Doctors and New Technologies – Part 2

Part 2 of 2 Parts

This part covers the wished for options and information about medical devices.

What I’d like to see on the websites This is what the doctor would like. While I can agree with the list as a valuable list, there should not be a segregation unless the device is for mainly clinicians. If the device is primarily for patients and caregivers, then everything should be applicable to the clinician, patient, and caregiver. I will go one step farther by saying that often the website for most devices are for sales only and of little or no value for clinicians, patients, or caregivers. Most are all hype and have little usable information and then we know that the device is of little value. The more hype, the less value the device has.

Have a section formatted for clinicians in particular. If the device is primarily for clinicians, then I agree. If the device is for all, then the website should get rid of the glitz and hype, and cough up valuable information to let the customers know what the product can do in the real world, not the hyped world. Again, I have found that the more hype, the less value there is for the usefulness of the device.

Have a “how it works” section with screenshots and concise text. While many people seem to love videos, too often, they miss the points and the videos leave us wondering about why all the hype. And, this I mean sincerely. We are consumers and want information about a device, not glitz and hype. Whether the person viewing the site is a clinician, patient, or caregiver, we want to know what the device does for the patient, and what other devices it may communicate with to make it more useful. Videos are great for entertainment, but not so great for information. If you are a visual learner, great, but don't force non-visual learners to constantly replay a video. This will only drive them to abandon the website and your product.

Provide a downloadable brochure for patients/families and another for clinicians. Now if manufacturers want to make separate downloadable brochures for clinicians and one for patients/caregivers, I will not object as this could help both. I do strongly agree with the doctor on this point, brochures are easier to read and mark up than many PDF files. Both may be easily forwarded, but the brochure will be the easiest for the patient to understand.

Include information regarding the relevant evidence-base supporting use of the product. Yes, this would be nice for both the clinician and patients. The more hype we have to read the less likely we are to consider the device.

Include information on how valid/accurate the data collection is compared to conventional clinical practice. This would be appropriate for most devices, especially since the specifications will probably be not as restrictive as devices that are used in the proper way in a lab setting. Most clinicians will need to realize this to understand that the devices are not for use in a lab, but out in the real world by real patients trying to help themselves. Most websites are not properly set up clearly to explain what clinicians are seeking and often not what patients are seeking. Often there is so much “feel good” hype and glitz that patients and clinicians can find little useful information. This will lead both to look elsewhere and maybe overlook a device that could be very useful. When will manufacturers learn?

Offer a free 30-day trial. This is purely a sales pitch and why a doctor would suggest this is hard to understand. The reason many companies offer this is because they know that if people order something, they are seldom going to return it unless it is so bad that people are angry with the product. Even then some people will not return the product and companies are counting on this and know the sale has been made.

Summarize how the product is different or better than similar available products.

This is also a sales tactic and we see this done when a company feels they have a superior product, but be careful, as often this is done to hide weaknesses as many are familiar with in software products.

Summing it up. The doctor has in general done her homework and offers good advice to manufacturers. Like many products, medical devices will be one product that doctors will often be called on to give an opinion about. Some doctors are blogging about devices and some patients are doing this. Should we rely on the information? This is difficult to answer, as not everyone is honest about relationships they may have with a manufacturer.

Some doctors are very reputable and will clearly state if they have any relationship with a manufacturer. In general these devices can be relied upon. Most patients are also very clear that they have a relationship with a manufacturer or if they are speaking from experience with the device. If they are actual users speaking from experience, generally these reviews can be relied on.

The weakness is that there is seldom a database of device reviews and everyone is not privy to the reviews that have been made. As much as we want to have information we can rely on, I seriously doubt this is a priority for manufacturers as most are only concerned about sales and will continue to put out all the hype they can to “convince” consumers their device is what they need.

Maybe the doctor was engaging in some wishful thinking, but until enough people speak up, we will not have reliable information for most devices. Until manufacturers understand what may drive sales, we will continue to have hype, glitz, and very little information of value. If people, doctors, patients, caregivers, and others will refuse to promote medical devices from manufacturers that have poor glitzy websites and refuse to give the information needed by all concerned, then we have lost and hype will continue in device promotions.

Yes, I have been overly expressive about hype and glitz, but from experience, this is the biggest turn off for me about the few devices I have investigated. Websites that say “This is a must have for your peace of mind,” or similar statements have made me leave the website and look elsewhere for something similar. My peace of mind is knowing that this is probably the poorest product available.

