Telemedicine – the Beauty and the Beast

There are several good definitions of telemedicine and I will cite the one from the American Telemedicine Association, which reads as follows, “Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve patients' health status. Closely associated with telemedicine is the term "telehealth," which is often used to encompass a broader definition of remote healthcare that does not always involve clinical services. Videoconferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education and nursing call centers are all considered part of telemedicine and telehealth.

Telemedicine is not a separate medical specialty. Products and services related to telemedicine are often part of a larger investment by health care institutions in either information technology or the delivery of clinical care. Even in the reimbursement fee structure, there is usually no distinction made between services provided on site and those provided through telemedicine and often no separate coding required for billing of remote services.

Telemedicine encompasses different types of programs and services provided for the patient. Each component involves different providers and consumers.”

This is broader in scope than I had envisioned, but in many ways more inclusive than I would have defined telemedicine. And yes, telemedicine has a national association. It needs one for all the issues that telemedicine encounters when crossing state and international boundaries.  

The beast is the many state medical associations and groups that have succeeded in putting limits on telemedicine by lobbying state legislatures. They are attempting to restrict it even further. At present, over 30 states have laws requiring that doctors have a physical examination requirement (PER) before any prescription is issued. These have become so restrictive that some patients are dying because they cannot obtain access to doctors. Fortunately, in some of these states, universities are stepping forward and establishing telemedicine programs utilizing nurses, nurse practitioners, and physician assistants that travel to rural areas and do the physical examinations for the doctors and communicate via video conferencing.

This study by the University of Tennessee while small, shows what can be accomplished and bring in the primary care physicians of the patients at the same time. For those wanting to check if a university in their state has a telemedicine operation, you will need to use your search engine and type in something like “telemedicine by universities”. There may be a list, but I have not located it. It is unfortunate that more universities with medical programs are not doing more to promote telemedicine.

Telemedicine is fraught with legal landmines and areas where the law has not kept pace with technology. Some medical practices such as psychology is pushing the envelope in hopes that they will be an influence to prevent state and federal lawmakers from passing laws that further restrict good medical practices. Read this article about some of the activities of the American Psychological  Association.

Even patients are wanting to be able to use telemedicine when traveling outside their home state or across international borders. However, most states currently do not allow doctors to practice across state lines unless they are licensed in the state. Reciprocity is a term foreign to the medical profession and state medical associations or chapters of national associations are mounting stiff opposition to this. I think that a patient that lives in Minnesota, for example, and travels to Florida for a few months should have the legal right to stay in contact with their doctor back home in Minnesota for new prescriptions and consultations via telemedicine. Currently this is not legally permissible.

There are patients that obtain extra prescription before traveling, but even some states are working to prevent these prescriptions from being filled in another state. Some pharmacies that are regional or have outlets in many states do fill these prescriptions because they have access to the patient's file and can see the doctor list for the patient and prescriptions previously filled.

For those wanting to do more reading, here is a magazine that is still on the Internet but last copyrighted in 2002, in other words a dead magazine. It does list a few organizations that are still active on the page, bottom center.  There is also a journal for telemedicine here.

Back to Diabetes Basics – Part 3

Hypoglycemia and Hyperglycemia

Hypoglycemia and hyperglycemia are two terms to get to know and remember. Knowing how to treat low blood glucose episodes (hypoglycemia) and high blood glucose episodes (hyperglycemia) is important in your management of diabetes. In my last blog, some numbers were given for goals in blood glucose management and they are important.

Hypoglycemia is considered for BG readings below 70 mg/dl (3.9 mmol/L). Most people get noticeable symptoms when BG goes below 80 mg/dl (4.4 mmol/L), but others do not until BG gets lower. Readings of 70 mg/dl and above are normal for most people and generally of no concern. Trends below 80 mg/dl need to be watched carefully if they get near the 70 mg/dl level. Why do I use the mg/dl behind the numbers? This is what the meters are set to read in the USA. All other countries use the mmol/L.

