months before actively taking part. It has helped change us further, adapting our attitude, behaviour and language. We both found that the more we changed, the more rewarding it seemed for both the people living with diabetes we were caring for, but also for us as healthcare professionals. It was a win-win scenario. 

It is very difficult to make these changes.  Medical training schools us to listen, extract information as a clinical history, analyse it and come to a conclusion about diagnoses and management plans.  As Athinyaa is fond of saying, the clinician needs to put aside the 'fixer'. Life's problems don't have simple fixes, unlike medical problems. We defined the medical / diabetes problem on our agenda, but what about the person, what about what they valued and wanted? You cannot separate diabetes from someone's life. As I heard pointed out recently, if you hate diabetes, you hate a part of yourself. 

The change was that we were listening to the person. We were separating the person and the problem, leaving aside the medical problem and the 'fixer' and listening to the person. Setting aside the medical problem as we saw it, it left us able to hear them. In doing so, we moved away from the traditional directive model of care to a partnership with the person with diabetes. A vital part of this partnership recognises the person with diabetes as the Expert.   Our role is to be one part of the person’s wider support, adding our own knowledge and skills as diabetes specialists to theirs. And yes, this relationship based on trust is about mutual respect, but we believe that the healthcare professional must offer this respect to the people living with diabetes before deserving or expecting it in return.

The people who we saw in our clinic responded with impromptu feedback. This was part of listening rather than a formal survey. It also happened through the diabetes online community.  They said the experience was better.  While we strongly believed in this engaged supportive care, it was out of step with other colleagues. The feedback was important to us as we needed that encouragement to keep going. Every person with diabetes we have come in contact with, real and virtual, over the last several years has motivated us to change and adapt.

This was an organic change, to a culture of partnerships based on honesty, transparency, active listening and above all, unconditional positive regard. Now, we were not awful physicians to begin with, but to acknowledge our weaknesses and apply these principles in a focused manner meant we were able to enter into meaningful engagement with the person living with diabetes.

So what changed? Just us - as individuals and as a team.

Why did we change? For the people who trust us with their health, because they always come first

@RNeilABlack

@athinyaa

#DiabetesWest

Libre - what do I reckon

I've been asked a few times (well, a couple of times), on Twitter what I think of the FreeStyle Libre so instead of sending a million tweets all at once, I've tried to summarise those thoughts here.  Remember this is just what I reckon* and bear in mind that at the time of writing, I've had a total of five weeks use out of their sensors.  For more thorough reviews over a much longer period of time, you should be reading Mike's blogs here.

* I'm going to keep linking to that video because a) it's funny and b) it's a reminder to keep grounded about our opinions on stuff generally

I've already written twice about the Libre:

- This is about how I felt before I started
- This is about my experiences of my first sensor

But I'll try and give some of my more general thoughts on it in case it proves helpful to anyone thinking of parting with the money for the first time.

• It gives you more information, and (here's the caveat), with the right understanding, more information is very powerful.  It's not about the number of results - with the right tolerance for pain, you can get the same amount of data but the information (about what direction your BG is heading) is a very important addition

• It can be a very motivating tool.  Diabetes isn't a game, but approaching it like one can be beneficial.  I get a big psychological boost from seeing the trace line staying within the bounds that I set spurs me on.  It also gives me confirmation that I know what I'm doing (at least some of the time), but...

• When things aren't going my way (particularly when I'm high), I find the Libre very demoralising to the degree that I think it almost has an adverse effect on me.  Recently my BG was rising and rising and rising and I'd ruled out illness, bad carb counting, bad insulin/cannula... everything.  And still it rose.  As it's so easy to swipe and test, that's what I do.  And it makes me unhappy and frustrated which doesn't help.  With a fingerprick, I feel like I make much more of a choice to test, and so I can switch off from it if I want.   I don't approach it in the same way with a Libre.

• It makes me feel more confident that I can correct from a relatively good reading (say 7.5mmol) to something 'better' like 6mmol and not go too low.  It's like it gives me the opportunity to nudge my BG either up or down to stay within my own target range.

