Specialist

I can’t tell if the problem was the doctor, the system or my own perceptions and biases. Whatever the source, I found myself feeling judgmental and annoyed as I followed a pediatric specialist on her morning rounds recently. Sweeping into one patient’s room – at the hospital because of abdominal pain – the endocrine specialist proceeded to rapid-fire questions about diabetes. After a few minutes, the specialist concluded with: “I’ll be honest with you, I don’t think you’re taking your diabetes seriously.”

The patient looked at her disconsolately, as if to say, “Sure. Fine. You’re right. Diabetes sucks when you’re a kid and I DON’T care about it. And by the way, I’m here for my stomach pain.”

The specialist went on, offering her one of two insulin regimens. “You can do this one, which doesn’t offer very good glycemic control but suits unmotivated patients like you better,” She drew an illegible graph of glucose curves on the back of the patient’s food menu. Or, you could do this one, which requires blood glucose testing around 6 times a day but gives you much better control.”

The patient, of course, chose the “easy” plan, which still required 3-5 finger-pokes a day to check blood sugar and insulin injections as well.

Somewhere in the middle of this – I think when the patient chose her arduous “control” plan – she started to cry. The specialist waited impatiently, softening her voice imperceptibly, “Now, you don’t have to start that. We’ll take good care of you. Sometimes you need to hear the hard words.”

I stood there wondering what must be going through the mind of this obese teenager who already needed both oral and injected diabetes medications. She only recently arrived in this part of the country, doubtless because of some unstable situation where she lived in Atlanta. I wondered how many friends she had, if she liked the Pacific Northwest, what she was most afraid of at this time in her life. I surmised that kidney and eye disease – however dire – were not on the top of her list of current fears. I wondered if this was how the specialist treated all her patients. As we left the room, I got my answer. With a terse laugh, she said, “I make a lot of my patients cry.” Not hard to believe.

Sure, I was then and continue to feel imperious and rather self-important. I’m disapproving of this doctor’s bedside manner, and in watching her, I’m inclined to feel critical of specialist medicine in general. But I have to remember that as we stood in that room, my mind was filled with family medicine questions. We pride ourselves on our communication abilities; our ability to relate to patients and our genuine interest in people’s lives. But what do we have to show for it? Would a family doc have better motivated this recalcitrant teen to care about her diabetes? Do FP’s have better diabetes management outcomes than specialists? I doubt it. Maybe this specialist’s approach was a good as any other…since nothing NO approach has been successful so far in conteracting the allure of food and sedentary living.

Bottom line, healthy living is a less-appealing alternative to sitting around all day eating high-calorie foods. Most of us eat more calories that we need for breakfast. But, since so far neither approach seems to be working, I vote fro the one that is at least pleasant for the patient. The one that allows the doctor and the patient to work together and understand each other. When I end up sick, I’m pretty sure this is the kind of doctor I’ll choose if I’m given – unlike this patient – any choice in the matter.

Power Of Prayer

My favorite room in the entire hospital is the chapel. For a thousand reasons, many I’m sure you can guess or innately understand, I bathe myself in the serenity of the chapel as often as I can.

I was raised a Protestant Evangelical Christian (only recently learned this loong definitive categorization of my religion). People from my walk of faith believe in prayer. It’s a big deal. My mom is a self-entitled “prayer warrior” (the ‘war’ is with Satan and his demonic hosts). Her mother before her is regarded by all in the family also as a prayer warrior…but Yoda-level. My mom remains at Skywalker speed thus far.

My own place in this spiritual maelstrom is decidedly less interesting or remarkable. My problem is that I can’t figure out what I think prayer even does. C.S. Lewis said that prayer doesn’t change God…it changes us. But there are clear examples in the Bible where the faithful prayed to God in a clear attempt to change His mind. There are examples where human devotion and prayer did in fact change God’s mind.