Symptoms of hypoglycemia vary by individual, but may include extreme hunger, nervousness, excessive perspiration, rapid heartbeat (tachycardia), headache, fatigue, mood changes, blurred vision and difficulty concentration and completing mental tasks. Extremely low glucose levels can lead to disorientation and convulsions, even coma and death

People with type 2 diabetes still need to be concerned about readings heading downward from 80 mg/dl and especially if on insulin or Sulfonylureas as they can cause hypoglycemia very easily. Although Metformin will not cause hypoglycemia, in combination with Sulfonylureas, hypoglycemia can become a problem. Many doctors are not aware of oral medications causing hypoglycemia and this may lead to problems. Be especially aware of this if you skip a meal or if you are becoming ill. Test and if you are below 70 mg/dl, then take a glucose tablet, wait 15 minutes and test again. If you are below 60 mg/dl (3.3 mmol/L) take two glucose tablets and repeat. If you are below 45 mg/dl (2.5 mmol/L), and having a hard time thinking, have someone call 911 as you need treatment immediately unless you have a glycogen pen and can have someone inject you. Most people with type 2 seldom have these available unless they are on insulin and have had serious hypoglycemia previously.

Hyperglycemia is difficult to detect for most individuals. There is much disagreement as to where hyperglycemia starts. Irrespective of what number you choose to believe, the American Diabetes Association (ADA) has set the upper limit for A1c's at 7.0 percent. This equates to 154 mg/dl (8.6 mmol/L). I have also seen ADA use the number of 180 mg/dl (10.0 mmol/L). It is known that complication damage occurs at an A1c value of 7.0% and higher. Some will argue that damage occurs above 140 mg/dl (7.8 mmol/L). I prefer using the 140 mg/dl as the starting point for complication damage and as the starting point for hyperglycemia.

Most people can only detect hyperglycemia by testing. When your blood glucose levels are above 200 mg/dl (11.1 mmol/L) it may be several days before you may notice any signs. Some people do not notice frequent urination and increased thirst, even then. This is another reason to test regularly. If you are a person that exercises regularly, a blood glucose reading of 240 mg/dl (13.3 mmol/L) means you must not exercise until your BG is below 200 mg/dl. It is always advisable to talk to your doctor about the amount of medication to use to bring high BG numbers down. Unless you have previously discussed this with your doctor and know what to do, it is always wise to talk with the doctor.

Both hypoglycemia and hyperglycemia can cause death and it is important to know what to do and how to treat both. Many people with type 2 diabetes don't think this will happen and ignore the signs for hypoglycemia or think it is not important to test regularly for hyperglycemia. People with type 1 diabetes know the value of testing because they are on insulin, but people with type 2 diabetes are often not even told about this until they are prescribed insulin. I lay this problem at the feet of doctors because they do not stay current with oral medications and often do not understand what the combined side effects are for multiple oral medications. I also believe the ADA is responsible because they promote stacking (using more than one oral medication) of oral medications and do not give appropriate warning of the dangers.  Read this article on the Joslin website for a chart of oral medications and the side-effects. It does not cover the problems when using combinations or stacking. More on this in another blog.

Doctors and the Different Types of Practice

Doctors and those in the medical profession are mostly like you and I. The one difference is the amount of education they have and the type of experiences is what sets them apart. Some excellent doctors always work for the patient and strive to give the highest quality service. Like any profession, there are the “bad apples” and we need to avoid them as they give medicine a bad reputation. In between there is all types and variations. Do not forget the physician practitioners and physician assistants. We must also include the nurse practitioners. When I use the term medical profession I mean to include all of them. Doctors work with the other medical professionals, but many do not like them as part of their practice while other doctors welcome them.

