Diabetes, Why Isn't Medicine Doing What It Should?

This was published in the British Journal of Diabetes and Vascular Disease. Some of you might like to read the article. In reading this, I have to wonder why the doctors in the United States cannot do anything right. For this, I think some of the blame belongs to the American Diabetes Association and the American Association of Clinical Endocrinologists. More of the blame belongs to the certified diabetes educators that do not educate, but use mandates and mantras.

Most of the blame has to fall on our medical insurance industry that listens to the Centers for Medicare and Medicaid Services (CMS), especially now that the insurance industry has learned how to sidestep the no prior exclusion part of the Affordable Care Act, by almost monthly changing the formulary from which they will reimburse for diabetes and other medications. Some insurance companies are doing exactly this and as a result, many people with diabetes are having a difficult time staying on one medication that is doing well for them. Some of the better companies are consistent in their formulary which is a good thing.

Diabetes care cannot prevent complications in every patient, but surely, doctors could prevent much of the tissue damage that happens in their patients' lives. Unlike in England, here the electronic medical records (EMRs) are very proprietary so that data on diabetes is impossible to obtain. Presently there is not a government agency that can collect data on a national basis to track diabetes and what works and what does not work. These same government agencies rely on information provided on a voluntary basis, which leaves gaping holes in the successes and adverse events that happen with diabetes medications.

The information collection and sharing needs to improve or more doctors will be leaving the practice of medicine. Yet, with the government not staying ahead of the progress, it could be another decade or more before EMRs become usable for the benefit of all – government, health care providers, and patients. Maybe then, the insurance industry will be forced into compliance.

The United States medical system relies on voluntary reporting for much of the data that the different government agencies rely on and report to the public. They cannot give accurate numbers of people at different ages with any type of diabetes. They presently use algorithms for most reporting which gives a very good estimate, but not an accurate number.

When people with diabetes are in the hospital, care has been improving, but still too many errors happen. The first is some nurses that don't understand the ratio for insulin to grams of carbohydrates for each individual. Then many doctors over use basal insulin and cause hypoglycemia. The other big problem is that the food plan for people with diabetes that is promoted by dietitians. It is overloaded with carbohydrates at a time our body needs fat and protein to aid healing, but the dietitians will not allow this.

I can understand that young doctors are less likely to choose Diabetes and Endocrinology as a career. It is a well-known fact that medical, nursing, and other healthcare students have little training in diabetes. There are not enough certified diabetes educators to serve the current diabetes population and with the projected increase, there is little effort to train more. One CDE organization says they are working on this, but when everything is tied up in committee, who is to know what intentions have priority. The other CDE organization is trying to put a strangle hold on who can practice as a CDE. Both organizations work with so few people with type 2 diabetes that I must wonder when they will force their members to stay away from mandates and mantras and start teaching diabetes education.

Until the Federal and State governments start requiring insurance to cover telemedicine, little growth in treating rural diabetes patients will happen. When I think of the diabetes education that could be taught by a form of telemedicine, it stinks that most healthcare providers will not use this. Then we have other medical professions working to stop telemedicine through state medical boards. This is protectionism rather than education at its worst.

Some in Medical Profession Afraid of Technology

Well, maybe not all in the medical profession, but at least the author of this Joslin blog raises issues which are upsetting. I am upset by a statement by Howard Wolpert, M.D., Director of the Joslin Institute for Technology Translation (JITT) when he says, “While the iWatch has the potential to enhance diabetes care in the digital realm, it is still lacking crucial functionalities that prevent the iWatch, and similar devices, from serving as a sufficient replacement for current technologies, such as continuous glucose monitors.”

Now I have to wonder how he arrived at this. I don't think the Apple iWatch intended to replace continuous glucose monitors. If the iWatch can read the data from the current and future versions, then I don't see the problem. Too many of the diabetes tools are too proprietary and guard their data zealously. Dr. Wolpert does say, “I think this has tremendous potential. But for patients to effectively use this information, the information collected needs to be analyzed to identify patterns and this needs to be coupled to specific guidance and feedback to patients around their diabetes self-care.”

This sounds very typical of Joslin. They seem to assume that people with diabetes are too stupid to self manage their diabetes. Most doctors do not have the time to provide specific guidance and feedback to patients around their diabetes self care. And in many areas there is definitely a lack of certified diabetes educators to provide education about self-care.

“Apple collaborated with Mayo Clinic and Epic Systems to create Health and HealthKit and while these partnerships provide new and innovative ways to improve access to care, they also pose regulatory issues. Dr. Wolpert cautions that with diabetes, companies such as Apple do not, “always recognize the challenges associated with developing individualized tools for diabetes care.””

At least Apple collaborated with the Mayo Clinic and Epic Systems and this may be why Joslin is negative about the iWatch. The Joslin blog author goes out of the way criticize Apple at every turn as if the two organizations don't know about diabetes or even HIPAA. While it can be understood that it might take some time to make the best benefit out of the data, the author is doing a great job of decrying Apple and the iWatch.

“One of the drawbacks with all the data collected with multiple sensors using wearable technology is overloading the patient and caregiver with too much information,” said Dr. Wolpert. “It can be counterproductive if the information is not processed and analyzed, and if the treatment recommendations are realistic and manageable for the patient. The benefit derived from using the technology needs to outweigh any additional burden that might go along with the use of the technology.”

The second statement above is why I have to wonder why Dr. Wolpert thinks all patients' are stupid. Many of the tech savvy people are often capable of making better use of the data than many doctors make. To begin with, most primary care doctors do not even look at the data from the blood glucose meters or even the logs kept by the patients. All they are interested in is the HbA1c test and maybe ask a few questions and you are out the door.

“This is setting the stage for a transformation for the way healthcare is delivered, particularly for people with diabetes who often need around the clock guidance,” Dr. Wolpert concluded.

Apparently Dr. Wolpert has unlimited amount of time to spend with a limited number of patients. Most doctors spend about 15 minutes per quarter or about one hour per year, so we cannot count on around the clock guidance. It is obvious that someone lives in a dream world.