August 9, 2013

Doctors That Will Not Give You Record Access

Even if physicians think we can be a pain in their backside, we as patients have to wonder what they are trying to conceal when they will not allow us access to medical information about us. Caveat – I have no problem when the patient has mental problems of not allowing them access to their medical records.

However, for the rest of us, come-on doctors, what are you hiding? Yes, many physicians treat us as mental patients in their minds and have entered information in the medical records about us that they would be in the courts for years trying to explain and defend as not being libelous or maliciously defamatory. What causes them to do this?

One answer is because they are human and the medical profession has conditioned them to feel that they are god-like. When we rock the pedestal on which they are perched, they become very upset and since the medical record they maintain about us is the one supposedly safe place, they make some unwarranted statements part of the medical record.

Notice, I have carefully avoided saying who owns the medical records. This had been for the courts to decide and in general, they had favored the doctor. Now under the Patient Protection and Affordable Care Act (ACA), this may be changing. The patient will supposedly have access to the records. I say this cautiously, because several medical professional organizations are working to prevent this from happening. I have a feeling that this is headed for the courts for a final decision. Again I ask – doctor, what are you hiding?

I have been made aware of a work-a-round created in many electronic health record programs which will allow doctors to have their own confidential area. Some physicians are refusing to use this area while others look for it. More physicians are discovering that patients who are educated have a better outlook and desire to improve their health. This often causes a big reduction in medical costs and improved efficiency. The reason for this is that the patient is working for better prevention and when the doctor and patient work together, this often happens.

I would like to continue the doctor-patient discussion, but that will wait for another blog, as another area needs to be included here. This is the problem proactive to participatory patients are having accessing medical information that is obtained from remote patient monitoring. Presently, this is next to impossible for patients. Unless you have a doctor that is very forthcoming, the manufacturer of the device and many physicians will not allow patients to have access to this information. Even those doctors willing to share this information are often prevented from doing so by the device manufacturer. Many doctors that share the information do so at their own risk. So hopefully you as a patient will help guard this when it happens.

For more information from a different perspective, read this by Trisha Torrey. It explains what may happen to very proactive patients when they have doctors that don't like or appreciate patients wanting to learn and be proactive or have knowledge of their chronic condition. Hopefully, under the ACA these doctors will be put out of business permanently and their medical organization greatly weakened.

August 8, 2013

Problems with A1c and Obtaining Insulin

Before starting this blog, I must state that it is for people with type 2 diabetes only.  What was your latest HbA1c result? If it is like many of the people with type 2, it was probably 8.0% or higher. There are only a few reasons to have an A1c this high and actually an A1c higher that 6.5% should concern you. The only (in my humble opinion) reason to have an A1c this high is if you are very elderly, in poor health, and having difficulty taking your medications when you should.

Unless you have trypanophobia (a fear of injections) or aichmophobia (an intense or morbid fear of sharp or pointed objects), you need to learn about insulin and what it can do for your diabetes management. If you have these fears, consider reading this.

There may be other reasons, like having hypoglycemia too often which may be a good reason to have a higher HbA1c. Other reasons I don't consider as valid for letting your A1c reading become this high. They are:

#1. You have a doctor that will not prescribe insulin. If this happening to you, seriously consider finding another doctor. Your health is worth this. You will need to consider if there are other doctors available in your area. You will need to ask your doctor why he will not prescribe insulin very politely. If your doctor won't talk to you about insulin, then the decision will be difficult if there are no other doctors near you. I have had one person tell me that he had to question the doctor about why he would not prescribe insulin. He explained that he wanted to be on insulin and wanted a doctor that would prescribe insulin. When the doctor would not talk about this, he suggested that they could learn together. The doctor started to answer, but stopped. At that point, he knew he was going to need to drive about 75 miles one way to another doctor, but he asked the doctor for a referral and the doctor did give him a referral for the doctor he had thought he would be seeing.

#2. Your doctor has not given you any education. Most doctors do not have the time except for minimal education. Most doctors do not have access to certified diabetes educators (CDEs) or even registered dietitians (RDs) so this would not be a surprise. Self-education is often the only avenue open to you. This is part of the reason I have been writing blogs about sources for you to read. No. 1 and No. 2.

