April 19, 2014

Doctor–Patient, Communication Needs More Focus

This blog by Nancy Finn is a topic favorite and can really get me wound up. Communication is a term that many dismiss as unimportant in today's medicine. Physicians like the term patient engagement, and other buzzwords to describe one-sided communication and then claim patients do not communicate.

While this is true for many patients who are passive in nature because they expect the doctor to ask the right questions and give all the right medications. Too often these patients are over medicated and given too many unnecessary tests. Communication is a two-way method of making the most of situation and getting quickly to a proper diagnosis. But the failing of today's health care is the lack of effective communication, not only by the doctor, but by many patients as well.

Some of the reasons include:
  1. Many drama kings and queens,
  2. Many cannot concisely explain what is bothering (or ails) them,
  3. Many patients do not have the terms to use (health literacy),
  4. There is too little time with the doctor, and
  5. Many doctors cut the patient short from giving details.

This is sad that in this day and age, with many tools available to doctors and patients for better communications, the art of communication falls by the way-side and is not used. While it is estimated that 80 percent of serious medical errors involve miscommunication between caregivers. This happens in hospitals and between doctors when a patient is referred to another doctor. This is even more complicated now that electronic health records have entered the picture.

It is simplistic if every doctor is an hospital employee and the patient record is open to every doctor in this case. But let an outside clinic become involved and the error rate is back at the 80% level as one electronic health record (EHR) is isolated from another EHR and they are not allowed to communicate. Currently, most patients have no authority to transfer information from one source to another. Most records are HIPAA protected and a doctor or the patient is not allowed to override this isolation even if both agreed. Therefore, the doctor or someone he designates needs to print out the information to be transferred and this is the source of most errors.

Hand-offs is one area where communication has to improve. This is especially true for the elderly being discharged from a hospital to their home or to a nursing facility. The office visit is another. Poor communication is blamed for patient frustration, non-compliance with treatment and medications, and general lack of trust in the physician.  It is said by some that many doctors are interested in their patients and desire to make the right medical decision about medical care.

Doctors do have many distractions, such as continuing education, licensing tests to take, and government and insurer paperwork to complete. The number of required tests and conditions the primary-care doctors need to screen for, has increased dramatically. Then add to this the treatment regimens for chronic diseases like diabetes, heart and lung disease, cancer, and other problems that have become more complicated. These all make the 15 minutes for an office visit more difficult. Little time is available for communication and this puts more pressure on the doctors and unfortunately can cause more diagnostic errors.

Continued in tomorrow's blog

April 18, 2014

Some Ways to Become a Safe Patient

Many patients allow others to be in charge of their patient safety when in their own home, when at the doctor's office, and especially when in the hospital. This is not a good habit to follow and you, a person with diabetes, need to be conscious of your surroundings. Granted if you are taken to a hospital in an unconscious state, you will probably not be aware of what happens to you until after the operation or operations and you recover your awareness.

The following are good points by the CDC to help remind you how to be safe:

Speak up - Do not hesitate to ask questions. Ask your doctor about those worries you have and how to remind those around you about those worries. If you are in the hospital and are hooked up to devices for putting IV fluids in your hand or catheters to remove waste from your body, do not be afraid to ask how long they are necessary. Many catheters should be new each day unless surgically implanted or for IV use.

If you are going into the hospital, ask how they prevent infections and what they do to protect you after surgery to prevent infections. Hospital acquired infections are difficult to treat and can add to your hospital stay. 

Keep hands clean - Always make sure everyone washes their before touching you. You may irritate many doctors and nurses, but they are known for not washing their hands as they move from one patient to another. 

Become smart about antibiotics - Ask if a test will or has been done to be sure that the right antibiotic is prescribed. Often antibiotics are changed by doctors without tests. Each doctor has their favorite and when it does not work, they move to another antibiotic. Most insurance carriers are now insisting on tests to determine the most effective antibiotic.

Learn the signs and symptoms of infection - Many skin infections, such as MRSA, occur with redness, pain, or drainage at the IV catheter site, or surgery site. Often this happens with a fever and you should tell you doctor as soon as possible. If you happen to have MRSA or other hospital acquired infection, your stay will be increased.

Watch out deadly diarrhea, aka, C. difficile - Tell your doctor if you have three or more episodes of diarrhea in a 24-hour period, especially if you are taking an antibiotic. It is important that the diarrhea be brought under control quickly to prevent dehydration and death.

Protect yourself - Get yourself vaccinated against the flu and other infections to prevent complications. If you know there are flu patients near you or cases of MRSA, these vaccinations may save you from acquiring them. This is also important for insisting that doctors and nurses wash their hands.

