Are Our Doctors To Blame?

I have a few friends in the medical profession and one of them asked me to write this blog. I had to do some research, but it did not take as much time as I thought it would. When medical groups like the Society of General Internal Medicine (SGIM) and many other medical groups decided to participate in the “Choosing Wisely” campaign, some unintended consequences became rather apparent.

First, we as patients learned that some medical organizations were not concerned about doing what is in the best interest of patients, only their income. Many medical groups are using this as tool to avoid education of their patients. I can be thankful that some doctors are listening to their patients and taking positions opposite of their own medical organizations.

Other doctors are saying their own medical organizations are not taking a strong enough stand in their guidelines and putting patients in their place. Then they muddy to waters with their terminology to confuse patients even more. “Meaningful use” and “patient engagement” are the latest buzzwords for patients and how this is supposed to make it more meaningful for patients. How quickly doctors have forgotten that communication is what they are required to do, but most doctors have forgotten how to communicate. They talk at us rather than with us to arrive at the best treatment for what ails us.

When doctors order patients to do something, it is almost a crime when they don't understand the consequences of their orders. Twice in the last five months I have had doctors order me to take a certain number of units of my long acting insulin. Both times I have had to refuse because I was below 100 mg/dl and had no food in my system. The first time I was already at 72 mg/dl and when I refused the doctor came to my hospital room to observe me take my insulin. Since I was required to fast because of a procedure I would be undergoing the following morning, I ask the doctor if he was going to allow me to break my fast when I went below 60 mg/dl. When he answered no, I told him that I would be near that without taking the insulin and I did not want to remain in the hospital another full day while they allowed me to recover from a low. I refused to take my insulin and when tested in the morning I was at 59 mg/dl.

The second time I had completed the surgery and was not allowed any food until the following morning and then it would be only sugar free jello and broth. I was already at 79 mg/dl and I told the nurse I would probably be at or below 60 mg/dl by morning without my insulin. Actual blood glucose reading at 6:00 AM was 65 mg/dl using their meter.

Both times (at different hospitals) I was told I was doing things against doctor's advice and being very non-compliant. The second time I was not where I could reach the bedpan or it would have been used for target practice at the doctor. It would not have been very useful as it was only plastic and not what they were several years previous when they were porcelain covered steel. I could almost forgive the first doctor since he was a general internist, but the second doctor was my own endocrinologist. My next appointment this month could be rather heated.

The appointment went smoothly as the endocrinologist was busy with other patients and my nurse practitioner did not call him to the room at my request.

High Blood Glucose Levels = Wound Complications

If you wonder why I urge people to have better A1cs, this article in Medical News Today should hopefully get you to pay attention. A study released in the October issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS) shows how important blood glucose level are. The study shows that among patients undergoing surgery for chronic wounds related to diabetes, the risk of wound-related complications is affected by how well the patient's blood glucose levels are controlled before surgery.

Researchers and ASPS Member Surgeons Drs. Matthew Endara and Christopher Attinger of the Center for Wound Healing at Georgetown University, Washington, DC report the following findings. “The risk of serious wound complications is more than three times higher for patients who have high blood glucose before and after surgery, and in those with poor long-term diabetes control. They emphasize the need for "tight control" of glucose levels before surgery for diabetic patients at high risk of wound complications.”

Fortunately, I cannot speak to wound complications and needing surgery on one. I can say that I have been fortunate in three of the surgeries I have had in September and October and have had no problems with the areas operated on. Even the areas that were opened in my body have healed with good results. As of yet, I have been fortunate to not have chronic or any wound complications. As a person with type 2 diabetes, I will continue to manage my diabetes to prevent this from happening.

When Allen read what I was using for this blog, he ask if I knew a fellow, which I did, but not as a close friend. Allen said he had seen his name as being admitted to the hospital and went to see him. He was not permitted, as he had requested no visitors. So he decided to wait to see the dismissal notice and then went to see him at home. His daughter would not let him in and said her father did not want visitors. She did tell Allen that her father had diabetes and had an amputation.

