September 6, 2013

Doctors Often Bail on Care Discussions with the Elderly

Is it because many doctors are uncomfortable in geriatric medicine as they are uncomfortable in talking diabetes? I would have to say, yes! Is it important to reduce the risk of one ailment if it increases the risk of another? There are doctors that do just this and often don't realize they are doing this.

Clinicians or physicians very seldom engage patients, families, and especially caregivers in goals of care discussions about anything. These doctors rely instead on what they “know” to be in the best interest of the patient when in fact they are being disagreed with in many cases. What some of these doctors don't understand is that once they leave the office, the families or caregivers are talking about the appointment and how the doctor blew them off.

At least John Carney, President & CEO Center for Practical Bioethics is concerned about what these doctors need to consider. This underscores how we, as patients, need to broaden the goals of care discussion to aspects of our lives that include important considerations that go well beyond specific interventions. Goals of care conversations need to include topics like quality of life, comfort and functional status.

Two out of three seniors over 60 have two or more chronic conditions and under half have three or more. This means that many patients face these considerations. Here is where we need to help the physicians understand what our goals are and to some extent the factors that need to be weighed for our benefit. This is an important consideration if we are already using caregivers. Therefore, caregivers do not let the doctors bully you into what they think is best for us. Yes, the doctors need to assess, if they even know how, how the patient is doing if they have dementia. Is being observant the best approach, or is some action necessary?

We, as the patient, our families, or our caregivers need to raise the concerns about what is best for us with the doctors. Then if the doctor will not participate in the discussion, maybe it will be necessary to find a different doctor. Finding a solution that is clinically expedient or that meets some prescribed pathway should be avoided and should be something that reflects the values, preferences, and goals that will satisfy the needs of the patient.

Ethical issues can be raised in the discussion about advances in medical treatment as long as the discussion is a two way street. This means that the decision is a shared one based on the values of the patient. Do not go into hypothetical discussions, but talk about real issues in real time involving real life. Then formulate a plan that clearly reflects the goals of the patient.

Patients, family members, and caregivers that have an investment in achieving a shared outcome will work harder together to make it happen. Doctors that operate in a “best interest of the patient concept” may just find that they have done more harm than good because the patients, their families, or their caregivers have not bought into the “best interest” plan.

September 5, 2013

Is There a Best Way, Part 3?

What works for me, may not work for you. Your mileage may vary. These phrases are used by many people when talking about diabetes and a few other chronic diseases. Why? Because they understand that people are looking for quick fixes, rules to follow, and simple answers when none exist. But, these people will generally ignore these explanations, because for them there has to be some cure, rule, and reasonable answer that they can latch onto and use.

Understanding that each person can be different or unique is foreign to them. All they see is male and female, that one male is just like another male, and that females are different. They forget that males come in a variety of heights, with varying head sizes, waist sizes and strengths. Even those that know this, forget this when talking about diabetes. They want only the simple rule or a pill that will make them right with the world and let them return to the life they were living.

Sorry folks, but diabetes will not fit this way. It is not a disease that you can take a pill for in the morning and you are set for the day. Even some will claim there is a pill or natural herb that will cure them. What they will not admit is that they were able to beat back prediabetes or even at the early stages of diabetes with diet and exercise and some of the other lifestyle changes and by maintaining this regimen are preventing the onset of full blown diabetes. Now they have this pill (probably a sugar pill) or natural herb and they will sell this to you for a fantastic price. I see people suckered in by this more often than I like.

Diabetes or prediabetes can be stopped and managed with lifestyle changes with emphasis on diet and exercise and managed that way for many years. Even the number of years a person can manage their diabetes without medications is unknown. Some can do it for a few years and others are capable of this regimen for decades. Some have good retention of their beta cells and for others, well, their beta cells start giving up sooner.

There are so many variables that affect diabetes and how different people handle these variables that projections are impossible to make. While this blog is by a person that has type 1 diabetes, he discusses some excellent points that will apply to people with type 2 diabetes. I do like this statement that he uses in his last paragraph - “There are many roads to take living with diabetes. So don’t worry if your road looks a little different from my road.”

September 4, 2013

Format of Shared Medical Appointments Important

This blog by Dr. Fisher really had me scratching my head and then I needed to read the link he provided. Dr. Richard Kratche, a family physician at Cleveland Clinic who conducts group visits for physicals seems quite happy with the results. Now I admit this would not make me happy and even if waivers of confidentiality were signed, who is to say that people won't talk about what they heard. Gossip is common and people like to embellish when they can.

Some people are comfortable with this arrangement, while others shudder at the thought. Now granted, I am familiar with a different type of shared medical appointments (SMAs). A couple of doctors in two western rural states have peer mentors for diabetes education. One doctor has four peer mentors and the second has two peer mentors. The doctor with four peer mentors has two for type 1 diabetes and two for type 2 diabetes. Both doctors have patients that travel up to 100 miles one way and they want to make the best use of their time. Both doctors are family physicians and have patients on oral medications and insulin. The second doctor does refer the more complicated patients to the first doctor and they make things work between them.

