Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Monday, August 11, 2008

How Not to Treat Diabetes


This is the sound of a very angry dinosaur approaching.

Very nice 60-something patient with coronary disease, hypertension, hyperLDL, gout (the usual) and relatively mild diabetes. A1c's over the last two years ranged from 7.3 to 7.8%; ie, not perfect, but not horrible, MANAGED WITH DIET AND EXERCISE*. Already taking eight different meds for coronary disease, hypertension, hyperLDL, gout (the usual), so I was emphasizing exercise, diet and lifestyle management. Certainly considering adding some metformin at the next office visit.

So this patient is admitted for some chest pain (after going to the ER without calling me first) which was presumably found to be non-cardiac. (I wouldn't know; I never got any info from the hospital.) While there the blood sugar was found to be over 300. (I don't know if they checked an A1c; I never got any info from the hospital. ) I saw the patient in follow-up the other day, only to find out...(wait for it:)

They had added three (3) diabetes medicines:
  1. metformin 500 mg BID (not just once a day, but twice!!)
  2. glyburide 5 mg BID (not just once a day, but twice!!)
  3. Januvia 100 mg.
Three new meds; all at once. Not one pill; not two pills; but five more pills a day were added to the medication regimen, when the A1C isn't even over 8%.

Ok, all you cardiologists, (and endocrinologists; according to the patient one of them came by also) since you obviously weren't paying attention on the second day of your third-year Medicine clerkship back in medical school; does this sound familiar:
Start low; go slow.
Hello!!! That means starting only ONE new drug at a time and WAITING to see how the patient does on it. MONITORING patients over "time" (that means not all at once.) You're not going to fix the patient's diabetes in 48 hours by loading up on meds in the hospital.

Ok; this isn't working very well (since my hands are still quivering with rage) so I'm just going to have to try channeling the poor man's CrankyProf:

You ignorant idiot fucktards! Bacteria in the bovine stomach fermenting grass into bullshit do their jobs more intelligently than you. It's a wonder you figured out which end of the pencil to take your Medicine Boards with, especially since it was probably stuck up your ass to begin with. Scarier still is that ignorant innocent patients entrust their lives to you. Morons like you make me want to beat you over the head with a 2 x 4, just to try and knock some sense into you. Here's the only problem with that: Why ruin a perfectly good 2 x 4?

Still hopping mad; this approach is simply not working. I'll just leave it at this, then maybe go punch something:

Ignorant assholes posing as docs piss me off.

(*References: Exercise, diet and lifestyle management is the cornerstone of diabetes management.)


At Mon Aug 11, 05:49:00 AM, Blogger Jobbing Doctor said...

Hi Dinosaur,

I am a GP in England and we get this kind of Crap all the time. It is usually instigated by the pond-life end of the clinical spectrum, often by inexperienced younger doctors who don't think, or the ubiquitous quacktitioner who cannot think outside their tramlines.

I blog regularly about this. Didn't think it was prevalent in USA.


At Mon Aug 11, 09:11:00 AM, Blogger Nurse K said...

So this patient is admitted for some chest pain (after going to the ER without calling me first)

Just one little quibble---if have every risk factor for an MI, you shouldn't bother to call your PMD's office before going to the ER with chest pain unless it's something obvious like chest pain with cough or whatever. The heart muscle be dyin' while you're on hold on the phone, yo.

At Mon Aug 11, 10:12:00 AM, Blogger rlbates said...

Please, don't punch a wall and break your hand. This would be a good time to make yeast bread. My mother always said that kneading the dough (or punching it) was a great release of anger/frustration (and it's so much easier on your hands)

At Mon Aug 11, 12:40:00 PM, Anonymous Anonymous said...

Rather than ruining a 2x4 by using it for a task it is not designed to handle. I would suggest using the proper tool.

A Clue x 4. A tool specially designed to beat a clue into the clueless and sense into the senseless.

At Mon Aug 11, 02:52:00 PM, Blogger Pink said...

Sounds like the fucktard(s) who did that would have had one of those "never events" if the patient had stayed in the hospital for a wee bit longer. Perchance no payment might be the catalyist needed to call the patient's PCP? Or not. **shrugs**

At Mon Aug 11, 07:53:00 PM, Anonymous Anonymous said...

Maybe the hospital needed a good clinical pharmacist to do med reconciliation/discuss medication related problems before the patient left the hospital. They teach us pharmacists "start low, go slow", especially with the senior citizen patients.

At Mon Aug 11, 08:01:00 PM, Anonymous Anonymous said...

I am not justifying the overkill in the hospital.
But excuse me Dino, if your patient's HgB AIC was consistently over 7.0 then the PCP (that would be you right) was not appropriately managing the patient in clinic visits either. When talking about "ignorant fucktards, maybe you should also spend a little time looking in the mirror.

At Mon Aug 11, 08:56:00 PM, Anonymous Anonymous said...

I'm still trying to understand why one would add 3 meds. Maybe its the pediatrician in me, but we definitely don't shoot the whole wad like this.

At Mon Aug 11, 09:21:00 PM, Anonymous Anonymous said...

Where can I buy a case of Cluex4's?

At Mon Aug 11, 10:26:00 PM, Anonymous Anonymous said...

The PCP spews venom when he doesn't even know how to treat diabetes himself.
May I suggest reviewing the guidelines Lord Almighty PCP.

At Tue Aug 12, 12:19:00 AM, Anonymous Anonymous said...