#3. Your doctor is stacking oral medications and they are not working. You started on one oral medication and then when your A1c did not come down enough or when it started to rise, your doctor added a second medication. When those results deteriorated, a third medication was added. With the side effects of each medication, this could have become intolerable. But you wanted to get your A1c level down. You may have even asked for a stronger medication, but the doctor refused.

#4. Are you not managing your diabetes? I don't like to use accusations, so I will ask some questions. Have you reduced your carbohydrate consumption? Have you been able to test enough to know what the different foods do to your blood glucose levels?

#5. Are you not taking your medications? Do you take them when directed or do you forget occasionally? Do you have a schedule for taking your medications? Have you talked to your pharmacist about what to do if you remember you forgot the previous dose? How often do you forget? For help you might want to read this blog.

#6. Are you able to exercise and what is your routine? When your blood glucose levels are higher than they should be, are your able to exercise for a longer time? What exercises do you do or are you limited in what you can do?

I could continue to list reasons, but this could only serve to discourage you and cause you to stop your self-education. What you need to do is have an honest discussion with your doctor. Do this after you have given a lot of thought whether you wish to stop the complications and manage your diabetes. Unfortunately, only you can make this decision. Yes, you may ask for help if you have someone that can and will assist you, but you will need to ask.

If possible, you need to honestly assess your situation and decide what you are capable of doing, how you can better manage your diabetes, and whether insulin is the medication you need. Some of my blogs that may be of assistance for using insulin include – blog 1, blog 2, blog 3, blog 4, blog 5, and blog 6

August 7, 2013

Intensive BG Monitoring Is Useful

Granted, I have changed the title from a question to a positive statement. I firmly believe that if the study had been properly set up and too many variables not tracked that should have been accounted for, the results could have been much more positive.  Patients were eligible if they were 35 to 75 years of age, had type 2 diabetes not treated with insulin, and HbA1c levels between 7% and 9%.

Yes, the “experts” said, “They were not convinced the extra cost of SMBG (self-monitoring of blood glucose) was worth the marginal added benefit. Also, this approach may not be generalizable outside of a clinical-trial setting, they said, noting that patients tend to tire of such self-monitoring in the long run.” None of the “experts” participated in the study. The problem with most studies of this type is that no education is given to the participants beyond a minimal amount.

Yes, some are taught more, but many are not given enough practice to have this become a habit. And this is a must to make the desire become important and make a person want to manage their diabetes. No, I do not think that intensive blood glucose monitoring needs to be done long-term, but at diagnosis, the first six months are critical to determine how the different foods or food combinations affect your blood glucose. This is one way to know which foods may need to be eliminated or reduced in the meal plan.

Then over time, you will need to up the testing intensity again when you add new to your meal plan foods, when you are ill, and when you are having problems for which you have no easy answers. What the “experts” do not realize is that by cutting to testing supplies over the years, people are less likely to maintain A1c's below 7.0% and this is the reason many people end up with progressive diabetes. People do need the education and encouragement to test more than twice per day, but testing for most people with type 2 diabetes should not require more than five times per day once a routine has been established.

Yes, there will be days when more testing may be required, and there may be days when less testing may suffice. With education and support, many people should be able to prevent their diabetes from becoming progressive. Yet, the “experts” don't care about the desires of patients and look at diabetes as progressive when it does not need to be. Because of the pronouncements of the “experts”, the insurance companies are happy to increase their profits by limiting the testing supplies for diabetes.

Please read about the study here and make your own analysis.

August 6, 2013

Dramatic Results When Treatment Tailored for Elderly

See what happens when the elderly are the only group in a study? This proves that the elderly should not be excluded from research studies and that they may be successful in managing their diabetes. This study was done in the United Kingdom, but provides a great example of what is necessary and may be accomplished by the people over the age of 70. Can the feeble minds at our leading research facilities wrap their heads around this study and end the discrimination against the elderly?

All patients were over the age of 70, and were included in the trial because their GP (general practitioner) thought they needed more medication. Oh really, doctor, elderly patients need more medication and it is your job to over medicate them? The findings were stark because those patients who were given the drug were three times more likely to reach their target than those who were not involved in the study, and received standard treatment. But researchers were particularly excited by the result from the placebo group, in which 27 percent met their targets without any medication.

