ADA, Diabetes 'Battle' Is Not for Patients

Again, we as patients need to question what the American Diabetes Association may do to help provide assistance for the patients. I am aware that the ADA is for the medical community, but even there, this seems little hope in receiving help from the medical community – especially primary care physicians. With Dr. Robert Ratner, chief scientific and medical officer for the ADA who says, “Many people with type 2 diabetes who are on medications don't need to do home glucose monitoring at all," in talking about oral medications.

Until Dr. Ratner changes his message or is no longer an officer of the ADA, people with type 2 diabetes need to boycott any activities by the ADA. I realize many people support the ADA unconditionally and my message falls on deaf ears.

The interview that Kevin L. Hagan did with Medscape in October 2015 is another indication of how far out of touch the organization is with people with type 2 diabetes. The first question sets the tone.

“Medscape: This is a big anniversary year for the ADA. Where do you see it headed in the near future?

Mr. Hagan: The roots of the ADA are as a professional medical association; we were founded by 28 physicians 75 years ago. Over the course of the past 75 years, our mission has evolved, and today we serve both healthcare professionals and consumers.”

If we are consumers, then the ADA has nothing of value for us and we would not shop there. We are patients and we certainly don't receive much of value from the ADA. Most of the ADA's efforts are aimed at people with type 1 diabetes. I have no objection to this, as especially children with type 1 diabetes need this support.

Mr. Hagan: “The cost of diagnosed diabetes is more than $245 billion annually, and it is an escalating price. For me, the front lines of that war on diabetes is at the level of the primary care physician (PCP). As an association, we need to give greater attention to that group.”

These are my thoughts and not Mr. Hagan's. This is the purpose of the ADA and we cannot expect better as patients with type 2 diabetes. Some doctors do treat patients with respect, but too many doctors are guilty of some or all of the following:

• Accuse the patient of causing their diabetes.
• Threaten patients with insulin to keep them on oral medications, when they should be on insulin.
• Refuse to give patients any information on diabetes, lack of education.
• They talk at us rather than with us to arrive at the best treatment for what ails us.
• Doctors say, “More knowledge for patients is not always better…”, “Lay people just don’t understand these issues…”
• Doctors will not individualize treatments for the elderly unless forced into this.
• When we dare ask about insulin for better diabetes management, we are chastised for failing to manage our diabetes with oral medications.
• Some doctors also say that using insulin is our punishment for failing to manage diabetes with oral medications.

Yes, many doctors do not treat patients with diabetes with respect, but bully and bad mouth patients behind their back and to their face. Until doctors learn to respect patients and treat them with respect, the battle will continue. The doctor /patient relationship is in disrepair and communication is sadly absent.

Are You Communicating with Your Doctor

Is Your Doctor Listening to You?

Establishing a strong doctor-patient relationship often depends more on you, the patient. This is sometimes difficult during the first few times you meet with the doctor. There are several steps you must accomplish to know that you have the right doctor and can establish a good communication between you. This will also determine the extent of your trust and desire to build a relationship with the doctor.

Probably one of the first steps will be in finding out during the first visits if the doctor uses the “cookbook medicine approach” or the “your story first approach.” It is important to know these as this will determine how you prepare for your visit. Both are polar opposites in their approach and you need to determine which is a better fit for you. I know I prefer the second approach, but I do have one doctor that uses the first approach. There are variations on both approaches and this can be a challenge. I know this because another doctor lets you tell your story first and then goes into the cookbook medicine approach and I had better answer his questions with a yes or no. When he has finished, then I can normally fill in the blanks that he has missed. This may or may not start another round of questions.

His method has resulted in my being more specific when I start and leaving the unrelated material for his questions. As we have perfected this over the years, he has modified his questions to allow for some detail and I give it to him as briefly as I can. One day when I was there for a checkup, or semiannual appointment, nothing was bothering me and I said as much. He stopped, looked at me, and casually asked what to do next. I said cover the lab results and we did, in more detail than he has ever done before. When he finished this, he asked if I had any questions. I told him that he had answered the questions I had as he covered the lab results, and I said we were done. He looked like I had just defeated him in an extended tennis match. I told him to take advantage of the extra time for his next patient and he seemed to recover immediately. He thanked me and told me to set up my next appointment in six months, and handed me the lab request sheet for the next appointment to give the person setting up the next appointment. Then he headed for the next exam room.

