Presentation to a Group in a City West of Us

I have held this, as I was not sure I even wanted to show what could happen when things go badly. At the urging of Tim and a few others I am posting this after Tim had read it.  This meeting was on the third Friday.

This was an unusual meeting. I was the only person originally scheduled and one of their doctors refused to attend with the rest of our group in attendance. In a phone call, I was able to determine that the doctor did like others being part of the meeting.

Once the meeting started, a CDE objected to the topic and felt we were not presenting it properly. We had not distributed the email copies; therefore, at that point I stopped presenting. I walked over to their doctor and told him I would be stopping with the CDE constantly interrupting. He asked the CDE to take over. When she did, almost all the members got up and left. I told those with me that we would be leaving as well. The doctor leader of their group asked people to stay, but most said no and continued leaving.

I explained to our group after we were on our way home what had happened to the group originally and that I may have caused the group to disband a second time. This I did not like, but I have had problems with her before and I wanted no more of it. I said I don't like what happened this evening, but felt that the other doctor had set this up and that was their problem. I told the others that I would not be going back and would not participate again until the other doctor has been removed and the group is open to others or groups of presenters. I said, we have had success with other groups and I will not be part of a group that discourages presenter groups.

The following Monday, I received an email asking me to return. I said no and that I did not like being called out by a CDE who was not part of the group in the first place. The answer was that she had not been invited, but had shown up at the request of the second doctor who was not in attendance. I said that I was sorry, but I would not be caught in further conflicts that had caused the group to disband originally and if I had caused this, I would not be coming back.

Tim, our local doctor, and I stayed in touch as we expected further emails and attempts to have one or more of us back. The doctor in attendance and Tim had exchanged emails with the doctor there, we were concerned about why we have been very successful with some groups, and this group was difficult. Tim was surprised that the meeting had ended quickly and quietly. I told Tim that very few have an interest in CDEs and they were not willing to listen to one. I said the group of us had received approval and to have one doctor throwing a fit and getting the CDE involved may have disbanded the group.

Tim commented that this could be the case for our group, but he hoped we would be more polite. I said some may be, but I would be one to leave and do it promptly. I told Tim that even if it was one of my relatives, I would still leave. Tim asked why I would do that. I explained that until the AADE lowered to the bar, created a group for peer mentors and peer workers, and did not constantly push for their own line of education and making it exclusive to their members, I would not wish to have much to do with them and their poor attitude about people with type 2 diabetes.

Tim agreed that setting up education for peer mentors and peer workers would be a positive as long as the AADE did not make it too burdensome and discouraging for people to attempt.

Diabetes Management under a Physician Shortage

In the next few years, what are we, as diabetes patients going to be able to do? There is going to be a physician shortage which we have been hearing about from doctors and their professional organizations. Even teaching professors are talking about this and a few patients. How long are we going to be forced to wait between appointments and think about how much time the doctor spends with you now. This can only be worse and your questions may not even be answered.

Ann Bartlett, who writes at Health Central dot com has an excellent blog on July 17 that deserves your attention. She is a type 1 and in this blog writes for all people with diabetes. Because of what she writes about the numbers of practicing endocrinologists, I will disagree with her statement that everyone should see an endocrinologist at least once a year. Some people will do very well in the early stages of diabetes, especially those with type 2 diabetes that do not need to lose weight or that are able to manage their diabetes with nutrition and exercise. Many people do probably need to lose some weight and are capable of doing so.

Where I do agree that people with type 2 needing to see an endocrinologist are those people with complex diabetes and often comorbidities requiring more attention than a primary care physician (PCP) has time to devote to the patient. Many of these patients are in the need of insulin therapy, but the PCP has not kept abreast of the knowledge required and so won't prescribe insulin. Instead, he has stacked one oral medication on top of another and in some unusual cases, the patients are taking up to four different oral medications. Too many and most of the time they still are having trouble maintaining good A1c's.

Ann is right when she says, “Third-party insurance providers, the big bad boy of this debate, are finally hearing the bell toll, and need to start offering fair reimbursement to doctors for services rendered.” Unfortunately, with the Centers for Medicare and Medicaid Services not expanding their payment to PCPs and endocrinologists, the rest of the insurance industry will not step forward and help, as they want to grow their profit margin. So our doctors are continually squeezed in the pocketbooks and wallets.

As a result, I will continue to advocate for state medical boards to loosen their strangle hold on nurse practitioners and physician assistants and allow them to operate with more independence. This blog has a map showing the states that are allowing NPs the freedom to practice medicine without supervision. Only 18 states are presently allowing this. It is a shame that the same information is not available for PAs. My endocrinologist has at least two NPs on his staff and I see one of them. I also see a NP at my Veterans Affairs (VA) appointments and I am very happy with both.

