P.A., a 54 year-old Hispanic man with a 5-year history of uncomplicated type 2 diabetes, reports to the Veterans Administration (VA) clinic for follow-up. After an initial period of partial glycemic improvement soon after diagnosis, his glycemic control has deteriorated, as reflected by hemoglobin A1c (A1C) levels that gradually increased from a nadir of 8.3 to 11.1% during several years. P.A. reports fingerstick blood glucose measurements between 250 and 400 mg/dl. He complains of fatigue and endorses polyuria and polydipsia, which he attributes to hyperglycemia. Insulin therapy has been recommended repeatedly at the clinic for the past several years but has always been refused. P.A. works as an interstate truck driver and fears initiation of insulin therapy would disqualify him from holding a commercial license. He denies needle phobia, fear of complications, or other barriers to insulin therapy. P.A. voices awareness of the risks of developing diabetes complications and the relationship between uncontrolled glucose levels and his hyperglycemic symptomatology. Because he holds a loan on his truck and driving is his sole source of income, loss of his license is perceived as tantamount to financial devastation. Despite counseling, P.A. is unwilling to consider alternative occupations. His diabetes regimen consists of high-dose oral therapy with metformin, 1,000 mg twice daily; rosiglitazone, 4 mg twice daily; glimepiride, 4 mg twice daily; and acarabose, 100 mg three times daily with meals. Counseling on lifestyle measures for diabetes with a dietitian and diabetes educators had been pursued soon after his …