• I feel like I've ended up eating fewer 'proper' meals and started snacking more as it gives me the chance to feel more in control of how my BG is behaving.  I'm not sure that this sort behavioural modification is a good thing or not, but it seems to be an unintentional side effect.

• It takes the stress out of some aspects of diabetes, particularly overnight basal testing.  Being able to get a full picture by swiping once every eight hours means I can test right before bed and first thing in the morning and start to identify any problem areas - I think that's a real positive.

• The graphs and data the software gives you are very helpful.  I've never seen my own "ambulatory glucose profile" before, but I feel a lot better being able to see it.  The HbA1c estimator is also pretty helpful, and (in my limited experience), not far off being accurate either.

• You have to decide for yourself how you define its accuracy.  I know what I kind of expect my BG meter to tell me when I start feeling low, and equally when I get that sticky feeling behind my eyes when I'm going high.  The Libre isn't always going to give me that same figure, but as long as I have that internal calibration, I feel pretty confident being able to dose or even correct from it's reading. But again...

• Knowing its limitations is important too.  Don't use if before driving (always finger prick), don't use it if you've got an arrow showing rapidly falling (or rising) glucose - you need blood to really understand what's going on.

As with everything related to diabetes, it's all very individual.  You might end up with a reaction to the sensor adhesive (as I know a few people do), you might find it helpful where I find it frustrating (and vice versa), or may not find it 'accurate' enough.

I wasn't sure before I started using it but I think it was worth the cost of the reader and one sensor to understand what I was going to get from it.  If you can spare about £100 then I'd probably say go for it, just to understand what your experience is.  After that it becomes a more informed decision - you understand more about whether what you get is worth it for you.

Hope that's helped someone somewhere!

Sugar and spice and all things in moderation

*Deep breath*

Sugar Tax.  I don't remember anything that has so divided that diabetes online community.  Sure we all have different views, that's what makes us a community.  Of course we don't all agree - where would the fun be in that?  But the announcement of the Sugar Tax has everyone scrambling for an opinion.

I'll admit a few things from the start.... firstly, I'm pro Sugar Tax (for reasons which I'll explain), and secondly, I'm not sure writing this blog is the best idea I've ever had - experience tells me it could end up with me taking a week off the internet....  It's important to realise that my opinion is no more valid than anyone else's.  I'm not right, but neither am I wrong.  It's just what I 'reckon'.  And who doesn't love a good reckon?

So I'm pro Sugar Tax... light your torches and grab your pitch forks.  Why am I in favour of it?  Incentivisation.  My academic background is in economics (so I'm also generally pro Free Markets too), and I like the theory of how individuals react to incentives.  That theory generally being that when faced with a choice over two 'identical' products, the rational choice is to choose the cheapest one.

Now Coke and Diet Coke aren't quite identical, but they're pretty close.  If one is cheaper than the other - the rational choice is to choose the cheapest one right?  Why pay over the odds for a Coke when Diet Coke is (almost) identical?  Add to that, the differences are that Coke has more sugar (and more calories) then you're almost winning twice.  Changing behaviour is difficult, but people acting rationally, understand the dis-incentive in choosing more expensive Coke, over cheaper Diet Coke - so it should work.

But this is where it gets tricky.  In theory, theory and practice are the same.  In practice, they aren't.

Sugar Tax comes with a whole host of other things to consider.  Is the level of tax going to be big enough to make everyone behave rationally?  Probably not (price elasticity of demand is what you're thinking of there).  Are there socio-economic implications of increasing tax on soft drinks?  Yes of course.  There are loads - too many to even begin to discuss here.

Is Jamie Oliver a bit annoying, and prone to the odd diabetes-related gaffe?  Yes of course.  Isn't it a half measure if it doesn't include sugary milkshakes?    Yeah.   What about my hypo treatment?  Agreed.  There are alternatives, but you need something that works for you.  Thankfully Diabetes UK have our back on that one.   Why not make fruit and veg a load cheaper instead?  Yeah why not?  Completely agree.  Ask a farmer how much he makes off a 20p cucumber...

