|Do You Have a Good Doctor? |
There is one often overlooked factor that can save you or someone you love from a future filled with amputations, failing vision, and dialysis: a family doctor who keeps up-to-date on diabetes treatment.
Not all doctors do. In fact, quite a few doctors out there got their training in diabetes care in medical school decades ago, and the only "diabetes education" they've gotten since then has been provided by the drug companies. Drug company "education" is nothing more than promotion for whatever is the newest, most expensive drug available for treating diabetes--with the side effects unmentioned or dismissed as insignificant.
Even those doctors who do attempt to keep up with the latest in diabetes treatments may do so by reading newsletters that summarize the most publicized recent research findings. But these, too, focus almost entirely on new drugs and often just summarize drug company press releases.
That is why a major part of your diabetes self-care should include finding a doctor who will become a partner, not an obstacle, in your quest for normal health.
While this whole site contains a lot of information that can help you assess the quality of the treatment you are getting what I've done here is put together a list of questions you can use to evaluate the care you are getting from the medical professionals you are paying for your care.
- Does your doctor support you in your desire to attain normal blood sugars?
A major warning sign that a doctor's knowledge of diabetes is out of date is the doctor who dismisses your concern about an abnormal blood sugar test because it isn't, in his mind, abnormal enough.
If your fasting blood sugar is over 110 mg/dl, or your post meal blood sugars are routinely going over 140 mg/dl at 2 hours, and your doctor tells you that this is normal or nothing to worry about, he is making it clear he is not aware of what mainstream medical practitioners now know about safe blood sugars. The same is true if your A1c is over 6.5% and your doctor tells you that you are fine.
A doctor who considers elevated blood sugars "nothing to worry about" is likely to put roadblocks in the way of your getting better control or he may lull you into a false sense of security.
Do you really want to have to wait until you've lost feeling in your toes, or had your first retinal hemorrhage, or your first test showing protein in your urine to have your doctor start taking your blood sugar seriously?
- Does your doctor order appropriate tests?
If you have not been diagnosed with diabetes, but your parents or siblings have diabetes, or if you have had gestational diabetes, or if you have had a random blood test that showed a high blood sugar level (one over 160 mg/dl) that suggests you may have diabetes or pre-diabetes your doctor should order a glucose tolerance test to see what is going on. The ADA now recommends this test for people with a strong risk of diabetes. If your doctor believes that the fasting plasma glucose test, alone, or an A1c test, is all you need for screening purposes, he is out of date.
If you have been diagnosed with diabetes, your doctor should offer you an A1c test at least two times a year and discuss the test results with you. If your result is over 6.5% he should work with you to get your A1c under the AACE recommended 6.5% level, and if you prod him, to under 6%. He should also test your microalbumin, which is a measure of kidney health.
If you are on medications, your doctor should also give you liver enzyme tests from time to time, to make sure that you aren't being injured by the drugs you are taking. If you are on Metformin, you should have your B-12 levels checked every few years.
Other good signs are if your doctor tests your pulses in your ankles to check your circulation and uses a filament or tuning fork to test the nerves in your feet. You should be referred for an eye examination done by an ophthalmologist, if possible, not by an optometrist. If there are findings suggestive of early diabetic complications on any of these tests, your doctor should urge you to lower your blood sugars and provide the appropriate drugs to help you do this.
- Does Your Doctor Prescribe Drugs Appropriately
Currently practice recommendations published by the ultra-conservative American Diabetes Association suggest that Metformin should be the first drug that doctors prescribe to a patient for diabetes.
Competent doctors should also know that the ER (extended release) form of Metformin does not cause the stomach distress associated with the plain form. The cost of these two versions of the drug is the same, so there is no reason not to prescribe the ER form. Old fashioned doctors may not know about it.
Unfortunately, old fashioned doctors are also still prescribing sulfonylurea drugs like Glipizide (Glucotrol) and Glimepiride (Amaryl) as the first drug they give their diabetic patients.
These drugs carry a "Warning" in the FDA-required Prescribing Information that states there is evidence that this class of drugs may cause a heightened risk of cardiovascular death. The reason for this appears to be that they also overstimulate receptors on the heart muscle, not just the pancreas. In addition, these drugs cause rampant hunger and weight gain and can cause dangerous hypos. Many doctors are not aware of the warning in the Prescribing Information, nor are they aware that these drugs are no longer considered to be first line drugs for diabetes according to the current practice guidelines.
Some doctors, instead of prescribing these old fashioned drugs, prescribe whatever is the newest, most hyped, and most expensive drug to their newly diagnosed patients, often without understanding what, exactly, it is that these drugs do.
Some of these very new drugs, for example, Jardiance, appear on the basis of a single study to be helpful for certain kinds of patients, but they are NOT intended to be the first drug a patient tries. They are still too new for their side effects to be well understood, and many of them only work well for a subset of patients. The place for these drugs in your life is after you've gotten your blood sugar down to the safe range, when you might then experiment to see if they do better than the mainstream treatments.
Right now, the safest mainstream treatments recommended for people with Type 2 diabetes are in this order: Metformin, Precose, repaglinide, and basal insulin (Lantus/Levemir/Tresiba.)
The sulfonylurea drugs and cheap and appropriate prescriptions for recently diagnosed people with Type 2, but they cause serious hypos and appear to damage the heart. Only after these drugs have been tried is a patient supposed to be prescribed one of the newer, very expensive drugs like Januvia, Victoza, Invokana and Jardiance.