April 17, 2014

Diabetes Does Not Have To Be Progressive

This blog by Nancy Klobassa Davidson, R.N. on April 4, 2014 represents a blog by a large medical organization (the Mayo Clinic) that identifies their blog author. No anonymity here like the blogs on Joslin Communications, a part of the Joslin Diabetes Center.

The topic is a controversial topic about diabetes being progressive. While I have to swallow hard to agree with parts of this, it is presented rationally and it is easy to understand. It is true that many people refuse to manage their diabetes in a manner strong enough to prevent diabetes from becoming progressive. The author does not account for the people that die of old age or other causes and not diabetes.

I would not argue that for many people, dying from diabetes or diabetes related causes (i.e., heart disease, kidney failure) is more common than we would like to have happen. We may be debating medical semantics, as some people have heart disease before developing diabetes and the same for kidney disease.

This statement by the blog author is important enough to quote. “Recently, I met a woman who was upset that no health care provider or diabetes educator had explained to her, at the time her diabetes was diagnosed, that diabetes is a progressive disease. She thought that if she "behaved herself," her diabetes could be cured, or at least stay in holding pattern.”

Yes, there are people with diabetes that mistakenly believe they can be cured. All I have to do is talk to the owner of a health food store and she will confirm this. She knows this is not true as she has type 2 diabetes, but says that about twice a month, someone will come to her store seeking a cure for diabetes. She tells me that people say the darnest things and her favorite is, “this is the twenty-first century, there has to be a cure.”

The author's logic presents both sides of the disagreement better than most. She does not state many of the obvious conclusions, but sidesteps many issues by saying, “this varies per individual, and everyone is different.” I can agree with this, because we all age and manage our diabetes differently. It is the definition of progressive that needs clarification. Progressive means aging or becoming older. With aging, our organs all lose their efficiency and the pancreas is no different.

For me, progression of diabetes would mean that it progresses to the complications and on to death. Some people are able to manage diabetes for many years (and even for decades) with nutrition (diet) and exercise. As the pancreas ages, oral medication may become necessary. As we continue to age, other injectables or insulin may become necessary.

As long as retinopathy, kidney disease, and heart disease caused by diabetes are not becoming worse with age, then diabetes has not become progressive. But you did not mention neuropathy you say. Correct, because about two-thirds of people with diabetes develop neuropathy and there is some conflict here as many, like myself, that develop neuropathy many years prior to being diagnosed with diabetes. My neurologist and I have an ongoing discussion about this as he says that with the development of diabetes, that the neuropathy is now classified as diabetic neuropathy.  Sort of the chicken and egg version of which came first.

Many people, without their doctor's threat, often feel that they have failed when it comes time to transition to insulin. Often they wait too long to do this. They haven't failed, it is just their normal thing as they age and the pancreas not functioning very well that causes the need for insulin. Insulin can be very helpful and a necessary tool in the management of type 2 diabetes.

Delaying to use of insulin too long causes high blood glucose levels and prolonged periods of high blood glucose is what causes the onset of complications. Insulin does not cause complications and in most cases if started early enough can prevent the complications and heal those that are just beginning.

Even though the blog used for reference above says diabetes is progressive, it is still worth reading.

April 16, 2014

An Impromptu Meeting with Our New Member

On Monday, April 14, Tim called to say that Dr. Tom wanted three of us to meet with the newest member and his wife. This would be Tim, Allen, and myself. Tim said he would be by in about 40 minutes to pick me up and then get Allen. After Allen was in the car, we talked about what Dr. Tom wanted us to discuss with them. This would include reinforcing what Dr. Tom had covered about calling him if he was having a hypoglycemia episode, titrating his insulin up or down for both types of insulin, and how often for about the first three months to test. He had asked Tim to discuss food plans, reducing his carbohydrate consumption, and carbohydrate counting.

When we arrived at his house, his wife greeted us, offered snacks, and asked what we wanted to drink. Tim thanked her and explained that we all carry our own not to cost members extra money. He told her not to be offended as we do this whenever we go to someone's place and at meetings.

The person with diabetes then entered the room and thanked us for coming. Tim repeated what he had said to his wife and asked how he and insulin were getting along. They suggested using the living room and Allen asked if we could use the kitchen since we had seen the large table. The wife asked why and Allen and I held up the cookbooks we had with us and Allen asked if the canned goods were in the kitchen.

When they kept pushing us to the living room, Tim asked why the kitchen was unsatisfactory and that we were there by their request and at the request of Dr. Tom. If they wanted our help, why were they making us sit in an area that would not be conducive to working with the cookbooks and an easy place to write. The wife carefully explained that the two teenagers would need to fix their meal before too long, and they did not like to entertain in the kitchen.

