October 25, 2010

Understanding Doctor Fails

Picture this: Your computer won't turn on, so you take it to the repair shop. The guy there tells you it's going to cost $60 for him to take a look at it. You leave the computer with him for two days. You pick it up, pay your $60, but when you plug it in at home you find it still doesn't work. The problem, it turns out, is that the repair shop you took it to was a car repair shop, not a computer repair shop.

This is a silly story, of course, because no one takes their computer to a garage to get it fixed. But sadly, something very similar exactly what happens to many of us when we take our malfunctioning diabetic bodies in to family doctors for repair. We assume they are experts in the diagnosis and treatment of blood sugar related medical problems when in fact, this is not true. Many doctors have been taught very little about how to diagnose diabetes and even less about how to keep it from ravaging the body.

To understand why, you have to understand how doctors are trained. In medical school they learn anatomy. They dissect bodies and learn the location, names, and perhaps the function of hundreds of organs and tissues. As far as diabetes goes, they learn the location of the pancreas and its anatomy, and may be shown the damage done to tissues by diabetes, though they will not be told that it is the high blood sugars people with diabetes live with that cause the damage, not some underlying disease.

After mastering anatomy, doctors are taught to recognize the symptoms of hundreds of common medical conditions, among which is Type 2 Diabetes. This is where they learn "diagnosis."


Doctors are taught that Type 2 Diabetes is a condition diagnosed by a fasting blood sugar test over 125 mg/dl. Unfortunately, many people, including most women, develop dangerously high post-meal blood sugars years before their fasting blood sugar is high enough to provide a diagnosis.

And to make it worse, since the diagnostic cutoff was arbitrarily set to 140 mg/dl until just thirteen years ago, many doctors practicing now who were trained before 1997 still secretly think diabetes isn't serious until fasting blood sugar reaches at least 140 mg/dl and because of this, won't treat diabetes aggressively for years after a patient is initially diagnosed until the fasting blood has deteriorated to where they consider it really diabetic. While they are waiting, high blood sugars are ravaging your organs.

A few doctors are taught to diagnose diabetes with a 2 hour oral glucose tolerance test and consider a 2 hour reading over 200 mg/dl proof of diabetes, but these same doctors often ignore 2-hour glucose tolerance test results when the one hour reading is over 200 mg/dl even though the official diagnostic criteria that define Type 2 Diabetes also state clearly that a person should be diagnosed as diabetic if they experience two or more random blood glucose readings over 200 mg/dl no matter when or how they were obtained.

On top of this, the growing reliance of family doctors on the A1c test they can do in thier office is causing even more doctors to fail to diagnose diabetes, as I discussed HERE.

All this explains why so many doctors fail to diagnose diabetes in a timely fashion and why so many people are walking around with diabetic blood sugars for years before they are finally diagnosed.


In medical school, doctors memorize the standard treatment recommendations for hundreds of different conditions. But since diabetes is just one of these many hundreds of conditions whose treatment they must memorize to pass their medical boards, they can give it perhaps a day of study, or perhaps only a few hours.

What they are taught is that people can avoid diabetes by eating "right" but doctors do not take courses in nutrition in medical school so they rarely know anything about how different foods affect the body or what diets actually lower blood sugar.

After doctors receive their degrees, they go through one year hospital internships followed by multi-year residencies, also usually in hospitals, where they work with more experienced doctors and treat the medical crises that bring people to hospitals.

During these years they will treat many people with Type 2 Diabetes--but only after decades of poor blood sugar management have caused these people to experience medical crises like heart attacks, amputations, kidney failure, or diabetic blindness that bring them to the ER.

Nowhere in his training with your doctor encounter healthy people with Type 2 Diabetes whose health is normal because they control their blood sugar and keep it at normal levels. He will not be taught that it is possible for people with Type 2 Diabetes to keep blood sugars normal and live normally healthy lives.

With this kind of training behind him, when your doctor sees a person with Type 2 who is not suffering from a major complication, he thinks they are doing very well no matter how bad their blood sugar might be. In fact, your blood sugar will have to be very bad indeed before your doctor takes any steps to improve it.

Most doctors do not prescribe any drugs to patients with Type 2 Diabetes until they have had an A1c over 8% for at least a year. This corresponds to an average blood sugar of 183 mg/dl, which is one high enough to wreak significant damage on organs. (Details about what sciences has learned about what blood sugar levels produce complications can be found HERE.)

