July 18, 2008

49% of all Doctors Were in the Bottom Half of Their Class

And sadly, many of you are seeing them.

For many of us it doesn't make that big a difference. We know what we have to do, we know what prescriptions we need to get to do it, and our doctor is just a handy helper who gives us the tools we need to maintain control.

But every now and then I hear from someone who is doing everything right and getting terrible results. They are eating low carb and seeing blood sugars over 200 mg/dl. They are injecting heroic amounts of insulin with a low carb intake and still seeing blood sugars over 180 mg/dl. Their weight is out of control, though they are eating the right number of carefully counted calories and are exercising. And their doctors don't have a clue what is going on.

That is where having a mediocre doctor can really hurt you. Mediocre doctors suggest weight loss surgery to people whose real problem is thyroid disease or Cushings. They tell people who can't get control with diet and oral drugs that living with an 8.5% A1c is preferable to using insulin because insulin will make them gain weight.
Or--and I have been hearing this a lot lately--they tell people that there is no reason to treat "pre-diabetes" even when these people are thin and have blood sugars that are rising swiftly and when they have a strong family history of diabetes and autoimmune disease.

If you find yourself dealing with a blood sugar issue that is not responding to the standard treatments that work for 80% of all people with Type 2 Diabetes--that is: cutting way down on carbs, exercising, and using a carefully selected oral drug and/or insulin--don't let a mediocre doctor ruin your health.

Unusual results require that you call on the services of a brilliant, top notch doctor. These doctors are rarely found practicing in small towns and suburbs. They are rarely found practicing out of community hospitals. The very best doctors, like the very best professionals in all fields, gravitate towards institutions filled with other brilliant leaders in their field where they can participate in cutting edge research and make names for themselves.

In short, you'll find these doctors at hospitals associated with top notch universities--the so-called Teaching Hospitals. They hold appointments as Professors of Medicine at top schools like Harvard, Stanford, or the University of Chicago. They teach, write, and publish research.

Because they practice at medical centers where other doctors refer their most difficult cases, they are likely to have seen lots of people with unusual, difficult to diagnose conditions. That means that when you show up with one of these conditions, they are far more likely to recognize it.

That is why when you have something unusual going on, these are the folks you need to see. Because if what your doctor has called "garden variety Type 2 Diabetes" is not responding to the treatments that normalize Type 2, it is possible you don't have Type 2 diabetes at all.

You may have early Type 1--in which case early intervention may make life-long control far easier because you may be able to preserve some of your beta cells. You may have an adrenal tumor which causes diabetes as a side effect of uncontrolled cortisol secretion. You may have undiagnosed thyroid disease. You may have pancreatic cancer. You may have any number of other unusual conditions that only a endocrine specialist would know about--conditions that have high blood sugar as a symptom along with other symptoms which point to another disease.

Even if you really have some form of Type 2 Diabetes, it may be an unusual form that requires a different treatment from whatever expensive drug or device the drug reps are pushing on your family doctor this month. And to find that treatment you need to see someone who graduated at the top of their class and who has devoted their career to keeping up with the latest in the field.

Think of it this way: You can take your Honda to Joe's Garage when you need a brake job, but you wouldn't take your Lamborghini there.

I don't know why it is, but when I suggest seeing these specialists, a lot of people give me long arguments about why they can't. Often it boils down to the fact that they are afraid of wounding the feelings of their nice, friendly family doctor--the same doctor who has been unable to diagnose or treat a condition that is worsening by the week.

At other times they fear that their insurance won't cover such a visit, though it often turns out they have not done the checking to find out if that is true. In many cases, the services of the specialists associated with a top university are covered just as fully as those of the guy down the street whose last formal training in diabetes care took place in 1983 when he completed his residency.

In other cases, you will have to petition your insurer to see the specialist, but you can do this via an appeals process. Worst case, if you know you need specialist services, you may have to switch insurance plans to one that has broader coverage or lets you go out of plan with a higher copay.

If you don't have insurance, it may come as a surprise to learn that the true experts aren't any more expensive to see than the piker down the street, and it is possible that the teaching hospital's social service department can help you get treatment if you can't afford to see the doctor and have evidence of a serious medical condition needing care.

In any case, the cost to you of ignoring the symptoms of a serious medical condition will be far higher over the long term than the costs of seeing someone who can sort out what is going on and get you the correct treatment.

Here's a check list to consult in making the decision of whether or not you need to see a true specialist practicing out of a top medical school-associated Teaching Hospital:

1. You have cut your carbs to no more than 15 per meal, but even with oral drugs and insulin you still see blood sugars well over 140 mg/dl at every meal.

2. Your weight is dropping dramatically even though you are eating what should be enough calories for your age, gender, and size.