Doctors and New Technologies – Part 1

Part 1 of 2 Parts

This doctor has a lot to say about new technologies, some good and some bad. I agree with her for most of the statements and I must question some of her qualifiers. She is right that deciding if a new technology will help a patient or a patient's caregiver is important. Often this is as difficult for a physician as it is for the patient or caregiver. Since this doctor is working with the elderly, her decisions are compounded by what the patient or caregiver may be capable of managing.

One question that many people forget to ask or consider is, does this device communicate with other devices and if not, does this make the device less of a help. Too often, our high-tech devices are proprietary to the extreme and therefore useless except in very narrow limits. Until ethics can become part of doing business, most products available today are more of a hindrance because most data has to be transferred manually between devices. When time is important, devices that don't communicate are a fraud on the buying public to say nothing about medical care.

Here are her questions and my comments as a patient.

Does it help me do something I’m already trying to do for clinical reasons?

This is a question every doctor must ask and every patient should want to know. For the patient or caregiver, they also need to ask if it will meet their needs. Also, what does the device handle and is it a tool that would be useful.

What evidence is there that using it will improve the health and well being of an older adult (or of a caregiver)? This is the one question that this doctor fails, as she uses a meta-analysis study to say there is no clear benefit for non-insulin people with type 2 diabetes to regularly self-monitor blood glucose. I have blogged about rigged studies here and do not doubt that many of the studies in the USA were also constructed to give the desired results. Then in my email of Feb 5, 2013, I received my newsletter from The Behavioral Diabetes Institute, which has this link to information in Diabetes Care on the ADA website. The link is to a file that is a PDF and you will need to use Adobe Reader or a PDF compatible reader to download it. It has seven pages and is good reading with the ADA “experts” for the first three pages and the rest is written by Dr. William H. Polonsky and Dr. Lawrence Fisher. They are a voice of reason about self-monitoring of blood glucose (SMBG) and how important it is to all people with diabetes. Then they cover people with type 2 diabetes not on insulin as they are the ones not given the education and training in SMBG and could really benefit.

How does the data gathering compare to the gold standard? Talk about being vague, gold standard is what? When medical people refer to this, there are too many meanings that could be applied and this leaves all types of variables open for speculation. I sincerely wish they would use lay-speak. I do doubt that many devices actually meet gold standards since some may not have gone through FDA approval. If they have, then they should be more reliable, but maybe not reliable enough to meet a gold standard. Also, we need to remember that specifications for some devices will be more liberal simply because the manufacturer knows that the device may not be used under ideal conditions when used by patients or caregivers.

How exactly does it work? Come on doctor, they are not going to give away these secrets. They are only going to disclose what the device is made to do and if it communicates with other devices and which ones. If we are able to read through all the hype, we may discover what the outcome of its use is, but don't expect much until you get the device and instruction book in hand. As a doctor, you have to expect little information about clinical use, unless it is for clinical use. Most of the devices are not made for doctor use, but for patient use and many manufacturers could care less about what the doctors find useful. In fact, they might sell more devices if they did care about what doctors thought of the device.

How easy is it to use? Now this would be a good place to have a doctor's opinion and to know if it is easy to use by a wide range of patients including the elderly. For the elderly, ease of use is a must because often the elderly may have limited vision and or lack of dexterity in their hands.

How easy is it to try? This can be the key to many medical devices. Does it require a large financial outlay, or cost of training, as this could very easily send it to the back of the list of devices finding unfavorable recommendations and interest.

How cost-effective is using this technology? Here the doctor really nails it when she says, “Sometimes we have simpler and cheaper ways to get the job done almost as well.” Some devices will be overly complicated in what they can accomplish when a simpler method may work more effectively.

Can this technology provide multiple services to the patient? Many patients may have more than one medical condition. This is especially true among the elderly and knowing whether a device has only one function or multiple areas that it covers, may make it more desirable than a single function device. Here is where one device may have a clear advantage by being able to export or import information to or from another device.

Does this technology work well for someone who has lots of medical complexity? This is where a medical device will shine, or show that it is useless. It must be operable by patients having multiple medical problems. If it is too complicated, it will not be worth the money, unless it is operated by a caregiver that is with the patient every day.

