We as Diabetes Patients Need to Stop Hostility from Doctors

This is one topic I have wanted to write about and have never able to put my thoughts together coherently. This blog from Kevin MD, written by Marjorie Stiegler,MD is about doctors and nurses ending their hostility. She has some excellent points that need consideration in the doctor and patient hostilities.

(Image source: Facebook.com/WeAreNurses)

The doctor and diabetes patient battle is getting worse and there seems no end in sight. I read patients' comments on forums about being blamed for getting diabetes, and many complain about the lack of doctor instructions for handling diabetes. Others complain that the doctor said they had diabetes and hand them a bunch of prescriptions and telling them to take according to instructions. Still others complain about doctors that are bullying them and only want the patients to do certain things and set unreasonable goals for them.

This is one truth I know: We all have value and doctors that demean us only degrade themselves. If they are unwilling to communicate with us in a respectful manner, then we should find another doctor.

It is a shame that other organizations that could help people with diabetes, especially those of us with type 2 diabetes, cannot or will not. One group is working tirelessly to be the only organization that can provide faulty nutrition. The other two organizations, that could teach people about diabetes, are also working toward this end and while they give out platitudes, they also are doing more harm to people with type 2 diabetes. All the people involved in the three organizations seldom teach, give mantras, mandates, and seldom any education to help us manage diabetes.

Doctors are important, however, many do not want to treat people with type 2 diabetes, and therefore do not learn about the medications, especially insulin, because they are so afraid of hypoglycemia that they refuse to prescribe insulin until all else fails and the patient will not live for many more years because of their neglect.

Nurses are almost more important. This is because they are more concerned about patients and do more than doctors are even willing to do.

Pharmacists are important when it comes to medications and they will do a lot to help patients afford some medications and will often discuss side effects with doctors to avoid medication conflicts.

There is more, but I will leave this for another blog in the future.

Personalization of Treatment Recommended More

I admit I am happy to see more articles about this and more writers emphasizing personalization of diabetes treatment repeatedly. Doctors may not be happy about this, but it is of their own doing, as they only operate on a one-size-fits-all theory.

I am surprised that the Veterans Health Administration supplied the data for the retrospective cohort study. This was done to examine the rate at which physicians discontinued or deintensified therapy when their diabetes patients' glycemic or blood pressure (BP) levels were low enough to do this. Participants included one cohort of 211,667 patients with diabetes who were older than 70 years and were receiving active treatment for hypertension, and a second cohort of 179,991 patients receiving active treatment for hyperglycemia.

Patients were considered eligible for deintensification if they had low BP or a low glycated hemoglobin (A1c) level in their last measurement in 2012 (index measurement). Very low BP was defined as less than 120/65 mm Hg and moderately low as systolic BP of 120 to 129 mm Hg or diastolic BP less than 65 mm Hg. Very low A1c was defined as less than 6.0%, and moderately low as 6.0% to 6.4%. The main outcome measure was discontinuation or treatment dose reduction within 6 months after the index measurement. The investigators also examined whether life expectancy played a role in the rate of deintensification.

Survey responses indicated that "risk of hypoglycemia" and "life expectancy" were considered the most important parameters and thus received the highest weights. "Important comorbidities," "complications," and "cognitive function" were moderately important, while "disease duration" and "resources and support system" received the lowest weights.

To use the algorithm, a clinician simply scores each of these eight items as low, moderate, or high risk, and the algorithm generates an A1c target. In the six original cases as well as the three new cases, the algorithm suggested a target that was nearly identical to the A1c values recommended by 57 experts.

Clinical decision-making is a tricky process, especially when the patient is complex. Because diabetes affects essentially every major organ and system of the human body, few diseases are more complex. To simplify treatment, professional organizations such as the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) develop guidelines and recommendations that are based on the best available evidence. When new evidence emerges that conflicts with existing guidelines, the complexity of treating complicated patients is amplified.

There is no better example than with diabetes, where lower glycemic and blood pressure levels proved not to be ideal for everyone, although there were subsets for which lower targets were better. Another possible explanation for lack of deintensification is that presenting patients seemed okay so clinicians chose the conservative path of leaving things alone. As Sussman and colleagues conclude, however, clinicians "should assess the potential harms of intensive therapy just as they do the benefits," a process that may demand new tools and a personalized approach.

