Saturday, November 16, 2013

The Nutrition Debate #161: Why Go to the Doctor?

Why, indeed! When my doctor of 21 years died last year (the one I eulogized here), his practice was sold and my medical records transferred to a nearby internist/cardiologist who used to ‘cover’ for him. At my first appointment, after the physical, the doctor asked me what he could do for me. I said I would like to be seen 3 or 4 times a year, to which he replied, to my surprise, that it didn’t seem necessary. True, I played my hand first, and he didn’t protest too much at my request to be seen that frequently, but I’m sure he would have settled for less.

What did this tell me? It told me that from his review of my file, and the physical examination, that I was a fairly “healthy specimen” compared to his patient base. I think his view of me was also influenced by my comment that I thought my previous doctor, of whom I was very fond – he saved my life, I used to tell him – had perhaps “milked the system” to help “pay the rent.” But I say this about others too, like my auto mechanic: I know I am helping him make his boat payments.

What this also told me was that my desire to be seen 3 or 4 times a year was being driven by my desire – that it was not “medically necessary.” Of course, my desire is in no small part influenced by the fact that I am on Medicare and I have good supplemental coverage. The result is that, since my doctor accepts Medicare (and must accept the Medicare allowed amount as “full payment,” and my supplemental pays the remaining 20% of what Medicare allows, I have absolutely no co-pays and a very low annual deductible. So, since I have “no skin in the game,” I can see a doctor as often as I want without any financial outlay (beyond the annual deductible). I think this is a lousy way to pay for medical care, but it is what it is.

My desire to be seen 3 or 4 times a year also gave me some insight into what motivates me to want to. Now, no offense intended, doc (I think he reads the column sometimes, and certainly will read one titled “Why Go to the Doctor”); but, I don’t go to see him for his personality. Although his is great; he is always positive, conversational, jaunty, indeed, almost bubbly. And, interestingly, besides being board certified in his specialties, he holds a PhD – a Doctor of Philosophy. How cool is that! But, on the specific treatment modality for type 2 diabetes that I follow, nutritional therapy, I bet I could hold my own – no, I daresay, I would whoop him handily on any “certification” examination.

But that’s all beside the point. In areas where I have no expertise at all, e.g., the medical aspects of diagnosis and treatment and etiology, pathophysiology and therapeutic interventions for the diseases of Western Civilization, there is of course no contest. So, one could say that is good enough reason to go to the doctor. And it is one of the reasons I go to see mine. But, as I said, my doctor (and I) see me as being “healthy,” for the most part. So, I don’t have to go to the doctor 3 or 4 times a year to monitor that. What other reason(s), then, do I have for more than, say, an annual or semi-annual visit?

The answer, my faithful readers, is to monitor the metrics that I use to track my diabetic health. Note the emphasis that I put on “that I use.” That is because the metrics that I use are very different from the ones my doctor uses.  In fact, my metrics differ from virtually all doctors who follow the government’s and the medical association’s and the insurance agency’s guidelines for the management of type 2 diabetes. I don’t want to get into the reason(s) for those differences here – I tend to go off on a rant when I do. I’ll explain more fully in the next column.  I just want to point out and stress that if you do the same, that is, rely on the standards that your doctor uses, you do so at great risk to your health. I’m sorry, doc, but that’s the truth, folks.

I have written on this subject before, and will again, as I said. It could become my mantra. And it certainly deserves articulation and recapitulation (as in the musical sonata form where the exposition is repeated in an altered form). Understanding this point is crucial to the type 2 diabetic who is taking responsibility for his or her own healthcare and has chosen to do it “through diet…mostly,” in the words of David Letterman in his recent conversation on TV with Tom Hanks.

So, to repeat, if you leave the evaluation of the measurement of your health to your doctor, most of whom will rely almost entirely on the standards which they must follow to assure that both they and you get covered by your insurance, you will, in my opinion, be poorly served. That’s a bit strong, but that’s the truth.

Bottom line: the main reason I go to the doctor is for a lab report. And until I have him trained (sorry, Doc) in what I am interested in knowing each and every time I go (and which my insurance will cover), I may have to ask for what I would like to have tested. Of course, his office weighs me and takes my blood pressure, as I do at home. I also test my fasting blood glucose daily for discipline and as a reminder and a “check.” It’s the other blood tests that I want: the lipid panel, the A1c, the C-reactive protein, and once a year the thyroid tests (free T3, free T4 and reverse T3) and kidney function tests (creatinine).
Last week a copy of my most recent tests arrived in the mail. My doctor is good about that; I don’t have to request it. And the lab report is accompanied by a modified form letter too. That’s nice. My blood pressure, by the way, was 110/70 (on meds). The lab test results: Total Cholesterol = 217; LDL = 122; HDL = 85; triglycerides = 49; A1c = 5.7. My fasting blood glucose, though, was 109mg/dl (!). I don’t know how that happened. It was 89mg/dl when I left home three hours earlier.


  1. My sugar is always higher with a blood test from a vein at the doctors office. At home with the kit you stick a needle in your finger and test it, it is always under 100 fasting in the morning(89 to 95). At the doctors it always is over a hundred 110, 111. I know they say from the vein it is a percentage higher.

  2. Hi Angelo,
    I don't really fret over the differences, and my sense is that you don't either. I have had serum (venus) reading very similar to my own, and they are frequently below 100, as are my home tests of capillary blood. I don't have a good explanation for the differences and would note that there are several variables: 1) 3 hours time difference from the time the blood was sampled, but many more before the blood taken in the office was tested in a lab in another state! ; 2) testing error (by the lab); 3) accuracy of the home test, although they were consistently in the high 80s/low 90s for several days in a row.

    I do not experience "dawn phenomenon," which would have put my fasting reading at home higher. They say that that is a spike in glucose that the liver provides to give someone a spurt of energy upon rising, in contrast to the 'resting' state of the metabolism while sleeping. That would have been the reverse of what I had experienced this day. In any case, I know I fasted my my serum insulin must have been very low, and that was what was important to me. The lab report kicked this 109 reading as 'out of range,' but neither the doc nor I was concerned.

    I was reading the ADA magazine while in the optomotrist's office this afternoon and saw a letter from a woman who said her "morning" readings were 160-180dl/mg and she didn't know what to do about it. The doctor or RD/CDE responded that "type 2 diabetes is a progressive disease" and then proceeded to tell her she would have to add another class or oral med to the two she was already taking. That was where I was 11 years ago. Thank goodness I learned there was another way!