Read a blog I wrote in May 2010 on patients and doctors. Also follow the links provided, as the information is still applicable and appropriate for this discussion. I do need to add a few new types of medical operations that exist today and are very important. For diabetes these can add value to the appointment and save many problems from developing. A few practices are beginning to see the value also. I am talking about shared medical appointments (SMAs). If you are a patient that insists on keeping your diagnosis a secret, they are not for you. You must be ready to talk and listen to others and have them know you. How many people participate in SMAs? This will vary by how much room a doctor has, how many patients are willing to attend, the size of the staff available, and how much preparation is needed. Doctors that are old hands at this and have the room have been known to have 25 or more patients. Others limit it to 10 to 15 patients. In my limited discussions with a few doctors using SMAs, they only have room for the smaller numbers. They utilize private rooms to talk with those patients unwilling to have the doctor tell them test results in the group setting or for someone receiving information that the doctor wants to share in private.

Most doctors use SMAs to dispense the same information to everyone at the same time. Examples include importance of testing, medication side effects, goal setting, lifestyle changes, foot care, and other information. Questions are answered and discussions on some points do happen. One endocrinologist uses this to mix new to diabetes patients with old hands with diabetes to breakdown the panic the new patients are experiencing. Other groups include people by experience, and some are with groups that want to stay together. Some doctors have registered dietitians (RDs) and certified diabetes educators (CDEs) assisting. Others use physician assistants and nurses. Other combinations also exist for the medical staff.

Concierge medicine is also gaining in popularity and doctors can spend varying time with the patients. Appointments can vary from a half hour to an hour and a half depending on the need. Some will have a secretary/receptionist and others will have no one but themselves. Some practices may be two or more doctors. For more information I suggest reading my blog here and follow the links to more on the topic. Investigate this site, which also is about concierge practices. I am aware of one husband and wife team in concierge practice that is investigating the use of shared medical appointments (SMAs) for different diseases, diabetes, cancer, multiple sclerosis, and one other disease.

Something being talked about and possibly happening is telemedicine. This study is the first I had read about it, but I think this will have a place in rural areas. By using nurses or nurse practitioners in the field, telemedicine may reach patients that otherwise would not have access to doctors because of the distance to be traveled and especially those no longer able to drive. It will be interesting to see this develop over the next few years.

An area of medical practice that is operating is retail clinics and pharmacy medicine. They are not quite as sophisticated as neighborhood or a few other inner city clinics that are staffed by doctors on a voluntary or small fee basis. The retail clinics are normally staffed by nurse practitioners, physician assistants, or pharmacists. There is opposition to these clinics, but they may have their place because of the coming shortage of primary care physicians. They may have a place to serve to take the pressure off primary care and emergency room medicine and they are more economical when compared to emergency room services. Patients rate most very high for service and satisfaction. Read about these services here and here.

In some states, actions are underway to regulate heavily many of the above practices and the state of California wants to force all doctors back into the practices or hospitals. The state hospital association is lobbying hard for this.

Series 3 of 12

Back to Diabetes Basics – Part 2

Why Keep Diabetes A Secret?

Having a diagnosis of type 2 diabetes is probably not something you would shout from the rooftop, but should you keep it a secret? Many people do just this and will not talk about it even to family members unless it is necessary. Extreme secrecy can be difficult. There was a situation a few years ago near here that made me laugh. Husband did not tell wife or anyone about his diabetes diagnosis. Two weeks later, his wife answered the telephone, and it was husband's doctor office calling to remind him of his diabetes education class the next day.

When husband learned this had happened, he hired a lawyer to sue the doctor's office for failure to keep his medical records private. Judge had a sense of humor and asked husband if he loved his wife and he answered yes. The judge said if this were true, why had he attempted to keep his disease a secret from his wife? The judge said he could understand the secrecy desire for the husband's affair uncovered by the sheriff. He handed down the following judgment. One-dollar fine to the doctor office – to remind them to be more careful and court costs on the husband for the lawsuit and wasting the court's time. He gave instructions to the wife that should she ever decide to divorce her husband, all she would need to do is file the paperwork and it would be granted. In addition, he wanted the court proceeding widely published.