The American Association of Diabetes Educators (AADE) could really help with education, but at present, they are reluctant to do so. I have been on their case for some time now and all it has gotten me is derogatory emails. Even my CDE cousin will not talk to me anymore because she knows I am serious.

The AADE is not adding CDEs at a rate needed to serve patients adequately. Therefore, the AADE should be required to open up a classification or group for peer-to-peer workers and peer mentors, give them some training and classes, and let them move out into the diabetes community and help people with all types of diabetes. Then they should provide continuing education for them. This is supported by several studies where peer-to-peer workers have helped other type 2 patients lower their A1c's. This would work for type 2 helping type 2's and type 1 helping type 1's.

Even the ADA and AADE Task Force that developed the Diabetes Self Management Educations (DSME) and the Diabetes Self Management Support (DSMS) National Standards included lay people and peer workers in the area requiring more research, yet the AADE has chosen to ignore this. Oh, yes, they will take credit for the CDC programs that they participate in for training peer workers, but will they open a designation for them and continue to assist them with more education – no. They can't wait to be separate from them and let them go their way. This is not the correct attitude to my way of thinking, especially with the shortage of certified diabetes educators.

Fortunately, some doctors in rural areas and some not so rural areas are seeing the need for peer-to-peer workers and peer mentors and having them educated. Then they are returning to help their doctor and other doctors in their areas. One doctor that I started to work with in Montana, now has three peer mentors in three chronic diseases doing what needed to be done for education of his patients.

Another area that needs to be opened up is telemedicine where doctors could practice across state borders and others could assist people in doctor sparse regions of the country.

Diabetes Self-management Education – Part 2

In part 1 of this blog, I discussed much of the importance of diabetes self-management education (DSME) and mentioned diabetes self-management training (DSMT) in mainly the context of use by certified diabetes educators. The article from this link provides much information. There are a few more points to be discussed and emphasized before I discuss more about peer mentors and peer-to-peer workers using this (DSME) to supplement self-monitoring of blood glucose (SMBG).

The topics of depression, physical disability, personal preferences, and quality of life were mentioned and need more emphasis. It is also important to consider hypoglycemia, life expectancy, and the incorporation of other professionals in the care of the elderly. These topics are important for professionals and need to be learned by peer mentors and peer-to-peer workers.

Mild depression for people with type 2 diabetes is about two-thirds of them and less than one-fifth may have severe depression. The article states that the rate of depression in patients is at least two times higher than the general population. It then continues to say the risk of an older person with diabetes experiencing a major depressive episode is 1.6 times higher. I think they mean the general population, but this is not said. The key of why this is important is this statement “Functional disability (difficulties performing activities of daily living and social activities) is significantly increased in the presence of both diabetes and depression, and it negatively affects self-care.” Therefore, screening for depression in the elder population is necessary. If depression if suspected, the depression needs to be resolved before any changes are made to the diabetes self-management plan.

In the previous blog, recent illness or an operation were mentioned, but physical disabilities also needs to be evaluated. The people over the age of 60 may have other physical limitations in performing the activities of daily living (eating, dressing, and toileting). They may also have problems in other areas of daily living such as using the telephone, preparing meals, traveling, and managing finances. Additionally, older adults are at higher risk of hearing loss, vision problems, decreased mobility, falls, fear of falls, and chronic pain.

Patients who are experiencing difficulties with daily tasks will need mandatory individual rather than group DSME. Treatment regimens will need to be relatively simple rather than normal or complex regimens. Learning new skills will take longer and may require referral to a visiting nurse to make sure the task is fully integrated into the patient's self-care regimen. A check back program to evaluate the learning progress may be necessary as well. A physical therapy or local elder services referral may be needed to assess the home environment and prevent potential injury from falls or accidents.

In elderly patients with type 2 diabetes, it is very important to find out what the personal preferences are with respect to care. It is well known that when patients' preferences can be incorporated into care plans, adherence increases, patient satisfaction increases, and the likelihood of improved patient outcomes goes up. Some patients will not need adjustments to their treatment plan, but others with physical or cognitive challenges, may need many adaptive changes.