Allen asked if they would come to his house so they could use the table and see what we talked about on the different food labels. They reluctantly agreed and we went to Allen's home. When we were seated, Allen took many items out and set them on the table. I opened my cookbook, as did Allen, and we started. Tim again asked how he and insulin were getting along. When he did not answer, Tim asked to see where he was recording his meter readings. When he pointed to his head, Tim said that is not acceptable. Since Allen had started working with the wife and carb counting, I stepped outside and called Dr. Tom.

When he heard what I told him, he asked where we were, and he said he would be there shortly. I waited for him to arrive and we went in together. Dr. Tom asked Tim how things were progressing and Tim laid out what needed to be accomplished. Dr. Tom said that he needed to record his blood glucose readings and asked Allen if he had his handy. Allen said he records his in his computer and carried a small pad to record them for entry when he is away from home.

Allen said he also has the program and equipment to download his meter onto his computer. Dr. Tom asked if he would show this to, and stopped. He asked if we had given the new member a nickname. Tim said no and asked if he would accept James as his nickname. When he got a quizzical look, Tim explained why we do this and he agreed then.

Allen quickly explained where he was at and I said I could take over. With that Dr. Tom, Tim, Allen, and James went to look at what Allen did with his blood glucose readings. James's wife asked if all the measuring was necessary. I asked if she was interested in helping her husband manage diabetes. She said yes, and I said we would be available to answer questions and be there via email or telephone to answer questions. I asked her if she had a scale similar to Allen's and she admitted that she did not. I said I would send her some information and URLs to let them look at different electronic scales. I asked if money was going to be a problem and she said no. I continued that she would use the scale quite a bit for six months or longer and then occasionally after that.

Allen came back then and asked how she was doing. She said better now that she had hopes of getting a similar scale. I asked if she now understood why we wanted to use the kitchen and she said yes. She said in the future, she would have us over later after the evening meal so that we could work in the kitchen. She hadn't realized how much she needed to learn and it was a bit overwhelming. Allen said don't run out and buy cookbooks like this one, with the word diabetic in the title, as he handed her one of his. He asked her to skim it and if there were any recipes her family would eat. When she completed a look, she said no and Allen said that is why he keeps it around to show people how bad they are.

Dr. Tom, Tim, and James then returned and James thanked Dr. Tom for coming over and explaining how important things were and how much his friends could help. Tim asked what nickname we were going to use for his wife. She spoke up and asked if Jill would work. Dr. Tom held out his hand and said, Jill, it is good to have you on board.

Jill asked James how much money he would need for supplies and then they decided that they could afford that and would order them as they could over the next few weeks. Tim had pulled up the blog about digital scales and said he would send the links in an email. Jill said that would help them decide and be able to order one. Tim opened one link for her to look at and she said that one looks good and the price is reasonable.

With that, we called it an evening and we pickup up what we had brought and Tim took me home.

April 15, 2014

Our April Support Group Meeting – Part 2

Continued from the previous blog.

Then the speaker turned to Tim and asked him to put up the list of complications. Once they were up, the speaker asked the PWD if he understood what this could mean. He was looking away and did not answer. The speaker asked the PWD why he would not look at the screen. No answer, and the questions was repeated and repeated several more times until the PWD tried to leave the room. The speaker stopped him and asked him if he was afraid to admit he had diabetes. The PWD was seated and the speaker asked Dr. Tom to join him.

Then he told the rest of us to be seated, as this was going to become tense. The speaker and Dr. Tom spent the next almost half an hour asking the PWD question after question. They waited just long for him to start an answer and receiving no answer, the next question was asked. Finally the PWD started crying and he was taken from the room by the speaker and Dr. Tom. As they were leaving, Dr. Tom asked another doctor to accompany them. In about 10 minutes the second doctor was back to get my meter and lancet device. He asked Tim to go through the slides and who ever could help explain, please do so.

We started covering the slides and the doctor came back for the rest of the family. Then about 15 minutes later, they all returned and the speaker explained what had happened and why they had been excluded intentionally. The PWD asked to speak and when given the okay, admitted that he had been in denial and his refusal to accept the diagnosis of diabetes. He then explained that his first A1c had been over 15 and then tonight having a second A1c over 14 was even a larger shock. He had figured out how cover with numbers for the meters he had and had used this for tricking those around him.

He said that with an audience of people with diabetes, he knew he was going to have a hard time. Then when the questions started he said the one that had gotten to him was the question - “What makes you think you are so special that you can't get diabetes?” He continued that he did not know of any family members with diabetes, but he had heard of several others that had no family history of diabetes, but still had type 2 diabetes.

