Doctors That Will Not Give You Record Access

Even if physicians think we can be a pain in their backside, we as patients have to wonder what they are trying to conceal when they will not allow us access to medical information about us. Caveat – I have no problem when the patient has mental problems of not allowing them access to their medical records.


However, for the rest of us, come-on doctors, what are you hiding? Yes, many physicians treat us as mental patients in their minds and have entered information in the medical records about us that they would be in the courts for years trying to explain and defend as not being libelous or maliciously defamatory. What causes them to do this?


One answer is because they are human and the medical profession has conditioned them to feel that they are god-like. When we rock the pedestal on which they are perched, they become very upset and since the medical record they maintain about us is the one supposedly safe place, they make some unwarranted statements part of the medical record.


Notice, I have carefully avoided saying who owns the medical records. This had been for the courts to decide and in general, they had favored the doctor. Now under the Patient Protection and Affordable Care Act (ACA), this may be changing. The patient will supposedly have access to the records. I say this cautiously, because several medical professional organizations are working to prevent this from happening. I have a feeling that this is headed for the courts for a final decision. Again I ask – doctor, what are you hiding?


I have been made aware of a work-a-round created in many electronic health record programs which will allow doctors to have their own confidential area. Some physicians are refusing to use this area while others look for it. More physicians are discovering that patients who are educated have a better outlook and desire to improve their health. This often causes a big reduction in medical costs and improved efficiency. The reason for this is that the patient is working for better prevention and when the doctor and patient work together, this often happens.


I would like to continue the doctor-patient discussion, but that will wait for another blog, as another area needs to be included here. This is the problem proactive to participatory patients are having accessing medical information that is obtained from remote patient monitoring. Presently, this is next to impossible for patients. Unless you have a doctor that is very forthcoming, the manufacturer of the device and many physicians will not allow patients to have access to this information. Even those doctors willing to share this information are often prevented from doing so by the device manufacturer. Many doctors that share the information do so at their own risk. So hopefully you as a patient will help guard this when it happens.


For more information from a different perspective, read this by Trisha Torrey. It explains what may happen to very proactive patients when they have doctors that don't like or appreciate patients wanting to learn and be proactive or have knowledge of their chronic condition. Hopefully, under the ACA these doctors will be put out of business permanently and their medical organization greatly weakened.

Problems with A1c and Obtaining Insulin

Before starting this blog, I must state that it is for people with type 2 diabetes only.  What was your latest HbA1c result? If it is like many of the people with type 2, it was probably 8.0% or higher. There are only a few reasons to have an A1c this high and actually an A1c higher that 6.5% should concern you. The only (in my humble opinion) reason to have an A1c this high is if you are very elderly, in poor health, and having difficulty taking your medications when you should.

Unless you have trypanophobia (a fear of injections) or aichmophobia (an intense or morbid fear of sharp or pointed objects), you need to learn about insulin and what it can do for your diabetes management. If you have these fears, consider reading this.

There may be other reasons, like having hypoglycemia too often which may be a good reason to have a higher HbA1c. Other reasons I don't consider as valid for letting your A1c reading become this high. They are:


#1. You have a doctor that will not prescribe insulin. If this happening to you, seriously consider finding another doctor. Your health is worth this. You will need to consider if there are other doctors available in your area. You will need to ask your doctor why he will not prescribe insulin very politely. If your doctor won't talk to you about insulin, then the decision will be difficult if there are no other doctors near you. I have had one person tell me that he had to question the doctor about why he would not prescribe insulin. He explained that he wanted to be on insulin and wanted a doctor that would prescribe insulin. When the doctor would not talk about this, he suggested that they could learn together. The doctor started to answer, but stopped. At that point, he knew he was going to need to drive about 75 miles one way to another doctor, but he asked the doctor for a referral and the doctor did give him a referral for the doctor he had thought he would be seeing.


#2. Your doctor has not given you any education. Most doctors do not have the time except for minimal education. Most doctors do not have access to certified diabetes educators (CDEs) or even registered dietitians (RDs) so this would not be a surprise. Self-education is often the only avenue open to you. This is part of the reason I have been writing blogs about sources for you to read. No. 1 and No. 2.