In my humble opinion (which, remember, counts for no more and no less than yours), I think people hear the announcement of a Sugar Tax and assume it's the only solution being proposed.  I don't think it is, and don't see how it can be.  Affecting the behaviour of a huge number of consumers isn't going to happen overnight, and isn't going to be done by a 7p levy on a can of coke.

I think the majority of people know that being overweight and inactive is bad for you, but they don't change their lifestyle.  Many people also know that smoking is bad for you but people continue to do it.  Though that number continues to fall as tax rises and the number of places you can smoke decreases.  Multiple measures gradually affect behaviour.

We already have a limit on advertising junk food to kids.  Placing sweets near supermarket tills is on its way out.  Evidence shows that indeed in some parts of the world, sugar tax has some effect on changing behaviour.  It won't change the world overnight (not least because you won't see it for two years anyway).

It's easy to be cynical and say it's patronising, pointless, punishing those who are already worse off.  But it's also easy to think that we have a responsibility to ourselves to be healthy, to reduce our risk of cardiovascular disease, strokes and Type 2 diabetes.  And if we don't want to, that's fine, but you'll have to pay a small premium for it.

Anyway - it's just what I reckon...

Cheers.

I wish

I wish that "what's my blood?" wasn't the first thing I thought every morning.  I wish that sometimes, waking with the all too familiar feeling of a dry mouth didn't set the tone for my entire day.  I wish that feeling light-headed at 6am didn't mean scrabbling around in the dark for jelly babies before I can have a shower.

I wish I could drive whenever I wanted.

I wish that sticking a needle in my fingers seven or eight times a day wasn't necessary.  I wish I didn't have to stick a needle in my stomach twice a week.

I wish I could go away for the night, for the weekend, for a week, without it feeling like a military operation.

I wish that being ill was just that - and not an assault on my entire body.

I wish that I didn't have to carry so much stuff around with me all the time.  I wish I didn't have to keep spare sets of everything all over the place.

I wish I could go for a run without ziplock bags of jelly babies.

I wish my blood sugar didn't have to dictate my mood.  I wish my partner understood my mood-swings.

I wish I didn't look at a plate of food and see numbers.  I wish guilty pleasures didn't try to punish me for hours afterwards.  I wish that carbs didn't sometimes feel like my enemy.

I wish it wasn't a fight.

I wish my brain would switch if off sometimes.  I wish I didn't think about test results.  I wish I didn't have a familiar hospital routine.

I wish I could go to bed when I was tired without needing permission from a finger-prick.

I wish that this list didn't represent every day of my life.  I wish that sometimes it was just a little bit easier.  I wish I could have a day off.

Maculopathy and worry

I'm a worrier.  There - I said it.  I worry about things that I suspect most regular people don't worry about... I spend a fair proportion of my time convinced I've mortally offended someone, and that the sun might not come up tomorrow.

Having a long term condition like Type 1 diabetes unfortunately comes with a fair amount of worry as standard.  The longer you live with  it, the more aware you are of what can go wrong.  Whilst some of it lies within your own control (stable, lower HbA1c, attend regular checkups, good diet, active lifestyle etc.), sometimes life throws you a curve ball.

For me, that came a few weeks ago after my annual retinal eye screening appointment...

"Your latest eye screening showed results of diabetic maculopathy..."

What?  Worry levels set to max.

A small segue to talk about language... is that sentence above what anyone wants to read?  No.  Is it a bit clinical?  Yes.  Is there a better way of doing it though?  Not sure.  If there's something wrong - I want to know.  An alternative along the lines of "there was something wrong/abnormal on your last screening..." is more vague and isn't less comforting.  Language helps, but here I think it's a tough one to crack.

So I phoned up and made an appointment for the eye clinic.  You may have noticed I was in Glasgow last week so I had to wait until today for my appointment.  Worry levels dropped slightly, but remain constant.

My confirmation letter turned up before I went to Glasgow and didn't fill me with confidence...

Maybe it's a test?

So this morning I took my daughter to school and headed off to the eye clinic.  By this time, I'd had chance to talk to a few people who'd received similar letters and nothing had come from it.  Worry levels lowered.

Now the thing with the Eye Clinic is that it's very different to the diabetes clinic.  Different hospital, different environment, lots of people there for a lot of reasons.