He finished by saying he had now accepted that he has diabetes and the doctor we call Dr. Tom would be his new doctor. To help Dr. Tom, the PWD turned to Tim and asked if he could be a member of his support group and that he would be on insulin after he saw Dr. Tom on Monday morning. Tim asked for a show of hands from the group members of our group. It was unanimous and that was done.

The speaker asked what the reaction was to this type of intervention. This drew a round of applause and he held up his hands for silence. He continued that the reason for privacy he felt was necessary to help the PWD accept his diagnosis and this was the reason he addressed you when we were done. The speaker said the PWD has a lot of healing to do and will need the support group for help.

The speaker said he would send Dr. Tom a summary of the happenings that could be shared and he would then send it to Tim for distribution. He said if Tim does not have your email address and you wish to receive this, please give it to Tim after the meeting.

The speaker said he would still do the other session, but felt this evening could be valuable for everyone and did not want to let it get away. He said to let Dr. Tom know if they needed the second session. Tim asked when and the speaker said he could not do it in May, but after that he could. Tim asked for a show of hands that wanted the second session and it was unanimous for the first part of June. The speaker said he would check his schedule and let us know through Dr. Tom, but hoped it would work.

Another 45 minutes of questions and answers and the meeting ended. Tim obtained the email address for the PWD and let him know he would receive a notice of all meetings and receive a summary of all meetings even if he was in attendance. Tim was surprised when he gave his wife's email, but the PWD said she should come if she was allowed. Tim called her over and explained the rules of her being allowed and she agreed.

Several others thought they may not have given up their emails and felt that with the last two meetings, they would like to be present for the third meeting. Jessie and her husband then talked to Tim and told him that he was a distant relative of theirs and they would like to be informed if there were future problems with him. The PWD had noticed them and was surprised to see them. He asked if they had diabetes and we could see his chin fall when they said yes. He had the presence to ask if he had other relatives with diabetes. Jessie nodded and then he really broke down and cried.

Dr. Tom and the speaker both started toward him and he said that he was okay, but so very disappointed that he had not known about relatives having diabetes. The PWD asked Jessie to list those she knew about. She said herself, and listed five other of their relatives that had type 2 or type 1 diabetes. Now he was in shock as he had contact with them rather regularly and he wondered why he had not been told, especially the two with type 1.

Jessie said this was because the entire family was too secretive and very seldom talked about this with relatives. The PWD asked his wife if she had heard this, and she admitted that as a non-family relative, she had heard nothing about what he had just learned. He said this puts a whole new perspective on his situation. He said thank you to the speaker and said to Dr. Tom he would be there on Monday morning. Jessie said she could have spoken up earlier, but was not sure if she should. The speaker said that this was a lesson she would need to learn. After another 15 minutes, everyone was leaving.

April 14, 2014

Our April Support Group Meeting – Part 1

In the few weeks leading up to the meeting April 12, Tim received emails from several unable to attend March's meeting and Tim made sure to ask for extra chairs and made extra copies for each. When the meeting started, 89 were in attendance.

The speaker said I have a special presentation for you this evening. He said this is unplanned, but started this afternoon and the family has consented. I will be doing an intervention for you. He introduced the family, then the wife, and the person with diabetes. There were a few hands quickly covering mouths, as some recognized the person with diabetes.

The speaker asked the person with diabetes (PWD) to explain the action he was taking and why. The person with diabetes stood up and said I have some questions first. The speaker asked him to continue. He asked how many people had diabetes. Every hand went up and he was a little surprised. He next asked how many had diabetes for more than three years. Only seven people did not raise their hands.

Next, he asked how many had not known relatives with diabetes. Nine people raised their hands. Now he asked how many felt they had been misdiagnosed. No hands were raised and he said I have been misdiagnosed and don't have diabetes. I will do a test to prove it. Allen stood and asked when he had last had anything to eat. He answered about four hours ago. Allen then asked when he had last washed his hands and he said about an hour ago.

The PWD pricked his finger, tested, and then asked his wife to read the results. She said 209 is what the meter says. Then he picked up a second meter and also use this to test. When he read the results, 88, everyone looked around in disbelief. One doctor asked to see the meters before the test strips were removed and they were put away. They were offered and the doctor said, there is no blood in the test strip and the meter is still showing the number 88.

The speaker interrupted then and said the readings in his office three hours earlier were the same. The wife of the PWD asked if this was what he was using and had the meters preset to try to fool everyone. With that, she opened both test strip containers and said that the ones for the one meter, all had blood in them, and none on any of the strips for the second meter had blood.

