March 22, 2014

What Happens to Your Cell Phone When Seeing a Doctor?

This question has more to it than most people consider. I have a friend that says if the doctor has his pager off and his cell phone silent then he will put his cell on silent. I have another friend that will not put his cell phone on silent. Personally, I shut my cell phone off once I enter the reception area.

I have had several of my doctors say they are on call and that their pager is on when he/she comes into the exam room. This I can accept and appreciate the necessity. Only once did a doctor have to leave the exam room and not come back. His aid had instructions of what to do and I was rescheduled as I am sure several other patients were.

Another doctor had his aid knock on the door and entered when he answered. She asked him to step out of the room as there was an emergency. I could hear his aid say that his wife had just been brought into the emergency room and the ER doctor wanted him present. I could hear him state to give me my lab results and reschedule me as soon as possible. When rescheduling was complete, I asked the person if she had room for notes. She did and I gave her my cell phone number and said I would reschedule even farther out if he required more time for his wife. She thanked me for that.

Cell phones are becoming a distraction during office visits. Many physicians have posted signs in the waiting room and every exam room asking people to silence their cell phones or turn them off. I would like to discuss this further and suggest some courtesies for patients and physicians.

#1. When a patient is seeing a doctor, either shut off the cell phone or put it on silent. Even saying that, there are some legitimate reasons to inform the doctor that you have your cell phone on. I won't list every reason, but caregivers are at the top of the list. If an elderly family member is seriously ill or near the end of life, your doctor should understand your concern. However, some physicians will not, and a few are so puffed up with their own self importance that they have been known to kick patients out and tell them to find another doctor.

Occasionally a parent will have a sick child that they left with a baby sitter or relative. While instructions have been given, emergencies are still possible.

#2. The doctors should notify the patient that he is on call when he enters the exam room. Some doctors are considerate, but most are not considerate and figure it is none of your business. The inconsiderate doctors then wonder why patients wait until almost appointment time to cancel their appointment. I know I would wait until I was almost ready to leave for the appointment and then call and ask if the doctor happened to be on call that day. If he was, I would cancel my appointment. I have over an hour to travel to be at the doctor's office and could not afford to lose the two hours plus, if he was on call and ended up not seeing me.

#3. Both patients and doctors should realize that courtesy is a two way street and respect the other person. If you are on either end of the this situation, treasure the patient or doctor that has respect for you.

This blog by a doctor shows an unusual patience that most doctors would not put up with or allow a patient to do.

March 21, 2014

Not Taking a Medication – Who Is to Blame?

When I first read the title of this article, I thought this is probably just another attempt to put the blame on patients. However, as I read the blog, I realized that the author actually wanted to shift the onus to the medical system.

The author, Jessie Gruman, speaks rather pointedly when she says, “When clinicians and health systems start to take this issue seriously, such conferences might be useful. Until then, the statistics on non-adherence and efforts to improve our individual behavior are meaningless. Don't bother with the conferences or the interventions.”

The conferences she is talking about are those that the medical community calls to find ideas to force us, the patients, into becoming docile followers of the doctors. They are urging the use of smart pills, smart pill bottles, and mobile apps that will nag us, as our mothers did to make our beds when we were children. Then she says, “Before anyone starts fixing us, try fixing these three things.”

#1. Clinician prescribing skills: I almost roared with laughter when I read this area. It is true that most physicians pay no attention to patient's desires or even explain why we need a medication. They seem to think that we are to follow their orders and not question them about the medication.

We need to know - what the medication is called, what it is for; how to take it, how we'll know if it works, what to do about what side effects, and who to contact for advice about them.  We also need to know if there will be reactions with other medications we are taking.

From a practical standpoint, clinicians should be the starting place for improving medication adherence. If communicating about the appropriate use of medication is not a priority for them, why should using medications as directed be a priority for us?

