Noncompliant Docs Don’t Do You Any Favors

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When I run across something interesting (to me, anyway), I tend to put it in a folder on my computer. Sometimes I even remember where I got it. (Heaven forbid I should include the source in my notes!)

Take the following, for example:

Despite the existence of a number of practice guidelines and a broad range of pharmaceutical treatment options, more than 60% of diabetes mellitus (DM) patients do not reach HbA1c target goals. This unacceptable rate of treatment failure is related to poor adherence to clinical practice guidelines.

That was the lead-in to a continuing medical education (CME) program from the Potomac Center for Medical Education. It caught my eye because, for once, it was talking about treatment failure from health-care professionals and not from us poor, misguided, noncompliant people with diabetes.

Didn’t read that into the quote? Here’s the rest:

This CME program will help to address the above educational gaps among physicians and improve their awareness of the latest practice guidelines and available treatment options, so they can better manage their patients with diabetes.

Clear now?

There has been some research on the lack of knowledge on the doctor’s part adversely affecting his patients, but a friend of mine — I’ll call her Wendy — who is a certified diabetes educator (CDE), recently brought it home by telling me about some people in a diabetes class she taught earlier this year. Actually, all of those attending had a problem.

One person was on long-acting insulin, but his doctor was reworking his oral medicines in a (futile) effort to cover his meals. “Just lose some weight and it’ll work,” the doc reportedly said. Psst! Got a little tip for you: A rapid-acting mealtime insulin would work a lot better and might not have the poor person’s blood glucose whacking out all over the place.

Another was in kidney failure before anybody bothered to check renal function. Clinical guidelines call for kidney tests at least once a year: More frequently if circumstances warrant.

None had a meal plan. Only one-third of those attending knew what a carbohydrate is. One had been to a diabetes self-management class some time ago, but said he was so overwhelmed he “just did the best he could.”

One was taking glucose-lowering medicine (including insulin), grabbed an apple on his way out of the door, had been exercising, and was looking a bit shaky. However, he didn’t have his meter with him. “Do you know to keep some Life Savers in your pocket?” Wendy asked. Nope.

I often feel that I need to have gone to medical school so that I’ll know if my doc is up to speed. Since beginning my diabetes education, I’ve learned all too well how much many doctors don’t know about something that’s a common condition — and getting more common.

Research published in the November 2002 issue of the journal Diabetes Care still sticks in my mind. (OK, it helped that I live in the state where the research occurred and the lead author was a doctor I knew.)

Anyway, the lack of adherence to guidelines was much worse than I thought. Researchers who studied independent primary-care doctors in a rural Indiana county found that:

  • adherence (the new word for “compliance”) for foot exams was 15%
  • for HbA1c measurement, it was 20%
  • 23% for eye exam referrals
  • only 33% for urine protein screening (that’s where you keep an eye on the person’s kidney function)
  • lipid (cholesterol and such) profiles were ordered by 44% of docs
  • home blood glucose monitoring? 73%
  • and 78% for blood pressure monitoring

One year after local consensus guidelines had been developed, the percentages rose in most categories. Another year passed and…only foot exams and blood pressure measurements remained significantly improved from the initial survey.

While the study was done in a rural county, I suspect it isn’t much different in a city. After all, Wendy lives — and teaches — in a city. A city with a med school in it, I might add.

What a noncompliant doc means to those of us with diabetes is possible foot ulcers and amputation; diabetic retinopathy; kidney failure; cardiovascular problems; and more.

I know we pay our doctors to take care of us and many do a good job of it. But those who don’t can be very harmful to our health. I think it’s up to us to learn as much as we can so that we can determine (as well as we can) if our care is appropriate. That goes for all of our doctors: Not just the ones who treat our diabetes.

I once fired a podiatrist when he said he didn’t have to get a baseline and monitor my feet regularly. “If something happens, we’ll take care of it,” he said. I happen to believe it’s best to get a baseline measurement and see if conditions start going downhill. That way, intervention can begin at a very early stage of whatever may happen. Remember the person in the diabetes education class who was in kidney failure before anybody checked kidney function?

Why bother? I mean, diabetes only affects every part of our body that has blood flow. I guess we don’t have to worry much about our hair, huh?

Clinical practice guidelines for diabetes are not hidden in a secret place. They’re not locked up in a trunk hidden in a secret room behind the fireplace and you don’t need to follow a pirate-style map to find them. They’re published every January by the American Diabetes Association (ADA) as a supplement to the January issue of Diabetes Care. Anybody can read them. If you’re curious, you can go here and have at the latest one.

In fact, take notes. Ask your doctor about anything he’s been missing and ask why those tests haven’t been done. Keep up with what’s been checked, when it was done, and when the next one is due. Remember: it’s not your doctor’s life. It’s not your doctor’s complication(s). It’s not your doctor’s frustration, depression, and possibly hampered lifestyle from having the complication(s).

When it comes to diabetes and preventative care, we need to be in charge of our care, with the help of our doctors.

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