Allen asked me if I knew of this and I said I did not and an amputation told me a lot. I said that he apparently had kept it a secret from everyone and not managed his diabetes. Allen agreed and said he thought he was close to him, but apparently, not that close and he was not aware of the diabetes. I said this was a problem and he would probably have another amputation if he continued his secrecy and did not manage his diabetes.

We talked about what we could do. I said we should ask the local doctor if he knew him. Beyond that, the doctor will not be able to say anything more if he does know him. I said we could say if he is a patient of his, that he could promote our or his group as being beneficial for him. If he rejects the doctor's suggestion, there is nothing more that we can do.

Allen said he would check with the doctor and let me know. The next day Allen called and said the doctor knew of him, but he was not a patient of his. He checked with the other doctors and he was not a patient of any doctors here. Now Allen was upset and throwing out ideas to try. I finally told Allen to save his frustration and realize that he was not going to be able to help his friend. I did tell Allen just to call him and wish him well. Allen asked why he had not thought of that and said good-bye.

I did not hear from Allen for a few days. Finally, he called and said his friend would not talk to him and his daughter had been told to hang up the telephone. The next day he said that his friend had been readmitted to the hospital and the following day his obituary was in the paper. I had to tell Allen that it is terrible to die alone, but that he had done his best in reaching out to him and now he could do no more.

I called Ben and Barry and clued them in about what had transpired. Ben said he had also known the person. He, and Barry would see what they could do for Allen.

Yes, I was sidetracked, but the situation fit and helped me emphasize how important management of diabetes is to people's continued health.

Many Type 2s On Oral Medications Stop

Apparently no one thought this was important enough to talk about it earlier during or after the American Diabetes Association Scientific Sessions in Chicago. I am surprised that it even received a mention now.

A new study conducted by Carol E. Koro, Ph.D., “shows that a majority of people taking drugs to treat type 2 diabetes stop taking their medications within six months, while almost all of them stop taking them within a year. The rate of drug discontinuation among type 2 diabetes patients was 89 percent for those taking a GLP-1 agonist to lower blood sugar levels, 82 percent for those who took a DPP-4 inhibitor to stimulate the release of insulin by the pancreas, and 84 percent for those taking other diabetes medications.”

“Carol E. Koro, Ph.D., who along with colleagues looked at 134,696 type 2 diabetes patients placed on a GLP-1 agonist, 202,269 who were taking a DPP-4 inhibitor, and 1,014,630 who were prescribed another diabetes drug. All patients were commercially insured.” These are alarming statistics, but with the alarms about the GLP-1 agonists and DPP-4 inhibitors, we probably should not be surprised. I am concerned that the patients did not talk to their doctors' about this to prevent diabetes from becoming unmanaged.

Now an even more concerning factor is that Koro, “An epidemiologist at GlaxoSmithKline in Research Triangle Park, N.C., based her research on data from the Truven Health Analytics MarketScan database between 2005 and 2011, and tracked refill rate patterns to determine how much of their medications patients were taking.”

"These results demonstrate the need for improved persistence with GLP-1 agonist treatment," Koro said, “adding that estimates suggest that improving compliance with diabetes drug protocol could prevent 700,000 emergency room visits and 341,000 hospitalizations each year, saving $4.7 billion in health care costs.” The study was funded by the pharmaceutical company GlaxoSmithKline.

You have to know that the company drug reps will be pushing hard to reverse this. GlaxoSmithKline does not want a loss in revenue. This also points out problems in the confidentially of data when a pharmaceutical company like this can identify patients by doctor and what weight and sex the patients were.

It is sad that this happened, but to allow a pharmaceutical company access to this information is not good. It is understandable now why this was probably not reported earlier and for Diabetes Health to be reporting this now speaks volumes in their lack of concern for ethics and is just another point they have broken in patient trust.

Diabetes Equipment Information

Are you seeking information about equipment for diabetes? I have one source that I depend upon that is fairly reliable. There may be other sources that are easier to read, but I am not aware of them. There are many blood glucose meter comparison charts and I will list two of them later.

First, you will need a PDF reader like Adobe Reader or Foxit Reader. Both are free and can be downloaded. I use both for different reasons. The files that I show next in the second image below are all PDF files.