Presently There Is No Cure

A topic that often surfaces shortly after diagnosis is “the cure.” I am somewhat hesitant to discuss this here, but if I can prevent anyone from avoiding this approach, it will be worth it. There are charlatans out there just waiting to separate you from your hard-earned money. They exist in small town America, in the large cities, and on the internet. They have the skill and arguments to make it sound very convincing and may be doctors or just cunning salespeople. They have one thought, and it is getting you to hand over your hard-earned money for their false claims. Read my blog here for more.

There are also researchers and medical people that have plans to (as they claim) put diabetes is remission. They promote extreme low calorie regimens and certain supplement plans which may make it seem like diabetes is stopped and are safe to use. Just be careful as these are for the short term and research has not proven they will succeed for the long term. The stress on your body using these extreme low calories diets has not been researched beyond a few months. They have proven that they work for the short-term and that is their promotion to obtain your money. Then in a few months when your blood glucose levels start back toward the stratosphere, they will try to sell you another round of the same regimen. Your long-term health is being put in jeopardy. Do not attempt these plans without your doctor's knowledge.

Acronyms and Their Use

As you start reading and looking for information on the Internet, you will come across many acronyms used by people to avoid typing long or even short strings of words. This can be discouraging for the new person with diabetes. What do they mean in the context of the sentence? One that you need to be very careful with is this one – ADA. It still means American Diabetes Association and Americans with Disabilities Act. Many still use it for the American Dietetic Association, but as of January 2012 it was officially changed to AND (Academy of Nutrition and Dietetics).

Changes in names can be a good thing, but the change above was solely to camouflage a takeover of competing occupations and eliminate competition by criminalizing people not becoming certified under their organization. This is not a very professional objective.

How you see acronyms will vary with each writer. Many will give the program or profession name in one paragraph and then start using the acronym in the next or later paragraphs. Others will use the full explanation followed immediately by the acronym and then use the acronym for the rest of the article. Some writers assume that their readers know the meaning of the acronym and never give the full name. These are the writers that make it difficult for all types of readers. Time after time. when there is the possibility of confusion, I have seen comments asking for the full definition of an acronym. Some people are especially sarcastic about this and provide a definition they know is wrong and abrasive, but the writer seldom clarifies. Some writers do then provide the correct meaning for the acronym. A few writers do correct their habits, and the rest just disappear.

I do use acronyms, and if you catch me not giving the full meaning, please let me know. I use the full definition and then the acronym in parenthesis or the acronym with the full definition in parenthesis. I have used the full definition in the first paragraph or two and then start using the acronym; however, I am trying to break that habit.

Some of the Testing Basics

Hopefully, you are now comfortable with testing and are doing it regularly. You need to understand what the blood glucose (BG) readings mean and what actions are available to you. Whether you are endeavoring to manage your diabetes with exercise and diet without medications, or are using an oral medication, you need education about both and when to test. Most everyone tests upon rising from sleep and this is termed fasting blood glucose (FBG) and your goal should be between 80 mg/dl (milligrams per deciliter) (4.4 mmol/L) and 100 mg/dl (5.6 mmol/L, (millimole per liter). Or, as many write, keep fasting blood glucose (FBG) under 100 mg/dl.

Then we come to the next meal. Hopefully, you will be under 100 mg/dl for the pre-meal blood glucose reading (preprandial). If you are not, then consider what you ate that would keep you higher. I like the goal of one hour post meal reading being 140 mg/dl (7.8 mmol/L) or lower (postprandial). At the two hour postprandial blood glucose reading should be 120 mg/dl (6.7 mmol/L) or lower. However, if these become your goals, be careful as eating the American Diabetes Association's recommended meal consumption of carbohydrates will make these goals unachievable for many patients.

