Help me become a better doctor!

[studentMD]

Hi Everyone!

I am a student doctor planning on going into Family Practice. I am currently doing research on diabetic patients and would like your input!

Are there any areas of your life that are specifically affected by Diabetes and could be addressed by your physician? Areas such as your emotional, spiritual and social health?

How does diabetes affect these areas of your life?

What have you found that works to address issues in the non-physical aspect of diabetes?

What do you think your doctor could do to help you find balance in the emotional, spiritual and social areas of your life?

Thanks for any input!

StudentMD

[foxl]

How about learning about the increasing intrusiveness of the insurance industry into our care? (still fuming from my EEEEEEEW!) thread.

There is tons for you to learn -- read our forums for a while and you will get a completely different perspective than if you ask a question hoping for answers, I think!

[ShottleBop]

Actually, you could learn about diabetes very, very well, so that you can effectively advise us about the physical aspects of diabetes. And listen to us.

[MCS]

You want to know about D, as an old wise man said, be D.

By a lancet, a meter, and test your BG, 10-15 times a day, What ever your numbers are, try to get them lower, see how foods effect you. Eat nothing that is processed or has starch in it. No white foods. Test after every introduction of a new food, 30 minutes, 60 minutes, 2 hrs, etc. Build a list of things you can eat and the ones you can't.

When it gets to a point that you can't do this anymore, imagine then, a life time of it.

That should get your head going in the right direction.





Hi Everyone!

I am a student doctor planning on going into Family Practice. I am currently doing research on diabetic patients and would like your input!

Are there any areas of your life that are specifically affected by Diabetes and could be addressed by your physician? Areas such as your emotional, spiritual and social health?

How does diabetes affect these areas of your life?

What have you found that works to address issues in the non-physical aspect of diabetes?

What do you think your doctor could do to help you find balance in the emotional, spiritual and social areas of your life?

Thanks for any input!

StudentMD

[foxl]

Might also direct you to Shottlebop's post, here:

http://www.diabetesforums.com/forum/type-2-diabetes/45304-but-i-want-carbs-5.html#post519193

Currently bottom of the thread, about the FP with D and her beliefs on therapy.

[gary.keith]

Are there any areas of your life that are specifically affected by Diabetes and could be addressed by your physician? Areas such as your emotional, spiritual and social health?
[...]
What do you think your doctor could do to help you find balance in the emotional, spiritual and social areas of your life?

Welcome to DF! :) While I commend your desire to learn more about diabetes, in my opinion a family physician has no business trying to deal with anything except my physical well being. I have my God to help me with the spiritual side of things, my shrink to help with the emotional issues, plus family & friends to help deal with social issues. Please just stick to medicine and leave diabetes management up to me. That's how you can best serve me as my PCP!

[fgummett]

Hi and Welcome to DF!

I think someone wishing to learn more about D with a view to helping and supporting others is to be encouraged and applauded. :)

As above I suggest you will learn most by reading the many and various threads here on DF.

I think you may well be surprised by the level of knowledge and experience that exists outside the health care establishment... how much, many of us have learned and shared through our own research and personal experimentation.

An overriding message has to be that: while the the Doctor is an important part of our health care team, in the case of D (as in many other chronic conditions) it is we the Patient who must ultimately take responsibility and lead that team.

Please remain open minded throughout your professional career and especially be open to new ideas... for example: you will read here how many of us have found the ADA dietary recommendations to be way too high in the amount of carbs per meal.

Consider that Type 2 D does not start on the day of diagnosis but has been building for many years prior... so a proactive approach is needed... not a wait and see attitude.

Do not assume that Type 2 Ds are fat and lazy and are therefor untrustworthy or cannot be expected to act like adults.. particularly in matters of diet and BG testing. BG testing is vital to gaining control.

Finally I'd suggest that in the management of D, above all else, an ounce of prevention really is worth a pound of cure.

[studentMD]

I can see you are all concerned about getting good medical care from your physcian, and I assure you, I am well versed in the medical aspect of diabetes.

Research has shown that treating the whole person (including social, spiritual, and emotional) is much more effective than just treating the physical side.

Anyone ever feel isolated because of their diabetes? Feel any guilt or shame about it?

StudentMD

[foxl]

I, and suspect many here, am actually rather outspoken about my D.

Isolated, no. But alienated by my insurer, yes.

And despite what you think you know about medical aspects of D, many here feel that the advice given to patients is outdated, sometimes even wrong ..

