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 HbA1c 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!
No comments:
Post a Comment