An important concern with Cahn and colleagues' algorithm (and others that might be developed in similar ways) is that it is entirely based on expert opinion. There is no empirical data to verify that the identified A1c target is indeed the "right" one for the patient at hand. Furthermore, the very nature of personalization makes such evidence impossible to obtain. Because clinicians are scientists who are used to practicing evidence-based medicine, making such an important decision without clear-cut evidence may be uncomfortable. Still, the result could make the patient more comfortable. Isn't that the goal?

How Long Insulin Lasts

If you are using insulin, hopefully you know about how long an insulin vial lasts based on your usage. I know and I have had CDEs tell me otherwise and I have to wonder where they received their information. A vial contains 1,000 units of insulin and one insulin lasts 10.5 days and the other insulin varies from 11 to 13 days depending on the needs and occasionally I can get 14 days.

Again, the newsletter from Diabetes-in-Control has another problem with insulin that does not make sense and in this case, we are not given all the facts and readers should be wondering where the problem lies. If the there was a problem with the amount of insulin used, no mention was made about the A1c or blood glucose levels that should have possibly accompanied the problem of insulin usage.

The patient said he used 50 units of Levemir two times per day and threw out the vial after 30 days with some insulin remaining. Granted the shelf life of Levemir is 42 days once the vial is opened. It is obvious that the insulin is not being used correctly, but as readers, we are not given information to be sure it is dose being used or whether it is half a syringe that is being mistaken for 50 units. Know the latest A1cs could have been useful.

Lessons Learned:

• Inform patient about how long an insulin vial or pen should last. Inform the patient how long an insulin vial or pen should last once opened. This stresses the importance of proper expiration once opened versus shelf life.
• Explore with the patient not only what he or she is verbally telling you, but ask how often they use a new vial or pen, and if they have extras at home. If so, how many?
• Always perform a demonstration and ask for a return demonstration, and make sure the return demonstration is done correctly before discharge.

These are all things that should be done, but seldom are done. Even I was deprived of this, but at the time, I had a neighbor that is a nurse and I did ask several questions of her for several months until I was comfortable with both the amount I was using and that I was injecting in the correct areas.

How Telemedicine Started

This about the start of telemedicine really interested me and it is not often one of the originals tells it. A version of this article first appeared in Telemedicine Magazine. I am using the information that appeared in Medpage Today and am quoting the entire article.

How 'A Stupid Idea' Gave Birth to Telemedicine

by Jay H. Sanders MD

Jay Sanders, MD -- often called "The Father of Telemedicine" for his work introducing telehealth in the Southeast in the 1970s -- can remember the day that telemedicine was conceived, and by whom. To Sanders, the true father of telemedicine is Kenneth Byrd, MD. Here's his story.

It was late summer, 1967. I was working as a senior resident in medicine at Massachusetts General Hospital in Boston. In those days there was no emergency medical specialty. The senior resident and the surgical senior resident rotated two 12-hour shifts, running the emergency room. I was out front in the emergency department waiting for the next Boston traffic accident victim to come through the doors when the doors swung open and in came my professor, who was red-faced and upset.

I knew exactly why he was upset. These professors of medicine at the Massachusetts General Hospital were making a grand total of about $8,000 a year. So many of them moonlighted. One of the jobs that Ken Byrd was doing was moonlighting as the medical director at Logan Airport Medical Station. Anybody who knows Boston knows that the airport's only 3.5 miles away from the Mass General, except for one problem: the traffic.

In those days, there was only one tunnel under the Charles River, not three like there are today. And every day he would have to go back and forth 3.5 miles to Logan Airport to see airport employees or travelers who got sick. And every day he would get stuck in terrible traffic in the Sumner Tunnel. It would literally take him an hour each way.

He got so frustrated this one day in 1967 that he came through the MGH doors with an idea. Since I was the first one he saw, he came up to me and he grabbed my arm and he said: "Jay!" I said, "I understand, Dr. Byrd. I know you got caught in traffic again."

And he said, "No! I did, but I had this idea! What if I bought two TV cameras and put one at Logan Airport and one here in the MGH ER and I began to examine patients over TV? What do you think?"

Now I have to tell you I thought it was the stupidest idea I'd ever heard of in my life. But I had enough common sense to realize he was my professor. I was a resident and I said, "Gee, Dr. Byrd, that's a very interesting idea." And I've been working on his stupid idea ever since.