While this may not be an exhaustive list of qualifications for a medical device, it is a great start and shows that the doctor has a good understanding of her patients. This will be a must for any doctor giving an opinion about medical devices. This should also be a strong consideration for patients and caregivers and serve as a way to avoid being misled by the inevitable hype on many websites.

Key Diabetes Issues Not Being Addressed

When I read the title of this article, I had to clap and hope that I was reading it correctly and that the title was not all hype. The article did not disappoint me. They did not come out and state (the authors are being polite) that many studies were practicing age discrimination, but they did state, “despite the fact that nearly 20% of adults worldwide aged 65 years and over have diabetes, less than 1% of trials specifically targeted this age group, while 31% actually excluded patients over 65 years and almost all excluded those over 75 years.” Also only a small percentage of the studies included children 18 years and younger.

Of the studies they analyzed, just one in ten studied prevention or behavioral therapies and two thirds focused on drug therapy. The research has been published in Diabetologia, the journal of the European Association for the Study of Diabetes (EASD). The research was done by Dr Jennifer Green, Duke University Medical Center, Durham, NC, USA, and colleagues. Why they had to publish outside the USA would be speculation on my part, but does raise some interesting thoughts.

The one shortcoming I can see is that they emphasize some trials, but never account for the total number of the trials or 100%. In one method they account for two thirds or about 67% and one in ten or 10% for a total of about 77% and then in another method they list 75% of the studies as being therapeutic and 10% as preventive or 85%. This leaves 15% to 23% of the trials unaccounted for which is a major fault.

It is interesting that they mention that most of the studies were small to medium size. The statement that most were designed to enroll 500 or less participants (91%) is just outrageous for developing studies of clinical importance. Then the fact that many of the studies had a mean/median time to completion of 1.8/1.4 years also makes the studies of little clinical value. It is like they were looking for specific results and running the trials for longer periods would have exposed undesired results. This last statement is my thoughts.

Since the trials were taken from those registered with ClinicalTrials dot gov we must be concerned about some of the discussion. This statement does come into the discussion and we need to raise the validity concern, “"Only a tiny proportion of the trials analyzed--1.4%--listed primary outcomes including mortality or clinically significant cardiovascular complications," says Dr Green. " Furthermore, distribution of registered trials by country does not reliably correlate with diabetes prevalence."”

ClinicalTrials dot gov does not include 100% of trials around the world, but does include many when a pharmaceutical industry wants product approval from the Food and Drug Administration and wants the test results available to the FDA.

Even though this type of study is needed, I do feel that more material should have been evaluated and disclosed. I would like to see a study like this for USA studies only and see how skewed the results are. I am very concerned about the age discrimination in most trials. Not only because they discriminate once you reach the age of 65, but they also discriminate against those under the age of 18.

CDE's Ignore Patients with Depression

I had wondered when I would receive the next email from someone dealing with depression and being ignored by a CDE. This time it was two emails about four hours apart. Both had been referred to a CDE and did need assistance for diabetes. One is a type 1 and the other a type 2. Both had been diagnosed since the beginning of the new year and both were not receiving family or for one even spousal support.

The person with type 1 (19 years of age) was rejected by his family and they did not want him around because there was no history of diabetes and therefore he could not have diabetes. In essence, his family had turned their back on him. He was not welcome in their home and they did not want contact from him until he grew up and admitted he did not have diabetes. Is it any wonder he had depression?

He said in his email that they were almost done with his CDE appointment, but he wanted some information and help with his depression. He stated next that it seemed to him that the CDE could not gather up her materials fast enough and say on her way out the door, that she was late for another appointment. He wanted to know what it was about diabetes that drove people away from him. He knew he had depression because of the parent's rejection and how he was feeling around people. I was fortunate this time as one phone call was necessary and he had an appointment with someone that knew what to do for him. Three weeks later, he sent another email saying that he was happy with the appointment and felt that I had found him the right person. He said he would have several more appointments, but wanted to thank me.

The second person is in his late 40's and is wondering what to do. He had an appointment with a CDE and when she walked in, she asked how he was. He said he answered, depressed, and he said she turned around and left the room. He said he waited for 10 minutes and then walked to the reception area. He was told that this CDE would not see patients with depression. Now he has lost his family and has not been able to find help.