3. Your weight is rising dramatically though you are eating carefully measured portions of food which you have been logging conscientiously.

4. Your blood sugar control has been deteriorating very quickly over a period of several months despite your limiting carbs, taking oral drugs, and exercising--especially if you have a family history of autoimmune disease or Type 1 diabetes.

5. Your normal child has abnormal blood sugars--fasting over 100 mg/dl and post meal numbers over 140 mg/dl at 2 hours but your family doctor tells you that "pre-diabetes" doesn't require any treatment. If your child is not obese, it is even more critical that you get to a true specialist. If there is any history of autoimmune disease in your extended family and you see your child's blood sugar rising from month to month you MUST see such a specialist--the faster, the better. There are research programs going on now exploring options for preventing Type 1 diabetes and your child may qualify for them. Only a specialist at a top Teaching Hospital may even be aware of these programs. Early intervention can make a huge difference in your chlid's long term ability to maintain normal blood sugars.

You can help ensure that you get the most out of a visit to a true specialist if you prepare for the appointment in advance. For two weeks before the appointment, carefully log what you (or your child) ate at each meal and what blood sugar tests showed at 1 or 2 hours after eating. Note fasting blood sugars. Note daily weights if weight control is an issue. Bring copies of your lab work. Do not depend on your doctor to forward them. Often their staff forgets. You have a right to copies of all your lab work, though you may have to fax permission to the lab to release the results to you, or even have to visit the lab to obtain your copies. Whatever it takes, do it. If the specialist cannot see your previous lab work the appointment may be a waste of time.

Bottom line: If something strange is going on with your body, you need to see the very best doctor and the very best doctors practice out of the very best medical school hospitals.


Lili said...

Totally! What frustrates me to no end is there's not much support about this, even from other diabetics. I guess I don't understand the argument that because other people *can't* have better bg control (because it's physically impossible or what have you), it's wrong for someone else to try. Wrong to try! WTF.

It took me a long time to find a doctor who was willing to work with me, but it was so worth it.

Anonymous said...

You sound completely correct and I am going to look into University Hospital doctors. Most doctors that I have seen at public hospitals give a bad diagnosis and the medications are completely wrong. I think everyone should see a doctor they feel comfortable with and trust.

Arun.N.M. said...

I dont know to which category I belong.My patients should say that.I was in the top 10% of my class.Otherwise I wont b a doctor.I am not working in a big city medical school,but still I get consultations for difficult cases including uncontrolled Diabetes.

I feel it is always better to get a reference letter from your treating doc before going to a higher centre.Your doctor may also be able to guide you to select the appropriate consultant.

Many times I had seen patients going to a wrong consultant with a pre conceived self diagnosis[may be not in Diabetes] being made to do a hell lot of investigations without reaching a proper diagnosis.

Harold said...

49% of any group marked on a curve are in the bottom half of their class. It might be that those in the top of the class were more easily brain washed by those that believe the low fat high carb paradigm for the treatment of diabetes and therefore got better grades?

Anyway physicians today go through 3 to 5 years or more of post grad training before going into practice. I would argue that where they got that training and how they did in it is more important than their grades in med school.

Anne said...

Just because doctors are working at a university hospital does not mean they are going to be better than those in the community. My university PCP, cardiologist and neurologist all ignored two positive GTT's years ago because my fasting BG was "normal". I was sent away with the instructions to eat a "heart healthy" AMA approved low fat diet. Every year I was given another FBS and told I was "fine".

Now I am using a low carb diet and with the help of a glucometer, keeping my BG below 140.

I now have a PCP in the community who is willing to work with me. I am still looking for a cardiologist - mine retired.

IMQTPI said...

Amen, Jenny!

Thank you for steering me to a teaching hospital! I'm extremely fortunate to live near Stanford (and I, too, had the endless list of "why I can't do this" all ready to go - but now I'm *very* glad I followed your advice!)

My T2 diabetes wasn't responding appropriately to insulin or L/C dieting. And my doc was all set to sign-me-up for bariatric surgery or put me on a high-carb/low-fat [ahem] "healthy" diet - neither of which would have addressed my problems.

Thankfully, the endocrinologist at Stanford recognized that there was "something more" going on, and I'll be undergoing tests for other, more plausible, metabolic conditions (Cushings, in my case)...

It's too early in the game to get *too* hopeful, but I find it encouraging - and extremely refreshing - to deal with a medical professional who doesn't immediately assume that I've "eaten my way" into my current health state...

Anonymous said...

Couldn't agree more.
Plus another important factor, doctors who don't really know what they are doing are going to watch their patients inevitably disintegrate and are going to conclude this is going to happen anyway so why bother doing more or learning more.
Yest another piece of circular logic with which diabetes is surrounded.