Testing is the only way you have in determining how different foods and food quantities affect your blood glucose levels. A term you will see in blood glucose management is self-monitoring of blood glucose (SMBG – is the acronym). You will also need to test more frequently in the beginning to learn how long before you reach the high level of your BG. Many suggest one hour after first bite and for some people this can be too early. If you are a speedy eater (gobble down your food) this may work; however, studies have shown that you should eat slower for greater blood glucose management. Some writers do use the word control instead of manage for the same meaning. Some will suggest testing more often until you are comfortable with when your high level of BG happens. I suggest starting at the one-hour mark and testing every half hour the first few times until you see the readings start decline. Some people will test every 15 minutes. Somewhere between the highest reading and the lower next reading, the high may have occurred.

Occasionally the high mark can happen before the one-hour mark or beyond the three-hour mark. This indicates that the food you ate enters the blood stream quickly and was easily digestible and probably contained little fiber, if any. If it is after three hours, this indicates a higher than normal amount of fat, example – pizza. If you are saying this is confusing and too much to learn, you may as well know up front that there are not firm guides or rules to follow. It is important to know that what works for me, may not work for you. It is important to know that you need to become your own lab rat to determine how the different foods affect your system and what works for you. Many people keep a detailed journal during this time of the readings, what was consumed, and other observations that they feel is important. Read my blog here for further discussion of postprandial testing.

How often you test will depend on your desire to bring diabetes under excellent management and your budget. You will also need to find out how willing your doctor is to go to bat for you with the insurance company for additional testing supplies. Some companies will allow some extra test strips in the first few months, but then want to restrict you thereafter. Other insurance companies will only allow a set number of test strips per day. I recommend that you talk with your insurance company to find out what they are willing to allow. You may need to bargain with them and attempt to convince them of the need for allowing more test strips for the first three to five months. Don't be surprised if you are denied, but it is still worth the effort. If your budget will allow for the test strips, the knowledge you gain will be worth the cost. Medicare will not allow extra test strips.

As you are testing you are also looking for trends. If you are bouncing up and down at the two-hour postprandial, looking at your food log may provide clues as to why. If your FBG is on an upward trend for a couple of weeks then be concerned and be more careful of your last meal of the day. Also do not let a lot of time pass after rising in the morning as this allows your liver to dump more glucose into the system and can distort the trend. Many people can also have what is termed the dawn phenomena (DP) which is the livers function to dump glucose into your system to give you energy for waking up and starting the day. Upward trends should always be of concern and if they continue or start to trend upward more rapidly, always consider talking with your doctor. He may request an office visit and may increase the dosage of your medication or start you on a new medication.

Never be concerned with some bouncing up or down of BG readings, as this can happen if you are coming down with an illness or can vary with the food you ate at the previous meal. Trends up or down for longer that a month should be talked about with your doctor. He/she may need to adjust you medication. Trends under 80 mg/dl should always be talked about with your doctor. More about this in the next blog.

Series 2 of 12

Back to Diabetes Basics – Part 1

What You May Experience After Diagnosis

Where to start is the question. First, if you have just been handed the diagnosis of type 2 diabetes, either you had an idea because others in you family history have it, or this is a complete shock as you can recall no history of diabetes in your family. Granted, there could be other reasons that may have induced type 2 diabetes, but I will discuss them in another blog. You must realize that the symptoms are not what every person feels, but they are the minority. The feelings may be of a different intensity and length for each person.

The First Stage – Shock!

Are you in shock, have anger, or totally befuddled? I can understand this and even acknowledge that you feel this way. This is the first stage in the process you will eventually go through to come to grips with your diabetes diagnosis. My anger was short lived as I had a history of diabetes on my mother's side of the family. My anger was at the time directed at a doctor that kept calling me a liar for not knowing I had diabetes. Yes, he had some reason to be upset at me as I was diagnosed while on the operating table for angina. Stent insertion plus ballooning of several areas in my arteries was in process and they could not stop. On top of that, they had the problem of stopping the bleeding at the point of insertion when finished.