I asked him in a return email what had happened. He said that his wife had been present when he received the diagnosis and over the next month, the situation went from bad to worse. His teenagers rejected him and were asking him when he would have his legs cut off and they refused to change their eating habits. His wife would not change her cooking habits and the highly processed foods and would not prepare separate meals. He said he started cooking again and this helped for a while until the teenagers kept bringing home more horror stories about what happened to people with diabetes. Then his wife said she would not take care of him when things like this happened. He said he came home from work in March and they had moved out and two weeks later, he received divorce papers at work.

He stated that he had tried three different places to get counseling, but could not get an appointment at any of them. I asked if he had talked to his doctor or even to anyone in his church. He admitted that he had not and would talk to his doctor the next day. The next day I received an email saying his doctor had gotten him an appointment with someone and he would let me know if he was being helped. I am still waiting, but the appointment won't happen until near the end of April.

What surprises me is the lack of support the two received and the total rejection by both families. There may have been unknown facts with the second individual, but I have known other divorces where diabetes was the cause and one or the other spouse was not going to help with future health issues. Sad things can happen.

Hyperglycemia – No Pain, No Harm Done – Right?

My email inbox had a very interesting question recently. The person said, “If I don't feel sick, how will high blood sugars hurt me?” I have answered the question in several emails, but felt the topic was important for a blog of the experiences this person went through. Too many doctors do not explain high blood glucose and the damage it will cause over time. They most generally just tell people to watch what they eat and leave it at that. This may have been what happened to this person as she was recently diagnosed with type 2 diabetes. Metformin was a good start, but she gave no other information.

A query about blood glucose readings yielded a question mark and her dosage was only 500 mg at the evening meal. I was afraid I had been too blunt about having another visit with her doctor and asking for a blood glucose meter, test strips, and the rest of the equipment, as I did not hear from her for another two weeks. She said the doctor had told her not to be using that and she did not need to know what anything was and that he would tell her everything from her quarterly tests (I assumed A1c from that statement, but I will disclose the actual test later) and would increase her medications if needed. By this time, she was complaining about the problems metformin was causing. She was being sick almost every day.

My immediate email back to her was which type of metformin was she taking and when was she taking it? It was the metformin tablet and not the extended release. The doctor has told her to take it one hour before the evening meal and the pharmacist had said with her evening meal. She had mentioned this to the doctor and he had really chewed her out for not following his instructions. I suggested that she have a talk with the pharmacist and explain what was happening and what the doctor had said.

She had gone to the pharmacy, but passed out on arrival and was rushed to a hospital where she was given tests and a recheck for diabetes. Yes, her reading was over 600 mg/dl and she met with the hospital diabetes educator. The CDE had given her a blood glucose meter and showed her how to use it. She was on insulin while in the hospital and then given a prescription for metformin XR (extended release) and told to find another doctor after discussing what had happened. She also had prescriptions for the test strips and lancets, alcohol pads, and a few other non-diabetes medications.

As soon as she was released from the hospital, she went back to the pharmacy and they were happy to see her. The pharmacist suggested two other doctors and said this was a wise move on her part. The pharmacist was happy to see the prescriptions and said that the metformin XR could be taken most anytime, but the hospital had wisely recommended at meal time. Her dose now was 1500 mg at breakfast, and 1000 mg with dinner.

What her email said then really makes me happy that she has this pharmacist. This pharmacist discussed and explained each medication in terms she could understand and then took a highlighter pen and highlighted the important parts of the instructions. Then when it came to the diabetes supplies, the pharmacist asked if she would afford xxx dollars for the strips. She was told yes and the pharmacist said then she would put five containers in her bag and explained that if the insurance did not cover them, she would be billed. The pharmacist then took time to tell her about testing, approximately when to test pre-meal, post-meal, and before bed time. Then she said it was not a bad idea to have one box of alcohol pads around, but not to use them on the fingers for testing, but instead to wash her hands with warm water and soap and dry thoroughly. Not to handle the test strips with wet hands was her next instruction and then she explained what the alcohol would do to her fingers in the winter time. Bravo pharmacist!!!

She had called the first doctor, but he was not taking new patients at this time, but the second doctor was and she had a next day appointment. She took all her prescriptions and meter with her and the telephone number for the pharmacist. The nurse asked for her meter so that it could be downloaded even if it was only a few results. She was surprised when she was called for a blood draw, but did not say anything. After the nurse had gathered all her information and given her meter back, she said she got a big shock when a woman doctor entered and then she realized that her doctor was a niece that she did not even know was in the area. The last communication was when she was in Denver, Co.