The next appointment started out the same and this time he handed me my copy of the lab results saying everything was good and did I have any questions. I said no and he handed me the lab request sheet and said to set up the next appointment in a year. He stopped and then said if I did need to see him before then, paused, and decided to walk out with me to the desk for the next appointment and gave her the instructions and told her to note on my record that if I needed to see him before the next appointment – to schedule an appointment. She put her name and extension number on the appointment slip to use if I needed an appointment earlier than scheduled. It is this type of relationship that I have learned to treasure, but it took some time and learning how the doctor functioned.

I have another doctor that is all together different. He enters the exam room and asks me questions related to the reason for my appointment. Once he is sure I am there for the stated problem, it is all business of my explaining what has happened and when. Sometimes, because of the problem, I have had tests done beforehand and at other times after he is sure I need the tests. While he is waiting the test results, he moves onto another patient and then returns with the completed test results. Most of the time he tells me that here is a prescription for 10 days and communicates with me about calling for another appointment if this does not correct the problem. Because this has been a lifetime problem, he knows I know what to do and is very careful about repeated episodes.

The most interesting of my doctors has been the person I see for diabetes. There it is discussion of my A1c and the meter readings. She could spot trouble areas in a glance and knew what to ask. I am very sorry to see her leave the diabetes clinic. Now I will need to see how the next person handles the appointment. I will need to be on my toes to discern how I will be treated.

I am concerned about the new procedures being handed me by several of my doctors and I sense I am being slowly being pushed out of their practices because of Medicare. It may be because of the 2% cut or for other reasons that are being implemented in the affordable care act. Tests are being cut and I am being directed to the VA for more of my care.

Is Your Doctor Listening to You – Part 2

Part 2 of 2 Parts

In this part I will cover a blog from Dr. Rob Lamberts. I have followed his blog regularly for several years and enjoy his writing style. I also like his outlook on doctor-patient relationships. Occasionally he will cross into doctor-speak, but he generally says what needs to be said in patient terms for everyone to understand. He has a knack for bringing out the best in communications from the patient and from following him on Facebook I can understand why his patients want him as their doctor.

Doctor Lamberts tries to follow this list as a doctor when seeing patients: (Bold are his headings and comments are mine). Read his blog for his analysis.

1. Listen – He finds a lot of keys by listening.
2. Direct the dialog – Here he means not just asking the right questions, but keeping the patient on track. He will not accept a patient's self-diagnosis, but he wants to hear the patient's story and see if he comes to the same conclusion.
3. Believe the patient – He does not want to be considered ignoring a patient. He realizes patients can be self-conscious about what they are saying. He wants the patient to tell him what the problem is and will help by asking questions.
4. Examine – Dr. Lamberts uses the examination to get more pieces of the puzzle and develop a more complete picture of the problem.
5. Get more data – Family members can often provide other data and it is important to listen to them when an incomplete picture is present. Dr. Lamberts feels that this sometimes prevents additional visits for the same problem. Sometimes more visits are necessary to get more facts or until he asks the right question.
6. Make a list – This is not just the list that the patient may have which can often provide keys, but Dr. Lamberts makes lists also. He wants to know what are the things he can rule out, and what other possibilities are still in play. This is used to aid in determining which test may or not be needed.
7. Address the fear – Many times this is what brought the patient to the doctor. This fear needs to determined and confirmed as this will help the patient understand what is happening and know that their concerns are being addressed. It is also important to know when the patient does not have fear and may only need an excuse for work or school.
8. Order the right tests – More tests if often not better and can confuse the issue. Dr. Lamberts is correct here and only orders the test to rule out important bad diagnoses or strengthen the case for others. I like his thoughts of tests are not meant to change what I know, but to change what I do.
9. Look for patterns – It is often the pattern that makes the diagnosis, not the symptom. Getting a good, factual narrative from the patient, often eliminates many of the symptoms and creates the pattern.
10. When all else fails, do nothing – This is difficult for most doctors. The key here is ruling out serious problems. Communication is the next key so the patient understands to call back or get another appointment if the symptoms or a pattern develops. When the patient understands the plan and knows they will have follow-up, patients will cooperate with doctors that communicate.

Dr. Lamberts concludes his blog by giving advice to patients and is worth quoting.

