November 23, 2013

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.

November 22, 2013

Hospital Declares War on Dietary Supplements

This hospital official actually seems to be bragging about the actions of the Children's Hospital of Philadelphia (CHOP). He says that to his knowledge, his hospital has become the first hospital in the country to remove dietary supplements from the formulary.

Does he have valid points? Yes, he does, but he is picking the worst examples to emphasize his points. Part of the reason this became necessary resulted from the hospital asking the incorrect questions in the first place. This may have been a large part of the reason the Joint Commission of Hospital Accreditation forced them into this action. Many times in the past, the hospital just asked whether they (the children) were receiving drugs, and Dr. Offit thinks that many parents didn't consider supplements to be drugs. This point is often the case.

Dr. Offit says, “Here is the way it works now: When you come to the hospital, we ask parents whether their children are receiving dietary supplements. So, for the first time, we are really finding out about the level of dietary supplementation, at least in the pediatric population in our hospital.”

I still think the hospital may be asking for incomplete information. Why aren't they asking about vitamins and minerals? Why are they not asking about herbal medications and supplements? Many parents still think that dietary supplements include only vitamins and minerals and not the rest.

Dr. Offit is correct that they are all drugs. They could have a pharmacologic and physiologic effect that is drug-like, so I think that is a very fair request on the hospital's part. On the other hand, the Food and Drug Administration doesn't regulate these products as drugs, so for the 54,000 dietary supplements on the market, there isn't a very good safety profile. Their efficacy claims are often not true.

In addition the labeling may not be accurate. Of concern also is that there are drug-drug interactions. For example, St. John's wort, which is metabolized through the liver, can affect immunosuppressant drugs that are given to transplant patients. There have been several reports of patients who rejected their transplants because the child or adult has been taking St. John's wort.

If the children are taking supplements, the hospital strongly discourages their use and gives them a pamphlet to explain why it is that these products are not what they claim to be. If the parents still want to use a dietary supplement and hospital does not consider it to be potentially harmful like St. John's wort, then the hospital will give them a waiver to sign that says that they are using dietary supplements against medical advice.

If you are interested, a more radical point of view may be read here. It certainly supports the doctor's bragging.

November 21, 2013

Why Some Patients Resist Becoming Empowered

This is not an easy thing to assess, but many patients do not attempt to learn or become knowledgeable about why they see the doctor. This attitude may be costing them money, but they seem to care less. As long as the doctor can give them a pill, which enables them to get on with life, they are satisfied.

Here are some of the types of patients that will not work at or attempt to become empowered.

#1. Lazy or apathetic patients
These patients are generally not patients the doctors wish to see in their exam rooms. Doctors know that these patients can promise anything, but they will walk out of the office and forget about it. Their apathy prevents them from even thinking about why they saw the doctor in the first place. They are number uno in being non-compliant and this is why they cancel appointments or don't even show up. Doctors soon become tired of them and discourage their office visits.

#2. Patients who engage in nonsense thinking
These patients believe that all they have to do is show up for an appointment, then fill a prescription, and they will be as good as new. These patients may be easy for doctors to care for, but they may not be listening to the doctor, may not be taking their medication, and are not doing themselves or their doctors any favors. They generally are in denial of the important role they can play and this will have negative consequences in their well-being and their relationships with their doctors.

#3. Patients who are too trusting
While most doctors are reluctant to admit this, for many, this is their favorite type of patient. These patients are quite adherent, make their doctors god-like, and feel that the better behaved they are, the better care they will receive. Many patients, especially the elderly, have existed a lifetime trusting that their doctors will provide them great advice in their best interests. Even if these beliefs have been disproved time after time, these patients will never make their own decisions, question the doctor's decision, and will continue doing just what they are told to do by the doctor.

#4. Patients who are too ill or incapacitated
These patients generally are not healthy enough to be able to participate in their care to say nothing about becoming empowered. These patients generally need an advocate to speak for them. Whether the advocate is a family member, friend, or a professional advocate, good doctors appreciate an advocate’s role in helping patients that are unable to act wisely on their own behalf.