His constant calling me a liar for not knowing I had diabetes resulted in a bedpan being hurled in his direction and quite a scene as nurses came running. I said I wanted some quiet time and the doctor was preventing it. Even my roommate said his actions were disturbing and agreed with having him removed from the room. He asked to have his doctor come to see him. Short story – this doctor was told to stay away from our room as long as either of us was in the hospital.

Shock, anger, or being in a fog is expected when you receive the diabetes diagnosis. How you handle this will be important, as you need to consider what you do next. It is not expected that you will retain the information given to you the day of diagnosis. It is important that you be ready for the next appointment and have your questions ready to ask the doctor.

I hope that your doctor will have testing equipment available to give you, or give you a prescription for a meter, lancing device, lancets, and test strips. Be aware that if you are not offered a meter, lancing device, lancets, and test strips, you need to ask the doctor for a prescription before you leave. If you forgot, go back to the office and insist on a prescription. Some doctors will not as they do not want you to know what your blood glucose levels are or does not want you to become depressed by the readings. If you have one of these doctors, seriously consider finding a doctor that will give you a prescription. Your diabetes health can be better for it.

Some doctors will use certified diabetes educators (CDEs) that can give you answers to many questions and should reinforce anything the doctor has time to tell you. They can cover many areas of teaching you about diabetes and how to handle many aspects of the disease. Many doctors do not have CDEs available or will not use them. Some doctors use registered dietitians (RDs) and some doctors do not. In some of the more rural areas, doctors are using nutritionists and others with a nutrition degree because RDs are not available.

With the rapid increase in people with diabetes and a snails pace growth in the number of CDEs and RDs, other resources are being explored by some doctors. A minority of doctors are using diabetes mentors or peer mentors. A few doctors even use peer-to-peer groups. The last three are interesting as this indicates that these doctors are making use of knowledgeable patients that can use personal experiences to relate to new patients. This is a measure to help new patients feel like they are not alone in their struggle with diabetes, help educate new patients, and be available to answer some questions when needed. You should avail yourself of any education you have available. Your doctor is not available 24/7; therefore, you need to educate yourself to manage diabetes.

Okay, I have gotten ahead of myself and covered a few areas that should come a week to a month after diagnosis. Education about diabetes is important, but the first week will be very difficult for many people. If shock and anger don't take over for a few days, you are definitely in the minority. A few people will take the diagnosis in stride and be ready for the next step of being educated. Even if you are in a state of shock, keep the fog at bay long enough to learn that diabetes “is not your fault.”

Many people falsely feel that if they had done this or done that, they would not have diabetes. Part of this may be true, but people that are genetically disposed to diabetes should not feel this is their fault. Yes, their actions may have helped make the diagnosis happen earlier, but by having the predisposition for diabetes; most people have no control in preventing diabetes, just the timing of the diagnosis. There are possibly some people that are not genetically predisposed to diabetes that are diagnosed, but there is little evidence to-date supporting this happening in large numbers.

There is no advantage in dwelling on the past. This was a hard lesson for me to learn, but I had a good friend tell me that diabetes is the here and now and I needed to learn how to deal with it. Since this person did not have diabetes, it really stopped me and made me realize that unless I did just that, I might not be capable of managing my diabetes.

The Second Stage – Denial!

After the initial shock, anger, or what you want to call it, you may have denial. This is not necessarily the order, but can happen early on or years later. Denial can wreck havoc in diabetes management and make it difficult to recover. Denial is thinking you have mastered diabetes and don't have to do anymore to battle diabetes and just stop, or outright refusal to recognize that you have diabetes. Both are damaging to you and may make future management of your diabetes more difficult. Diabetes burnout is very different and should not be confused with denial.

The Third Stage – Acceptance!

