April 23, 2014

An Interview That Did Not Happen

It is with great reluctance that I am doing this blog. I have been attempting contact with the Academy of Certified Diabetes Educators and I trust one of the current board members that on March 26 stated that my request for an email interview was being forwarded to the Academy Board President. It is now April 23, and I have had no contact with the current board president.

This does concern me as a person with type 2 diabetes. Then I opened the ACDE website and this I quote,

An Important Legislative Update!

Indiana Diabetes Educator Licensure

The ACDE Board of Directors (BOD) was disappointed to learn that Indiana Governor Pence signed Bill SEA 233 into law. This bill allows for a person who has NO healthcare licensure or registration to obtain a “diabetes educator license” in Indiana. The ACDE BOD recognizes that only qualified licensed/registered health care professionals who have passed a validated examination are qualified to provide diabetes self-management education. We will work closely with NCBDE and the Indiana Medical Board regarding implementation of state regulations. Our goal is to educate legislators and the general public about the validity of the CDE® credential to ensure quality diabetes education services that meet national standards are provided to those with diabetes.”

Obviously, the Indiana state legislature and the Governor of Indiana saw a clear purpose for passing this bill and making it law. Could it be that the people of Indiana are not being served by the CDE profession? Could it also be that the medical community asked for this because of problems and lack of education being given by the CDEs in Indiana?

This should bring caution to both CDE organizations and cause for investigation before making the above statement. If either of my questions is answered yes, then the CDE profession needs to investigate the reasons the law was passed and find out what the members of their profession have done to cause the law in the first place.

I have been blogging about the lack of education for people with type 2 diabetes, whether on oral medications or insulin. Many of the doctors in the state of Iowa are also upset about the lack of and poor education provided people with type 2 diabetes. Even many people with type 2 diabetes do not like the education provided by CDEs when it amounts to mandates, mantras, and worn out cliches.

Several of our local doctors are working with people in the local diabetes support groups for education and spending some time educating groups of us to help their patients. It would be great if we could be reimbursed for some of our time, but currently we do this on a volunteer basis as we feel the urgent need to help the other people with type 2 diabetes.

The above notice from the ACDE website concerns me, as it appears that the organization wants to be in charge of limiting who can pass on knowledge about diabetes to other people with diabetes. This sentence from the above quote does make one question the motives and how exclusive they intend to become. “Our goal is to educate legislators and the general public about the validity of the CDE® credential to ensure quality diabetes education services that meet national standards are provided to those with diabetes.” Bold is my emphasis and whether the national standards will be for the benefit of people with type 2 diabetes.  Quality diabetes education requires more than mandates and without educators that have diabetes themselves, often we receive little education of value when they approach education in a one-size-fits-all mode.

Exclusivity is the motto of the Academy of Nutrition and Dietetics (AND) and we don't really need another organization that promotes they are the only organization to legally serve people with diabetes education. The AND organization also tried to limit freedom of speech about nutrition and criminalize people not in their membership writing about nutrition and teaching nutrition in North Carolina and Ohio.

April 22, 2014

Polypharmacy – How I Dislike You

You just can't make some doctors happy. Even though the doctor was smiling when he said I was a drug addict, I still took offense to the statement. Having had a doctor attempt to increase my dosage for several medications to bring me in line with the guidelines for recommendations for blood pressure medications and statins has left me with a sour taste in doctors. Add to this a great discussion with a VA doctor about eliminating one medication and reducing the dosage on another medication, I really can't understand why doctors are pushing to increase some medications so enthusiastically.

Admittedly, I would like to be off a few medications, but because of the lab reports and other tests, I know that I am where I should be for the results I am obtaining. I am lower than the guidelines for blood pressure readings, yet I have had to refuse to let the nurses take my blood pressure readings immediately after entering the exam room. Not only have they increased the pace from the waiting room to the exam room, but also taking the BP with the incorrect BP cuff is another trick they have used to bring my BP readings up.

Even my wife, who is a certified nurse aide, has the right cuff for me and my BP readings are consistently 115 to 125 over 60 to 75. Yet the doctors' nurses work to get my BP up to 140 (or higher) over 90 (or higher) so that the doctor will prescribe a higher dose of BP medication.

Now the cholesterol (lipid) panel seems to be all over the range. The latest test done at the VA showed everything within the normal range, but with a three day difference in blood draw, all my results done by the hospital lab were beyond the high limit of the range. I therefore have to wonder if the hospital lab reports are inflated for the doctors to enable them to increase the statin dosage. To check the hospital lab reports, on the same day, I went to the local hospital and paid out of my own pocket to have them do a blood draw and do a lipid panel. All the results were within the ranges and the ranges were the same as the VA and the regular hospital lab. All three blood draws were fasting and that is the reason I say that the results for the doctor were inflated.