For the elder type 2 diabetes patients, concern for hypoglycemia is a must if they are on insulin or a combination of oral medications and sulfonylurea is among the combinations. The elderly are more likely to be vulnerable with hypoglycemia occurring at lower blood glucose levels, be harder to recognize, and have poorer outcomes. In the elderly, hypoglycemia may show up in terms of neuroglycopenic symptoms like dizziness, weakness, confusion, and even delirium. This is unlike the symptoms of the younger generations called adrenergic such as tachycardia, palpitation, and sweating. In the elderly, hypoglycemia may aggravate common diseases such as coronary artery disease and cerebrovascular disease. The frail elderly may have outcomes such as injurious falls, even with mild hypoglycemia.

Taking the two diseases mentioned in the last paragraph and adding the two other pathological conditions of hypertension and dyslipidemia to the list and these often dominate the overall health of older patients. Functional status of older people with type 2 diabetes and cognitive decline changes the focus of care treatments from optimizing goals for diabetes to optimizing function and quality of life. The best treatment goals then become achieving the best possible glycemic management allowable, while maintaining independence and optimizing quality of life.

Factoring in that for some elderly with type 2 diabetes, life expectancy may be shorter than the time needed to obtain benefits from an intervention. Before recommending or implementing complicated, costly, or uncomfortable treatment regimens that may result in harmful side effects, it is necessary to realize that there will be reduced adherence to recommended therapies, and reduced general well-being. In other words, the time frame needed to realize benefits should be carefully considered relative to life expectancy.

Two other areas for discussion must include the use of multiple disciplines and care partners in the treatment of the elderly diabetes population. Because older patients with diabetes are clinically and functionally even more diverse than their younger counterparts, therefore they have even greater need for the services of specialists, including nurses, dietitians, exercise physiologists, behavioral medicine specialists, social workers, pharmacists, and rehabilitation professionals.

In chronic diseases such as diabetes, day-to-day care responsibilities fall mostly on patients. However, when patients are unable to assume full responsibility for their self-care, family members, friends, or other care partners may need to be involved. In older adults in particular, care partners can play a critical role in managing chronic illness, tipping the balance toward effective rather than failed self-care. If needed, family members or other caregivers should be included in DSME.

Because of the shortage of certified diabetes educators and even the absence of in many rural areas, this is an opportunity for peer mentors, and peer-to-peer workers to fill a need. For the ages about 60, the educators seem to vacate their responsibility and this creates a vacuum that needs filling. This is a reason to become educated in this area and work with the professionals that do care about the health status of the elderly. They, in my limited experience, are willing to share knowledge and give some training.

It is necessary for us to learn what we are able from these caring professional and undertake with their guidance the task of using DSME to assist the elderly diabetes patients. Communication is a must especially back to the doctor by the peer mentor and peer-to-peer worker. Because of HIPAA rules, unless a patient specifically asks the doctor to alert us of his/her medical health conditions, our participation will be severely limited.

Limitations aside, there are some elderly patients being served by peer mentors and peer-to-peer workers and the patients are sometimes filling in the information needed.  Never let the lack of information completely stop you as a peer mentor or peer-to-peer worker as the need for us is there and by learning about DSME and SMBG and other care areas, we will be useful.

Build a network of specialists, including nurses, dietitians or nutritionists, exercise physiologists, behavioral medicine specialists, social workers, pharmacists, and rehabilitation professionals, so that if the patient you are working with is in need of their services, you are able to recommend to the doctor, people that are available in that community. The doctor is the only one able to make the determination call and make the referral after evaluating your report and talking to the patient or their caregiver.

Always make a report to the doctor each time you visit a patient you are assigned and make the report as detailed as possible. What you leave out, may make a difference, so include any item even if you prioritize the list. This blog and the previous blog lists many of the areas of concern; however, it is not all-inclusive.

Occupations That Can Assist People with Diabetes

For this blog, I will start with the people that may have the least training. This is not to say that many do not have college degrees or have not learned from experience or the college of hard knocks. Some will do excellent work and be able to translate information into understandable meaning for people new to diabetes or people still learning about diabetes. Most will not be afraid to tell patients that now is the time to learn when they hear someone say, “It could not have been important as my doctor did not mention this,” or “I did not hear anything about this.”

Yes, many doctors do not cover everything because of time constraints. This is where peer-to-peer workers and peer mentors will become a valuable asset in working with other diabetes patients. They can use experiences to excellent advantage and gently challenge other patients to learn.

Peer-to-peer workers will generally be working on a one on one basis and will report to a doctor at some point. Some patients will do better in a peer-to-peer setting and this should be taken full advantage of, as education is so important. The informal setting is often more relaxing and makes the giving and receiving of information easier. If the person giving the information is given proper training, she/he can become a powerful tool in getting information to other patients.