After a patient has spent enough years with high blood sugars that they do start looking like they are headed for a severe medical crisis, doctors prescribe oral drugs--usually whatever the drug reps are pushing the hardest, even though there is a lot of evidence that prescribing insulin very soon after diagnosis--before damage has set in--results in far better outcomes years after diagnosis, even when patients only take insulin for a short while. (Details HERE.)


Once a doctor completes his residency and goes into private practice, 99% of his "education" about Type 2 Diabetes comes from people in the pay of drug companies--salespeople and other doctors who are taking huge "consulting fees" from a drug company to "educate" other doctors about how superior that company's drugs are supposed to be.

As a result,doctors are not informed about the serious side effects of these newer drugs until they have harmed so many people the FDA steps in. Even then, drug company flacks will provide a steady stream of reassurance about a dangerous drug until it is removed from the market (which usually takes 5-12 years after it starts injuring people.)

Doctors also learn little or nothing about non-drug treatments except for those that have been branded and are earning someone a lot of money. This is why when you learn about any diet from a doctor it usually has some other doctor's name (and financial empire) associated with it.

The rest of your doctor's medical knowledge comes from newsletters, heavily sponsored by drug companies. These distill a few gems of diabetes research into a headline and a one paragraph summary. These summaries cannot not explore the details of the research that can contradict the statement made in the headline that accompanies it. And when a highly promoted study funded by a drug company is debunked by academic researchers their studies often do not make it into the newsletters.

Since your doctor does not have the time to keep up with the thousands of studies concerning the hundreds of conditions he must come up with, he has no choice but to rely on these newsletters. Unfortunately, after reviewing them for almost a decade I have come to believe that 90% of what they tell doctors about appropriate treatment for their patients with diabetes is out and out false.

With this in mind, you can see why you so often come back from a visit to the doctor without anything more than a prescription for another expensive, side-effect laden oral drug. Your doctor does not have the time to learn all the ins and outs of diabetes. He does not have the time or interest required to read and analyze research or to hunt for better treatments for his patients. He does not begin to understand what is really raising your blood sugar or why you have so much trouble losing weight.

Until you have a medical crisis--a heart attack, amputation, or diagnosis of end stage renal disease--you doctor does not consider your case to be important, and in any event he believes that the drugs he can prescribe will only delay your ultimate and very unpleasant fate. So the faster you are out of his office so he can treat someone else whose condition is not their fault and who he might be able to help, the happier he will be.


In fact, it is possible for people with diabetes to achieve normal blood sugars, maintain them for years, and avoid developing new complications or seeing existing ones get worse. Details HERE. A very small sample of the success stories people send me can be read HERE.

Once you understand what is at stake and what you can do to improve matters, your doctor can even become an ally in your search for health--as long as you understand his limitations and do not expect him to do the hard work involved in teaching you what you need to know to regain your health.

With all this in mind, I'd like to offer you these tips:


1. Don't expect your doctor to know very much about diabetes. Educate yourself by reading books. You can find a selection of useful diabetes books listed HERE. You can also learn a lot by interacting with others online with Diabetes who will share what they've learned with you. You can find some support groups listed HERE. Keep in mind that each of us is different and what works for one person may not work for another, but feel free to try out different approaches people who are in excellent control themselves suggest until you find the one that works for you. Just be sure when you take advice that the person giving it knows what good control means. You can learn what blood sugar levels are associated with complications HERE.

2. Get your doctor to prescribe a blood sugar meter and testing strips. Armed with this powerful tool, you can easily determine which foods are safe to eat and which foods raise your blood sugar to damaging levels after you eat them. The meter will give you a much better idea of what it is safe for you to eat than any doctor will. Only by testing the food you eat can you find out which foods allow you to keep your blood sugar from rising into the danger zone.

3. Do not take any drug your doctor prescribes without researching it. Doctors are woefully ignorant about side effects and may brush off reports of side effects that are signs of very dangerous conditions.

Because drug companies have shown themselves perfectly willing to lie about their drugs' real side effects and to mislead doctors about their effectiveness, you cannot trust that your doctor is aware of the real dangers of prescription drugs.