[jwags]

I think the most important thing is to treat each one of us as an individual. Too many doctors and dieticians have a one size approach to everyone. I think the other thing that a doctor should encourage patients to maintain as close to normal bgs as possible. I basically had to go online and join different support groups to get better control of my numbers. Also refer patients to websites like Blood Sugar 101 Blood Sugar 101 (http://www.phlaunt.com/diabetes)

[Dougster]

Hi StudentMD,

First and foremost, get a copy of the film "The Doctor" (1991 - Starring William Hurt.) Make yourself watch it, at least once a year for the length of your studies, and your practice.

Second, cut out the 3M logo from any of the many boxes of your supplies and tape them to the walls of your exam room(s), they will serve to remind you to spend 3 minutes of your time on a personal level with each patient for each visit.

Remember, as it appears here by your fantastic question, you are treating people. If you need, make notes in the chart E.G. -"Larry likes to fish!" or "Mary likes to cook." review the chart before entering the exam room and walk in saying "Larry, how goes the fishing?" The trick is, really being interested, and remaining interested. It goes a long way, when you (and you will) have to share less than great news. Ever see a new patient form what asks, “What are your hobbies, sports or interests?”? Perhaps question "Spirituality as well on the form.

Encourage your patients to write down any and all symptoms, concerns, questions, etc., before their visit. That way you can make up the time you spent chatting with them by not waiting for them to recall their symptoms while you are examining them.

I think my doctor took it as a personal defeat that I was diagnosed with diabetes. His apparent deep concern was startling but also refreshing, and motivates me to bring my diabetes under control quickly! Let your patients know that you are counting on them to be well. It’s always better to be a member of a “team” who are concerned with one’s health. (Hence this forum!)

Diabetes is one of very few diseases in which the patient can be very proactive in the treatment. I took it as a wake up call, to take better care of myself. It encouraged me to exercise, and eat right.

Focus on the diabetics “can” as opposed to the diabetics “can’t”!

I feel if from the very start you the doctor are positive and energetic when you first see a patient, show them how much control they really have it will go a long way to having a healthier patient, not only in the physical, but like you mentioned, emotional, spiritual and social sides as well.

It's great to see photos of athletes who are diabetic, keep a few on the walls too. Make diabetes a challenge, not a sentence, ok?

Make personal calls to the patient, set aside some time for an unsolicited call, perhaps as your day winds down a little. Imagine the delighted shock of a patient who gets a call “out of the blue” from the doctor…”How are you feeling? How are the meds working? Just checking up on you…” I can guarantee your practice will be SOLID if you do this.

Also, express great faith in the patient. Say the words, “I have faith in you!”, let them know you are placing trust in them to control this disease. It’s often the case that people will go the extra mile when they know someone is counting on them. We (generally) hope to please others.

I am heartened that you would inquire on this forum, about the “whole patient”. I think you may do well in your studies, and practice.

One last thing, seeing as you mentioned “research on diabetic patients” and write this down please. Post it on your bathroom mirror. Read it every day before leaving home!
"Correlation does not imply causation"

Be well and happy!

A comfortably numb,
Dougster

[It Ain't Over]

Student DR.
I applaud you asking these questions. I have recieved very good treatment from many physisians over the years. I regard them all highly.
However you must understand, most of the 'treatment' comes from us here. This is a truly unique disease. Do you know of any other where your patients test themselves and then work out a course of treatment everyday?
Makes the office of the treating team to become more of a set of coaches. Sometimes coaches need to teach, sometimes to lead, sometimes to train, and sometimes to scold. I wish all the medical students had your outlook though.

[Josselyn]

GREAT RECOMMENDATIONS, Dougster! BTW, I loved The Doctor.

[xMenace]

This is a deep question. Very deep.

So much of my doctors' advice is just wrong, deadly even. But first you should understand how doctors decide on a best course of action. To put it bluntly, their information is filtered, funneled, and faulty (see reference below). It is determined by concensus, bad science, and politics. "This is the course of action you should take because everyone else is taking it." Never mind that successful treatment programs do possibly the complete opposite. They are wrong because we think they're wrong. (see reference #2)

Pfft!