Aside from the fact that I can’t figure out what prayer does, I still do it all the time. Daily. Through words whispered in the dancing light of our hospital’s chapel or written contemplatively in my journal. So, I must think it does something. What I do NOT believe is that is cures a kid of diabetes. So, in reading about a couple from my neck of the woods that recently let their kid die of ketoacidosis because they didn’t want traditional medical care, and instead only wanted to pray for her, I find myself angry at them. I can’t relate to them or find much validity in their thinking. Read the sad article here.

girl.jpgBut my position isn’t very theologically very sound, is it? I pray regularly, but if my daughter needs insulin, I wouldn’t dream of treating her with mere chants in a chapel. Yet I suppose that if I really believed in the power of prayer, I would have the faith of this girl’s parents; believing that her death is God’s will and for some greater good that I can’t see.

Frankly, I’ll never believe that, even if it means I don’t believe in prayer. Or God. I’ll fight to save my kids with prayer, and insulin, and radiation, and hyperbaric chambers if I have to. The great conundrum in the arguments for God’s existence is that the definition of him is incompatible with the world around us. The commonest definition of God is a being that is all-powerful, all-loving, and all-knowing. But when a beautiful 11-year old girl dies because her parents are on their knees begging God to save her instead of simply giving her insulin, at least one of those three elements of God’s being seem like they must be impossible. Either God didn’t know what was happening, didn’t care, or couldn’t do anything to stop it. The problem of evil is the Christian apologist’s greatest stumbling block. Evil like this – and endless other examples – is frankly impossible for believers to explain. Mixed up in all this are the brambles of free choice – i.e., if there’s a deer in the road, do you pray about it or hit the brakes?

And that’s just it…I believe the prayer should be mixed with insulin.  Neither should be separated; it took God-given brains to discover exogenous insulin in the first place.  I know there’s evil in the world, and that it contradicts the definition of the God I believe in.  I can’t explain this logical fallacy.  But prayer and action frequently disarm suffering, sometimes in surprising ways…and I can’t explain this either.

You Be The Doc – Gestational Diabetes

One of the more difficult things to deal with in medicine – I think – is borderline lab values. A huge component of most medical decisions relies on the patient’s latest labs; often the decision is almost perfunctory. But what about times when lab values are just barely positive? For example, a normal blood pressure is 120/80. What if a guy has 122/80? Is that hypertension? Should I put this disease on his problem list…there for insurance companies to see and thus charge him more for life or health coverage?

gdm6.jpgMost lab values can be manipulated to some degree. The entire field of biofeedback starts from this premise. In biofeedback models, the lab values can be changed by effectively willing your body to change it’s own parameters. If effect, you can think yourself to a lower blood pressure, lower cholesterol, more hair…maybe even bigger sexual organs I suppose. Go for it. Imagine big, big gonads if you want. See what happens.

Anyway, some people consider this mere quackery – I think it will be considered a fad in a few years – but some swear by it. And yeah, I’m sure there is some bridge across the Cartesian mind-body quagmire we’ve been wallowing in since Modernism awoke, but I’m not sure biofeedback is that bridge. Aside from whatever volitional input we may have on our bodies, there is the fact that all lab tests have margins of error associated with them. You hear about “sampling” error in all these perpetual polls in the presidential primaries. Obama leads Clinton 47 to 42 percent…but the margin of error is plus or minus 8 points. So Obama doesn’t lead anybody. He and Clinton are tied. Many of the good polling companies actually do some real statistics to come up with these numbers, brainball.jpgbut it doesn’t really matter much because none of us voters really care. All we care about is who’s gonna win the stupid thing? Who’s the prez gonna be? And, (for me) WHO’S FINALLY GOING TO PUT AN END TO DYNASTIC, BOURGEOIS RULE IN AMERICA?