Peer mentors may or may not work with groups of people. They can work in either an informal setting or a formal setting. When working in a group setting, they need to be open to taking the discussion in a direction that will teach the most people. Having just had my first session as a volunteer peer mentor by video conferencing (telemedicine if you will permit), there are many areas to be concerned about. With no formal training or certification to point to, a peer mentor must not make medical recommendations about medications or when to take medications. This is the function of doctors and other medically qualified individuals. This does not mean that you are prohibited from talking about different medications as long as you make comparisons and discuss all sides of any issues. There are areas where you have experiences that you may share, and many subjects that may be presented for discussion.

If you are working with patients of a particular doctor(s) like I am, you must set the ground rules before hand to not conflict with a doctor's instructions. I am fortunate that wife of this husband-wife team earned a degree in nutrition before her medical degree, so I don't need to answer most nutrition questions. I have been given permission to discuss pros and cons of different diets, suggesting what works best for one individual may not be the best for another, and then passing them to her for further discussion. Since I am a blogger, the two doctors knew my position on many issues and only asked me to tone down my position on a few issues. Because they have no certified diabetes educators that will work with them, they were looking for other means to cover many areas. We had discussed many issues in the weeks leading up to the shared medical appointment (SMA) and they had one SMA before this where they discussed doing this, but this still did not prevent a couple of the questions.

They knew areas where I could be aggressive in nature and that I normally would not tell readers to use a particular medication. We had a long discussion about the many times I would suggest to patients that they may need to consider finding another doctor. They explained their position on many of these issues and were surprised when I stated that their position was what I was looking for and expressed agreement. The wife did ask that I not get too expressive about some areas of nutrition, but that I was welcome to encourage people to find their own level for carbohydrates, protein, and fat. She felt this could be an area of concern for many patients as they only had one person on a low carb diet. She as a dietitian was not concerned about fat levels other than avoiding anything over 60%. She would prefer people stayed under 50%, but would allow people to experiment. She also stated she would prefer working with people at their dietary preference and if needed encourage them to eat certain foods the help balance their nutrients. This did not come up in the first session, but they will be doing more testing to determine certain deficiencies and suggesting supplements for those who cannot or will not eat certain foods. They both said my blogs had alerted them to the vitamin B12 deficiency for patients who had been on metformin for extended periods and they had one patient with a deficiency.

Nutritionists need to step forward and be recognized. I am talking about those that have a four-year degree or an advanced degree in nutrition. The field of diabetes is in need of people that are more concerned with the nutritional value of food consumed by people with diabetes that how many carbohydrates are in each meal. Nutrition for people with diabetes is not a one-size-fits-all proposition and we need guidance on an individual basis. We have had enough of the mandates, mantras, and dogma. This may work for some, but not the many.

One group that I have also had conflicts with is people that call themselves diabetes coaches. These people seldom have diabetes and come from a variety of professional pursuits. Of the four I have dealt with, all have come from the nursing profession. I know a few that have a dietitian background, and another that was a certified diabetes educator. I am not saying that there are not possibly good diabetes coaches, but I personally disagree with many of their positions and visions of how people with diabetes must eat, live, and sleep. I have only seen one that recognized the value of exercise. Most diabetes coaches promote the same mantras, mandates, and dogma as certified diabetes educators and dietitians that are members of the Academy of Nutrition and Dietetics (AND). This means whole grains and low fat and no compromises. Disagree with them or question them, and they will not keep you as a customer or client. Unfortunately, my experience has been – it is their way, or the highway. Considering the following paragraph, I may have had experiences with the bad apples in diabetes coaching.

On July 30, 2012, Allison B has an excellent blog on the Diabetes Coaches. This presented in a different light than I have encountered. Apparently, this category has some people that know what they are doing and can be an excellent addition to your healthcare team. They have an international  professional organization and do work across many chronic illnesses and diseases. Some of these coaches do have diabetes and speaks well for what they are accomplishing. Take time to read the blog as this may help you decide that this is a group you need. Many use the telemedicine type of communication, which means that can be successful to wide geographical locations.

Until the lawsuit is settled and there will be more, I will attempt to leave the registered dietitians and AND out of discussions. If there is more news that surfaces about them, yes, I will write about it.

Like any profession, the certified diabetes educators (CDEs) have their bad apples. Their numbers are not keeping pace with the need and increase of people diagnosed with diabetes. It would be interesting to know what the actual numbers of CDEs are and whether they are in practice as CDEs, whether they work full-time or only part-time, or whether they are writing books and doing speaking tours, and not actually serving patients.

If these people would do the education that their title says, we might not have the epidemic we are facing today. Lack of diabetes education is just that, little is actually being taught.