http://type2diabetestreatment.net/diabetes-mellitus/ask-dmine-the-diabetes-standards-of-care-and-my-heresy/
Hey, All -- if you"ve got questions about life with diabetes, then you"ve come to the right place! That would be our weekly diabetes advice column, Ask D"Mine, hosted by veteran type 1, diabetes author and clinical specialist Wil Dubois.
This week, Wil responds to a question about all those "standards" set by medical professionals about how we should be handling our diabetes treatment. No surprise that Wil has some pointed opinions on that!
Read on...
Got your own questions? Email us at AskDMine@diabetesmine.com
Dan, type 1 from Washington, writes: Every time I go to the doctor, they always state to me that the insurance company gets on them if they don’t put a type 1 diabetic on a statin and a blood pressure pill. However, as a patient, I do not take pills for prevention of disease unless I can find proof, beyond a reasonable doubt, that the pill is effective and not dangerous. That is, I do not have kidney disease and I do not have heart disease. I do not have high blood pressure. I have type 1 diabetes (35 years) and that is it. By the way, my A1C is always around 5.5. My cholesterol is 200 and LDL is 125 and HDL 60.
When I review the research, there is only marginal improvement in taking a statin (that is, it takes 100 people to be treated to prevent 1 heart attack), if you believe the studies all done and paid for by the drug companies that make this stuff. In addition, the Framingham Heart Study showed over half those who had a cardiac event had NORMAL cholesterol levels.
Why are we type 1 diabetics told that no matter what, you need to take this? I am tired of these doctors acting as if I have a disease I don’t have and telling me about insurance companies and how they get in trouble. And I am rational: I had an advanced cholesterol assessment done that even showed my LDL is the large fluffy type (pattern A) and not the small dense LDL (pattern B). Even so, I get harassed every time I see my general practitioner and my endocrinologist. Is all this really going on (insurance companies pressuring doctors to carpet bomb all type 1 diabetics with statins and blood pressure pills in the absence of clear cut research, replicated a few times, proving benefit)? I am tired of being treated for a disease I do not have by pills with marginal proof they actually prevent anything.
Wil@Ask D’Mine answers: Confession: I’m a heretic.
Of course, I wasn’t always a heretic. I used to be a True Believer. A believer in the standards of care. I believed that wiser people than me, using scientific evidence, had carefully created diabetes treatment algorithms that would assure long life, health and happiness. All I had to do was follow the rules.
I’m not sure when I started losing my diabetes care religion. It came in baby steps. But I think the first step was baby aspirin. When I was diagnosed, I was put on a statin, an ACE, and a baby aspirin. All standards of care. When I started working in diabetes treatment, one of my jobs was to make sure those damned noncompliant diabetics took their statins, ACEs, and aspirins.
Like any good zealot, I strongly advocated for the trio. I set a good example by taking them myself, even though I didn’t need them, and urged, cajoled, and begged my patients to do the same. I even created a cute visual aid using a toy medieval armor set where sword was diabetes meds, the statin was the breastplate, the ACE was the shield, and the baby aspirin was the helmet.
And then one day the high priests said, “Uh… never mind about that whole aspirin thing we’ve been pushing on you for decades. Turns out it doesn’t help. Our bad. But keep taking all the other stuff we told you to take.”
And the True Believer entertained his first doubt.
Time, wind, and rain erode mountains. The longer I worked in the field, the more fallible I realized the priesthood was. The standards of care weren’t carved in stone. They were made of Playdough. Every year they changed. Part of that was simply the fact that knowledge changes, but what I came to learn was that there was more politics than science involved in setting standards.
Speaking of science, I think I totally lost my religion when I was involved in a university “scientific” study that let me see up close and personal how poorly conducted such investigations can be. The lead investigator ran out of time, but needed a certain on-going volume of published works for job security in the dog-eat-dog academic world. Exhausted and fearing occupational consequences, this person just fudged the missing data.
I was horrified. Appalled. Knowledge wasn’t the goal. Successful publication was.
But I still half-heartily peddled the standard drugs at work. It was in my job description, even though it was no longer in my heart. Ironically, I even continued taking them myself, more out of habit than anything else. Then, worn down and worn out myself, one day I had a hissy fit and stopped taking all my drugs — even vitamins — except for my insulin and my thyroid pill.
Within days I felt 100% better. Ten years younger.
Officially, I’m still supposed to advocate for the standards. I mention what the standards are, and how they are created, but I don’t expend much energy on them.
And the play armor is no longer in my office.
Do the insurance companies hassle us for our lackluster application of standards of care? That depends on how you define “hassle.” Historically we get quarterly letters listing their members who don’t seem to be toeing the line when it comes to standards, but that’s about it.
However, the times they are a’changin’. These schizophrenic insurance companies that won’t pay for test strips are starting to put their money where the standards are. Increasingly, docs are being bribed to ensure that their diabetes patients meet the standards. If their diabetes patients behave, docs qualify for incentives. As in extra cold, hard cash incentives.
That’s today.
In the future, things look grimmer.
We are in a major state of turmoil in healthcare, and a model for the future that gets kicked around a lot is pay for performance. If this model is widely adopted, docs wouldn’t be paid for what they do, but rather they would be paid for what you do. They will be penalized if you don’t toe the line.
I can see a world in which non-compliant diabetics like you and me will be discharged from care because doctors won’t be able to be compensated for taking care of us. Regardless of how healthy we are.
Then what? Well, there may come a day when, in order to keep your healthcare coverage, you may have to fill the prescriptions for the standards and make the copay. But in the privacy of your own bathroom, no one will know if you take the pill or flush it down the toilet.
Of course, I never said that, and will deny saying it if asked. This column will self-destruct in five seconds.
Meanwhile, calmly and logically explain to your team how you feel, and request that they stop hassling you. If they don’t, for now, you have the option of shopping around. Healthcare is still a consumer market. You are the customer.
Find someone who’s still selling the kind of healthcare you want.
This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.Disclaimer: Content created by the Diabetes Mine team. For more details click here.
Disclaimer
This content is created for Diabetes Mine, a consumer health blog focused on the diabetes community. The content is not medically reviewed and doesn"t adhere to Healthline"s editorial guidelines. For more information about Healthline"s partnership with Diabetes Mine, please click here.
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