The speaker asked if anyone had their meter with them and new lancets. Ten of us raised our hands and the speaker asked me to bring my meter up. Once there, he asked that I remove the lancet and insert a new one. Next, I used an alcohol pad to clean the lancet device and set the depth to #3. Next, the speaker removed another alcohol pad and cleaned his fingers. Then he removed a test strip and inserted it in the meter.

When he asked the PWD to hold out his hand, he refused. He asked a second time and again he refused. The speaker asked if there was anyone he would let prick his finger. The PWD said he was the only one he trusted. The speaker announced that he was in denial then and had some depression in addition. The speaker turned to the group and asked Allen if he would come up. Allen got to the front and the speaker asked if Allen agreed with his analysis.

Allen said he agreed and asked the speaker if he could ask two questions and the speaker agreed. Allen asked the person with diabetes if he had pain in his feet that felt like a thousand needles. He answered no, but his wife said he doesn't like anything on his feet at night and had constructed a metal frame to hold the covers up away from his feet. Allen asked if he had been tested for vitamins D and B12. When he would not answer, his wife said no.

The speaker asked when he had been to his doctor and he would not answer. The speaker asked the wife and she said about nine months earlier. She continued that he would not see the doctor again and had protested seeing this doctor. If it was not for their two children, the wife said he may not have gone.

The speaker turned to me and asked if I had any questions. I faced the PWD and asked if he would let us know why he would not accept us testing his blood glucose and why he was afraid. He would not answer. The speaker turned to him and asked if he would allow Dr. Tom to do an A1c test which would measure his previous three months. He nodded his head and Dr. Tom came up and asked to borrow my lancet device. He carefully pricked one of his fingers, wiped away the first drop, and gently squeezed another drop for the A1c.

After getting the blood for the meter, he held it carefully for a several seconds and showed it to the speaker. The speaker asked the PWD if he wanted to read the results and he said no. Then Dr. Tom said it was over 14. Dr. Tom said this meant that his blood glucose for the three months was over 350 mg/dl. Then Dr. Tom asked what his first reading was and the PWD would not answer. His wife turned to Dr. Tom and said even higher.

Continued in the next blog.

April 13, 2014

Lifestyle Changes More Important Than Medications

This blog from the Center for Advancing Health (CFAH) is written by a person that attended the Diabetes + Innovation 2013 conference. I found her blog most interesting and while I am generally not able to attend such conferences, there are many thoughts she put forward that I have known and thus am not surprised. The following are lifted from that blog:

#1. Diabetes management falls squarely on the patients' shoulders. While many patients with diabetes feel that they should be receiving more information from their doctors, time does not allow for this. People with type 2 diabetes on oral medications often see their doctors at most two times a year. This will vary by the level of their HbA1c, but often depends on the doctor. The better managed their diabetes is, the less time their doctor will want to see them. Many patients managing diabetes with nutrition and exercise will not see their doctors but once a year once they have proven they can do this.

#2. The responsibilities and tasks of diabetes management can seem overwhelming. The fact that there is no vacation from diabetes can cause this and leave patients feeling alone and otherwise isolated. This is one reason our diabetes support group works so well and we enjoy each other's input. If you are feeling isolated, search out a support group in your community. Or if needed consider organizing a diabetes support group.

The following are three patient themes highlighted by Milly Dawson, the blog author:

#3. The main caregiver for a person with diabetes or prediabetes is himself or herself.
Diabetes prevention and treatment efforts should make it easier for people to make choices, but not in isolation, but within families and communities. The goal should be to make good choices about food and exercise. This “default choice” involves healthy eating at work and at home. It also means finding the right exercise regimen that the person can accomplish and enjoys on a daily basis.

#4. Behavior or lifestyle changes should be the first in treatment plans. Review the lifestyle changes from my blog – components of lifestyle change. Be sure to include weight loss if needed. Many of the lifestyle changes also reduce a person's risk of heart disease, cancer, mental illness, severe depression, and other health issues.

#5. People often have a hard time changing habits. To succeed, people often need other support besides doctors. Again, a support group, family, and community support may be needed. Do not forget caregivers, social workers, nutritionists, health coaches, and even peers, trained or untrained, online connections, and social media.

Presently, primary care physicians (PCPs) are not in a position to give the needed assistance. Often your time with a PCP is very limited and your insurance carrier generally is of no help.

The blog author rightly emphasizes food and exercise over medications. The American Diabetes Association and the American Association of Clinical Endocrinologists do not and push oral medications heavily, even before insulin. Food and the right food plan is critical in the management of diabetes.