As told by Jay H. Sanders, MD, president and CEO of The Global Telemedicine Group. A version of this article first appeared at Telemedicine Magazine, a quarterly publication that connects medical providers with the tech innovators revolutionizing the healthcare system.

The AAFP Promotes Bad Diabetes Information

In 2013, late April and the first of May, I did three blogs on the American Academy of Family Physicians(AAFP) website. I was correct then and my mind hasn't changed and is even more disappointed in the website now.

In listing the source of some articles the following is listed:

1. Portions of this article were developed by the American Academy of Family Physicians in cooperation with the American Diabetes Association.

2. Portions of this article were developed as part of an educational program made possible by an unrestricted educational grant from LifeScan, Inc., makers of OneTouch Blood Glucose Meters.

3. Portions of this article were developed with general underwriting support from The Coca-Cola Company.

Yes, number 3 is very disturbing and makes me concerned about other conflicts of interest for the AAFP.

The number of critical errors has increased and it is small wonder that the patients they treat are receiving any care, as they will be receiving more harm if the doctors follow the information on the AAFP website.

Quote: There are 2 blood tests that can help you manage your diabetes. One of these tests is called an A1C test, which reflects your blood sugar (or blood glucose) control over the past 2-3 months. Testing your A1C level every 3 months is the best way for you and your doctor to understand how well your blood sugar levels are controlled. Unquote

The wrong statement above is – an A1c test, which reflects your blood glucose control over the past 2-3 months. The HbA1c test reflects the prior four months and this is from David Mendosa's blog. This seems to be a common mistake made by many people and I would have thought a professional group would not make this mistake.

Quote: Your A1C goal will be determined by your doctor, but it is generally less than 7%. Unquote This should not happen and your doctor should never determine your goals. Yes, they may guide you, but never should they set your goals.

Quote: The other test is called SMBG, or self-monitoring of blood glucose. Using a blood glucose monitor to do SMBG, testing can help you improve control of your blood sugar levels. The results you get from an SMBG test can help you make appropriate adjustments to your medicine, diet and/or level of physical activity. Every person who has diabetes should have a blood glucose monitor (also called a home blood sugar meter, a glucometer, or a glucose meter) and know how to use it. Unquote

SMBG (self-monitoring of blood glucose) is not a test, but a series of blood glucose tests used to determine how certain meals affect your blood glucose levels, help you determine if you may have something else, such as hypoglycemia (low blood glucose), hyperglycemia (elevated blood glucose), or even possibly an infection or illness causing elevated blood glucose levels. For food, the testing needs to be done in pairs with one test just prior to eating and the second test done 1 or 2 hours after first or last bite. A single test after a meal is meaningless and will not tell you whether you need to eliminate a food or greatly limit it.

Not every person that has diabetes needs a blood glucose monitor (continuous glucose monitor – CGM). Most people with type 1 should use one, but most people with type 2 diabetes only need a blood glucose meter. A few type 2 people would benefit by using a CGM.

The three prior blogs are – blog 1, blog 2, and blog 3.

Trial Hypoglycemia under Real-World Significantly

If you are using insulin or one of the sulfonylureas, you may have experienced a mild or even a severe episode of hypoglycemia. All doctors have a great fear of patients have an episode of low blood glucose levels, and this is the main reason they do not like to prescribe insulin. Of course, they also follow many of the recommendations of the American Diabetes Association.

This is expected by doctors because most have little or no knowledge of meal plans for people with diabetes that will make it easier to avoid hypoglycemia. Real-world rates of severe hypoglycemia among certain subgroups of patients with diabetes are considerably higher than those seen in randomized clinical trials, a new analysis shows. The Big Pharma companies that do clinical trials carefully select patients for trials and limit the number of carbohydrates that the patients consume at each meal. No big surprise here.

The findings were published online December 17 in Diabetes Care by Ram D Pathak, MD, an endocrinologist at the Marshfield Clinic, Marshfield, Wisconsin and the University of Wisconsin School of Medicine and Public Health, Madison, and colleagues.

Using electronic health records for an insured cohort of nearly one million adults with diabetes seen during 2005–2011, the majority of which was type 2 diabetes, the authors found rates of severe hypoglycemia requiring medical intervention of 1.4 to 1.6 per 100 person-years. This is in contrast to the 0.3 to 1.0 rates seen in the standard-care arms of randomized clinical trials.