This link should take you to Diabetes Health magazine. Then about one fourth of the way down the right column you will find this - 

 

You are welcome to explore, but I suggest going to the last line above and by clicking on it, you will be taken to the following image.

These are the five choices and you are welcome to explore. I have saved the first two items and the last item. I am not sure, but I believe the new charts for 2014 will be available sometime in January 2014, as they usually are.

The following are links to other blood glucose meter comparisons: I am not sure they will be updated each year; however, the first is generally updated whenever a new meter is available on the market and is carried by them.

http://www.walgreens.com/marketing/library/centers/diabetes/bgmcc.jsp

http://www.diabetesdaily.com/voices/2013/07/blood-glucose-meter-accuracy-comparison-chart/

The following link covers a wide variety of diabetes equipment:

http://www.diabetesforecast.org/landing-pages/lp-consumer-guide.html

Most is in discussion about the items with some good pointers on use and advantages and disadvantages of some of the equipment. There are almost no charts for comparison purposes.

Fitting SGLT2 Inhibitors in Diabetes Care

This is yet another doctor that believes diabetes is progressive and talks about it in that way. He does not acknowledge that the progression can be halted, but that the complications can be mitigated to some degree with the right medication. How deflating this must be for his patients.

He is talking about SGLT2 and how this medication is needed to lessen to severity of the complications. He states, “We need different treatments and different combinations of treatments to focus on these different factors at different times as the disease progresses.”

Clifford J. Bailey, PhD, Professor of Clinical Science at Aston University in Birmingham, United Kingdom says, “We now have very good evidence that good glycemic control, especially at the very beginning of type 2 diabetes, after diagnosis, is also very important in the long term to reduce the onset and severity of the complications of type 2 diabetes and to reduce macrovascular risk. Therefore, there is very good rationale for using as many therapies as we need at different times to control hyperglycemia.”

Now, if he would just read what he said, he might just realize that the onset of complications can be managed and diabetes can be non-progressive. Here again, I would be inclined to believe that this doctor is not big on diabetes education and lets his patients wallow in ignorance; therefore insuring that he has patients to treat for the complications.

At least we can know that he has conflicts of interest in his promotion of SGLT2 medications. Disclosure: Clifford J. Bailey, PhD, has disclosed the following relevant financial relationships: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Abbott Cardiovascular Systems, Inc. (formerly Advanced Cardiovascular Systems, Inc.) ; AstraZeneca Pharmaceuticals LP; Bristol-Myers Squibb Company; Boehringer Ingelheim; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.; Eli Lilly and Company; Merck Sharp Dohme; Novo Nordisk; Takeda Pharmaceuticals North America, Inc.; sanofi-aventis

Serve(d) as a speaker or a member of a speakers bureau for: AstraZeneca Pharmaceuticals LP; Bristol-Myers Squibb Company; Boehringer Ingelheim; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.; Eli Lilly and Company; Merck Sharp Dohme; Novo Nordisk; sanofi-aventis

Received research grant from: AstraZeneca Pharmaceuticals LP; sanofi-aventis

At least he does list the problem areas for the class SGLT2 medications, but even then he couches it very carefully by promoting the drug while listing the urinary track infections and stating that the patients need adequate renal function before taking the drug. He does state the following - “Chronic kidney disease is an issue in advancing years in patients with type 2 diabetes, and so that is one of the precautions that needs to be seriously considered when choosing to use this type of therapy. That said, because this type of therapy is non-insulin dependent, it can be used early in the progression of type 2 diabetes as an add-on to the monotherapies that we have available at the moment.”

I would be very cautious if renal function may be impaired and I would demand to be tested for this before allowing this medication to be prescribed to me. This is a subject that needs to be raised with your doctor.

Again, a Doctor Refuses to Test for Vitamin B12 Deficiency

Allen called Friday morning in a panic. He said that a friend of his could not get tested for vitamin B12 deficiency. He was seeing the same doctor Allen had his trouble with. Allen wondered if he should take his friend to the endocrinologist we see or take this up with the local doctor. He said his friend had been taking metformin longer than he had.

