By David Spero | August 22, 2007 2:48 pm
Thanks to everyone for their comments on my last post ("Sicker Than Sicko"). I think we agree that no medical system is perfect. But countries with national health-care systems cover everyone. They focus more on management and prevention, and less on high-tech treatments of complications that should have been prevented.
Still, I think that Michael Moore’s excellent documentary, Sicko, gives a wrong impression. He implies that, if everyone had access to care, our health-care system would be OK for us. But that’s not true. Even when Americans do have medical insurance, our doctors may do as much harm as good.
As I describe in my book Diabetes: Sugar-coated Crisis, the medical system can hurt people with diabetes in at least six ways. Four of them are:
We know that good outcomes in diabetes depend on people taking control of their own condition. But some doctors want to keep control for themselves, even though they know we’re on our own whenever we’re not in their office.
Richard Bernstein, author of Dr. Bernstein’s Diabetes Solution, tells this alarming story. When he was 35, he was slowly dying of poorly-controlled Type 1 diabetes. He had neuropathy, kidney disease, eye problems, chronic fatigue, and frequent hypoglycemia.
At that time, he was an engineer, not a doctor. He saw an ad for the first portable blood glucose meter, which was being marketed to emergency rooms for use at night, when labs were closed. He tried to order one, but they would only sell to doctors. Fortunately, his wife was an M.D. psychiatrist, and he ordered one in her name.
Bernstein started checking his blood glucose 6-8 times a day, carefully noting how each different food affected his blood glucose level. He learned that if he avoided almost all carbohydrate and gave himself very small doses of Regular insulin before each meal, he could keep his blood glucose at normal or near-normal levels 24 hours a day. Most of his complications disappeared. He felt great.
Excited and hoping to help others, Bernstein went to his doctor, author of several books on diabetes care and an official in the American Diabetes Association. Bernstein encouraged him to make the meters available to all his patients. The doctor replied, “What are you trying to do? Put me out of business?”
“Doctors couldn’t do much then besides check blood sugars and prescribe insulin,” Bernstein told me. “If patients could check their own sugars, what would that leave for the doctors to do?”
Blood glucose self-monitoring is now widely accepted. But it took over ten years of pushing before it became standard practice. Even now, many insurers deny benefits for monitoring equipment and training. As Ephrenia wrote in reply to my last post, doctors often refuse to prescribe diabetes education or self-management training. People with diabetes and their families often have to fight for the control they need.
Medicine often sabotages self-management in other ways. Health-care professionals may damage self-confidence by dumping large numbers of behavior prescriptions on you all at once. “Just eat what we say, exercise, check your blood glucose, take your medicines, check your feet, and see me every few months, and you’ll be OK. If you don’t, terrible things will happen to you. And oh, yes, don’t forget to reduce stress.”
Very few people can make so many changes all at once, and when they don’t, they may become discouraged and stop trying. Instead, providers should support people through making small changes and build on small successes. Few people go from being couch potatoes to walking briskly three miles a day. But they can start with smaller steps and build up.
I had a client who started with a program of walking down to her mailbox by the curb every day. That was all she could do. Her doctor told her it wouldn’t do any good; it wasn’t enough. But over a year, she built up to walking three miles a day. She lost weight and got her blood glucose under better control. The doctor was wrong.
Professionals also damage our self-confidence by labeling patients with terms like “noncompliant,” “nonadherent,” or “obese” (Latin for “overeating,” as if that was the only cause of the problem). Other damaging labels include “in denial”—you’re not serious about your condition—and “chronic progressive”—you can’t get better, you have to get worse, and there’s not much you can do about it. Such labeling and blaming makes self-management much harder.
What experiences have you had with self-management support by your providers? Are they helpful? Are they there for you? Or are you on your own with it?
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