The next stage is acceptance of diabetes and the desire to manage it to the best of your abilities. And yes, denial can happen after what may seem like acceptance, but generally does not. Acceptance means that you recognize diabetes is what you have and have decided to manage it as only you can do. Yes, you will rely on your doctor for guidance and assistance, but you have accepted it as your diabetes and intend to do battle with it.

A Possible Fourth Stage – Depression!

Now that I have covered the main stages that most people encounter, I need to add a possible fourth stage. This stage does not generally happen to about one-third of people diagnosed with diabetes, but may happen to the other two-thirds. This is generally a minor depression and may happen at anytime from diagnosis to years later. Only about 19 percent of people develop severe depression. The risk is there and needs to be considered and dealt with when it happens.

I have had diabetes for eight plus years and have had what I believe was depression only twice, the last about a month age. I was in a down mood or funk and had to force myself to continue to work on blogs and do my research, but there were days I did not want to do anything. I don't know what happens to everyone, but unless you really are seriously depressed, take it in stride and work to overcome it. Seek professional help if you feel the need. Some do have serious depression and need to seek professional help. This is normally the best route to follow and get the help necessary.

The last item for this blog is a statement by William Polonsky, PhD, CDE, and director of The Behavioral Diabetes Institute in San Diego, CA. He states that “diabetes does not cause anything.” That is right; diabetes causes nothing, no complications or related problems. This may surprise a few people, but the cause of the complications and some other problems is the poor or lack of diabetes management. You may think that this is what diabetes does, but no, if you maintain blood glucose levels at or near normal, the complications are unlikely to happen. Old age may happen before diabetes complications and you will likely die from old age before diabetes or its complication take over if you accomplish excellent blood glucose management.

This also puts to rest the first myth. Many believe that diabetes is progressive and continues to get worse. If diabetes is managed properly, progression will not happen and people may live a long, normal healthy life. The factor that adds reality and keeps this myth in front of people is that few people actually do what they are supposed to do to manage diabetes. For them diabetes is progressive and their quality of life is often in jeopardy.

Series 1 of 12.

Barriers to PA Counseling in PCP Setting

What other excuses will researchers come up with and doctors provide for not doing their jobs? We constantly hear about the time factor and how doctors are not reimbursed if they spend extra time with patients in need of physical activity (PA) counseling. This I cannot put entirely on the doctors as our medical insurance industry works hard to enforce time limits on doctors. Doctors working for certain type of practices and especially those doctors that are hospital employees are often so tightly managed that they can be docked pay for not staying within limitations of time spent with patients.

Before heaping too much blame on doctors working for hospitals, we need to understand what they are facing. Many hospitals have training areas and training programs, they want the doctors to refer the patients to PA. So far this sounds good, but considering that most insurance companies will not cover this unless it is part of a therapy program for certain medical conditions. Research has shown that physical activity reduces the risk of all-cause mortality in coronary heart disease, hypertension, type 2 diabetes, certain cancers and other chronic conditions. In addition, many patients may have a membership in the local YMCA or YWCA and cannot afford the hospital prices.

I have a difficult time with a hospital that disciplined a doctor employee for volunteering one evening a week to work with patients and other members at a YMCA for two hours. This just shows how greedy the hospital is, not considering that the doctor by volunteering his time may be bringing more patients to the hospital. The hospital was only concerned that he was not volunteering his time for the hospital therapy area where they could charge people for using the facility.

The study pointed out that lack of knowledge and training in health promotion also was a barrier causing a lack of effective physical activity counseling in the primary care setting. In many areas of the USA, there are few areas for people to be able to have exercise programs twelve months of the year. Summer heat in many states and winter snow in northern states make for restrictions to physical activity. Not everyone has room in their homes for exercise equipment or the ability to afford the equipment.

