Many Doctors Cause Non-Compliance

Yes, I said this and I know this happens. Why, you ask. Because the doctor is in a hurry to see the patient and only half listens and decides quickly what is best for the patient to be able to move on to the next patient. It is rare to find a doctor today that listens or even asks questions for their understanding.

Most doctors will not even consider insulin as a first line treatment, but do consider it as a treatment of last resort. They often use the threat of insulin as a way to force their patients into working harder to manage diabetes using oral medicines. Instead, they prescribe regular metformin or one of the Sulfonylureas. Then the doctors are upset when patients complain if nausea from metformin prevents them from eating and they stop taking it. Then for those on a sulfonylurea the patient suffers an episode of hypoglycemia and this scares them into stopping this medication. They then label these patients as non-compliant.

Instead of prescribing metformin ER (extended release) that often is better tolerated, they tell the patient to take their medicine or find another doctor. When this happens, the patient might be better served to find another doctor, but the search could be futile because many doctors are the same and would rather label a patient non-compliant than do what might be of help for the patient.

The other issue is of food plans. Most doctors tell patients to eat more carefully or hand them a food plan with no explanation. These doctors will not refer the patient to someone that can work with them in designing a food plan that will help manage diabetes and explain the reason for the changes needed. In addition, they can help direct the patient to finding the needed foods that aren't always expensive.

Most doctors will not refer patients for diabetes education or to work with other professions that might provide assistance. They also will not do anything to find out about family, work schedule, or even lifestyle that can be changed. Many doctors prescribe one or more medications and have them scheduled for another appointment. No instructions are given for times when medications cause problems and no instructions about calling if there are problems. In other words, the attitude is here are your prescriptions and don't bother me until your next appointment.

This is why I will continue to support doctors in several states that are training peer mentors for education of diabetes patients they serve. Several of the doctors have agreements with a few nutritionists that are not registered dietitians or members of the Academy of Nutrition and Dietetics (AND). They also work with the diabetes patients to educate them about food and work with them in areas of nutrition for levels of carbohydrates they wish to consume.

I have heard from two of the peer mentors that I correspond with and they are very happy that the patients are gaining a benefit and most are doing quite well in managing their diabetes. I have even had correspondence from two of the doctors thanking me for finding two nutritionists, which led to three others. One of the doctors has found a CDE that will work with them and not against them like so many have in the past.

Are Patients Customers or Not?

I thought I knew the answer and had settled for myself that a patient is a patient, is a patient. However, some that are also declaring that patients are not customers are doing an excellent task of making me doubt myself.

The definition used for customer is a person or entity that obtains a service or product from another person or entity in exchange for money. Customers can buy either goods or services. The stickler (any puzzling or difficult problem) is that health care is classified by the government as a service industry because is provides an intangible thing rather than an actual thing.

Here is why the patient shouldn’t be considered a customer, at least not in the business sense.

#1. Patients are not on vacation. They are not in the mindset that they are sitting in the doctor's office or the hospital to have a good time. They are not relaxed; they have not left their troubles temporarily behind them. They have not bought room service and a massage. They are not in the mood to be happy. They would rather not be requiring the service they are requesting.

#2. Patients have not chosen to buy the service. Patients have been forced to seek the service, in most cases. Whether the quality of service is excellent or poor, often the patient has to accept what is provided.

#3. Patients are not paying for the service. At least not directly. And they have no idea what the price is anyway. This is where the insurance industry and the health care industry are in collusion to hide information from patients.

#4. Patients are not buying a product from which they can demand a positive outcome. Sometimes the result of the service is still illness and/or death. This does not mean the service provided was not a good one. Yet many doctors and hospitals insist that they did nothing wrong, when in fact, the service was loaded with errors and adverse events.

#5. The patient is not always right. A patient cannot, or should not, go to a doctor or hospital demanding certain things. They should demand good care, but that care might mean denying the patient what the patient thinks he or she needs. The doctor is not a servant, the doctor or hospital does not have to do everything the patient wants. The doctor or hospital is only obligated to do everything the patient needs.

#6. Patient satisfaction does not always correlate with the quality of the product or the quality of care. A patient who is given antibiotics for a cold is very satisfied, but has gotten poor quality care. A patient who gets a knee scope for knee pain might also be very satisfied, despite the fact that such surgery has been shown to have little actual benefit in many types of knee pain.

Hospitals are presently promoting (not focusing) what they call “patient centered” care. Some doctors are doing the same and the result is anything but patient centered. It is profit centered and promotes what the hospital and the doctors want, not what the patient needs in most cases. It involves unnecessary tests and procedures which often results in harm to patients. The hospitals and doctors make everything sound rosy and great, but everything is done to satisfy hospital dollar needs.

This is one reason not to use the term customer but keep the term patient, as the patient needs the service. They don't need the service often demanded by many doctors and hospitals, but they still need health care. While health care workers and providers are exposed to all the human foibles of temperament, background, values, and expectations, the patient needs health care, but does so under duress and health needs, often to remain alive.