#5. Fearful patients believing they can't receive safe and/or affordable care
These patients have in the past have suffered a medical error or have experienced egregious behavior by a provider. They, or a loved one, may have been injured by or violated by a doctor, or they may have been treated by a doctor who was drunk or high. It is no wonder that these patients want to avoid the doctors. Some of the patients who avoid care do so because of modesty issues. Many of these patients suffer post-traumatic stress, which further inhibits their ability to seek care. With these patients, they know intellectually that avoiding care may make them even sicker, or will exacerbate an injury.

#6. Patients who fear retaliation
For whatever reason, these patients are afraid to stand up for themselves fearing retaliation and poor care from the provider. For some reason they lack the confidence to advocate for themselves. Most of these patients don't realize they can question the doctor in a polite way to get the care they need. They need to realize that doctors will not provide substandard care in reaction to empowered patients who practice respectful empowerment. The key is “respectful,” because best empowerment practices require respect from all participants. No doctor is worth seeing at all if he or she retaliates by providing less than stellar care to a patient who asks good questions and makes considered decisions.

#7. Patients that are healthcare illiterate or illiterate
These patients are troublesome to many doctors.  Often doctors are not even aware of the problems these patients experience. It is a wise doctor that discerns this problem in patients. Most of time, as long as the bill is paid, no one may be the wiser. My blog here describes what can happen when an illiterate person asks for help. When doctors become aware that the patient is healthcare illiterate or illiterate, most will ask that they bring a family member or friend to help them. Some will even take extra time to explain what is necessary and make sure they understand what is happening. It is a poor doctor that knowingly ignores a patient with this problem if they are aware of it.

#8. Patients that will not believe anything the doctor says and then head to the nearest holistic healer or health food store
These patients are the bane of most doctors. All they are interested in obtaining is a name for what they have and then they tune the doctor out. They will take prescriptions if given them, but will never have them filled. Most of the time these patients just want information to describe what they need from the health food store or holistic person. The doctors can only hope that they don't need an operation or have something serious as even these are often refused.

There are probably more types of these patients that have little or no respect for gaining knowledge about helping themselves. Granted the illiterate are a special case because they haven't the skills to become empowered, but given encouragement by their doctor can progress a long way toward this. I included them because they do need legitimate help, but often the office staff ignore them unless the doctor makes them help.

November 20, 2013

Today's World with Diabetes

As in the United States, diabetes education is lacking around the world. Who is responsible for the lack of diabetes education? The medical professionals in all countries of course, because they treat all diabetes as a progressive and a lifestyle disease. They have the feeling of why waste the resources on people that cannot manage their diabetes.

With American and World Diabetes Month upon us, all people with diabetes need to be pushing for diabetes education. Without education, the world diabetes epidemic will continue and the numbers will grow. In addition, the costs will continue to rise and eventually become uneconomical for most governments. Diabetes education could go a long way to stem the diabetes epidemic. If done properly, patients would know that diabetes does not have to be progressive and could be held in check for a few years or for decades. The cost of education could reduce overall costs and be beneficial for patients and governments.

Yet, without the medical communities being on board, the education will not happen, diabetes will continue to grow in numbers, and continue to be progressive for those that will not self-educate themselves about diabetes. Yes, doctors, you need to support education about diabetes. In addition, doctors will need to screen more patients for diabetes, especially since about half of the people presently with diabetes do not even know they have diabetes. This also applies to the millions that have impaired pancreases and are progressing to diabetes, because doctors will not warn these people and give them the education to make proper food plans and exercise.

Some statistics that should make doctors want to educate patients include:
#1. Over the next 20 years, the number of people with diabetes in Africa will almost double. This region has the highest mortality rate due to diabetes.
#2. 21.2 million people in Europe don’t know that they have diabetes.
#3. 6 of the top 10 countries for diabetes prevalence are Pacific Islands.
#4. China has 114 million people living with diabetes. India follows up in second with 63.0 million, and the U.S takes third with 24.1 million.
#5. More people in the United States die each year from diabetes than AIDS and breast cancer combined.
#6. In 2012, 4.8 million people died due to diabetes.
#7. 471 billion U.S. dollars were spent on healthcare for diabetes in 2012 alone.
#8. WHO projects that diabetes will be the 7th leading cause of death in 2030.