I am beginning to think I need seriously to consider changing doctors and hospital labs. Not only would I save on distance traveled, but I may also save on frustrations. When it comes to my diabetes, I don't like the idea of leaving the endocrinologist I have, but I am tired of having the suggestion of letting my A1c get above 7.0 at every appointment.

Yes, they tell me that is because of my age that they make this suggestion. I tell them that until I am unable to prevent hypoglycemia, except for the rare episode, I will continue to manage my diabetes to the best of my abilities. Only three readings below 60 mg/dl in the last year and two were at times I suspected I would go low because of injecting the Novolog too close to the Lantus injection site and testing proved I was going low and the glucose tablets did their work. The lowest reading each time was 56 mg/dl and 58 mg/dl. I consider these low, but not severe lows. The third time I injected Novolog when I should have injected Lantus.

Now am concerned because I do not have the symptoms when I get below 70 mg/dl of sweating, being shaky, or the other symptoms. I seem to have become hypoglycemia unaware in the last year and that does concern me. As a person with type 2 diabetes on insulin, I always believed that only people with type 1 diabetes had this problem. This confirms that the analogue insulins can cause this condition in both types.

April 21, 2014

Participants Wanted for New Diabetes Trial

Normally I will not promote studies, but this is one that may deserve your consideration if your are taking metformin and should consider adding another medication.  I will be quoting from much of the press release.

Researchers at Washington University School of Medicine in St. Louis are seeking volunteers for a study that compares the long-term benefits and risks of four widely used diabetes drugs. The drugs will be given in combination with metformin (Gulcophage®), the most commonly prescribed medication for treating type 2 diabetes.” 

The trial will run for a period of five years. The researchers will evaluate how the drugs affect blood sugar levels, diabetes complications and quality of life, as well as the medications’ side effects.

“In addition to determining which medications control sugar most effectively over time, we will examine individual factors associated with better or worse response to different drugs,” said Janet B. McGill, MD, professor of medicine and principal investigator at the Washington University study site. “This is a long-term study that will provide targeted diabetes care at no cost to participants.”

Although short-term studies have shown that drugs to lower blood sugar can be effective when used with metformin, no long-term studies have been conducted to determine which combinations work best to keep diabetes under control.”

The nationwide study is called the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness (GRADE) study. It is expected to involve 5,000 patients across the country and 300 locally who have been diagnosed with type 2 diabetes within the past 10 years.” Bold is my emphasis.

To be eligible for the study, people with diabetes may be taking metformin, but they cannot be on any other diabetes medication. During the study, all participants will take metformin along with a second medication randomly assigned from among four classes of medications that are approved for use with metformin by the Food and Drug Administration.”

Three of the study drugs increase insulin levels. They are: sulfonylurea, DPP-4 inhibitor, and GLP-1 agonist. The fourth option is a long-acting form of insulin.”

Participants will receive free clinical evaluations and management of their diabetes medications throughout the course of the study, including at least four clinic visits a year.”

“For more information or to volunteer, call study coordinator Lori Buechler at 314-362-8285, e-mail GRADESTUDY@wustl.edu or visit the study’s website,” http://endo.wustl.edu/current-clinical-studies/.

The last paragraph is the important contact information. To be eligible for the study, people with diabetes may be taking metformin, but they cannot be on any other diabetes medication.

April 20, 2014

Increasing Doctor–Patient Communications

Continued from yesterday's blog

I admit I don't have much faith in doctors and many patients being able to improve communications under the current circumstances and health care laws. Many patients have lost access to their doctors and have been placed by their insurers with new doctors. This not only make communications more difficult because both are starting over with new beginnings. Others that have retained their doctors are wondering if they have a good thing and why so many others have had to move doctors. A lot of nervousness currently exists and this affects communications.

Nancy Finn thinks technology will help in communications. While she may be seeing some improvements and changes, I have some reservations about what I am seeing in the lack of technology advances and refusal by doctors to accept technology, except what is useful in practice or will earn them money. Some doctors to satisfy the stage 2 “meaningful use” requirements are making use of patient portals on a very limited basis and most are not allowing corrections to records. Believe me, I have tried as I have found some serious errors in my medical record.

Nancy thinks that if patients and providers use tools such as the internet and mobile phones to track medical conditions, everyone can benefit. She also lists tools such as patient portals to engage in e-visits, and email to discuss non-emergency issues between visits.

