Noncompliant Docs Don’t Do You Any Favors

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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  • Steve Parker, M.D.

    You’re right.

    Note that most physicians, to stay in business or keep their job, have to see a large volume of patients. Some large clinics require their primary care docs to see six patients an hour. That means an individual patient may not get much of the doctor’s time.


  • J Kohler

    I am a type II since diagnosed in 1992, had it probably for a few years prior, no one tested me even though I always told them of the family history (father type II, brother type I, aunts and uncles both sides both I & II). I have maintained very good control, stayed with just diet and exercise for 5 years, but have asthma and you know steroids. Last week I had 2 facet joint injections of steroids in my neck. That night my sugar soared so first thing in the morning I called my dr’s office. I said I think I need to go on insulin to cover this. I feel like I had to fight to get the insulin, but 2 phone calls later they called in a prescription. I was given humulin r with a sliding scale, but no other directions, on a Friday night. I went on line and with my experience taking care of my dad, I figured I needed to use the sliding scale to cover meals. I started testing with my meter every couple of hours, but my dr’s office only put down for my strips to test once a day. So I have to pay for those out of hand. Why does it seem like I have to fight to try and have my glucose under control and take care of myself? These questions I plan to take to my dr, who is usually very supportive, but this happened once before too without me receiving the insulin and I was sick. I feel like I lost some clear vision and who knows what else. I guess I am just ranting and venting because I know there are some people out there that do not take care of themselves and sometime that means all type II are considered to be lazy, overeating slobs that cannot pass up a goodie. thanks for letting me vent.

  • Linda the Pharmacist

    I am a Pharmacist, paid by our state Public Employees Insurance plan to counsel diabetic patients who enroll in their diabetes self-management program. I meet with my patients every 3-6 months, depending on their level of management, and make sure they are getting the proper lab tests done according to ADA guidelines and help them manage their diabetes. I have found that many insureres offer these program to their subscribers or have other healthcare providers available to help patients manage their diabetes. If you primary doctor is not as pro-active as you would like, check with your insurer. Help may be a phone call away. And congratulations to those of you who ARE pro-active and advocate for better care. That is truly the way to contain healthcare costs.

  • Diane

    I had gestational diabetes 12 years ago. The diet didn’t work so I ended up on insulin. Six years ago I was diagnosed with type 2 diabetes. It runs in my family (Father, Aunt, Grandparent and Sister all T2). I have always led a healthy lifestyle and have been a “normal” weight. I started swimming on a swim team when I was 8 years old and to this day I continue to swim so much so that I was asked to join the Master’s swim team by the local YMCA. I also kick box, take Tae Kwon Do, ride my bike and walk/jog to mix up my exercise. I exercise at least 4 – 6 times a week for an hour. I have been taking metformin since I was diagnosed 6 years ago. I gradually started to need increased doses and am maxed out on it. I recently started to gain weight (hitting the big 50 soon) and noticed my A1C was on the rise. I decided to go to an endo to see what the next course of action should be. During my visit he said to me “If you loose 20 lbs you can get off meds” He said it as if I was a big fat blob who sat on the couch eating bon bons (I never ate a bon bon)and it was my fault that I had diabetes. He never asked if I exercised nor did he ask if I follow a diet. I told him the exercise I did and that I can’t eat any less. He didn’t seem to believe me. He suggested I go to the Dietician which I did, who also didn’t seem to believe me when I said I followed a diet (counting carbs) and exercised a lot. I started taking Januvia with Metformin and my BS seems to be getting better and I lost a few lbs. When I sent my BS numbers to the Dietician she responded that she greed that my numbers are better but to make sure I make diet changes and incorporate some exercise. I was dumfounded. I don’t think they heard a word I said or even worse don’t believe me. They are assuming that since someone is a bit overweight they don’t take care of themselves and don’t exercise. I wanted to scream as loud as I could ‘I DO EXERCISE’ ‘I DO WATCH WHAT I EAT”. My theory is that when the meds aren’t as effective, I gain weight (all in the tummy area) and when I have my meds corrected for better BS control I go back to a “normal” weight. I do not believe I can get off meds even if I did loose 20 lbs. It all makes me MAD.

  • Marcie

    Generally, my doctors (I’m in the military health-care system, so I get a new one every so often) have been pretty good about meeting the care guidelines. However, none of them has ever given me a referral for nutrition information or guidance — not even given me a printed out “diabetes diet” sheet. My last doctor was civilian, and care was at about the same level. However, he never once checked my feet — not even when I requested a referral to have plantar warts treated!

    I do know that the doctors nowadays are really pushed for time, so I always go in prepared. I have written down anything I need to talk about — getting prescriptions re-written, anything that worries me, etc. — and always ask for a print out of my lab results. I go on the net for information — to reputable sites, such as this one — and get a couple of diabetes magazines, including the hardcopy of this one.

    I do believe that we have a big responsibility for our own well-being, but doctors have the responsibility to at least point us in the right directions for information.

    So far, this system has worked for me — knock on wood — but I realize that I have lots of advantages that others don’t. I’m a former LPN, I have internet access, and I have good health insurance. Without these, I’m positive that I wouldn’t be able to handle this situation.