#3. Your doctor is stacking oral medications and they are not working. You started on one oral medication and then when your A1c did not come down enough or when it started to rise, your doctor added a second medication. When those results deteriorated, a third medication was added. With the side effects of each medication, this could have become intolerable. But you wanted to get your A1c level down. You may have even asked for a stronger medication, but the doctor refused.


#4. Are you not managing your diabetes? I don't like to use accusations, so I will ask some questions. Have you reduced your carbohydrate consumption? Have you been able to test enough to know what the different foods do to your blood glucose levels?


#5. Are you not taking your medications? Do you take them when directed or do you forget occasionally? Do you have a schedule for taking your medications? Have you talked to your pharmacist about what to do if you remember you forgot the previous dose? How often do you forget? For help you might want to read this blog.


#6. Are you able to exercise and what is your routine? When your blood glucose levels are higher than they should be, are your able to exercise for a longer time? What exercises do you do or are you limited in what you can do?


I could continue to list reasons, but this could only serve to discourage you and cause you to stop your self-education. What you need to do is have an honest discussion with your doctor. Do this after you have given a lot of thought whether you wish to stop the complications and manage your diabetes. Unfortunately, only you can make this decision. Yes, you may ask for help if you have someone that can and will assist you, but you will need to ask.


If possible, you need to honestly assess your situation and decide what you are capable of doing, how you can better manage your diabetes, and whether insulin is the medication you need. Some of my blogs that may be of assistance for using insulin include – blog 1, blog 2, blog 3, blog 4, blog 5, and blog 6

Intensive BG Monitoring Is Useful

Granted, I have changed the title from a question to a positive statement. I firmly believe that if the study had been properly set up and too many variables not tracked that should have been accounted for, the results could have been much more positive.  Patients were eligible if they were 35 to 75 years of age, had type 2 diabetes not treated with insulin, and HbA1c levels between 7% and 9%.


Yes, the “experts” said, “They were not convinced the extra cost of SMBG (self-monitoring of blood glucose) was worth the marginal added benefit. Also, this approach may not be generalizable outside of a clinical-trial setting, they said, noting that patients tend to tire of such self-monitoring in the long run.” None of the “experts” participated in the study. The problem with most studies of this type is that no education is given to the participants beyond a minimal amount.


Yes, some are taught more, but many are not given enough practice to have this become a habit. And this is a must to make the desire become important and make a person want to manage their diabetes. No, I do not think that intensive blood glucose monitoring needs to be done long-term, but at diagnosis, the first six months are critical to determine how the different foods or food combinations affect your blood glucose. This is one way to know which foods may need to be eliminated or reduced in the meal plan.


Then over time, you will need to up the testing intensity again when you add new to your meal plan foods, when you are ill, and when you are having problems for which you have no easy answers. What the “experts” do not realize is that by cutting to testing supplies over the years, people are less likely to maintain A1c's below 7.0% and this is the reason many people end up with progressive diabetes. People do need the education and encouragement to test more than twice per day, but testing for most people with type 2 diabetes should not require more than five times per day once a routine has been established.


Yes, there will be days when more testing may be required, and there may be days when less testing may suffice. With education and support, many people should be able to prevent their diabetes from becoming progressive. Yet, the “experts” don't care about the desires of patients and look at diabetes as progressive when it does not need to be. Because of the pronouncements of the “experts”, the insurance companies are happy to increase their profits by limiting the testing supplies for diabetes.


Please read about the study here and make your own analysis.

Dramatic Results When Treatment Tailored for Elderly

See what happens when the elderly are the only group in a study? This proves that the elderly should not be excluded from research studies and that they may be successful in managing their diabetes. This study was done in the United Kingdom, but provides a great example of what is necessary and may be accomplished by the people over the age of 70. Can the feeble minds at our leading research facilities wrap their heads around this study and end the discrimination against the elderly?

All patients were over the age of 70, and were included in the trial because their GP (general practitioner) thought they needed more medication. Oh really, doctor, elderly patients need more medication and it is your job to over medicate them? The findings were stark because those patients who were given the drug were three times more likely to reach their target than those who were not involved in the study, and received standard treatment. But researchers were particularly excited by the result from the placebo group, in which 27 percent met their targets without any medication.

This shows what can happen when great studies are undertaken for the benefit of the elderly. Presently, patients over the age of 70 are treated using a blanket method of aggressively reducing blood glucose levels, but that does little to take their complex needs into account.

