Friday, August 23, 2019

Retrospective #188: “Older Patients with T2DM and Co-morbidities…”

A story in, “Older Patients with T2DM and Co-morbidities Don’t Feel Heard,” got my attention. Diabetes in Control is a weekly digest of articles primarily for physicians who treat patients with Type 2 diabetes. The lede was, “Most adults with T2DM have at least one co-morbid condition, and almost half of them have three or more.” The most commonly reported chronic co-morbid conditions were hypertension, arthritis, retinopathy, hypercholesterolemia (high cholesterol), coronary artery disease, and neuropathy.
The source for the story, a study in Clinical Diabetes, was making an important point about patients being heard. All patients in the study were ≥ 60 years old, white, highly-educated and had good glucose control.  That’s me. It relates how difficult it is for a “new” patient to get the attention and cooperation of a physician when, in his or her professional opinion, the “proper care” differs from the patient’s opinion.
This is, after all, seen as justified by the physician. The patient is just a layman with no professional liability for malpractice, no risk of sanctions from medical practice boards, or loss of reimbursement from Medicare and supplemental insurance for not following professional practice standards and guidelines. But I’m spoiled. My doctor (now deceased), who treated me for over 20 years, set me on the course of eating Very Low Carb and oversaw the complete turnaround of my progressively worsening T2DM from “out-of-control-on-3-oral-diabetes-meds” to “in-remission” on a minimum dose of  just one oral (Metformin). He has my everlasting gratitude.
My “new” doctor is also great. He reviewed my “history” and told me to just, “Keep doing what you’re doing.”  That’s great! My physician (and I) determine the risks and benefits of me not following “treatment guidelines.”
But not every doctor is willing to do that. The Control piece said: “Many participants also felt that their preferences for care were not taken into account by their provider. Participants also reported feeling that their care was not addressed to their individual needs and medical history, and desired more tailored treatment regimens specific to their needs. Generally speaking, patients want to have more interaction with their providers so that they can discuss the difficulties they are experiencing and vocalize their preference for treatment.”
It concludes, “Effective patient-provider communications and shared decision-making have been shown to not only improve patient satisfaction, but also increase adherence to treatment plans and improve health outcomes.”
Setting aside the “empathy” and “older age” aspects of these criticisms (I personally have not felt either in my interactions), I note how “their [the patients] preferences were not being listened to,” is a recurring theme. Two things came to mind. 1) I am dead set about not taking a statin (again). I did 5 or 6 years ago (before I knew better), but my doctor discontinued it. Today, however, especially with the new AHA/ACC guidelines, I am still considered (by most doctors) a candidate for a statin. Personally, I consider my latest lipid test lab results to be stellar: TC = 207, HDL = 90, LDL = 110, TC/HDL ratio = 2.3 and triglycerides = 34. And my Trig/HDL ratio (0.38), a powerful statistical indicator of cardiovascular risk, is also stellar. And, when they were last tested, my LDL particles were Pattern A (large, buoyant and fluffy). Many doctors would not prescribe a statin with these lipid “labs,” but some would, and the new AHA/ACC guidelines dictate that I should take one. But “my preference” is a definite “NO!”
Then, 2) theres the question of diet. What should I eat? Should I follow what has worked for me for the last 11 years, resulting in my losing and keeping off (currently) 145 pounds? Or, should I eat what the AHA or the Dietary Guidelines for Americans tell me to eat? Once again, “my preference” tells me that I know more about what diet I should eat than the USDA/HHS. My n = 1 experience, aided by frequent testing, has taught me what to eat.
As reported in the Medscape Physician Lifestyle Report 2014, 68% of overweight or obese doctors eat a Typical American, AHA, or Mediterranean style diet. Just 14 percent eat a “Weight Loss (calorie restricted or otherwise) Diet,” 5% a “Paleo” style diet and 11% various other diets. I suppose, Very Low Carb, LCHF, Keto or even Atkins Induction were included in the 11% various other diets, but most physicians wouldn’t admit to such heresy.

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