After doing some research, Nancy may be on to something. This article, published on April 7 in the Star Tribune describes something I was not aware of until I read it. Doctor on Demand started about four months ago and is now in 40 states, with 1000 doctors on staff. A 15-minute video session costs $40. Minnesota Blue Cross and Blue Shield is behind this and telemedicine is being used for home visits and people going to a kiosk which has some instruments available to take vitals. Some even have an autoscope tool with a camera attached to look into ears.

This doc-in-the-box is quite satisfying for many patients. Other doctors are raising the issue of the quality of care, but patient satisfaction is running high. Even advocates for virtual exams say they work best for routine cases, but when it comes to complicated diagnosis and treatment, there is no substitute for an office visit. Even I am going to investigate what may be happening in my state of Iowa and whether this might be available here. I do doubt that Medicare is involved in this, as the only telemedicine they have become involved in to-date is when providers are on both ends.

Nancy Finn also covers wearable devices, phones and the internet to monitor chronic conditions. She lists mobile phones to text instant messaging and to deploy apps to track heart rate, blood pressure, blood glucose, weight, and fitness.

Rather that list the suggestions that Nancy has for patients and doctors, I suggest that you take time to read her blog. One item she did not mention in constructing a personal health record is to make use of Microsoft HealthVault. Read about this here and with any choice you make, please use a secure choice.

I will quote her last paragraph as it expressed my thoughts as well. “When all the parties in the health process understand the need for communication and work at providing the pathways to make it happen there will be less frustration and dissatisfaction, and the safer practice of medicine for all concerned.”

April 19, 2014

Doctor–Patient, Communication Needs More Focus

This blog by Nancy Finn is a topic favorite and can really get me wound up. Communication is a term that many dismiss as unimportant in today's medicine. Physicians like the term patient engagement, and other buzzwords to describe one-sided communication and then claim patients do not communicate.

While this is true for many patients who are passive in nature because they expect the doctor to ask the right questions and give all the right medications. Too often these patients are over medicated and given too many unnecessary tests. Communication is a two-way method of making the most of situation and getting quickly to a proper diagnosis. But the failing of today's health care is the lack of effective communication, not only by the doctor, but by many patients as well.

Some of the reasons include:
  1. Many drama kings and queens,
  2. Many cannot concisely explain what is bothering (or ails) them,
  3. Many patients do not have the terms to use (health literacy),
  4. There is too little time with the doctor, and
  5. Many doctors cut the patient short from giving details.

This is sad that in this day and age, with many tools available to doctors and patients for better communications, the art of communication falls by the way-side and is not used. While it is estimated that 80 percent of serious medical errors involve miscommunication between caregivers. This happens in hospitals and between doctors when a patient is referred to another doctor. This is even more complicated now that electronic health records have entered the picture.

It is simplistic if every doctor is an hospital employee and the patient record is open to every doctor in this case. But let an outside clinic become involved and the error rate is back at the 80% level as one electronic health record (EHR) is isolated from another EHR and they are not allowed to communicate. Currently, most patients have no authority to transfer information from one source to another. Most records are HIPAA protected and a doctor or the patient is not allowed to override this isolation even if both agreed. Therefore, the doctor or someone he designates needs to print out the information to be transferred and this is the source of most errors.

Hand-offs is one area where communication has to improve. This is especially true for the elderly being discharged from a hospital to their home or to a nursing facility. The office visit is another. Poor communication is blamed for patient frustration, non-compliance with treatment and medications, and general lack of trust in the physician.  It is said by some that many doctors are interested in their patients and desire to make the right medical decision about medical care.

Doctors do have many distractions, such as continuing education, licensing tests to take, and government and insurer paperwork to complete. The number of required tests and conditions the primary-care doctors need to screen for, has increased dramatically. Then add to this the treatment regimens for chronic diseases like diabetes, heart and lung disease, cancer, and other problems that have become more complicated. These all make the 15 minutes for an office visit more difficult. Little time is available for communication and this puts more pressure on the doctors and unfortunately can cause more diagnostic errors.

Continued in tomorrow's blog

April 18, 2014

Some Ways to Become a Safe Patient

Many patients allow others to be in charge of their patient safety when in their own home, when at the doctor's office, and especially when in the hospital. This is not a good habit to follow and you, a person with diabetes, need to be conscious of your surroundings. Granted if you are taken to a hospital in an unconscious state, you will probably not be aware of what happens to you until after the operation or operations and you recover your awareness.