Thankfully the sign is big enough

It's basically chaos.  The whole thing is overseen by a receptionist with 10 different paper lists which she updates as people hand over their different coloured appointment letters (all whilst she's sorting some other problem out on the phone).  It's not welcoming in the slightest.  Worry levels increasing...

I'd got there early (overly worried about being late) and was whisked away for an eye test and some drops.  Interesting point to note is that if you're ever asked to read a line on the eye chart, you don't have to just try and read the bottom one (I thought it was a game).  If there's a red line across the middle, that's the average - anything below there and you're doing well!

"Drops will take 20 minutes to work and wear off in 3-4 hours.  Through the grey double doors and wait outside room 8 please"

This is the door opposite room 8.  Worry levels increasing.

Reassuring...

The 20 minutes of purgatory you go through when waiting for the drops to work is a strange time.  Your vision gets gradually worse whilst you contemplate your vision getting worse.  It's also a time for people watching (the national diabetes sport).

There's a lot of things to dislike about waiting rooms.  I often feel they're a window into your future to some extent.  A few people turned up with orthotic shoes on.  Someone else had an eyepatch.  Everyone was older than I was and it seemed unfair (not for the first time), that this was happening to me.  Worry levels replaced by despair.

Finally I got the call.  I'd been in the building for almost 40 minutes.  I was in the consulting room for another six.

The doctor told me (with a smile on her face), that I was the first Type 1 patient she'd seen for a while.  I smiled back, but wasn't sure I'd got the joke.  She told me my previous HbA1c results were good (thanks!) and I mentioned I'd had it tested in Glasgow last week and it was 49mmol/mol (or 6.6% in old money)...

"Wow" she exclaimed.  "Be careful!  Do you have any hypos?  Do you drive?"

As we all know by now, that one exchange is a blog in itself.  My HbA1c is above NICE recommended guidelines (and will no doubt stay there).  Of course I have hypos, I inject a drug that causes them if I don't eat exactly the right amount/do any exercise/it's a bit warmer than usual.  Of course I drive.  Why wouldn't I?  Normally, I'd have said something, but I'd had enough.  All I wanted to know was how bad the results were.  Worry had returned.  Despair had fled.

"Look here" she said, indicating to the top of her ear, shining a bright light into my eye.  "Look up".  More shining.  "And down" eye drops and bright lights don't mix well.  "To the left".  Almost over.  "Aaand right".  Repeat for the other eye.

"OK, I'm happy to discharge you from this clinic" she announced brightly.  Eh?  What?  You sent me a letter that said maculopathy.  That's bad.  I've been worrying about this for over a fortnight.  That's it?

"How do you mean?"  I asked.  "Just go back to normal eye screening every 12 months?"

"Yes, yes that's fine!  I mean there's some bleeding..."

"What now?"

"Yes but it's perfectly normal" she said as I climbed down off the ceiling.  "Sometimes when you've had diabetes this long, you'll get small bleeds in the tiny blood vessels, but it's any leaking we're worried about.  There were a few spots on the scan, but I can't see them now so it's all fine".

OK.  I'm convinced by that I think.  I picked up my coat and bag and paused.  It's still my appointment right?

"Can I have a look at my scan?"  I asked.  No problem.  "Can I take a picture?"  She looked a bit taken aback this time, but again, no problem.

So here it is.  This is the thing that's had me worried for over two weeks.  You might be able to see a few tiny yellow spots to the left of centre (depends on how big the image goes for you).  The bleeds are a little to the right, as tiny red dots.

Eye eye

"Nothing to worry about".... tell me another one.

Thanks to everyone that spoke to me about their experience of "that letter" before I went for my appointment today.  I won't name you here, but if you're reading this, you should know who you are.  Your support was really helpful.  Thanks again.

Transforming Transition

Now I’ll confess I never experienced clinic transition – certainly not in the way we think of it today.  I was diagnosed with Type 1 in 2002 at the age of 21 and after the usual few appointments with my DSN, I was thrown into the all too familiar world of adult clinic – sitting down with a consultant twice a year.