#2. Medication labels: The pharmaceutical and drug distribution industries are unconcerned that the accompanying printed material requires a twelfth grade education (or higher) and a magnifying glass. Apparently, it is too costly to use a larger box and larger print. Even then, the technical wording often requires a medical dictionary for health literacy.

#3. Pharmacist availability and focus: I am fortunate to live in a state that requires the pharmacist to answer all questions and explain a medication. Do they do this? For the most part, they attempt to comply, but seldom succeed. They make it easy for people to answer no and if a patient comes back later with questions, they say they are busy and seldom answer the questions. I have found that you have to make statements like, this is the law and I did not know what questions to ask when handed the prescription.

A few pharmacists then say that you refused counseling when you picked up your prescription. They have already checked the box on the computer, so technically they feel they can ignore your questions.

Many people are concerned about the lack of privacy and are afraid to ask questions. I will give one elderly woman credit. She was asking questions and the pharmacist was being evasive and using many medical terms. She stopped the pharmacist and said, “Listen sonny, stop the medial gibberish, my son is an inspector for the state pharmacy board in this state and I will inform him of your actions unless you start answering my questions in plain English.'

He continued in his ways and next thing, her son, with the Iowa Pharmacy Board, stepped forward, showed his credentials and locked the pharmacy. He took out papers from his briefcase, completed them, and asked who was in charge. The store manager was called and in turn had to call in the head pharmacist who was on a day off. After she had explained the medication to his mother, the pharmacy was reopened. When the inspector had explained everything to the head pharmacist, he escorted the other pharmacist out of the store.

Yes, we all can have problems in taking our medications as directed, but all of us have in common these three experiences:

  1. We don't get complete information from our clinicians about why our medications are important and how to take them over time.
  2. Information about use of those medications is incomprehensible and often unavailable (online and off) to many of us.
  3. We lack easy and private access to counseling from our busy pharmacist.

The author concludes her blog with this statement. “Fix these, then let's talk about finding out just how big the problem of medication adherence is in this country. That is when efforts can be targeted toward what we can do to make better use of the medications we hope will end our suffering and save our lives.”

March 20, 2014

What Communication Does and Does Not Do

This is a classic case of poor communication and then excellent communication. This is based on a true experience of a relative, but names are withheld at his request.

The doctor did not explain the possible side effects or instruct the patient to call if he experienced any of them. Statins that are prescribed are often just handed to the patient with no explanation. Many doctors are very sure of their abilities and figure that the patient should just follow orders.

Then when the patient starts experiencing muscle pain, he is surprised and either stops taking the statin or heads for the computer and looks up the side effects and stops taking the statin. Some profanity is said about the doctor and the patient says nothing to the doctor.

The lack of communication continues at the next appointment and the doctor asks why his bad cholesterol (LDL) is still elevated. The patient says he does not know. Therefore, the doctor prescribes a stronger dose of that statin. This time the patient decides to talk with his pharmacist. The pharmacist asks if there has been any muscle problems and the patient says yes.

The pharmacist asks if he used any other pharmacies and the patient said no. The pharmacist asks if the patient is still taking a certain medication and the patient answers yes. The pharmacist says she will call the doctor's office as he should not be taking but 10 mg of the statin to avoid problems with that medication. When she hangs up with the doctor, she says the doctor had gone ballistic and would not give the lower dose. She said he was to stop the other medication, but she could not recommend that.

Patient asks what he is to do. Pharmacist asks if he would see another doctor. Patient asks if this doctor knows how to communicate with patients. That he does the pharmacist says and dials the phone. When she hangs up, she says the doctor will see him in 30 minutes on the second floor in this building. The pharmacist then says to wait a few minutes and she will print off a list of the medications that he is taking and side effects of each and conflicts with other medications.

The pharmacist then has a copy for the doctor and discusses them with the patient. The patient is now enthused about seeing the new doctor and happy with the pharmacist.