Sorry, this is a blog, so I can digress and feel only a little bad. The points are that lab values are manipulatable both physiologically and statistically. The statistical manipulation – the margin of error, for example – exists because determining something like the amount of glucose molecules in a sample of blood isn’t exactly easy. There’s 2 major ways to do it, and a 3rd less-popular way as well. Each way is different from each other, so if you determine glucose values using Type 1, and then use Type 2, you have to convert one to the other’s value to even determine if they’re equivalent. The conversion is a math equation, not observational science.

Why does an average doc like me care about all these details? Well, these facts play out in my mind when I get a lab value that is juuuussst barely out of range. A positive value means the patient has a new disease that can affect their ability to get health insurance (a quaint little reality of this American health system I admire so much), but also can affect their care. One little lab value can determine if a person suddenly needs to take expensive medicines – brand-name cholesterol-lowering meds are a couple hundred bucks a month, for example. Or it may mean that they now qualify for surgical exploration to find a possible tumor. Some people have had things cut off of them – like breasts – only to find that they didn’t have cancer at all. This is called the false-positive rate and is one of the biggest reasons why I try very hard NOT to do even little tests on patients unless it really looks like they need it. Breast self-exams are a classic example of dangerous false-positive tests that lead to sometimes catastrophic interventions occasionally for no reason. **Disclaimer on this one: major controversy exists about whether or not breast self-exam are good or bad. This was just an example. Keep doin’ em if you do ’em.**

When pregnant, one of the things we screen for is gestational diabetes (we call it GDM). This disease only shows up during pregnancy, and often vaporizes just after the baby is born. It more resembles Type 2 DM than Type 1 in that it won’t really kill you in the short-term, but deranged glucose values give the patient headaches and lots of nausea and makes them feel pretty much miserable. The problem is that high glucose in the mom can lead to huge problems with the baby. First of them being that the baby can be, in fact, HUGE. But they can also end up obese in life. They usually end up with REAL diabetes. Being so big, there are risks for the delivery that aren’t pretty too.

gdm4.jpgSo, we need to avoid GDM. We screen for it by giving the mother an oral glucose test at 28 weeks. She drinks this sugary solution – absolutely disgusting…I’ve tried it – and then testing her blood sugar levels an hour later. This is a classic screening test: It has lots of false-positives, but fewer false-negatives. It’s reasonably good for catching GDM. But because of the fasle-negatives, we do a second test to try to filter some of them out, which is basically the same test with more sugar solution and blood tests every hour for 3 hours. People who have out of range glucose values for both tests, probably have GDM and need treatment which can include testing glucose values 3-5 times a day (rather painful, a bit bloody, and not cheap). The might also get insulin shots, based on the glucose values. They are usually sent for nutrition counseling to teach them how to eat basically no-carb foods. They also get regular ultrasounds every month or less to determine if the baby is getting too big, which may lead to C-section. And while we’re on the topic of false-positives, ultrasound becomes less and less accurate for determining weight as the pregnancy progresses. By the end of the 3rd trimester, the US could be off by as much as 2 lbs! An alarming US can easily lead to surgery when in fact the baby is of normal weight.gdm3.jpg

So, my patient had a 1-hour glucose test of 199. The cut-off is 150. That’s obviously positive – she qualified for the 3-hour test easily. The first test of the 3hr is a fasting glucose test (arguably the most important) and she was well under the limit. Her second test, at one hour, was also well below the threshold for GDM. Third test – at 2 hours – also negative. Then, at 3 hours, her test was 164. The cut-off was 160. She has a positive value. She may very well have GDM.

You be the doc. What would you do?

Here’s some possibilities:

A.) Bring her back for another 3h test, since they can be falsely positive (and, actually falsely negative). In other words, they aren’t always accurate.

B.) Give her the full-monty: regular US, daily glucose monitoring, insulin, diet counseling, weekly visits, evaluation for c-section

C.) One or two elements of option B – a partial intervention, so to speak

D.) Tell her the test is “fine” and leave it at that. Effectively, regard the test as negative, and tell her this.

E.) Bring her in and just test her glucose twice a week. Treat her if one of those values is out of range.

**I’ll describe what I did in a week or so.**