Dr. David Strain, from the University of Exeter Medical School, who led the study, said: "People over the age of 70 are more likely to have multiple complications, such as heart disease, as well as type 2 diabetes. Yet perversely, these patients have so far been excluded from clinical trials, precisely because of these complications. It means they are generally treated with a 'one-size-fits-all' approach. We found that simply by individualizing goals and setting realistic targets, then spending time talking to patients rather than aggressively chasing targets resulted in nearly a quarter of patients achieving better glycemic control, without the need for medication."

Dr. Strain said: "This was a small trial, but the results were quite dramatic, and it is the first strong evidence that individualized care can make a huge difference to the lives of older patients with type 2 diabetes. We now need to build on this evidence with further research."

Yes, further research may be required for the dense American researchers to understand what their discrimination is doing to the lives of the elderly that are in essence just being written off and given the one-size-fits-all treatment. It may be even possible to reduce the medical costs and give pride back to the elderly population.

The points that are unclear to me that could be disconcerting are the A1c's at the start of the study and what the individual targets became during the study. If they are above 9.0% and the lower targets were still above 7.5%, then there may be some other concerns about individualizing treatments.

I had written and asked for a copy of the study, but none was forthcoming. This is a shame. I sincerely hope that the USA researchers learn from this study and don't continue to stick their nose in the air. Someone may flatten it for them.

Does Type 2 Diabetes Have Subclasses?

Before getting started on this topic, I must state that these are my opinions only, based on my reading and are no way official opinions. While some people have been alluding to sub groups or subclasses of people with type 2 diabetes, I believe the evidence is mounting for more people to come out in support of this idea. We now know that ethnicity is a factor and I am not sure how to list the young type 2's that have more deadly type of diabetes than children with type 1.

I personally feel that an apples to apples comparison is not totally accurate for those adolescent and young adults with type 2 diabetes, but I could be in error. “The study population was derived from the Royal Prince Alfred Hospital Diabetes Database and focused on individuals diagnosed with diabetes between the ages of 15 and 30 years. Records were matched with the Australian National Death Index to establish mortality outcomes for all subjects until June 2011. Clinical and mortality outcomes in 354 patients with type 2 diabetes (mean age at diagnosis, 25.6 years) were compared primarily with 470 patients with type 1 diabetes with a similar age of onset (mean age at diagnosis, 22.0 years) to minimize the confounding effect of age on outcome; disease duration was 11.6 vs 14.7 years.”

While type 1 diabetes is generally considered a more severe type of diabetes, the results highlight that young people with type 2 diabetes have double the risk of dying when compared to those with type 1 diabetes and after a much shorter duration of having diabetes.

Therefore, I would think this should be considered one subclass of type 2 diabetes. Studies are finally being done to compare how different ethnicities are affected by type 2 diabetes. While much more study is need for those in Africa, they tend to have a lower insulin sensitivity, but seem to compensate by releasing greater amounts of insulin.

Among those of East Asian origin, they have very good insulin sensitivity, but seem to have a harder time releasing insulin when it is needed. This means in the clinical settings, they develop diabetes more easily and do so at a lower BMI. Because East Asians have more difficulty releasing insulin, generally they need to start insulin therapy at an earlier stage of diabetes.

Caucasians fall between the two extremes in both insulin release and insulin sensitivity. Now in addition to the above subclasses there are probably more that have not been studied, such as the Eskimos and American Indians, but until there are studies verifying this, we can only guess. I would even hazard a guess that the African Americans could also be a subclass separate in part from those from Africa itself.

I also believe that even among Americans, there could be several subclasses of type 2 because we have thin type 2's and obese type 2's. We have many people that are able to manage their diabetes with nutrition and exercise and others that have a difficult time even on low levels of medication.

Will we have any discussion within the ADA about this? I highly doubt this and would be more inclined to believe that with the current attitude of physicians wanting cut and died answers, that it will require a much stronger voice than mine to give them a wake up call. Plus, with their conflicts of interest, unless some of their corporate sponsors raise the question, this will never see the light of day in the American Diabetes Association discussions.