I suggested that he try the local doctor and see if he was sincere in the concern he had expressed earlier. Allen said this was what he was thinking and said he would call me back later. That afternoon he called and said the doctor had taken him immediately and did several tests like the endocrinologist had done on him. Allen said that his vitamin B12 level was even lower than his had been. His vitamin D level had been slightly higher than Allen remembered his had been. Then Allen said the doctor had also checked the potassium and magnesium levels and they were low.

Once the doctor had the test results and found out why he had not been tested by his doctor, Allen said he had called the doctor and made his results known and told the doctor to be in his office that evening. Allen said he then called the pharmacy to see what they had for potassium and magnesium supplements and wrote a note for him to purchase the supplements and take one a day for 30 days and he would be retested then.

Then Allen was asked to leave the room while he gave vitamin B12 and D shots. In the discussion when Allen was back in the room, the doctor asked his friend not to drive until his levels were back in the normal range. He then asked Allen to let him know if he did drive and he would ask for his license. He was scheduled for shots in the next two weeks and then he would be tested again the third week before they decided whether he needed more shots. He would be started on vitamin B12 and D supplements at that time if no more shots were required.

Allen said that he was asked to stay while his friend checked out. The doctor had thanked him for bringing his friend and said that this would go a long way in helping him convince this doctor that many people could not eat their way to good health and levels of vitamin B12 on metformin. I told Allen that I had sent the URLs for this article and this article to the doctor and received a thank you for sending them. Allen asked me to send them to him as well.

Allen said his friend wanted to drive, but Allen said the doctor was serious and recounted what had happened to him. Allen said he had also alerted his friend's daughter about the situation and she had agreed to help her father until this was over.  I asked Allen how old his friend was and Allen said only a year younger than he was.

Allen anticipated my next question and stated that he was on VA assistance and that he had been warned about his vitamin B12 levels, but had ignored them. I said he may not have been very low or they would have given him a shot then.

Allen said his friend had asked him to drive for his tests the following week at the VA and then for his appointment the week after. I said that he may be taking them serious now, but at least he knows. I commented to Allen that he could send out an email to everyone now and emphasize to people the importance of being tested for vitamin B12 especially if they had friends or relatives on metformin. Allen thanked me for allowing him to do this and he would have Tim send it on to people in the other groups.

Allen concluded by saying he had asked his friend to consider joining our support group, but his friend was not sure he wanted to. Allen said he was not going to pressure him, but would continue to promote the idea with him.

Can We Trust WebMD for Reliable Info?

At least one of my Senators is speaking out about transparency. “The contract has raised concerns for one senator. Sen. Chuck Grassley, R-Iowa, told the Times that "disclosure and transparency would be a good practice for any recipient of federal funding to promote the administration's health care plan."”

“Even if certain content is not produced with federal funding, but the same company takes federal government money to produce other materials, consumers would be better-informed by knowing the financial relationships.” Senator Grassley is an influential member of the Senate Finance and Budget committees.

WebMD has received a $4.8 million deal with the government, through the Centers for Medicare and Medicaid Services, to educate health care workers about parts of the health care law.

“WebMD says it doesn’t believe it had an obligation to disclose to its broad consumer base its $4.8 million contract with the government. The company says the contract, while awarded to WebMD, went through its Medscape platform, which provides continuing education to doctors in a password-protected portal and is run independently from WebMD’s news operation.”

CMS (Centers for Medicare and Medicaid Services) officials defended the contract.  “As part of our broad outreach and education efforts that we have conducted across CMS programs for years, we are working with Medscape, which is owned by WebMD, to inform Americans about the new opportunity to enroll, many for the very first time, in quality affordable health care coverage,” the CMS statement read.

Anyway you slice this, a conflict exists and the intent harms readers because they do not know who or what entity is behind the articles. All I can say is thank you to the Washington Times for their investigating and bringing this to the attention of all.

Then we are able to hear from a doctor that does not appreciate medical content providers that go political. It is refreshing to see this happen and realize that patients are not the only people that wonder when this happens.