At the time, I wasn’t too bothered.  I was 21, starting my post-grad course at university – for all intents and purposes, I was an adult, and despite the whirlwind of diagnosis, I managed OK…ish…at the beginning.

So what about actual transition for those diagnosed at a younger age?  How are they supported (and indeed how should they be supported) in moving from a paediatric clinic to an adult environment?  Happily, that was the focus of one of the best (and most inspiring) talks I attended this week.

The session was split as follows:

•         Setting the scene with the new diabetes transition sample service specification –Jonathan Valabhji, Bridget Turner
•         Engaging with young people in transition: tools and training for HCPs designed by young people – Heidi Forsyth, Scott Graham, Megan Lott, Lois Marshall, Gemma Thomson
•         Trust, transparency and growing up together: a western tale – Neil Black, Athinyaa Thiraviaraj

The balance that this gave was great – hearing about how it should be done looking at the guidelines, then seeing two real world examples of how it’d been done, one from the viewpoint of people with diabetes, and one from healthcare professionals.  I don’t think it’s overly controversial to say that, whilst DPC is a conference for healthcare professionals, the sprinkling of patient voices throughout brought some of the sessions to life – this was no exception.

So let’s begin at the beginning – why is transition important?   This came across well in all the presentations.  Bridget and Jonathan spoke about how our brain can take up to 25 years to fully develop and so support during this period is vital.  They also spoke about how audit data suggests that young people with diabetes receive poorer care than others (and we know the National Diabetes Audit doesn’t show brilliant care for anyone with Type 1 in particular).  Continuing my unofficial #DPC16 theme, Bridget gave a great example of individual experiences of transition:

How does transition make young people feel?

  

Some of the other challenges included young adults starting university and letters being sent to wrong or old addresses, making it harder for people to engage directly with the service.  Some felt they moved clinics too early, others too late.  Another example of how care plans need to be individualised.

The team from Diabetes Scotland set out one of the clearest examples of why transition is so important, giving this list of what’s happening in young people’s lives between the ages of 16 and 25.  “Try adding managing diabetes into all that as well”

What's going on in your life?  Just this...

There were examples of some good experiences too (which is encouraging).  Those who’d been to defined transition clinics, had had overlap (and continuity of care) with paediatric and adult services or had experienced ‘guided independence’ (i.e. a transition group offering peer support and education) reported positive experiences of transition.  So there are pockets of good practice which is good.  So how can those be expanded?

The Diabetes Scotland team gave a great presentation on the Youth Engagement Toolkit.  They’d developed a set of tools to be used by healthcare professionals with young people in a transition environment.  They included a training day for diabetes teams that was co-facilitated by young people, case studies and videos to better understand young people’s experiences and a Facebook group (plus signposting to it) for young people with Type 1.  These aim to help clinicians build a better connection between themselves and young people, are treat the individual, not the condition.

One quote from the Facebook Group summed up the feelings of one of the young people: “I had no idea that groups like this existed, literally only found out about this group today during a clinic visit.  Nice to know everyone else has the exact same problems and deals with the same stuff, including having the complete fear about every single clinic visit”.  That idea of the benefit of knowing other people all have the same frustrations was something I touched on during my talk in the education session.

The pilot study of the toolkit showed that 97% of healthcare professionals who completed the evaluation thought the toolkit would be beneficial.  I got the chance to meet the team after, and the passion and enthusiasm that came through from the young people involved was clear to see.

Finally, Neil and Athinyaa gave an incredibly moving talk about “Growing up together”.  The simple idea was that while young people are growing up with Type 1, the clinicians too needed to grow their idea of what care in transition should be like.   The first transition clinics in their area came into being in 2007, and whilst they consisted of adult and paediatric joint reviews, “it felt more like two individual sets of care, rather than joined up transition”.

Neil gave a truly moving speech about how social media became the first catalyst for change, back in 2012.  Experiencing tweet-chats on diabetes changed his view on how people were actually living with Type 1 day in, day out.  He said “The power of the diabetes online community cannot be over-estimated” and I think it struck a chord with a number of people in the room.  Athinyaa spoke about what changed over the coming months, talking about how communication skills became a central point of focus.  Instead of asking questions like ‘how is your diabetes?’ or ‘let’s talk about your blood sugars’, conversations became centred on the individual… ‘how are you?’, ‘what would you like to talk about today?’.  Agendas were set by the young person rather than the clinician.