Doctors have to be advocates of action. You need to lead patients down the right paths. But those paths are not what your map tells you are right. It's the gunslingers that are getting it right: Dr. Bernstein, David Mendosa, Gary Taubes, and a host of faceless virtual world diabetics like myself. My endo, local head of internal medicine in a 500 bed hospital, had never heard of basal testing before I taught him. He still doesn't believe it's necessary. My 5.9% A1C and near riddance of severe hypos somehow won't sink in, even though it's IMO the most important insulin management technique. Most doctors have no idea that low fat diets kill. They are the number one cause of metabolic syndrome. Doctors should understand that this is a hard disease to manage. Most doctors won't acknowledge that crtical decision frequency is stated in hours and minutes, not quarters and months. We need to make decisions now. We need to know how to make decisions now. Two days of lectures by diabetic educators and nurses barely scratches the surface of need. Doctors should be prescribing support: local support groups, local Expos, local virtual communities, and world virtual communities. Doctors should understand that medications (not insulin) equates to failure. I'm not saying or implying that meds aren't needed; what I'm trying to drive home is that lifestyle changes are necessary for all diabetics. We need to give up the sugars, the refined grains, and even the whole grains. We have to control insulin levels or we're doomed to a life of complications and heart disease. Diabetics need comprehensive treatment, not escalating medications.

reference for point #1:

Canadian Diabetes Association 2008 Clinical Practice Guidelines (http://www.diabetes.ca/for-professionals/resources/2008-cpg/)

The following basic principles were adopted to ensure
that the values and empirical basis underlying each recommendation
were explicitly identified, and to facilitate the
critical scrutiny and analysis of each recommendation by
other organizations and individuals.
• Each recommendation had to address a clinically important
question related to 1 or more of the following:
detection, prognosis, prevention or management of diabetes
and its sequelae. Health benefits, risks and side
effects of interventions were considered in formulating
the recommendations.
•Whenever possible, each recommendation had to be
justified by the strongest clinically relevant, empirical
evidence that could be identified; the citation(s) reporting
this evidence had to be noted adjacent to the relevant
guideline.
• The strength of this evidence, based on prespecified criteria
from the epidemiologic literature and other guidelines
processes, had to be noted (3-8).
• This evidence had to be incorporated into a recommendation
that was assigned a grade based on the available
evidence, its methodological strength and its applicability
to the Canadian population.
• Each recommendation had to be approved by the
Steering Committee and Executive Committee, with
100% consensus.
• Guidelines based on biological or mechanistic reasoning,
expert opinion or consensus had to be explicitly
identified and graded as such.

Ref #2

Low-carb Diets Prove Better At Controlling Type 2 Diabetes (http://www.sciencedaily.com/releases/2009/01/090105175326.htm)

[xMenace]

Awesome post Dougster, but I do disagree with the following.

One last thing, seeing as you mentioned “research on diabetic patients” and write this down please. Post it on your bathroom mirror. Read it every day before leaving home!
"Correlation does not imply causation"


I think correlation does imply causation, and that's part of the problem. It is more correct to say "correlation does not prove causation!"

Just my opinion.

[CarrieJett]

Get to know your patient really well, ask a lot of questions, and refer them to a good endocrinologist. If they don't like them, refer them to new ones until there is a good fit.

[fgummett]

Here's a thread about a Doctor I admire : http://www.diabetesforums.com/forum/diabetes/41928-diabetics-suffering-no-reason.html

[sanflan]

Read Dr. Bernstein's book and believe it. Don't think that your patients can take more and more medication and insulin and eat whatever they want, especially a low fat diet. Don't fall for low fat, this is a deadly theory and probably got me where I am today.

Don't discount what your patients say. Be polite and try to listen. Don't tell your patients that you have never heard of this or that reaction to a drug, They have access to the internet and will think you are either uneducated or dishonest when you say, well I have never heard of that before.

Don't place so much trust in 26 year old drug salespersons (even ex cheerleaders) Be skeptical and research each and every drug yourself. Be aware of how much diabetes costs the patient.

Let your diabetic patients tell you what they do or don't do to control their disease. You will learn a lot just by listening.

Good Luck to you, I am impressed with your interest and I bet you will be a good doctor.

[Joeprep4820]

I feel that many doctors today can empathize little with their patients. You treat them, but you don't know what the patient is going through, so think of things going on in the patient's mind before something is prescribed or suggested.

[Jan B]

HI!

I would like to applaud you for choosing to be a primary care physician. I love my PCP, and have not seen an endocrinologist for years. There is an endo in the same practice as my PCP that I am free to see, but I don't feel the need. My PCP is extremely interested in and knowledgeable about diabetes; he listens to me and trusts me. (He also has a T1 sister.) He even started something similar to this forum for all his diabetic patients to share experiences, etc.

I also admire that you know how important it is to treat the whole person instead of treating a patient like a disease only!

Diabetes and emotional health go hand in hand in my opinion. My doctor always shakes my hand upon greeting and spends at least 5 minutes talking to me before we get to business. Sometimes it's personal; sometimes we discuss new medical information we have both learned since our last meeting. I think most of us dread going to the doc, most of the time, but when I leave the doctor's office, I always feel better when I leave, never worse.

