June 19, 2013

Doctors and Insulin Equals Fear

When it comes to insulin, is it really the patients that doctors are concerned about, or their lack of knowledge. Possibly, it could be that their ability to threaten the patient is what would be lost. I would not put much importance in a doctor survey that was conducted for this study. I have much more respect for the doctor telling a patient what this doctor did and working with the patient to find a doctor willing to do insulin therapy and in this case an endocrinologist.

The excuses presented are not laughable, but must be taken with a grain of salt. This is a small survey of only 71 primary care physicians at York Hospital in York, PA. The authors say that 66% of the doctors felt that putting a patient on insulin would be too burdensome. Too burdensome for whom, themselves or the patient. The next statement really may be true to a degree, but to say that 97% of their patients would be willing to start insulin, if it did not involve needles may be an overstatement. I could agree if the patients only had that choice and possibly were not trying to get off oral medications because of the discoveries of potentially deadly side effects.

Then add to this a Canadian study which found that doctors are more reluctant to start their patients on insulin than the patients are themselves. Read my blog here about the study. The following statements I made in that blog are very applicable here and I repeat them.

What they found is that doctor's fears of common side effects such as weight gain and low blood sugar were amplified compared to their patient's fears, and that doctors were more concerned than their patients about the possibility of injection-related pain and anxiety. They also discovered that many doctors where only familiar with the insulins of past usage and older delivery systems. They needed to be reeducated about the newer insulins and methods of delivery.

Like many of us now using insulin, we find it much easier to use, if we use care and learn to use it properly. Instead of eating to a certain amount of insulin, we need to learn to count our carbohydrates and adjust our fast acting insulin accordingly. This will prevent most of the risk of low blood glucose and by limiting our carbohydrates; we can prevent the weight gain many fear. Exercise, if medically able is another way of assisting the prevention of weight gain.
I would guess that this is what drives many primary care physicians to make the statements they did and why they don't feel insulin is right for their patients. Put this with the author's statement of 69% of doctors saying patients would perceive going on insulin as a failure to manage their disease. Is this because the doctors use this myth to keep their patients on oral medications?

I admire Yiyi Yan, MD, PhD for stating, "We know that education helps patients in their use of insulin, but our study indicates that there needs to be more education of primary care physicians on type 2 diabetes management and insulin usage as well. We think concern about how they think their patients will react is the biggest barrier to initiating insulin." This sounds very reminiscent of the Canadian study.

Other statistics given by the study include:
#1) 88% agreed that insulin therapy has better effect on glycemic control than oral diabetes drugs.

#2) 75% agreed that early initiation of insulin could prevent diabetes-related complications.

#3) 88% said they were comfortable initiating insulin therapy among their patients.

#4) 53% reported that the different types of insulin products created confusion in prescribing.

#5) About 60% thought insulin regimens were too complicated for most of their patients to understand.

#6) Only 6%% thought insulin therapy should be managed solely by endocrinologists.

#7) 16% deemed insulin therapy too expensive.

#8) 38% felt insulin therapy was too time-consuming.

Additional author comments include that those who were uncomfortable with insulin therapy believed that education was needed. Many physicians disagreed with the necessity of maintaining tight glycemic control. Although the authors state that experienced primary care physicians were more aware of guidelines and were more comfortable with insulin initiation, I am still concerned that education is needed for PCPs and especially education on the myths they still believe and follow.

Please take time to read this blog by Jan Chait at Diabetes Self Management. She uses her personal experience and the study to relay some excellent advise.

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