“Let me end with a bit of advice for patients:

1. Tell your story first. If you have theories, tell them only after you’ve told the story, otherwise you may cause the doc to jump to conclusions.
2. Don’t be ashamed if it sounds silly. You feel what you feel, and sometimes the strangest symptoms are the key to the diagnosis.
3. Say why you came to be seen. What is the worst symptom and what do you fear the most?
4. Don’t insist on tests or medications. More is often less. The best doctors, in my opinion, order less tests and give less medication than the worst ones.
5. Get a plan. Understand what the plan of action is, and when you should call or come back in.
6. Don’t ever assume. If you don’t get results, never ever ever ever assume “no news is good news.” Never. You got that? Never.
7. Try not to be an interesting patient. It’s bad when you are a puzzle to your doctor. Words like, “man, that’s interesting,” or, “I’ve never seen anything like this before,” are usually bad signs. It’s even worse when you are presented in front of a group of doctors or are published in a journal. Don’t seek fame in this way. Stay boring.

P.S. That last one is tongue-in-cheek.” Emphasis in bold is mine.

Don't get me wrong, both doctors have good things to say, but I personally feel that Dr. Lamberts is a doctor I would enjoy seeing more than I would Dr. Wen. This is contrary to what I would normally think or do. Both blogs are worth the time reading on a regular basis.

I will mention another blog of mine using lessons doctors have learned by listening to patients.

Is Your Doctor Listening to You – Part 1

Part 1 of 2 Parts

How doctors blog does say a lot about them. Some are very caring and understanding, while others are brisk and matter-of-fact in their approach to patients. This is evident in their writing as well. Communication is the topic of these two blogs and express both of the above approaches.

The first blog is by Dr. Leana Wen and I will take time to list her points and give my thoughts as a patient. I will encourage you to read each doctors blog and then read my response.

Tip #1: Answer the doctor’s pressing questions first. This requires a very concerted effort on your part to be polite. You must restrain yourself when doctors behave this way. This is how many doctors are and they are easily upset when things are not accomplished in their order.

Tip #2: Attach a narrative response at the end of these close-ended questions.

This will often tax your diplomacy, but it can work. If the doctor asks more questions to follow-up, you know that you are getting his/her attention. Don't over dramatize the point as a simple statement of the facts will generally work the best.

Tip #3: Ask your own questions. This can serve you well if properly done. Some doctors are running on autopilot and this can bring them out of it. Be careful if the doctor just repeats the question and then it may be important. Then if you fumble because you don't understand, often then the doctor will know to reword the question. Always respond to the best of your ability.

Tip #4: Interrupt when interrupted. This will work for some doctors, but be polite and use diplomacy. For those doctors that refuse to let you interrupt, follow their lead even though you may be irritated. If this technique works, keep the narrative brief and state the facts.

Tip #5: Focus on your concerns.

Yes, if you feel like the doctor is ignoring your concerns or not listening, use your best diplomacy and politely interrupt. Express your concerns and Dr. Wen's example is appropriate, “Excuse me, doctor, I have tried to answer all your questions, but I am still not certain my concerns have been addressed. Can you please help me understand why it is that I have been feeling fatigued and short of breath for the last two weeks?” (insert your health concerns) or what the problem is. Do not over state the problem, just give the facts as you know them. If this does not bring the doctor into the discussion of your problem, then you may need to consider more drastic action. Depending on the seriousness of the problem or medical issue, ask the doctor if you need to see the emergency department. Don't use this if you really wish to keep your doctor.

Tip #6: Make sure you are courteous and respectful to your doctor.

Yes, your doctor is supposed to be a professional and is probably doing their best to help you, but don't let them bully you into totally doing things their way and ignoring your medical problem. If at all possible use diplomacy and be respectful. This will normally build a solid doctor-patient relationship.

When I was much younger, as a teenager, I was kicked in the groin by a cow and the doctor was very careful and when he was done with his examination, he said that I had a tear in the bladder and this could likely affect me for the rest of my life. After leaving the military, I had a rough time and the doctor I had did many of the same procedures. He said basically the same thing, and gave me a new antibiotic to help with the healing again as it had somehow torn slightly.

After moving to another part of the state, the trouble flared up again, and it was not six months later. I could tell the new doctor had dollar signs in his eyes, as he would not call the previous doctor, so I ended the conversation and appointment and went home. There I called my previous doctor, and he was kind enough to call in a prescription to my pharmacy. In the meantime I had my previous doctor locate another doctor and forward my records to him. He asked me to come in for an appointment and he also gave me a prescription and said if I had more problems to call and he could prescribe the antibiotic again. I went another 28 years before I had any more problems.