The idea of them as a team ‘growing up’ really came across so passionately, and the journey that they’d been on to learn how to move to deliver that individual care was clear to see.

The speakers in the Transition session

Transition can’t be an easy time for anyone living with diabetes, and whilst I never experienced that directly, a lot of the messages about how young people can feel totally disengaged with their diabetes really struck a chord with me.  It’s refreshing to see that there’s now a (non-mandatory) service specification for commissioners when looking at transition, and being able to hear about experiences from both sides of the appointment table was really refreshing.  I got to speak to everyone involved in the session afterwards and the genuine emotional connection they all feel with the topic had definitely inspired the room.  We know there’s lots of areas for improvement in diabetes care (not least transition), but I think it’s got a lot of focus and good things are coming.

Glasgow 2016 - some personal highlights

There's more serious stuff to come from #DPC16 - a lot more.  But the conferences (#YDEF16 included) did have a personal side to them as well, and I wanted to get things down on paper before I forget them.

There's a good chance I'll return to this as and when another memory fights its way through the current brain fog, but these are the things that have stood out for me on a personal level over the last four days:

• Meeting members of the #doc.  It's always top of the list when you get to meet people you spend so much time talking to.  Finally getting to meet (in no particular order) Laura, Kelly, Kris, Sandie, Dani, Mike, Ellie, Bob, Helen, Partha, Pratik, Emma, Becky, Ali, Neil, Pete, Sophie, Lis, Jon, Jane, Amy, Hannah, Jane-Claire and anyone else who I've definitely forgotten (sorry - can barely remember my own name right now).  Memories were made - I thank you.

• Getting to speak at both conferences.  I think Kelly and I delivered a solid couple of workshops at #YDEF16 to say we'd only met for the first time the night before (and only had one practice run).  Standing up in the Arena on the first day of the conference and being given a platform to give my experiences on education at #DPC16 was a real highlight and I'm grateful to Bridget from Diabetes UK for allowing me to share the stage

• Watching my friends speak.  I saw Kelly deliver a great speech about her Sugarbuddies experience, and Laura talk so passionately about NICE guidelines, both within a few hours of each other.

• The 5k fun run.  It take a lot to motivate me out for a run before 7am.  But it WAS fun (sorry Ali) and it lead tomy fastest 5k time and the creation of...

• The #DPC16 #DOC T-Shirt... a sixth form leavers present for the Conference Age

• Sanofi Coffee.   The Sanofi stand was the default meeting place for everyone and I think it was a unanimous vote that their coffee was the best (other pharma coffee stands are/were available)

• Seeing people you weren't expecting to.  Basically half of my diabetes team in Sheffield showed up for the conference which is not wholly unexpected, but running into so many of them in such a busy environment was a surprise, but a very welcome one

• Hearing the conclusion of something I'd been a part of.  The very first lecture at #DPC16 gave the results of the clinical trial I took part in for two years.  I'd heard the headline news, but to see the presentation was very interesting (and a little controversial)

• Meeting so many people.  Obviously putting faces to names from the #doc was incredible, but having the chance for a few words with those who'd spoken so passionately or chaired incredible discussions was a great opportunity.

• Being part of something.  I wrote a quick overview of what seemed to be the messages of #DPC16 and I think to have been there and be part of that rising tide of change was a real highlight.  Having the chance to add my voice to the huge buzz that was already there is a highlight, and to be able to share what's going on with everyone was a real privilege

• A couple of quotes.  Nick Oliver said at #YDEF16 "I don't know if any of you have had a hypo, but we tell people with diabetes to eat 15g of carbs and wait 15 minutes.  I dare you to do that".  Partha Kar told a room full of diabetes clinicians "None of you are experts. People with diabetes are the experts. We're all just specialists, at best".  It's reassuring how much they get it.

I think there's more to add to that list, and I'll no doubt return to this in the coming days as my brain settles down.  But for now, that's just a few of so many things that made this week special.