The nurses are excellent, and very quick to pass any messages along, and to call in any refills I might need.

I wish you much future success. WELCOME to DF!

[Mich]

Student MD:

Of the aspects of Diabetes Management that you mention, some are being currently addressed by a growing non-profit group in southern California called the Behavioral Diabetes Institute. Home - the Behavioral Diabetes Institute offers Diabetes Workshops, Clinical Programs and Diabetes Behavioral Research (http://Www.behavioraldiabetes.org)

The website contains downloads and videos free online to people who are dealing with emotional burdens and stresses of Diabetes.

Mich

[Rddoms]

StudentMD,

I have a bit of a unique perspective into this as I am a Type 1 diabetic as well as a second year medical student. I do feel isolated every once in a while, and guilty when my HbA1C is sub-par. I was diagnosed right after taking my SAT, and I was on a downward spiral for a few years. It sounds a bit silly, but my first doctor didn't scare me enough. I had no idea what diabetes could do to the human body, and thus pretended like it didn't exist. It was almost like an addiction: I had to hit rock bottom before I started to take care of myself.

If you aren't diabetic, you wouldn't believe the effect the disease can have on you patients' lives. It made me shut myself off to the rest of the world for a while, and that just complicated the situation. It wasn't until I had an Endocrinologist listen to me that I started taking care of myself.

One of the strange things is that doctors don't always tell you all of the options when it comes to treatment. I had an A1C of about 9 until my third doctor allowed me to try an insulin pump. After that my A1C was within an acceptable range.

People that are having trouble accepting their disease should also be referred to a psychiatrist. Calming one's fears is empowering and can lead to better patient compliance. My current doctors allowed me to get back on the pump after my old one sent me to the ICU two times in as many months. Doctors that use their patients' input and help them get the treatments they desire (if warranted) are going to have compliant and healthy patients.

I have a lot more that I could add, but I will stop there for now. PM me if you have any questions.

[Joeprep4820]

The Psych idea is not a bad idea, but as a Type 1 of 21, almost 23 years, and someone who grew up with it through childhood, I think meeting with a group of diabetics of the same age would be a better solution. When I was 12 and having trouble with the disease, my endo recommended a camp that was just for diabetics ages 10-16, and it was great meeting people who were going through the exact same thing I was. For people a bit older, I'm sure things such as Happy Hours, picnics, barbecues, circle groups, and more, could do meet and greets.

[Joeprep4820]

BTW, 11 years later, I still take a week's vacation each year and work as a counselor at the same camp, and work as a fundraiser for it.

[Dougster]

xMenace, I appreciate your compliment, and agree to your use of "prove". I had learned it as "imply". I see no problem with upgrading it to PROVE, which I will do from now on.

Josselyn, I am glad someone else liked it, and I agree, there are some great comments here. Like I told my doctor when I was first diagnosed "I am in great company!".

Be well and happy!

A comfortably numb,
Dougster

[studentMD]

thanks so much! i really appreciate your honesty!

[studentMD]

StudentMD,

I have a bit of a unique perspective into this as I am a Type 1 diabetic as well as a second year medical student. I do feel isolated every once in a while, and guilty when my HbA1C is sub-par. I was diagnosed right after taking my SAT, and I was on a downward spiral for a few years. It sounds a bit silly, but my first doctor didn't scare me enough. I had no idea what diabetes could do to the human body, and thus pretended like it didn't exist. It was almost like an addiction: I had to hit rock bottom before I started to take care of myself.

If you aren't diabetic, you wouldn't believe the effect the disease can have on you patients' lives. It made me shut myself off to the rest of the world for a while, and that just complicated the situation. It wasn't until I had an Endocrinologist listen to me that I started taking care of myself.

One of the strange things is that doctors don't always tell you all of the options when it comes to treatment. I had an A1C of about 9 until my third doctor allowed me to try an insulin pump. After that my A1C was within an acceptable range.

People that are having trouble accepting their disease should also be referred to a psychiatrist. Calming one's fears is empowering and can lead to better patient compliance. My current doctors allowed me to get back on the pump after my old one sent me to the ICU two times in as many months. Doctors that use their patients' input and help them get the treatments they desire (if warranted) are going to have compliant and healthy patients.

I have a lot more that I could add, but I will stop there for now. PM me if you have any questions.

Thank You! that's exactly the kind of stuff I need to learn to be able to become a better doc!

StudentMD

[Subby]

People that are having trouble accepting their disease should also be referred to a psychiatrist. Calming one's fears is empowering and can lead to better patient compliance. My current doctors allowed me to get back on the pump after my old one sent me to the ICU two times in as many months. Doctors that use their patients' input and help them get the treatments they desire (if warranted) are going to have compliant and healthy patients.

