Retrospective #446: “Docs’ Beliefs” prevail…

Thank goodness for the headline in this Medscape Medical News story by Miriam E. Tucker: “Docs’ Beliefs Guide Prescribing of Glucose Monitoring in Type 2 Diabetes.” It means they still prescribe routine self-monitoring of blood glucose (SMBG) in patients who aren’t treated with insulin (or a sulfonylurea). The danger from insulin or a sulfonylurea (e.g.: micronase, glyburide, glipizide) is hypoglycemia (low blood sugar), so a CGM would be better.

That doctors still do this is enormously encouraging to me, a type 2 for 34 years who takes a fasting reading every day, for motivation, and recently had an A1c of 5.0%. It is troubling to me, however, that several doctors said that they prescribe SMBG less than they did 10 years ago, when their professional societies were encouraging the practice.

The evidence to stop prescribing SMBG, described as “qualitative data,” was presented here in The Annals of Family Medicine by a medical student at the Cleveland Clinic. The student told Medscape that “for patients who do not take insulin, the preponderance of evidence shows it increases cost without improving HbA1c.” Talk about “out of touch.”

Patients need awareness and motivation. You need to do something with the information. You need to make wise choices about what to eat. You need to not rely solely on your doctor to treat T2D with drugs. Self-monitoring of blood glucose provide information and have aspirational and motivational value. The medical student seems to acknowledge this, though. He does say “our study addresses the physician perspective, but there’s also the patient perspective.” Her team’s next step will be to assess patient’s perspectives. Brava, I say. There’s hope for this future clinician.

But the abstract, co-authored by half a dozen MD/MPHs at the Cleveland Clinic, make it clear where this study is going. It states, “The majority [of primary care physicians] continue to recommend routine self-monitoring of blood glucose due to a compelling belief in its ability to promote the lifestyle changes needed for glycemic control. Targeting physician beliefs about the effectiveness of self-monitoring of blood glucose, and designing robust interventions accordingly, may help reduce this practice.” This is what medical students are being taught today. They’re myopic and, worse, narcissistic. One physician said, “I try to steer non-insulin dependent patients away from testing at home, mainly because it doesn’t change WHAT I DO. I monitor their diabetes based on the HbA_1c and occasional sugar checks.” It’s me, me, me, me… No thought or consideration to what the patient can do to control their blood sugars.

Okay. There can be exceptions; if you believe that your patient has “low health literacy or physical or cognitive impairment,” then it goes without saying the patient’s diabetes care should be solely in the hands of a health care provider. This may include those who have daily home health care, are hospitalized or institutionalized. But for the rest of us? Are we not capable of participating in the management of our own health care, especially with a condition that is entirely dependent on what we eat for optimized management? But therein lies most of the problem…

Most physicians seem to not accept that type 2 diabetes is a dietary disease. Nor do most patients. Doctors know it, or should know it, given their training in human biology and physiology, but to admit it would require that they repudiate everything they have been telling their patients about nutrition for over 40 years. I don’t blame them for following the guidelines of their medical associations and the prescribed Standards of Practice. It would be hard to look the patient in the eye and say, “I've been wrong all along. It's all been a big fat lie.” (apologies to Gary Taubes)

But that isn’t necessary. A doctor who believes in “patient-centered care” has the option of leaving the daily management of patient’s blood sugar control up to the patient. After all, the clinician only sees the patient a few times a year to monitor their T2D condition, and modify their medical therapy. But the patient has the opportunity multiple times every day, at every meal and in between, to make wise choices that will improve their condition. Take your medication (if you still need it), and make wise choices about what you eat! Hint: eat fewer processed carbs and simple sugars.

Self-Management of Blood Glucose (SMBG) is thus the best way for patients to educate and motivate themselves. If by prescribing SMBG the doctor’s beliefs contribute to the patient’s self-care, that’s a good workaround! Bravo!