The email said that the doctor spent about an hour with her discussing testing and nutrition, and what foods she should avoid and lots of good information. Her A1c was still high as the doctor had expected. Turns out the previous doctor only used the oral glucose tolerance test for everything. I think he is behind the times. She is to bring her meter in for downloading every fourth Monday of the month so the doctor could review it. She is to have another appointment on the next time she brings in her meter. Future appointments will depend on what the meter readings show for diabetes management. She even said the new doctor had discussed hypoglycemia and hyperglycemia and given her a few sheets of facts so she did not need my answer any longer. She said she was happy that I asked so many questions as this had given her the confidence when she was talking to the CDE and to understand how important the information was that she was receiving.

After this, she said the communication from the previous doctor was very unpleasant and between the new doctor and her, they asked the local sheriff if he would pick up her records. For a small fee, he would, but even the deputy reported he was happy that both had provided letters of authorization for the transfer. Her new doctor even had to take time to unseal the box and confirm to the deputy that they were her records and that the box had been received unopened. She would not say that the records were complete, just that she had received what was in the package. She then stated the doctor had sent her a bill for the time and packaging, which she talked over with her new doctor. Both felt it was unethical, but agreed that it should be paid since charges were being filed by other patients for malpractice and this could be added to the charges. She concluded by saying that her new doctor had found several areas of problems and she is to go in tomorrow to review whether these would be added to the complaints since queries had been sent to all doctors receiving patients of his.  She is very happy with her niece as her doctor. 

When Patients Can Obtain Their Own EKG

I can appreciate good doctor blogs from time to time. As I said in this blog, these devices are coming. I was somewhat surprised by this one, but we will see more of them in the year ahead. This doctor does what is expected by saying he does not have time to read every EKG presented. That is as it should be under the current medical system, but when the Affordable Care Act becomes the system, and pay is based on cost reductions and penalties for failure to reduce costs, then doctors will have no choice but to consider patient used devices.

Remote patient monitoring (RPM) devices will apparently be coming on the market in a variety of ways (prescribed and over the counter). For those devices that are prescribed, doctors and hospitals would be wise to have one of these in stock and test the reliability for themselves. Then rather than downplaying the FDA approval, they need to discern whether they are as bad as envisioned, or if they are indeed reliable as the Food and Drug Administration has determined. This will mean that the specifications for the patient device may not be a tight as the instrument used by trained personnel in their labs, but it will give some indications of problems needing further medical attention or not.

Doctors and hospitals may also want to have over the counter devices on hand to test them as well. Doctors and hospitals that do not, will be opening themselves to much criticism when they dismiss these as just another device that makes their jobs more difficult. Yes, we know the hypochondriacs will insist on having these devices, but people with the disease or illness will also use them often to their advantage. This will be much like the blood glucose meters people with diabetes use now. Some learn how to use them properly and to interpret the readings, while others just think they are doing this for the benefit of their doctor, which is wrong.

Is the doctor right to be concerned about the legal aspects of prescribing a remote-monitoring device? He is probably right to be concerned, but eventually, our medical system is going to need to realize that devices approved by the FDA for patient use must be excluded from frivolous lawsuits against doctors. This will be especially true when remote patient monitoring becomes required under the Affordable Care Act. Yes, even then there will be people that purchase the wrong device and sue because it malfunctioned for them. The get rich quick schemes people think up will continue until they are no longer alive and then another person will take up the scheme.

Image courtesy of maximintegrated.com

Do I expect to see many more devices for patient monitoring being blogged about? Yes, some will be balanced and concerned like this doctor, but many will be ranted about and have little value for the consuming public.

Does Your Doctor Care If You CAM?

Maybe your doctor will not care if you are using complementary and alternative medicine (CAM), but you should. Not informing your doctor can cause health threatening and even life threatening situations if you keep this a secret. There are too many cases of patients saying that these medications are natural and therefore my doctor has no need to know, and they end up in the hospital or dead. Family members then are left to wonder what happened. Of course, they will blame the doctor, but this is when an autopsy can uncover the real cause.

If patients and doctors both used communication, most of these problems could be avoided and everyone could be in a better state of health. Many times doctors will just sarcastically dismiss CAM or tell the patient not to be taking vitamins, herbal medications, or homeopathic products. It is the wise doctor that will take the name of the medication and look them up and maybe learn something, but most doctors are against CAM because they were not taught about it in medical school and therefore it holds no value.