Student MD, while I agree with most of what Rddoms says here, how about considering some counseling and education before a psychiatrist. If you can find a good local counselor or psychologist with personal knowledge of diabetes, it could be a wonderful resource. I think that a lot of fear around diabetes is due to word of mouth knowledge, and not getting to the bottom of the real rate of risks etc, so a Diabetes Educator who is kind, sympathetic, and most of all a great educator, would be another wonderful resource. Have some faith that people can navigate denial and understandable issues with complex diseases, and that it is the sort of issue to work through with the right communication and support, before sending them off to run the risk of being pumped full of brain-stuffing meds.

[Rddoms]

I completely agree with you Subby. As far as seeing a psychiatrist, I'm talking about when someone is having a great deal of trouble and nothing else works. Camps, group meetings, Diabetes educators, etc. would obviously be the first option. My problem is that My doctor didn't let me know that things like that were out there (I had no idea that camps existed either) and I got really bad really fast.

It is obviously going to be different for each patient. Most would benefit from education/camps in the very beginning, while some are going to need more extensive help form the beginning.

The three biggest pieces of advice I have for a Family Doc that is going to take care of diabetics:

1. Let your patients know how serious the disease is. Also, let them know that they can live a long and healthy life if they take care of themselves.

2. Get your patients started with a diabetic educator, nutritionist, psychiatrist (whatever you think would benefit them most) at the start. If people are covered physically, emotionally, and get the proper education, you are going to have better patient compliance and healthier patients.

3. Keep up to date on all of the treatment options. Know all of the available pumps, insulins, BG meters, CGMS, etc. That way you can help your patient use the treatment modality that would work the best for them.

[gettingby]

One bit of advice that I have is to really listen to the patient. Don't disregard anything they say. Like for example. My endo's nurses always ask the same questions before the endo sees me. One of the questions is "Any problems with depression?". My normal answer to this question is no but for a while now, I've been suffering from some form of depression. When I answered yes to that question at my last visit, the nurse was visibly concerned but the endo was not. So, if a patient says that they are experiencing depression, don't just "write" it off. Talk to the patient and see if you may be able to recommend changes or a referral to someone else.

I have to say that most patients are educating themselves more today than in the past. If the patient asks about a test or treatment plan that you don't know much about, admit that you don't but do put forth the effort to research it. I have brought up some questions about certain tests that my endo didn't even think of recommending. :)

Sorry for the long post but just hang in there and remember that the people you see aren't just patients, they are people with genuine concerns. If you can't handle their concerns, they are going to go elsewhere.

[dbaratta]

Hi Everyone!




Thanks for any input!

StudentMD

PUT DOWN THE BOOK AND LISTEN TO THE BODY.

[mortis505]

You have received a lot of great advice so far. Now I'd like to add my $0.02.

Remember that the person in front of you in the exam room is an individual. That individual has needs, fears, likes, dislikes, and that as a doctor, you have sworn to do no harm. So take a moment and consider this patient on all levels. When talking to them, don't just stare into their file, make eye contact with them. If they are a minor, talk to them as well as the parents. And don't speak down to your patients using strictly medical lingo. Actually speak to them in plain English, describe the the conditions, trials, tribulations that they are/will be facing in basic terms.

Let them know that as their Doctor that you are there for them. If they are having a difficult time, be available for them. Ive seen some Doctors that keep a second cell phone just for patient use for after hours calls.

As has been said, Diabetes is not a one size fits all disease. Stick around for a while and you might learn one of our mantras. YMMV!!! Your Mileage May Vary. This is just further proof that works for one human organism, may not work for another.

Don't diagnose without proper testing. More and more we have been seeing what many doctors would consider a "crossing of the lines." Children being diagnosed with T2 and adults being diagnosed with T1/1.5/LADA. Diabetes doesn't care about age. It doesn't care about how "healthy" you have been in the past. But you can make a difference in getting proper treatment to your patients. If a 40 year old patients presents to you, BG @ 573, positive for keytones, constant urination, oral thrush, and approx 40 lbs of weight loss over the last 4 weeks, do NOT automatically assume that the man is T2 just because he isn't a juvenile so cant have T1 since T1 is called Juvenile diabetes. Get the proper tests. One of our great users here even has a statistic about 20% of all T2s are actually misdiagnosed.

Above all, keep an open mind and actually listen to your patients. They are the ones going through this. If you see that they are having a hard time, talk to them. A simple "What can I do to help." is often one of the best things a doctor can say to someone, especially when said with sincerity.