The following are good points by the CDC to help remind you how to be safe:

Speak up - Do not hesitate to ask questions. Ask your doctor about those worries you have and how to remind those around you about those worries. If you are in the hospital and are hooked up to devices for putting IV fluids in your hand or catheters to remove waste from your body, do not be afraid to ask how long they are necessary. Many catheters should be new each day unless surgically implanted or for IV use.

If you are going into the hospital, ask how they prevent infections and what they do to protect you after surgery to prevent infections. Hospital acquired infections are difficult to treat and can add to your hospital stay. 

Keep hands clean - Always make sure everyone washes their before touching you. You may irritate many doctors and nurses, but they are known for not washing their hands as they move from one patient to another. 

Become smart about antibiotics - Ask if a test will or has been done to be sure that the right antibiotic is prescribed. Often antibiotics are changed by doctors without tests. Each doctor has their favorite and when it does not work, they move to another antibiotic. Most insurance carriers are now insisting on tests to determine the most effective antibiotic.

Learn the signs and symptoms of infection - Many skin infections, such as MRSA, occur with redness, pain, or drainage at the IV catheter site, or surgery site. Often this happens with a fever and you should tell you doctor as soon as possible. If you happen to have MRSA or other hospital acquired infection, your stay will be increased.

Watch out deadly diarrhea, aka, C. difficile - Tell your doctor if you have three or more episodes of diarrhea in a 24-hour period, especially if you are taking an antibiotic. It is important that the diarrhea be brought under control quickly to prevent dehydration and death.

Protect yourself - Get yourself vaccinated against the flu and other infections to prevent complications. If you know there are flu patients near you or cases of MRSA, these vaccinations may save you from acquiring them. This is also important for insisting that doctors and nurses wash their hands.

April 17, 2014

Diabetes Does Not Have To Be Progressive

This blog by Nancy Klobassa Davidson, R.N. on April 4, 2014 represents a blog by a large medical organization (the Mayo Clinic) that identifies their blog author. No anonymity here like the blogs on Joslin Communications, a part of the Joslin Diabetes Center.

The topic is a controversial topic about diabetes being progressive. While I have to swallow hard to agree with parts of this, it is presented rationally and it is easy to understand. It is true that many people refuse to manage their diabetes in a manner strong enough to prevent diabetes from becoming progressive. The author does not account for the people that die of old age or other causes and not diabetes.

I would not argue that for many people, dying from diabetes or diabetes related causes (i.e., heart disease, kidney failure) is more common than we would like to have happen. We may be debating medical semantics, as some people have heart disease before developing diabetes and the same for kidney disease.

This statement by the blog author is important enough to quote. “Recently, I met a woman who was upset that no health care provider or diabetes educator had explained to her, at the time her diabetes was diagnosed, that diabetes is a progressive disease. She thought that if she "behaved herself," her diabetes could be cured, or at least stay in holding pattern.”

Yes, there are people with diabetes that mistakenly believe they can be cured. All I have to do is talk to the owner of a health food store and she will confirm this. She knows this is not true as she has type 2 diabetes, but says that about twice a month, someone will come to her store seeking a cure for diabetes. She tells me that people say the darnest things and her favorite is, “this is the twenty-first century, there has to be a cure.”

The author's logic presents both sides of the disagreement better than most. She does not state many of the obvious conclusions, but sidesteps many issues by saying, “this varies per individual, and everyone is different.” I can agree with this, because we all age and manage our diabetes differently. It is the definition of progressive that needs clarification. Progressive means aging or becoming older. With aging, our organs all lose their efficiency and the pancreas is no different.

For me, progression of diabetes would mean that it progresses to the complications and on to death. Some people are able to manage diabetes for many years (and even for decades) with nutrition (diet) and exercise. As the pancreas ages, oral medication may become necessary. As we continue to age, other injectables or insulin may become necessary.

As long as retinopathy, kidney disease, and heart disease caused by diabetes are not becoming worse with age, then diabetes has not become progressive. But you did not mention neuropathy you say. Correct, because about two-thirds of people with diabetes develop neuropathy and there is some conflict here as many, like myself, that develop neuropathy many years prior to being diagnosed with diabetes. My neurologist and I have an ongoing discussion about this as he says that with the development of diabetes, that the neuropathy is now classified as diabetic neuropathy.  Sort of the chicken and egg version of which came first.

Many people, without their doctor's threat, often feel that they have failed when it comes time to transition to insulin. Often they wait too long to do this. They haven't failed, it is just their normal thing as they age and the pancreas not functioning very well that causes the need for insulin. Insulin can be very helpful and a necessary tool in the management of type 2 diabetes.