Diabetes Management under a Physician Shortage

In the next few years, what are we, as diabetes patients going to be able to do? There is going to be a physician shortage which we have been hearing about from doctors and their professional organizations. Even teaching professors are talking about this and a few patients. How long are we going to be forced to wait between appointments and think about how much time the doctor spends with you now. This can only be worse and your questions may not even be answered.

Ann Bartlett, who writes at Health Central dot com has an excellent blog on July 17 that deserves your attention. She is a type 1 and in this blog writes for all people with diabetes. Because of what she writes about the numbers of practicing endocrinologists, I will disagree with her statement that everyone should see an endocrinologist at least once a year. Some people will do very well in the early stages of diabetes, especially those with type 2 diabetes that do not need to lose weight or that are able to manage their diabetes with nutrition and exercise. Many people do probably need to lose some weight and are capable of doing so.

Where I do agree that people with type 2 needing to see an endocrinologist are those people with complex diabetes and often comorbidities requiring more attention than a primary care physician (PCP) has time to devote to the patient. Many of these patients are in the need of insulin therapy, but the PCP has not kept abreast of the knowledge required and so won't prescribe insulin. Instead, he has stacked one oral medication on top of another and in some unusual cases, the patients are taking up to four different oral medications. Too many and most of the time they still are having trouble maintaining good A1c's.

Ann is right when she says, “Third-party insurance providers, the big bad boy of this debate, are finally hearing the bell toll, and need to start offering fair reimbursement to doctors for services rendered.” Unfortunately, with the Centers for Medicare and Medicaid Services not expanding their payment to PCPs and endocrinologists, the rest of the insurance industry will not step forward and help, as they want to grow their profit margin. So our doctors are continually squeezed in the pocketbooks and wallets.

As a result, I will continue to advocate for state medical boards to loosen their strangle hold on nurse practitioners and physician assistants and allow them to operate with more independence. This blog has a map showing the states that are allowing NPs the freedom to practice medicine without supervision. Only 18 states are presently allowing this. It is a shame that the same information is not available for PAs. My endocrinologist has at least two NPs on his staff and I see one of them. I also see a NP at my Veterans Affairs (VA) appointments and I am very happy with both.

The American Association of Diabetes Educators (AADE) could really help with education, but at present, they are reluctant to do so. I have been on their case for some time now and all it has gotten me is derogatory emails. Even my CDE cousin will not talk to me anymore because she knows I am serious.

The AADE is not adding CDEs at a rate needed to serve patients adequately. Therefore, the AADE should be required to open up a classification or group for peer-to-peer workers and peer mentors, give them some training and classes, and let them move out into the diabetes community and help people with all types of diabetes. Then they should provide continuing education for them. This is supported by several studies where peer-to-peer workers have helped other type 2 patients lower their A1c's. This would work for type 2 helping type 2's and type 1 helping type 1's.

Even the ADA and AADE Task Force that developed the Diabetes Self Management Educations (DSME) and the Diabetes Self Management Support (DSMS) National Standards included lay people and peer workers in the area requiring more research, yet the AADE has chosen to ignore this. Oh, yes, they will take credit for the CDC programs that they participate in for training peer workers, but will they open a designation for them and continue to assist them with more education – no. They can't wait to be separate from them and let them go their way. This is not the correct attitude to my way of thinking, especially with the shortage of certified diabetes educators.

Fortunately, some doctors in rural areas and some not so rural areas are seeing the need for peer-to-peer workers and peer mentors and having them educated. Then they are returning to help their doctor and other doctors in their areas. One doctor that I started to work with in Montana, now has three peer mentors in three chronic diseases doing what needed to be done for education of his patients.

Another area that needs to be opened up is telemedicine where doctors could practice across state borders and others could assist people in doctor sparse regions of the country.

What To Consider in a Blood Glucose Meter

Are you confused by all the hype about blood glucose meters? You should be and there is a lot of hype. Every writer approaches this from a different perspective and promotes what they feel is best. There are some general guidelines that it is often wise to follow. I want it understood that I am not promoting any meter over another, but I do urge you to consider the points I lay out and do not be afraid to talk to pharmacists and others that may assist you and provide guidance.

#1. What will your medical insurance cover. This is often what will determine the type of meter that you will chose because the cost of test strips can be prohibitive and you may need to consider this first.