One of the main issues involving diabetes is the lack of attention and funding we have seen from governments. Considering the number of people affected and its cost impact, diabetes prevention and research does not receive nearly as much support as diseases like cancer and HIV/AIDS. For people with diabetes to be able to take the important action of monitoring their blood sugar regularly, we need to make it financially feasible for them to purchase the supplies they need, and we need to teach them and their care team why and how they need to do this monitoring. This is a statement by William Hsu, M.D, Senior Director of Joslin Health Solutions International. Bold is my emphasis.

Dr. Hsu continued, “Getting governments involved is just one of the issues faced in this growing epidemic. Nearly half of people with diabetes are undiagnosed, this makes it an impossible problem to solve when people don’t know there in an issue in the first place. Diabetes awareness –including prevention, diagnosis and treatment– must start at the community level. We must reach out across spheres of influence to help take the stigma out of diabetes, to help people realize that it is better to know about, and then take control of their diabetes, rather than to ignore it. We also need to take the long view, building to the future. Training medical students and junior doctors and nurses from other countries in diabetes knowledge and skills in listening to and engaging patients will ensure that we can affect the next generation and beyond.”

WHO (World Health Organization) is another organization that is dedicated to preventing and minimizing the complications of diabetes globally. Through their Diabetes Programme, WHO “oversees the development and adoption of internally agreed standards and norms for the diagnosis and treatment of diabetes, its complications and risk factors.” It promotes and contributes to the surveillance of diabetes as well as advocates for the prevention and control of diabetes in vulnerable populations.

The International Diabetes Federation (IDF) is dedicated to engaging in action to tackle diabetes from the local to global level. At IDF, the main focus is worldwide awareness and advocacy. Aiming to increase public awareness and encourage health improvement, IDF promotes the exchange of high-quality information about diseases and provides education for people with diabetes and their healthcare providers.” This is from their website.

Why can't the other organizations have similar goals? At present, all the doctors seem to want to accomplish is let diabetes continue without education and testing supplies, to be able to treat the complications of diabetes. The shame of this will be on them.

November 19, 2013

Complementary and Alternative Medicine, CAM

When it comes to complementary and alternative medicine (CAM), I wonder why it is doctors will not accept information and sometimes even patients that try to be honest about their natural medications and are pushed out by some doctors.

In this blog, Dr. McCarthy states, We doctors have a strong (and understandable) tendency to think within our own traditional medicine worlds. But, there is a much bigger world than traditional medicine when it comes to making patients feel and get better. And sometimes it’s patients who need to teach doctors.” Bold is my emphasis.

Yet many doctors could care less. Even the Children's Hospital of Philadelphia (CHOP) has removed nutritional supplements from their formulary. They say that because most nutritional supplements are unregulated, they may be dangerous. On top of that, the hospital will not allow patients to use most supplements without running a medical gauntlet and signing all sorts of forms.

While I do use a few supplements, I do not appreciate doctors that completely oppose them. I understand people on the diabetes medication metformin and why they often develop vitamin B12 deficiency. Metformin can in many people cause problems of B12 uptake and cause the deficiency. Yet many doctors still claim that a well balanced diet is the only way and will not test for any deficiencies.

Now I will say that I have no doctors that will not test for deficiencies and they will when I request them. Fortunately, I have not needed any tests because the VA has and will be testing for most vitamins and minerals.

Now, I will direct some attention to patients that refuse to tell their doctors about natural and nutritional supplements they are taking. This is important for any new medications your doctor prescribes. Unless the doctor knows all the natural medications you are taking, the prescription medication may have adverse effects with the natural supplements.