I have been keeping up with news about the commonly prescribed diabetes drugs for almost a decade and you can learn what research has found about all of them by following the links you'll find HERE. You can also search this blog using the Google search at the right, to find posts about various drugs. Updates to the main Blood Sugar 101 site are tracked on a separate blog HERE.

When prescribed a drug for some other symptom or a diabetic complication, the best way protect yourself against the dangers of drugs is to learn how to read the official, FDA required Prescribing Information published for each drug.

You can find these online. They often include terminology unfamiliar to non-medical people. Usually you can use Google to find a medical dictionary that will translate these terms. If you need help, stop by one of the many online diabetes discussion forums where you will be able to find people who can help you interpret what you read.

The prescribing information will tell you how effective the drug really is and what factors might make a specific drug dangerous--for example pre-existing conditions or interactions with other drugs you might also be taking. It will also warn of the side effects associated with the drug, though sadly it will not tell you which are temporary and go away when you stop the drug and which are permanent.

Drug companies mix trivial side effects with the ones that ruin lives and give no hint to doctors which are which. Doctors are so used to people reporting the trivial side effects that they often ignore the serious ones. If you suffer a known side effect from a drug--for example sinus headache from Januvia, or muscle aches from a statin drug--do not assume it is trivial. These kinds of side effects may often indicate a more severe problem that left untended can harm you. (Immune system problems with Januvia and muscle wasting from statins.)

4. If your family doctor can't help you with a serious problem insist on seeing a specialist. Specialists get more in-depth training with a narrower subset of conditions.

But that said, don't assume that a specialist is competent just because they claim to be. Sadly, many of us have learned that the world is full of incompetent specialists, including endocrinologists. Doctors often refer you to specialists with whom they network--usually doctors that practice out of the same hospital, and may be ignorant about which doctors in your region are really the most competent.

As a rule, specialists practicing at prestigious regional medical centers are more likely to be competent than those practicing out of small community hospitals that only handle routine cases.

The good news is that most people with Type 2 Diabetes can do extremely well with a combination of self-education, meter-testing their diet, and the use of safe drugs like Metformin and insulin which have survived the test of time. The less you trust that your doctor is the expert, and the more you use your doctor as a resource to prescribe you the tools you have learned about that that can help you safely regain your health the better off you will be.



vivian said...

Massively important and helpful post. I'm saving this to pass on to newly diagnosed friends and relatives. Thank you.

Ned Kock said...

Very true. Glucometers and test strips can be purchased without a prescription, and are very inexpensive. Many lab tests are also available in pharmacies at reasonable prices without a prescription (e.g., A1C tests).

Jenny said...

Ned, Strips are available but none of them are "cheap" for many people in this economy. So if a person has insurance a prescription makes testing much more accessible.

The A1c test available at pharmacies is so innaccurate as to be a complete waste of money. I have blogged about the research that proves that HERE

I Trust My Body said...

"Get your doctor to prescribe a blood sugar meter and testing strips. Armed with this powerful tool, you can easily determine which foods are safe to eat and which foods raise your blood sugar to damaging levels after you eat them. The meter will give you a much better idea of what it is safe for you to eat than any doctor will. Only by testing the food you eat can you find out which foods allow you to keep your blood sugar from rising into the danger zone."

Excellent advice! Knowing your foods and their effects on your health ... that's 90 per cent of the battle right there.

ItsTheWooo2 said...

With all due respect, it isn't fair to say that family docs / internists do not take a new case of diabetes seriously. They do. Family docs and internists specialize in preventative care - this is their forte, they help outpatients, your parents and your grandparents, AVOID the complications down the road from all of their diseases (e.g. hypertension, a-fib, and yes diabetes).

Family docs do take these things seroiusly, that is why they give drugs for hypertension (even though it is asymptomatic, we take hypertension seriously because of how powerfully it can ravage the body with kidney failure and strokes and heart disease). This is why we give drugs for a-fib (strokes). Diabetes is also considered serious and doctors do think it should be managed as well as it can be.

GOOD family doctors (not all, but the good ones properly doing their jobs) will start their new/mild diabetics on metformin and other drugs, monitor their a1c, advise them on diet and lifestyle changes, teach them how to monitor their sugar at home, etc. Even women with PCOS who have not developed diabetes yet are often treated like diabetics and given metformin.