When the patient completes the paperwork and meets the new doctor, the patient is surprised at the amount of time the doctor spends reviewing his records. The doctor then discusses the medical history with the patient and covers the medications the patient is currently taking. He then calls the pharmacist and asks her two questions and writes three prescriptions for the patient, and then discusses each with the patient.

The patient asks a few questions and the doctor explains that he will have a blood draw before leaving and another appointment in four weeks with a blood draw before that appointment. This will tell them the status under the current medications and what changes occur in the four weeks for possible needed perscription changes. The patient is told if any of the side effects that they have discussed are noticed, the patient is to call the office immediately, and hands him a card with the phone number and his name on it.

The doctor hands him a two sheets for the blood work and asks if he has more questions. The patient says maybe by the next appointment as he was going on the internet to do some reading. The doctor asks if the patient has an email address and then asks for it saying he would send him an email with an internet listing of reliable sources and at his next appointment, they would set the patient up with a patient portal to his records and secure email to ask questions of the staff.

After the blood draw, the patient goes to the pharmacy. The pharmacist fills the prescriptions and also covers the side effects. She asks if the doctor had covered these and instructed him to call if any developed. The patient says yes, and thanks the pharmacist.

The second example is what should happen, but seldom does. The first doctor wonders why his patients are not taking their medications, but figures he is better off without non-compliant patients. The second doctor knows what happens and makes sure he covers side effects and explains them to the patient. The second doctor also instructs the patient what to do if he experiences any side effects.

The second doctor also asks about dietary supplements and looks for problems and this is the doctor we all need, but often cannot locate. Therefore, we have work at training our doctor and talking very carefully with our pharmacist.

March 19, 2014

Should Supplements Be Studied As Prescription Drugs?

This is one article that I have mixed feelings about and am concerned that we may lose a proper perspective about testing. The article has some good truths in their discussion, but I still have reservations.

This could not have been better stated. “On February 25, the US Preventive Services Task Force (USPSTF) made a remarkable confession: conventional medicine isn’t qualified to properly assess the benefits of dietary supplements.” Conventional medicine in general does not appreciate dietary supplements and does not understand them. They maintain that if we ate the proper foods, we would not need them.

Conventional medicine forgets that there are circumstances that dietary supplements are needed when the body looses its ability to digest and absorb the essential nutrients from foods. Most often, this occurs when diseases interrupt this ability and some people also have this happen as they age and this is most common among the elderly.

It is necessary to quote this. “The group’s Recommendation Statement on dietary supplements and the prevention of heart disease and cancer, which evaluated and combined existing studies on multivitamins and individual nutrients, concluded that:
  • Studies on dietary supplements should be designed differently than drug studies (which are largely random controlled trials, or RCTs);
  • Existing dietary supplement studies aren’t representative of the general population, and don’t show “true subgroup differences” (e.g., how a nutrient will affect a young Hispanic woman versus an older Caucasian man);
  • Research should target those who are deficient in the nutrient they are testing instead of patients with optimal nutrient levels (a point that should be self-evident but has always been ignored);
  • Disagreements on appropriate nutrient levels “hinders progress in understanding potential benefits of dietary supplements”; and
  • Due to these factors, there is simply not enough evidence—using conventional medicine’s customary approach—to determine whether multivitamins, vitamins A, C, or D (with or without calcium), selenium, and folic acid help prevent heart disease or cancer, or not.”

The discussion only concerns heart disease and cancer, but should also include other diseases and the medications that can cause deficiencies, such as metformin can affect vitamin B12 absorption in about 30% of individuals.

Most doctors in conventional medicine do not even understand the conflicts between most prescription medications and dietary supplements. Very few doctors even understand that some foods can conflict and cause serious problems with many prescription medications.

In the last statement above, grapefruit, which contains furanocoumarins, (furanocoumarins are a class of organic chemical compounds produced by a variety of plants) is creating potentially fatal side effects in many drugs. The number of drugs being affected has in the last four years has risen from 17 drugs, and now stands at more than 85 drugs that may be affected by grapefruit. Seville oranges (often used in marmalade), limes, and pomelos also contain the active ingredients (furanocoumarins), but have not been as widely studied. Statins is a prime example of a drug affected by furanocoumarins. I have written about this here.