The above tips will generally serve you well in most situations. I have had doctors be on autopilot and I have been able politely to bring them back to the present. One doctor had to think a long time about what I had done. At the next appointment, he did apologize and we even discussed how to bring him back to the now. He had asked his nurse if she had seen him go on autopilot and she had to admit this was a problem for him.

Dr. Wen does describe a trend happening because of the pressure more doctors are facing to see more and more patients. She says that today doctors spend less and less time listening. “Cookbook medicine” (I like this term) is prevalent, with doctors resorting to checklists of yes/no questions rather than really listening to what’s going on with the patient.

Doctors Can Help Reduce Medications

Reading news articles sometimes is very unnerving.  Not only was I offended by this one, I was irritated and not sure I wanted to blog about something that might have value. The title is really a turn-off and made me think an overly aggressive doctor was the author of the press release. Then I read the second paragraph and when it stated a professor – then I knew that it was one of the academia that has little or no knowledge of the real-world happenings. This is still no excuse, but just another lesson on how the people they write for are belittled and thought of as minds they should be the ones molding for compliance – BS.

This is a Danish study and does have value as very few American doctors even consider this approach. In America, doctors push pills for type 2 diabetes and very few will listen to other alternatives. In Denmark, doctors are more patient oriented and encourage patients to take charge of their health and see what they can do for lifestyle changes to stay off medications.

A doctor in the United States refusing to hand out medication until the patient shows the need is almost unheard of. The doctors here would much rather push medications (notice I used the plural) than allow the patient to prove they can stay off medications with exercise, weight loss, and food habits. Occasionally you find a doctor that will allow this to happen, but very rarely. Many insist on medications and then when the patient demonstrates the ability of managing their diabetes, they are still reluctant to allow them off medications. Some doctors will allow this to happen, but not that many.

I would say that the Danish doctors are to be commended for their actions and maybe a few of these doctors should be allowed to teach in our medical schools on the topic of diabetes management for type 2 diabetes.

This is one time when better heads should prevail and articles not titled by people with little knowledge of the disease they write about. This is the title that I found so offensive - “Complications In Diabetes Treatment Can Be Avoided When Patients Cooperate With Their Doctor.” I personally think the title could be improved dramatically and made for people to want to read the article if a title like this was used, “Diabetes Treatment Can Be Improved When Doctors and Patients Share A Common Goal.”

Nurse Practitioner Groups Unite

Primary care physicians move over, the new American Association of Nurse Practitioners (AANP) is now united (as of January 1, 2013) and looking to expand their role in healthcare. As of this date, the American Academy of Nurse Practitioners and the American College of Nurse Practitioners will be the above AANP and have a combined membership of 41,000. The merger will strengthen NPs' influence; the growth of the specialty has already amplified its voice. NP numbers have risen nearly 80% in just more than a decade, from 87,000 in 2001 to 155,000 in 2012, with 11,000 graduating from NP programs this year alone.

There are many reasons for the two groups to merge, but the largest is the Patient Protection and Affordable Care Act (ACA) which will mean about 30 million more patients will enter the healthcare system through 2019. Then according to a recent study in the Nov/Dec issue of Annals of Family Medicine, the shortage of primary care physicians is expected to exceed 52,000 by 2025. Then factor in the fact that the medical groups are coming out in favor of limiting the functions of NPs, makes it even more important that they present a united position.

NPs have been doing the right thing and working to present a consistent front in the establishment of national guidelines for scope of practice. Currently this varies from state to state. Some states require NPs to practice under the supervision of doctors, and in other states, they can practice independent of doctors. One objective that may be required under the ACA rules is the ability to order home healthcare for patients. Presently, to be reimbursed by Medicare, NPs can order home care only through physicians.

There are many other areas that NP can work in as well. I don't care the arguments raised by the American Academy of Family Physicians (AAFP) and other professional medical organizations, we are headed for a primary healthcare dilemma of great seriousness and the professional medical organizations are thumbing their noses at those that can help. If you are ready to accept long delays in seeing your doctor and even longer delays between appointments then support the physicians. Read my blog here to understand that NPs are on a par with doctors and may actually help reduce the cost of healthcare. Doctors are not really working to reduce healthcare costs because they continue to order more and more costly tests because they can.

Review this map for the states that are welcoming NPs and those that doctors have presently under their control. The map shows the states still allowing NPs to practice very much like primary care physicians.