If doctors and hospitals would treat patients with care and respect instead of with dollar signs the patient represents, doctors and hospitals would not need to constantly be inventing new terms to describe patients and confuse issues.

Doctors Can Help Reduce Medications

Reading news articles sometimes is very unnerving.  Not only was I offended by this one, I was irritated and not sure I wanted to blog about something that might have value. The title is really a turn-off and made me think an overly aggressive doctor was the author of the press release. Then I read the second paragraph and when it stated a professor – then I knew that it was one of the academia that has little or no knowledge of the real-world happenings. This is still no excuse, but just another lesson on how the people they write for are belittled and thought of as minds they should be the ones molding for compliance – BS.

This is a Danish study and does have value as very few American doctors even consider this approach. In America, doctors push pills for type 2 diabetes and very few will listen to other alternatives. In Denmark, doctors are more patient oriented and encourage patients to take charge of their health and see what they can do for lifestyle changes to stay off medications.

A doctor in the United States refusing to hand out medication until the patient shows the need is almost unheard of. The doctors here would much rather push medications (notice I used the plural) than allow the patient to prove they can stay off medications with exercise, weight loss, and food habits. Occasionally you find a doctor that will allow this to happen, but very rarely. Many insist on medications and then when the patient demonstrates the ability of managing their diabetes, they are still reluctant to allow them off medications. Some doctors will allow this to happen, but not that many.

I would say that the Danish doctors are to be commended for their actions and maybe a few of these doctors should be allowed to teach in our medical schools on the topic of diabetes management for type 2 diabetes.

This is one time when better heads should prevail and articles not titled by people with little knowledge of the disease they write about. This is the title that I found so offensive - “Complications In Diabetes Treatment Can Be Avoided When Patients Cooperate With Their Doctor.” I personally think the title could be improved dramatically and made for people to want to read the article if a title like this was used, “Diabetes Treatment Can Be Improved When Doctors and Patients Share A Common Goal.”

Think Your Hospital Is Looking Out for You?

If you think when you are in the hospital that the hospital is looking out for you, you are in the minority. Day after day, we see news of people that have stories to tell that are not showing hospitals in a good light. We hear of friends or relatives of friends that have died because of medication errors, errors in medical judgment, and errors in operations performed on the wrong patient. It will soon be apparent to even the most careful of patients that they will need a patient advocate if they are to be admitted to a hospital.

Even then, patient advocates will have a difficult time. Hospitals do not like patient advocates and do their best to work around them or even conceal what is happening. Yes, several decades ago, there were accidents and errors, but not at the ratio of today. We had doctors that spent time with patients and checked in regularly. We had nurses that knew what to do and communicated with the patient’s doctor(s) and the patients. They would alert doctors of changes in a patient's condition and test results.

Then came larger hospitals and more lawsuits. To protect their profit margin, nurses were marginalized, doctors restricted in their duties by the hospitals. Patients in the hospitals are being seen less often and not by their own physician. Is it any wonder there are more errors and improper medications given? Allergies are not checked and communications are limited.

This article in a Diabetic Connect newsletter says a lot and lays out many of the problems we encounter as people with diabetes. This from the article needs to be quoted, “The problem with hospitals is that they standardize care much more than they individualize care. This is due in large part to the huge volume of patients they service, and the need for general protocols. General protocols, however, do not work all the time for patients with diabetes. If you have never used insulin and the plan is to give you insulin in the hospital, work with your health care team to understand what to expect. I would advise family members to carry blood glucose meters with them and have them available for a quick check if necessary so that you can alert the hospital of a potential problem with high or low blood sugars.”

These general protocols can make it impossible to manage blood glucose levels in the range that you are accustomed to. Most hospitals do not want you to use your pump if you use one. They even discourage continuous glucose monitors. Occasionally you will find a hospital that will allow the patient to manage their diabetes while in the hospital, but this is rare and must be decided upon before admission. I would even suggest getting it in writing.

Another issue the article raises that I can appreciate is some hospitals are giving rapid-acting insulin after a meal. This surprisingly allows the patient to not eat the food that you will be served and/or eat what you think will be sufficient for your needs. Then the amount of insulin can be adjusted for the food eaten. Most hospital food is not very enticing and is loaded with carbohydrates. This is because of the dietitian mandate that people with diabetes should have 60 grams of carbohydrates at every meal.

I do appreciate the author's comment and I quote, “I do not in any way want this to scare you, but rather to encourage you to be an active participant in your healthcare. Any and all family members and loved ones should be involved as well.”

Hospitals need to learn how to treat people with diabetes. This will mean every family member will need to be on board and maybe even a diabetes patient advocate. If the patient is going to be incapable for any period of time and a family member is unable to be present, even a medical power of attorney will get their attention as long as the persons present are listed on the document. Even then, many hospitals will try to circumvent this document.

If you are the patient, make sure that you dot all “I's” and cross all “T's” and that your wishes are known, if possible, before admission to the hospital. Remember that the hospital protocols may not be in your best interests for diabetes management. Hospitals have protocols that are in their interest to protect their profit margin and prevent lawsuits.