In their SMAs, they use the peer mentors for gathering information and meter readings and then the doctor first takes any combination patients (husband/wife, parent/child), covers the lab results with them, and covers their meter printouts. Then each moves to single patients (not that they are single), and covers their lab results and meter printouts. All the time, the peer mentors are conducting education with those waiting to see the doctor or have seen the doctor. Both doctors have educated the peer mentors they have involved in the education.

I have been involved with both doctors either at the start of their training their own peer mentors, or after a few sessions when the peer mentors wanted to ask me questions. We do this by video conferencing and often after hours. I have substituted with one doctor when one of his mentors was in the hospital and this worked out quite well with video conferencing. Depending on the time of year, even if one mentor cannot be present, they have been able to use the video setup to take part.

This has been working very well for the two doctors I work with in Kansas, but that may end this year because they have hooked up with the U. of Kansas and their telemedicine group for more education across more diseases, diabetes being one of them. This happens, but several of the patients have asked if I will still answer emails and send copies to their doctor when I answer them. The husband and wife doctor team talked to me about this and they are talking to the patients, so this has not been resolved yet.

Therefore, apparently SMAs come in many varieties and ways of dealing with patients. I admit I do not wish my lab results made public unless I chose to let someone know outside the SMA. Even when I blog about people's results that are part of our support group, I am very hesitant to do so, but a couple have said use the numbers since I use made up names. Even George commented that he said his A1c in front of us and no one criticized him for what it was. That is the way we are George. And, the situation you were in, we knew you had nothing to compare to and we knew that you will learn.

September 3, 2013

Is The Practice of Medicine Affected By ObamaCare?

Yes, the practice of medicine is being affected by the Patient Protection and Affordable Care Act, aka ObamaCare. In my reading, Kathleen Sebelius says anything good is because of the new healthcare reform. But when reporters ask about something not going right, she generally blames others.

I don't know how she will react to these figures, but they are not pretty by any stretch of the imagination. The source is The Apothecary/Congressional Research Service. This reports that the Obama administration compliance with the ACA statutory deadlines during the first three years of implementation. Deadlines completed on time or early 32 deadlines. Deadlines completed late counted 17; those not completed as of May 31, 2013 counted 24, and not completed due to lack of Congressional appropriations numbered 9.

I knew this would not please secretary Sebelius and I was right. Congress took the brunt of the blame for not authorizing funds for the personnel to complete the deadlines.

Most of the things the administration wanted will not happen, but the unintended things are happening. Some are good while others are bad. On the one side, consumer health care has been given an impetus and products are being produced that are unrelated to the accountable care model the administration is pushing. On the other side, hospitals are merging and acquiring doctors and this is making the market less competitive. This is causing gaming of third-party payment formulas and other things that are causing our health insurance premiums and taxes to become higher than they would have been.

The clearest explanation of the Obama administration desires for health reform comes from the Harvard Medical School and Professor Atul Gawande. He thinks that medicine should be more like engineering with all doctors following the same transcript and not exercising their individual judgments. This means the medical profession can no longer be individualistic, but like engineers building a mechanism whose parts actually fit together. These workings are to be more finely tuned and tweaked for better performance in providing aid and comfort to human beings.

With more doctors working for hospitals and other institutions, rather than in private practice, hospitals are using their doctors to obtain more money from Medicare. Although MedPac (Medicare Payment Advisory Commission) is finally taking notice, the practice may not be easy to stop. Yes, hospitals can charge more for the same services that the doctors can charge if they bill Medicare as independent practitioners.
Read the article in the New York Times about the fee schedules.

September 2, 2013

New CMS Supplies for Diabetes

This is a call for information from people that receive diabetes supplies under the new bidding system of the Centers for Medicare and Medicaid Services (CMS). Since we only have one person in our support group that will eventually receive the new supplies, but to date is still under the old system and he will not receive new supplies until mid-October, if then, according to the last notice he received.

Five of us receive our supplies through the VA system and the rest of us on insulin are continuing to receive their supplies through the local pharmacy. To date, the new CMS system has not affected our testing supplies.

The rest of us have been a little rough (figuratively) on him, asking him questions and to keep us up to date if, and when, he receives any information. We are like kids in the five and dime wait for the supply truck to arrive with the latest shipment of toys. Several of us are asking if he will be able to obtain the test solution for the new strips and we are reminding him of this far too often I fear. He has assured us he will be asking when he places the order. We are all placing bets that this will not be available.

Allen is also waiting to get his hands on a few of these test strips to send them to an address he has obtained and will not tell us. He says they will be tested for accuracy. We have all chipped in the funds to pay for the test strips and the cost of the shipping.

Several of us are also talking about purchasing an extra meter for the test strips we use and also a vial of test strips for him to use as a check for the new testing supplies he will receive. He has agreed to this and thanks us for our efforts, but is not sure he wants to double test that often. I will admit that he is taking this enthusiasm of ours quite well and is starting to give it back to us.

Please. if and when, someone reading this blog that is under the supply system subject to CMS supplies, and receives diabetes supplies, we would appreciate hearing from you. My email is on my profile page. Several of the group is asking why I am not posting this blog sooner.