If you have a doctor that is opposed to all natural supplements and won't talk about them, then you need to talk to your pharmacist about potential conflicts. Save yourself from problems.

November 18, 2013

Sensing Systems May Become Common

With the progressively falling cost of miniaturized wearable gyroscopes, accelerometers, and other physiologic sensors, as well as inexpensive data transmission, sensing systems may become almost as common as cell phones for healthcare. Neurorehabilitation can develop these mobile health platforms for daily care and clinical trials to improve exercise and fitness, learning skills, and physical functioning.

Wearable, wireless motion sensor data, analyzed by activity pattern-recognition algorithms, can describe the type, quantity, and quality of mobility-related activities in the patient community. Data transmissions from the sensors to a cell phone or the Internet will enable continuous monitoring.

Having remote access to laboratory quality data about walking speed, duration and distance, gait asymmetry and smoothness of movements, as well as cycling, exercise, and skills practice, opens new opportunities to engage patients in progressive, personalized therapies with feedback about the performance. Also important will be clinical trial designs that will be able to include remote verification of the integrity of complex physical interventions and compliance with practice, as well as capture repeated, ecologically sound, ratio scale outcome measures.

Yes, the future looks bright for many applications of remote patient monitoring. If this works as well as envisioned, many applications may help reduce future medical costs because patients will benefit in immediate feedback on progress of rehabilitation. Instead of not having any measures about progress and using best guess analysis, as is the practice now, real time information will be available.

Yet, I can imagine many people balking at the new technology. Why would they balk? Some will say that they don't want to be spied on and feel that the new technology will used for that. Others just do not want to follow directions and will not work as diligently as they might be expected to be and with the new sensors, will not be able to lie like they do now. Others will know that they cannot play the sympathy card.

For an interesting idea being developed for Google Glasses and tracking diabetes information, read this blog by Mike Hoskins on Diabetesmine.

November 17, 2013

Can Doctors Operate In Transparency?

My answer would be an emphatic no. Most doctors do not want to operate in total transparency. Most doctors have too much baggage with ties to BIG Pharma and the pharmaceutical representatives they see on a weekly or biweekly basis. Their drug company reps ply them with not so little gifts and financial incentives to prescribe the medications that their companies manufacture. That was the reason for my blog here and saying that this could reduce the overall cost of medicine if these drug reps/doctor relationships ended.

This doctor, Dr. Leana Wen, believes doctors should operate in transparency and this link will take you to her reasons and then to her disclosure. She is getting agreement on some fronts and some strong opposition from many doctors within the American Medical Association (AMA). In addition, some drug company reps and doctors are now gaming the system to reclassify what they receive. They are working to avoid having the money received appear in the government reports under the sunshine law. It is unknown at this time whether they will legally get away with this, but they are trying.

Then we have the doctors that receive money for research, do consulting for the drug companies, and are on the speakers roster for drug companies. Why do many doctors court these conflicts of interest? Because of the reimbursement cuts that Medicare and third party insurers have been handing out for the last two decades.

We all know that our healthcare system is broken and in dire need of reform. We all know the statistics: the U.S. spends $2.7 trillion on healthcare, 30% of which is waste in the form of unnecessary tests and unnecessary treatments. Conflicts of interest are rampant, with 94% of doctors reporting an affiliation with a pharmaceutical or device manufacturing company, and many more insidious influences including salaries being tied to “productivity”. Dozens of studies have shown that these conflicts of interest have a real impact on care, and are a major driver of excessive cost and avoidable harm.

In a time when patients are already vulnerable and scared, patients have become even more afraid that they may not be receiving the right care for the right reasons. Doctors, too, have become afraid of their patients. A lot has been written about the fear of malpractice leading to hiding mistakes and practicing defensive medicine.

This Medscape article helps explain what Dr. Wen is attempting to accomplish and the reactions from other doctors. Some doctors are in favor of her actions and many are opposed. With the government publishing what doctors will be receiving in 2014, it would seem that more doctors would support Dr. Wen's actions, but this is not what many doctors want. Many are even opposing the actions of the government.