I am surprised by this doctor actually blogging about her experience, but this must be an above average (and I mean way above the norm) doctor. Claire McCarthy, MD is a primary care physician and the medical director of Boston Children’s Hospital’s Martha Eliot Health Center.

She states that in a study, researchers in Canada found that 64.5 percent of children were using some form of CAM, but more than a third did not tell their doctor. She also says that in the general population about 75 percent of patients using CAM don't make this known to their doctors. She cites three reasons for this secrecy – patients are afraid their doctors won't be happy; patients don't think their doctor needs to know, and the doctor did not ask.

I agree with her assessment that safety should always be first and foremost. Doctors will not know whether they are being safe in prescribing a medication without knowing everything the patient is taking. Medications can have interactions and not always good interactions. Therefore, it is imperative that patients communicate all medications and CAM being taken. Not all CAM physicians are cautious when giving out herbal and homeopathic medicines and can cause adverse drug interactions unintentionally.

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.” This is a doctor that has her patient’s safety where it should be – first.

In her blog, she even lists the National Center for Complementary and Alternative Medicine (NCCAM) so that people can explore the site. She blogs here and here and is interesting to read for parents with small children.

More Americans Are Managing Diabetes, Oh Really?

The introduction to this article is not a good indicator of what is happening and it should not garner the readership it is receiving. It should not make people with diabetes feel confident either. The title is very misleading as it only mentions diabetes when it should also mention the three measures or health issues they were discussing. They are talking about blood glucose, blood pressure, and cholesterol levels.

All three of the sources I found actually mislabeled the article. Two said diabetes and the third source – Medscape – listed it as diabetes risk factor. I fail to see how diabetes risk factor is involved when a person already has diabetes. Granted using the term diabetes probably brings more readers like it did me, but this is promoting the wrong assumption about the article and they don't mention the three issues until the second paragraph.

Yes, we all need to be concerned about the three issues as they are interrelated and one can affect the other two to a point. However, what bothers me is that they don't give this interrelation, but they say that two decades, yes, two decades ago, the rate of people with any type to diabetes meeting or exceeding the three measures of good diabetes management was only two percent. Now 20 years later the number has risen to only 19 percent. Shame on the ADA and the rest of the medical establishment for this lack of progress.

They then claim this is a huge improvement and don't even give the numbers of people with diabetes in 1988 and the number of people in 2010. The begs the question of how are they relating the numbers to claim this is a huge improvement. Dr. Joel Zonszein, director of the Clinical Diabetes Center at Montefiore Medical Center in New York City, not participating in the study expresses my feelings. He says that with the increased awareness of diabetes and many newer medications, it is disappointing that only 19 percent meet all three measures.

Zonszein also states something that is upsetting for many - 100 percent of people with diabetes should be on statins - because only 50 percent were on statins. He also said that the 50 percent of the people not having the recommended levels of blood pressure should be on drugs for that. That is right – he wants to shove pills at people rather than see if other means might help first – typical medical response.

Then as if rubbing salt into the wound the article states that is it important to keep these measures as close to the “recommended” goals as possible. The article says this will avoid serious complications like heart disease, kidney failure, and vision problems. They quote of the ADA recommendation for A1c as being 7.0 percent as if this will prevent complications. I'm sorry to say that this may only slow the rate complications and allow diabetes to progress, but this is not a goal. We want to stop complications and prevent progression. Even though the recommendation by the American Association of Clinical Endocrinologists (AACE) of 6.5 percent is not ideal, but much better even for the elderly.

Even though Zonszein is abrupt and seems to lack compassion in his statements, he does raise a few good points. He states that young people developing type 2 diabetes seem to have a particularly aggressive form of the disease. They seem to respond less to insulin and are more insulin resistant. He does state that education is the key for all people with diabetes. Where he gets this is a puzzle. He says that presently people often don't get education until late in the disease. This may have been partially true two decades ago, but today with the internet; more people are getting education earlier. Whether they apply the education is the question.

Fortunately, with the internet, his next point is where many people draw the line. He says that people need the education to know what is going on so that you will take the medications. He claims that when you are not feeling sick, it is difficult to take the pills. He may be partially correct, but young people of today use the internet to look up the different “pills” and find the side effects and purpose of medications.

I agree with Zonszein that this paper is an alarm, but only because our medical community is doing so little to educate people and bring diabetes under better management.