Rates of severe hypoglycemia were particularly high among older patients and those with chronic kidney disease, congestive heart failure, cardiovascular disease, depression, and higher HbA1c levels. Severe hypoglycemia was also

more common among patients taking insulin, insulin secretagogues, and beta-blockers.

Strategies that reduce the risk of hypoglycemia in high-risk patients are needed. These data can inform the development of clinical management strategies to effectively reduce the occurrence of severe hypoglycemia in community-treated patients.

Kasia J Lipska, MD, an endocrinologist at Yale University, New Haven, Connecticut, who has studied hypoglycemia in the elderly, told Medscape Medical News, "The rates of severe hypoglycemia are usually much lower in randomized clinical trials than in real-world populations. That's most likely because patients recruited for clinical trials are typically healthier and less likely to experience hypoglycemia compared with the complex patients we see in clinical practice." Well stated Dr. Lipska and I completely agree.

Individuals with chronic kidney disease, congestive heart failure, and/or cardiovascular disease had between four and eight times greater rates of severe hypoglycemia than did those with diabetes but without those comorbidities.

Ascertaining hypoglycemia using claims or EHR data is very difficult, Dr Lipska pointed out, adding, "This is something that I think needs urgent attention. Hypoglycemia is common, dangerous, and potentially avoidable, but we have no systems of surveillance for hypoglycemia."

She praised the investigators for "a great job compiling multiple sources of data and using a list of potential ICD-9 codes for hypoglycemia," but she noted that information about events occurring outside the hospital system is still missing.

And she said that by capturing hypoglycemic events that occurred during hospital stays, "we can't easily attribute them to ambulatory management of diabetes. Interventions to reduce inpatient hypoglycemia will need to differ from those targeting hypoglycemia in the outpatient setting, so looking at these events separately might be helpful as well."

This is one of the better studies on hypoglycemia and Dr. Lipska's input adds more value.

Are You Using Generics or Brand Name Drugs?

Prescribing generic medicines instead of brand name drugs whenever possible cuts costs, improves patient adherence, and improves health outcomes, according to a newrecommendation from the American College of Physicians.

“Generic medications are cheaper and patients are more likely to get those prescriptions filled,” said Dr. Amir Qaseem of the American College of Physicians, who coauthored the recommendation. “This is for both physicians and patients,” Dr. Qaseem told Reuters Health by phone.

I like what Dr. Qaseem has stated, “Despite what some patients and even doctors may believe, generics are consistently as effective and safe as their brand-name counterparts.” The ACP has reviewed existing evidence and found that for Medicare beneficiaries with diabetes, for example, up to 45 percent of prescriptions are for brand-name drugs when identical generics are available. Choosing these generics instead, and choosing therapeutically similar but chemically different generics in some other cases, could save up to $1.4 billion for Medicare, the reviewers found.

Brand name prescriptions are almost twice as likely to be prescribed but never picked up from the pharmacy than generics, and not adhering to prescribed medications leads to higher out-of-pocket costs for patients later on, the reviewers wrote in the Annals of Internal Medicine.

“Often, patients don't tell their doctors they can't afford an expensive drug they were prescribed; they just fail to take it, or take it at sub-therapeutic (too low) doses because of its cost,” said Dr. Jerome Avorn, professor of medicine at Harvard Medical School in Boston, who was not part of the new study. “And this has major health effects.”

The new recommendation “is based on a thorough review of data from a huge number of relevant studies in the medical literature, raising it above the level of 'conventional wisdom,'” Avorn said.

The American College of Physicians (ACP) is one of the most widely respected bodies in medicine, Avorn told Reuters Health by email.

Some physicians may not be aware that a generic form of a medication is available, or may refer to the drug by its brand name out of habit, which results in more expensive prescriptions, Qaseem said.

Continuing physician education programs could keep doctors abreast of available generics, as well as interactive options on electronic health records, he

said. “A large scale public awareness campaign is what’s needed,” he said. “Many think if it’s cheaper it’s not as good.”

But, there are some cases when a generic substitution is not available or is not appropriate for a particular patient, he noted. Yes, this sometimes happens and doctors need to be aware of the finances of the patient, as there are often assistance programs available.

“This information about generics is especially timely now, given all we've seen in the last year or two demonstrating that brand-name companies can charge whatever they please for their products, even if the price is astronomical,” Avorn said. “It's not clear that will change any time soon, making it even more important to educate doctors to use generics whenever possible.”