Yet in many communities, schools that have the facilities are underutilized and in general are off limits to the communities to use. Other communities have what used to be dance halls or roller rinks that would work but many are being demolished for lack of use and to make way for commercial buildings or houses. Sometimes there are people that have the training to work with people to assist them in getting physical activity, but the doctors are either unaware of them or prohibited from working with them by their employer or in a few instances the local medical association, because heaven forbid, anything that might take money away from the doctors is not allowed.

I do understand doctors not providing counseling when they will not be reimbursed for it, but to restrict what a doctor does during his off duty or after office hours on a voluntary basis is the height of greed by hospitals and some group practices. In November 2011, the Centers for Medicare and Medicaid Services added coverage for preventive services to reduce obesity. This covers counseling to promote weight loss using intense interventions on exercise and diet. What is stopping this from succeeding? It is the restrictions and guidelines that must be followed before the primary care provider will receive reimbursement. There are too many hoops to jump through for many to have incentives to make this succeed.

For those interested in the article, here is the link. If you are interest in finding a program that will not penalize a doctor or can afford a gym, YMCA, YWCA, or other activity center membership do this. Ask your doctor if he has the training and knowledge to assist. Some will find a way even if they will not be reimbursed, or you may need to find a doctor that can assist. Some do exist through telemedicine, concierge practices, and other types of medical practices. Even some specialty doctors are involved.

Shared Medical Appointments Revisited

It does not seem possible that from May 2010 to now I have gone from being a total skeptic about this topic to an advocate. There are many types of diseases that could benefit from shared medical appointments. Why are they not as popular as they could be? This is a multifaceted situation that troubles many of those that have found success within SMAs.

I have recently talked with two physicians that have been using SMAs with good success. I am apologetic that neither will allow me to use their names and would only talk to me after affirming that I would not reveal their location or the type of practice. I can only say that other doctors are pressuring them to discontinue this part of their practice.

From my own observations, I can say that many doctors do not understand the benefits of SMAs and see no purpose to them. Other doctors view them as a threat and want to have them banned. Now a few doctors may well see them as a threat as they are the ones losing patients to these doctors. A couple of patients have expressed the satisfaction of finding others with the same disease and getting the communication going that they felt their former doctor was ignoring. They said that hope was restored and they felt that they were learning where before they were in a constant battle to have simple questions answered.

To this, I can only say that the medical community climate is changing and doctors that are unwilling to adjust, may be adjusted out of practice. Patients are starting to realize that they have rights and need communication with the doctor.

I have discovered the medical groups in some states are becoming entrenched and protective of their way of life; they are opposing anything new that happens to work. Those doctors that are hospital employees are strongly opposing concierge medicine and anything remotely resembling this. In many areas of this country, hospitals are hiring doctors away from private practice.

I need to get back to SMAs, as they can be a real benefit. Yes, they can benefit people with type 2 diabetes. However, this may be difficult for some doctors to use, as many people with type 2 diabetes want to keep it a secret. Their doctor and office staff can know, but not their neighbors or others in their community. SMAs may reveal this to those they do not wish to have known about their diabetes. Even our informal group has this happen when one of our members knows another person with type 2 diabetes and many of us have been asked not to talk about them with our friends.

One doctor has a small group with the same type of disease. He said that they really delve into different areas of the disease and contact each other outside the SMA. The doctor is now trying to get other types of diseases with four or more patients together for SMAs.

Just think of the information exchange that could take place for diabetes, multiple sclerosis, cancer, and other diseases. Granted, some people will not feel comfortable in SMAs because of their desire for secrecy, but others could really benefit. It is the open exchange of information that seems to help people in SMAs and points to the real benefits.

Other types of SMAs do exist that are more open and patients are encouraged to exchange ideas and information.  This article from the Veterans Administration is also an excellent reference.  I must apologize as two of the links I had here no longer exist as the American Association of Family Physicians has pulled the information because of opposition to SMAs.  The VA reference is still valid, but you will need a PDF reader to view the file now.