The problem isn't that family docs aren't trying... the problem is that the advise and treatment sucks ass. Most people who are diabetics need to be told flat out, frank out: stop eating carbs. Stop eating sugar 100%, and choose primarily protein, fat, vegetables. Avoid pasta, bread, cereals. Avoid carbs if you can. Eat fruit only in moderation. Avoid canned, sweetened, dried fruit. Avoid juice.
But docs are educated in shitty advice, taught to believe it's calories primarily, or glycemic index, or whole grains, just like the rest of the population. So the dietary counseling they give patients is like "eat whole grain pasta" and stupid crap like that. If family docs knew that a very low carb diet can pretty much entirely control mild diabetes most of the time, they would recommend it. The problem is they don't know. They think the diet they are advising is the right one (usually this ends up being some kind of "Mediterranean" based diet which still way too many carbs for a diabetic... or if the doc is totally ancient, they will advise a low fat diet that is low in sugar).

And, the really big problem is this: most diabetics - most people - don't want to make major changes to their diets. I recently visited one of the docs in my family practice I have been seeing most of my life. He pretty much flat out told me that advising dietary change to a patient is, and I quote "like talking to a wall".

Jenny said...


Having just come from a doctor's appointment where the room was festooned with pictures of baked potatoes and pale brown "wheat bread" displayed as examples of "Healthy eating for diabetes" I have to say what I've been saying all along.

If you give people a diet that WORKS they'll adopt it with enthusiasm. The hundreds of letters I've got from people who tried the "Test test test" approach confirms that.

It's when doctors give people with diabetes diets that don't work and that leave them starving (due to blood sugar spikes) and fat (due to stimulating insulin release) that they ignore the advice.

Most people with diabetes have been on every diet doctors recommend and seen them fail miserably. They don't try them because they HAVE tried them and they don't work.

I be the doctor whose office is full of posters warning about the dangers of saturated fat and urging patients to eat plain baked potatoes complains that none of her patients takes her diet advice, too.

ItsTheWooo2 said...

Your website attracts a very special patient. You attract the sort of patient who wants answers, who went out of their way to search out better treatment. Your experiences will not be representative of the experiences of a family practitioner who sees patients who are far less enthusiastic about taking charge of their health.

I have lost 160 pounds (and am now 115 pounds, so I visibly look very thin, so people ought to associate me with diet success). I have controlled PCOS and my reactive hypos entirely with this diet. I am also a registered nurse. Even though I am a living testimonial of what sort of diet is a good idea for weight control, in my experience, people don't even want to *hear* it. I see my overweight coworkers, diabetic coworkers and others chowing down on sugars and starches all the time. They just don't want to hear it.

There is an element of truth that people dont' necessarily want to make major changes to their diets.

I do agree entirely the dietary advice is bad and it needs to be changed (so that those who are willing to make changes will know what kind of changes to make)... but it's also true that a whole lot of people, most people in fact, don't even want to *attempt* to reduce sugar and starch in their diet.

PBER57 said...

Thank you Jenny. This is an important subject for diabetics.

I cant figure out why a group of Dr's dont specialize more on the internist level and start strictly diabetic clinics with the explosion of diabetes. They would have a thriving practice! Theres alot of us out there.

Could you imagine intial exams like Dr Bernstein gives for all of us at diagnosis! Wow they would hit it out of the park.

When I look at care reading various web sites @ Tu and Diabetes Daily it is pitiful the care many receive. My family Dr could care less about my blood sugar logs let alone my spikes.

Your own your own babe with this condition.

Jenny said...

Insurance won't pay for more than a 20 minute appointment. Bernstein doesn't take insurance which is why his services are priced beyond the reach of most people with diabetes. He isn't charging any more for his time than other doctors, but he gives his patients so much of it.

But that is the problem. And it's getting worse not better as insurance (and medicare) reimbursements drop.

We are on our own. Fortunately, though, Diabetes is one of the conditions where self-education can lead to extremely good results. If you look at your doctor mostly as a resource for getting prescriptions and testing, you can get by. But if you expect them to do something for their hefty fees or solve serious medical problems that emerge. Forget it.

I'm still going through miseries with my extremely erratic blood pressure. The attitude is, "We've done the tests, we've prescribed the drugs. We have no idea what is going on and yes, it could kill you. Get lost." And this isn't one you can figure out reading the research.