I would urge you to read the information on the first link at the top of this blog.

March 18, 2014

Agave, Not As Diabetic Safe As Advertised

You have read something about agave and diabetes, and it was found safe. What was safe years ago isn't the product we have now. The people that have been promoting agave and agave syrup drew the attention of people that want to make a fortune selling sugar to people with diabetes.

The tropical sweetener has long been used in Mexico and most of Central America as part of a traditional diet. It is a recent introduction to the American market and closely related to a rising interest in natural and diabetic friendly foods.  Don't be misled as agave syrup is still processed and no longer a natural sugar.

Dr. Andrew Weil states that, “Fructose is a major culprit in the rising incidence of type 2 diabetes and nonalcoholic fatty liver disease. It may also increase risks of heart disease and cancer.”

WebMD states that agave syrup contains 55% to 90% fructose and this source lists agave as being low glycemic index, but with the fact it is sold as a natural food product, it is still unregulated in the United States. We all know that high fructose corn syrup is low glycemic index, but has a devastating effect on blood glucose levels for people with diabetes.

Fructose in agave syrup is concentrated and the elevated intake is associated with clogged arteries, elevated levels of uric acid, and increased body fat. These are dangerous to the health of people with diabetes.

Different groups are promoting agave syrup as natural and good for us. It is neither raw nor good for people with diabetes. From one product to another, even if the labels are almost identical, blood glucose levels can vary dramatically because of the processing method used.

Please do not allow yourself to be sucked in by those promoting it a natural and good for people with diabetes. Just remember that the Latino community has a very high rate of diabetes.

NOTE: Now there is more news and it all claims how great agave is for people with diabetes. What they don't tell you until well into the article or press release is that the trial was done with mice. It was done in Mexico and used their processes which are not the same processes used in the manufacture of agave in the United States. In addition, I may have a bias - why was this released by the American Chemical Society (ACS) instead of researchers for diabetes - if it is safe for people with diabetes.

This tells me that if they can market this carefully without the FDA becoming suspicious and they don't overstate what it does, there is money to be made. All press releases today, March 17, 2014 do stated that the trials involved mice, but the one TV announcement said nothing about this. Of course the news media will use the story since they can make the connection that agave is from the same plant that is used to produce Tequila.

March 17, 2014

Incretins Receive Pass for Questionable Safety

I think the title of the article says a lot - No Compelling Evidence Linking Incretin Therapies, Pancreatic Cancer. The word compelling is characterized by this definition (of an argument, evidence, etc) convincing. The U.S. Food and Drug Administration (FDA) and its European counterpart started reviews last year of the medications, which came on the market less than a decade ago, after a study suggested a safety concern.

Now I have concerns – only one year of reviews – is not long enough to be sure there are no problems and I suggest that people continue to be cautious. Several others have written blogs about this, including one by David Mendosa titled safety-diabetes-drugs. While I think this is good, call me a skeptic. Pancreatitis pain is often not expressed by many patients. They want something to bring their blood glucose levels under better management and they often think that then their pancreatitis will go away.

It is true that the incretins do spur the pancreas to produce more insulin after meals. However, if the pancreas is losing the ability to produce more insulin, is this doing any value by stressing the pancreas even further? This is the reason people should not leave insulin as the medication of last resort. Our doctors are always pushing people to take more oral medications.

The New England Journal of Medicine says that the European and FDA say that reviews of animal and human studies had found no treatment-related adverse effects on the pancreas. What is not disclosed is how healthy were the rodents used and were healthy type 2 humans used in the studies. This is often the case and why I have no faith in the studies.

Then the last paragraph even creates more doubt when it says, “Although the review ''provides reassurance,'' the agencies ''have not reached a final conclusion'' about whether the drugs can cause pancreas problems and will ''continue to investigate this safety signal,'' the authors write. Meanwhile, the drugs' labels appear adequate, the agencies conclude.”