This shows what can happen when great studies are undertaken for the benefit of the elderly. Presently, patients over the age of 70 are treated using a blanket method of aggressively reducing blood glucose levels, but that does little to take their complex needs into account.

Dr. David Strain, from the University of Exeter Medical School, who led the study, said: "People over the age of 70 are more likely to have multiple complications, such as heart disease, as well as type 2 diabetes. Yet perversely, these patients have so far been excluded from clinical trials, precisely because of these complications. It means they are generally treated with a 'one-size-fits-all' approach. We found that simply by individualizing goals and setting realistic targets, then spending time talking to patients rather than aggressively chasing targets resulted in nearly a quarter of patients achieving better glycemic control, without the need for medication."

Dr. Strain said: "This was a small trial, but the results were quite dramatic, and it is the first strong evidence that individualized care can make a huge difference to the lives of older patients with type 2 diabetes. We now need to build on this evidence with further research."

Yes, further research may be required for the dense American researchers to understand what their discrimination is doing to the lives of the elderly that are in essence just being written off and given the one-size-fits-all treatment. It may be even possible to reduce the medical costs and give pride back to the elderly population.

The points that are unclear to me that could be disconcerting are the A1c's at the start of the study and what the individual targets became during the study. If they are above 9.0% and the lower targets were still above 7.5%, then there may be some other concerns about individualizing treatments.

I had written and asked for a copy of the study, but none was forthcoming. This is a shame. I sincerely hope that the USA researchers learn from this study and don't continue to stick their nose in the air. Someone may flatten it for them.

August 5, 2013

Does Type 2 Diabetes Have Subclasses?

Before getting started on this topic, I must state that these are my opinions only, based on my reading and are no way official opinions. While some people have been alluding to sub groups or subclasses of people with type 2 diabetes, I believe the evidence is mounting for more people to come out in support of this idea. We now know that ethnicity is a factor and I am not sure how to list the young type 2's that have more deadly type of diabetes than children with type 1.

I personally feel that an apples to apples comparison is not totally accurate for those adolescent and young adults with type 2 diabetes, but I could be in error. “The study population was derived from the Royal Prince Alfred Hospital Diabetes Database and focused on individuals diagnosed with diabetes between the ages of 15 and 30 years. Records were matched with the Australian National Death Index to establish mortality outcomes for all subjects until June 2011. Clinical and mortality outcomes in 354 patients with type 2 diabetes (mean age at diagnosis, 25.6 years) were compared primarily with 470 patients with type 1 diabetes with a similar age of onset (mean age at diagnosis, 22.0 years) to minimize the confounding effect of age on outcome; disease duration was 11.6 vs 14.7 years.”

While type 1 diabetes is generally considered a more severe type of diabetes, the results highlight that young people with type 2 diabetes have double the risk of dying when compared to those with type 1 diabetes and after a much shorter duration of having diabetes.

Therefore, I would think this should be considered one subclass of type 2 diabetes. Studies are finally being done to compare how different ethnicities are affected by type 2 diabetes. While much more study is need for those in Africa, they tend to have a lower insulin sensitivity, but seem to compensate by releasing greater amounts of insulin.

Among those of East Asian origin, they have very good insulin sensitivity, but seem to have a harder time releasing insulin when it is needed. This means in the clinical settings, they develop diabetes more easily and do so at a lower BMI. Because East Asians have more difficulty releasing insulin, generally they need to start insulin therapy at an earlier stage of diabetes.

Caucasians fall between the two extremes in both insulin release and insulin sensitivity. Now in addition to the above subclasses there are probably more that have not been studied, such as the Eskimos and American Indians, but until there are studies verifying this, we can only guess. I would even hazard a guess that the African Americans could also be a subclass separate in part from those from Africa itself.

I also believe that even among Americans, there could be several subclasses of type 2 because we have thin type 2's and obese type 2's. We have many people that are able to manage their diabetes with nutrition and exercise and others that have a difficult time even on low levels of medication.

Will we have any discussion within the ADA about this? I highly doubt this and would be more inclined to believe that with the current attitude of physicians wanting cut and died answers, that it will require a much stronger voice than mine to give them a wake up call. Plus, with their conflicts of interest, unless some of their corporate sponsors raise the question, this will never see the light of day in the American Diabetes Association discussions.