#2. If you do not have insurance, then economic considerations may be the most important. There are economical meters and test strips available that are reliable and that do not have all the bells and whistles that many people think they need and never use.

#3. If you are one of the fortunate people with few economic barriers and chose to go outside your insurance, then you have a wide range of considerations in making a choice.

Once you have determined which of the above applies to you, now the choices become even more difficult. They may be very limited in selection or you may have a wide range to choose from. This will depend on your insurance company and there are some real issues under Medicare which have yet to be resolved. Unless the courts act soon, many on Medicare may be caught with no supplies.

TV ads are very deceptive and often misleading, yet many people become suckered in and spend the money. Then when they receive the meter and test strips, they realize that they have been had, but there is seldom a way to return them. These companies will be very evasive in an attempt to make you keep what you ordered.

Many of the TV ads advocate for alternate site testing and this is okay if you seldom have a hypoglycemic episode and are fairly consistent in your readings from your fingertips. You need to know that the reading you receive from an alternate testing site is an indication from 15 to 25 minutes ago depending on the area used for alternate testing. Also, there are very few alternate test sites that are totally pain free. I urge anyone on insulin not to consider alternate site testing because if you are having a low, you need the now readings of your fingertips.

Many people were enticed into the talking meters and then wondered what to do when they were out in public. I have heard them in restaurants and other places and people just could not muffle the sound. So if you are a person desiring secrecy, forget these, as secrecy is next to impossible.

If you have a computer, you may wish to consider a meter that will upload to your computer. Normally the cost is for software and a cable from a USB port to the meter.

These two blogs seem to think you have all the choice and can purchase any meter which may not be the case.

There is a growing concern about the test strip accuracy and I strongly urge people to read two blogs of many (this one by Ann Bartlett and this one on Diabetesmine) about the declining accuracy and that apparently no one is doing anything about it. I can only feel fortunate that I have one of the top two meters listed in several reports – meaning that the tests strips are considered the most accurate.

Don't Get Caught in This Hospital Greed Trap

In April, I was in the hospital because they could not determine whether I was suffering from heart problems or severe indigestion. Shortly after being put in a room, I received a paper to sign saying that I was admitted as an outpatient and not as an in-patient. Since I knew what this meant, I asked to be discharged.

Guess what they told me? They would not discharge me as I needed to remain for observation. I requested a second time and refused to sign the paper because I knew that the total bill would become mine as Medicare and my supplement insurance would not cover anything but some of the tests. I knew that once the diagnosis was for severe indigestion that all the heart tests were going to be charged to me as well and they kept doing them even though I tried to refuse them. Surprising what some sedatives can do to your will to prevent the continual testing.

They even continued to push the paper for me to sign in front of me which I somehow was able to keep from signing. Even during discharge they tried to slip it in, but I still did not sign it. Now I have the Medicare statement showing what they did and did not pay for and the hospital and I will continue to argue about the bill. Medicare did cover the first blood work only to show that I had no enzymes from a heart attack and the first EKG showing no heart irregularities, but they paid for no more of the tests the hospital insisted I needed.

Medicare did pay for the medications for the severe indigestion for the first day only and then stopped that since I should have been switched to over the counter medications. This leaves me with a substantial medical bill which I will not be able to pay and they wonder why I wanted to be discharged. Next time I will discharge myself, if I even allow myself to be admitted. Yes, I will do this “against medical advice” and think nothing about it. I am tired of the hospital greed.

I regret now that I even went to the emergency room. Yes, I bypassed the ambulance services because of my experiences with them before, where I was forced to pay for their services because they incorrectly submitted the bill to my insurance. Plus, the ambulance is required by Medicare to take me to the local hospital which I refuse to let happen.

I was fortunate that my diabetes supplies and medications were not taken away from me and I was able to maintain reasonable control of my diabetes against doctors orders. He wanted my blood glucose levels at 180 mg/dl minimum, and I was constantly at 120 mg/dl to 145 mg/dl. When he finally figured out what was happening, I was being discharged. Prior to that, the nurses only knew that I was refusing to eat the hospital food except for some sugar free jello. The diabetic meals were carb loaded and beyond what I could handle. Even the tea was loaded with sugar and I could taste it and refused to drink it. The one nurse even poured a little in a small cup, spit it out, and had to agree with me.

Well, these are lessons learned and not to be repeated.