March 16, 2014

Do You Love Insulin?

Type 2 diabetes and insulin go well together when needed, but I certainly do not love insulin. Yes, I advocate for insulin use because it is generally not prescribed except as the medication of last resort. Many doctors also use insulin as a threat telling their patients that they have failed in their management of type 2 diabetes. The last time I had a doctor tell me that he wanted me to go back on oral medications, I said no way doc and left.

In the months since, I have talked to two other people with type 2 diabetes and both have similar experiences of having been intimidated by their doctor to stay on oral medications. The one woman was beside herself because she had lost weight and increased her exercise regimen, but her blood glucose levels continued to rise. When I met her, she was having trouble obtaining readings below 200 mg/dl. As we were talking, I saw Brenda and asked her to come over.

After introductions, I had the person tell Brenda what had happened. Brenda spoke up as I knew she would and was very explicit about her feelings toward some doctors. Brenda asked where she was seeing her doctor and asked if she would consider changing as she felt her doctor was good and that the endocrinologist I was seeing would be a good fit for her. After finding out where each doctor was located, she decided to start with the doctor Brenda was seeing.

Brenda said she had one more thing to purchase and then she would accompany her to her doctor and attempt to get her an appointment as soon as possible. I said good, as she needed to get her blood glucose levels down quickly. We continued to talk while Brenda finished her errand. I told her to make sure she obtained her telephone number to ask her questions. I said she may also give you her email address and information about our support group and I gave her some information about that.

When Brenda was finished, she asked where the person was parked and said since it was close she could ride with her and after she had obtained an appointment, she would bring her back to her car.

About 15 minutes later, I received a call from Brenda to inform me that the doctor was seeing her then. Later Brenda called again and said she had Allen and several others meeting them where I had introduced the person to Brenda and I was invited. We had an hour of discussion about insulin and she had had an injection while seeing the doctor and would wait without food for four hours and take another reading to see what her blood glucose level was. Then she would call the doctor. She would then be given another dose to inject herself. She would also be given an insulin to carb ratio to start with.

Allen said good, this was a good way to learn what her ratio was and not to have a snack while she was waiting. We nicknamed her Susan after Brenda said she would be at our next meeting. Susan said she was fairly proficient with carb counting and this would help in getting used to insulin.

Tim arrived then and after introductions set his laptop up and asked for her email address. Susan looked alarmed and Brenda said it was okay as this was the way we stayed in touch and it was only for our use and not for sale. If she joined our group, she would be given notice of all meetings and if she could not attend one meeting, she would receive a summary of the meeting. Those were normally done anyhow, but it was one thing that seemed a good reminder of the discussion.

Then Brenda said you would also be given the emails for all members and the URLs for good reading about diabetes, if you are interested. Then Brenda pointed at me and said this is the blogger of our group and you will be given the URL for his site. Brenda then said I don't read every blog, but I do read more than I tell him. Susan asked, you write about diabetes? I said yes, and related topics you may or may not have an interest in exploring.

At that point, Susan asked if anyone read the blogs by Tom Ross and Tim said most of us do and Bob also has lists of other type two bloggers and pulled up the first list and then the second and rest of the lists. Then Susan asked why she had not seen one blogger, and Brenda stated because she has type 1 diabetes. Brenda continued that we read many other blogs, but Bob only lists type 2 bloggers. Susan asked if we participated on any of the diabetes forums. I said we have, and once I have your email I can send you a list of those that I am aware are active.

Susan said that was not necessary as she had five currently. Brenda and Susan both said they needed to head home and Brenda said to call after she had talked to the doctor and that once she had the list of members with emails and phone numbers, any of us could also answer questions. Brenda thanked me for having brought her into the discussion with Susan and Susan echoed that. Tim, Allen, Barry, and I talked a little longer and then headed for home.