- Does Your Doctor Suggest Insulin When Oral Drugs arn't Normalizing Blood Sugar?
If you are on two or three oral medications and are still seeing high blood sugars, your doctor should suggest that you use insulin to get your blood sugars into the safe zone.
Insulin works, and modern insulins are much easier to use than those available in the past. If you have Type 2 diabetes and your fasting blood sugar is still higher than 140 mg/dl with all those other other medications in your body, your doctor should suggest Lantus or Levemir. (Assuming you have insurance. If you don't, these expensive insulins may not be appropriate, but the cheaper R insulin and N insulins are.)
The same is true if you cannot get your post-meal blood sugars under 140 mg/dl two hours after meals especially after cutting back on your carbohydrate intake.
- Does Your Doctor Stop a Medication If You Are Not Seeing The Desired Result or Are Having Troubling Side Effects?
One of the most worrisome things I observe in people posting online, is the number of people who are experiencing what are known to be dangerous side effects from commonly prescribed medications, whose doctors tell them to keep on taking them. Such side effects included muscle pain from statins, severe water retention with Avandia (which can lead to heart failure or retinal damage), and continual vomiting with Byetta. The first two symptoms can be signs of a condition that lead to permanent organ damage. Vomiting may be a symptom of pancreatitis, a known side effect of Byetta and Victoza which can be fatal.
Even worse, many patients report being put on expensive drugs that don't appear to do anything for their blood sugars. Often they are told that they should stay on the drug because it can help their beta cells to regenerate. No drug on the market right now can make that claim backed up by solid research in humans. Mouse studies and lab tissue studies may hint at this regeneration, but when humans are studied, so far, it hasn't been found. In the case of Actos and Avandia this claim has been found to be completely false. Some doctors are putting people on Jardiance because they misinterpreted a study that found it helpful to people diagnosed with heart disease. However, there is no evidence that it prevents heart disease, and the study that found it helpful for heart disease also showed that it did very little to lower blood sugar. The benefit appears to be its diuretic effect.
If a drug is making you miserable and not improving your blood sugar, there is no reason to take it.
- Does Your Doctor Know that Cutting Carbs out of the Diet is Recommended for People with Diabetes?
Believe it or not, I still run into people whose doctors told them to cut fat out of their diet, not carbs, as if it were fat, rather than carbs that raises blood sugar.
Doctors still rarely advise their Type 2 patients to try cutting down on carbs to improve their blood sugars, though this is changing, and some doctors, who have several patients who have normalized their blood sugar with a low carb diet are starting to recommend carb restriction.
But even though he may not be an enthusiastic low carb proponent, your doctor should be aware that cutting as many grams of carb out of your diet as you can is a safe, effective way to lower blood sugars, and that all the recent research about low carb diets shows that they work and that they improve, rather than worsen, cholesterol levels. Your doctor should also know that the evidence now is that the low fat diet worsens lipids and doesn't prevent heart disease, so that there is no reason right now to prescribe a low fat diet for someone with Type 2 diabetes.
- Are Your Doctor's Staff Reasonable and Accessible?
Because family doctors are so overburdened, many of them have set up their practices so that for routine matters you deal not with them but with staff. These staff may be highly trained nurse practitioners as competent as the doctor or they may be LPN nurses with only a year of education beyond high school who nevertheless believe themselves competent to "screen" your call and who may decide not to pass your message on to the doctor.
Because you will be dealing with these staff, it is very important to find a practice where the staff people you have to deal with are helpful, friendly, and, most importantly, willing and able to pass your message on to your doctor without garbling it.
If your doctor refers all his patients to a "diabetes nurse" for day to day case management, all the issues discussed above apply to the nurse. A diabetes nurse or staffer who considers your call with a question about a blood sugar problem frivolous, or who won't discuss your concerns about a rising blood sugar with the doctor because your fasting blood sugar is under 140 mg/dl is very dangerous to your health.
If your doctor expects a nurse to help you adjust your insulin doses, ask what their training is (you'd like them to be a Certified Diabetes Educator) and how long it has been since they've updated their training. There are a lot of "diabetes nurses" out there who are still treating patients with insulin regimens from twenty years ago--the kind that cause hypos and force you to eat too many carbs and keep your blood sugar too high to avoid going low.
What To Expect of a Good DoctorEven the best family doctor is probably going to be too busy to remember much about your case and he isn't going to have the time to discuss with you the various new treatments and drugs for diabetes.
Diabetes is a "do it yourself" chronic disease, and you will have to keep up with the diabetes news on your own by tuning into discussion groups or reading newsletters like Diabetes in Control.
But what your doctor should be able to do for you is this:
- Help you try out a new diabetes treatment you've heard about or explain to you why it wouldn't be appropriate for you.
- Order appropriate tests after explaining to you what questions the tests can answer.
- Give you your actual test results, not a summary, and explain to you what they mean, answering any questions you may have.
You have a right to keep a copy of your test results and should always have one made for you before you leave the office. Keep these test results in a file as you may need to refer to them in the future if you change doctors.
- Refer you to an appropriate specialist if something comes up that is not in your family doctor's area of competence.
- Provide you with free samples of drugs he wants you to try if you do not have medical insurance, so you can find out if they work for you before investing. If you don't have insurance or are in financial difficulty and have diabetes, he or someone in his office should be able to explain to you how to sign up for drug company or state programs to help you get the drugs you need. He or his staff should also be willing to fill in any necessary paperwork you need for insurers, drug support, or work.