Patients Trust Doctors but Consult the Internet

This is one study that does not reveal anything new to me. Members of our informal group have been talking about this for some time. We all were disappointed when one of the group had an appointment with a doctor for something other than diabetes. The doctor informed him that if he went on the Internet to search about his condition, he did not want him as a patient. Since he knew that he would, no matter what the doctor stated, he did think to ask a few questions.

Why would any doctor today make this statement? What was he trying to hide? The last question was why he would chase patients away? The doctor did say that for this condition there was not much good information on the Internet. Our friend did think to say why did the doctor not have a list of reliable websites to hand out rather than drive patients away. Doctor asked if he was intending to use the Internet and our friend said most definitely as he used it for other medical problems, among them diabetes, and that with a group of friends would be searching the Internet. The doctor just stated that he did not want him back as a patient. At least our friend stated that with this attitude, he would not be back to a doctor that was against technology.

We have had quite a bit of fun with this experience. A couple of phone calls were made to the office to see if this was indeed true. The person answering the phone just says yes, if you are a person that will search the Internet, the doctor does not want you as a patient. This has raised other activities like a doctor search and name search. Apparently this doctor has succeeded in maintaining an almost zero presence on the Internet, except for an address and office location.

In our research, we did discover that very little was available on the Internet. What was available was from studies that did not give out much information. The member did get another appointment with a different doctor. This doctor did a different series of tests and determined that the first diagnosis was not a complete diagnosis and that two important steps had been bypassed. The doctor asked if he was going to research for more information on the Internet and when our friend answered yes, the doctor handed him a list of URLs that could help. The doctor stated that there was other information, but he did not consider much of it as reliable. The doctor was right and had done his research. We found several other sites, but the information was not as complete.

Back to the study which found no evidence that the users of online health information had less trust in their doctors than patients who did not seek information through the Internet. Xinyi Hu, who co-authored the study as part of her master's thesis in communication was somewhat surprised and suggested that doctors need not be defensive when their patients come to their appointments armed with information taken from the Internet.

“"As a practicing physician, these results provide some degree of reassurance," said co-author Richard L. Kravitz, a UC Davis Health System professor of internal medicine and study co-author. "The results mean that patients are not turning to the Internet out of mistrust; more likely, Internet users are curious information seekers who are just trying to learn as much as they can before their visit."”

“Almost 70 percent of the study subjects reported they were planning to ask their doctor questions about the information they found, and about 40 percent said they had printed out information to take with them to discuss with their doctors. More than 50 percent of subjects said they intended to make at least one request of their doctor on the basis of Internet information.”

This says a lot about what people do with the information they glean from the Internet and that they would not be asking questions if they thought the information was not worthy of discussion. Doctors that are afraid of patients looking for information on the Internet, either are afraid of their lack of skills, or their knowledge of the topic. It is a good doctor that says he is not up on the information for the disease or illness of the patient and says we can learn together. This also says that the doctor is appreciative of a patient that is proactive in their care.

While many doctors hesitate to say that their education about an illness or a disease is not as recent as it should be, there are some that are confident in their skills to learn that they will challenge most patients to learn with them. These doctors should be valued as they want what is best for their patients and will spend the time learning so they can answer questions their patient asks. I have even seen doctors admit they are not current in their knowledge and refer a patient to a doctor that is current. This says that the doctor is a caring person and realizes that they do not have the time, or possibly even the interest at that time in their career and are confident in knowing what is best for the patient.

Sleep Deprivation by Doctors Harms Patients

Sleep Deprivation is touted in the medical profession and doctors seem to think that it is okay. Not only that, but for doctors that report working too many hours are ostracized for reporting this. It is no wonder patients are so distrusting of doctors. We are slowly learning that doctors are not taking their Hippocratic Oath seriously and doing more patients harm than good.

These are some of the bad apples that need to be weeded out of the profession. It is small wonder that residents and doctors in training are fighting the system to reduce the work hours. I was harsh about the treatment of medical residents working hours, but this study points out that doctors are even harder on their fellow doctors when they do not work as many hours as their cohorts feel they should.

The lead investigator stated that they were surprised by the results of the study of before 2003 hours worked and the after 2003 hours worked. They suspected that the outcomes would have been the same before and after 2003. Instead, the complication rate decreased.

The following is an important statement, “In fact, many residents record their hours at below 80 and really work 80 hour weeks, and those that record otherwise or speak up are retaliated against by their superiors. Unfortunately, there is no real law to ensure the uniform standard being implemented by UCLA in accordance with the 2003 guidelines is actually being followed in other hospitals. The health care profession needs that type of enforceable law to make sure health care providers are not exceeding the maximum allowable hours and putting people's lives at risk.”

This ties in with another article by Trisha Torrey about the lack of hospital autopsies being performed. This is how many hospitals hide poor care and avoid families learning about mistakes doctors are making. Read this article as it points out many of the habits of hospitals to avoid troubles with family lawsuits.