Delaying to use of insulin too long causes high blood glucose levels and prolonged periods of high blood glucose is what causes the onset of complications. Insulin does not cause complications and in most cases if started early enough can prevent the complications and heal those that are just beginning.

Even though the blog used for reference above says diabetes is progressive, it is still worth reading.

April 16, 2014

An Impromptu Meeting with Our New Member

On Monday, April 14, Tim called to say that Dr. Tom wanted three of us to meet with the newest member and his wife. This would be Tim, Allen, and myself. Tim said he would be by in about 40 minutes to pick me up and then get Allen. After Allen was in the car, we talked about what Dr. Tom wanted us to discuss with them. This would include reinforcing what Dr. Tom had covered about calling him if he was having a hypoglycemia episode, titrating his insulin up or down for both types of insulin, and how often for about the first three months to test. He had asked Tim to discuss food plans, reducing his carbohydrate consumption, and carbohydrate counting.

When we arrived at his house, his wife greeted us, offered snacks, and asked what we wanted to drink. Tim thanked her and explained that we all carry our own not to cost members extra money. He told her not to be offended as we do this whenever we go to someone's place and at meetings.

The person with diabetes then entered the room and thanked us for coming. Tim repeated what he had said to his wife and asked how he and insulin were getting along. They suggested using the living room and Allen asked if we could use the kitchen since we had seen the large table. The wife asked why and Allen and I held up the cookbooks we had with us and Allen asked if the canned goods were in the kitchen.

When they kept pushing us to the living room, Tim asked why the kitchen was unsatisfactory and that we were there by their request and at the request of Dr. Tom. If they wanted our help, why were they making us sit in an area that would not be conducive to working with the cookbooks and an easy place to write. The wife carefully explained that the two teenagers would need to fix their meal before too long, and they did not like to entertain in the kitchen.

Allen asked if they would come to his house so they could use the table and see what we talked about on the different food labels. They reluctantly agreed and we went to Allen's home. When we were seated, Allen took many items out and set them on the table. I opened my cookbook, as did Allen, and we started. Tim again asked how he and insulin were getting along. When he did not answer, Tim asked to see where he was recording his meter readings. When he pointed to his head, Tim said that is not acceptable. Since Allen had started working with the wife and carb counting, I stepped outside and called Dr. Tom.

When he heard what I told him, he asked where we were, and he said he would be there shortly. I waited for him to arrive and we went in together. Dr. Tom asked Tim how things were progressing and Tim laid out what needed to be accomplished. Dr. Tom said that he needed to record his blood glucose readings and asked Allen if he had his handy. Allen said he records his in his computer and carried a small pad to record them for entry when he is away from home.

Allen said he also has the program and equipment to download his meter onto his computer. Dr. Tom asked if he would show this to, and stopped. He asked if we had given the new member a nickname. Tim said no and asked if he would accept James as his nickname. When he got a quizzical look, Tim explained why we do this and he agreed then.

Allen quickly explained where he was at and I said I could take over. With that Dr. Tom, Tim, Allen, and James went to look at what Allen did with his blood glucose readings. James's wife asked if all the measuring was necessary. I asked if she was interested in helping her husband manage diabetes. She said yes, and I said we would be available to answer questions and be there via email or telephone to answer questions. I asked her if she had a scale similar to Allen's and she admitted that she did not. I said I would send her some information and URLs to let them look at different electronic scales. I asked if money was going to be a problem and she said no. I continued that she would use the scale quite a bit for six months or longer and then occasionally after that.

Allen came back then and asked how she was doing. She said better now that she had hopes of getting a similar scale. I asked if she now understood why we wanted to use the kitchen and she said yes. She said in the future, she would have us over later after the evening meal so that we could work in the kitchen. She hadn't realized how much she needed to learn and it was a bit overwhelming. Allen said don't run out and buy cookbooks like this one, with the word diabetic in the title, as he handed her one of his. He asked her to skim it and if there were any recipes her family would eat. When she completed a look, she said no and Allen said that is why he keeps it around to show people how bad they are.

Dr. Tom, Tim, and James then returned and James thanked Dr. Tom for coming over and explaining how important things were and how much his friends could help. Tim asked what nickname we were going to use for his wife. She spoke up and asked if Jill would work. Dr. Tom held out his hand and said, Jill, it is good to have you on board.

Jill asked James how much money he would need for supplies and then they decided that they could afford that and would order them as they could over the next few weeks. Tim had pulled up the blog about digital scales and said he would send the links in an email. Jill said that would help them decide and be able to order one. Tim opened one link for her to look at and she said that one looks good and the price is reasonable.

With that, we called it an evening and we pickup up what we had brought and Tim took me home.