I love the guy I sent to the hospital from urgent care with chest pain and a KNOWN previous history of cardiac disease--got his troponin, etc., etc., PLUS a hsCRP. WTF? Do you really need a CRP to tell you this guy is high-risk for heart disease? Hell, no, he HAS it. How much do you think was spent on that test that changed NOTHING? I'm guessing somewhere around $150.

At Tue Aug 12, 08:54:00 AM, Blogger Lynn Price said...

Do ER docs/nurses ask the patient if they have a PCP? If so, wouldn't it be prudent to interface with them so they can discuss meds? Docs get consults from other docs within the hospital, so it just strikes me as the logical/smart thing to do. Otherwise, don't cases like this turn into a right hand doesn't know what the left hand is doing?

At Tue Aug 12, 06:48:00 PM, Blogger Nurse K said...

Obviously, Lynn, we all know who does and does not have a PMD. If they don't, they're referred to one prior to discharge.

An A1c of 7.3-7.8% kinda sucks, no offense, there Dino. I've been a [type 1] diabetic forever, and my doctor'd be pissed if I had those #s all of a sudden. Why not metformin WITH diet and exercise and taper off the metformin if the glucoses normalize with diet/exericise? 7.3-7.8 correlates with, what, an average gluc of 190-200 or so? That patient is at risk for, at the very least, infections, dehydration, feeling like crap in the short term with those numbers. With his/her risk factors for other things such as heart disease, isn't aggressive management from the get-go indicated?

At Tue Aug 12, 09:22:00 PM, Blogger #1 Dinosaur said...

NurseK: If you think 7.3-7.8 "sucks", I'm glad you don't see most of my other (type 2) diabetics who usually live in the 8's, 9's and even 10's. Don't kid yourself! Diabetes control is far more within the patient's control than the Dr's.

Also, 7.3-7.8 correlates with an average sugar in the 160's-170's. (Calculator here.) Not great, but not 200's.

I never said I was happy with it, but this guy isn't the greatest about coming in for visits. He also bounces back and forth between me and his cardiologist, who always changes some of his medicines around (toprol to coreg) just for the hell of it. I have no problem starting metformin, but three new meds all at once!! Puh-leeze.

Lynn, you dear, sweet naif:

Everyone always asks if patients have PCPs. That way they can code the visit as a consult and get 50-75% more money for the same service. The ER asks, too; I'm not sure they pay attention to the answer. The problem is that they don't trust any tests they haven't run themselves. Hence the massive duplication of effort. The left hand wouldn't know what the right foot was doing unless it kicked itself in the ass.

At Tue Aug 12, 09:33:00 PM, Anonymous Anonymous said...

The ER never asks if the patient has a PCP, and it the patient tells 'em, they don't care. That's why occassionally they admit our patients to hospitalist service and don't call us.

At Tue Aug 12, 10:36:00 PM, Anonymous Anonymous said...

"I never said I was happy with it...."

But you were never unhappy enough to do anything about it now were you dino. Even if your (lack of) action is not the standard of care.

"I have no problem starting metformin, but three new meds all at once!! Puh-leeze."

Again dino where you you in this process? The hospital docs are not this guy's PCP, YOU ARE. Just when were you thinking about starting treatment on this guy anyways, AFTER end-organ damage? You can whine about patient compliance but the simple fact is you didn't even try to medically treat this guy's diabetes. One wonders what type of role you have in your patient's HgBAiC's running in the 8-10 range. Do you bother to treat them? Are you treating someone with a HgBAiC of 10 with oral meds? Jeez do you even know how to treat diabetes.

At Tue Aug 12, 10:46:00 PM, Anonymous Anonymous said...

PS: One thing we agree on is your last statement:

"Ignorant assholes posing as docs piss me off"

But frankly I am thinking about you with that statement.

At Wed Aug 13, 12:42:00 AM, Anonymous Anonymous said...

Wow, what a pissing war!
I personally think that adding three new meds at those doses is pretty friggin stupid. Hello, it's a hospital. It's ACUTE! I'm sure these folks will have someone relook at that situation prior to sending them home after a couple days. NOTTTTTTTTTTTTTTT!

At Wed Aug 13, 10:21:00 AM, Anonymous Anonymous said...

Maybe this trip will be a wakeup call to this man. It does sound like it's time to admit that HE is not going to do the diligence to stay off diabetes meds, and maybe it's time for a prescription. I would think he would have trouble with lows with all that started at once.

I disagree with thinking about the high-range of the test being okay. I have a SIL who went down that path and now has neuropathy in her feet. She really needed intervention sooner. She is also not one to stick to a personal-responsibility plan. But she doesn't mind appointments or pills, so that is really the best thing for her.

Myself, I'll do ANYTHING to stay unmedicated and I take the time to thank my PCP for working we me on this.

At Wed Aug 13, 11:49:00 AM, Anonymous Anonymous said...

I am with everyone else...When the hell were you planning on managing his diabetes? I guess in the PCP world you live in high A1C and BS above 300 is okay. Were you waiting for the funeral to slip him a prescription for metformin 500 1/2 tab every other day? You know go slow and all...

I bet the ER docs were saying the same thing about you...dumbass PCP and tried to make up for what you should have been doing...

At Wed Aug 13, 02:07:00 PM, Blogger Family Med Resident said...

To Nurse K and the others:

A1C of 7.3 often can be treated with diet change, and SHOULD be. If you have Type I diabetes your A1C goal is *different* from someone with Type II. There is good evidence that someone with Type I should be under 6. On the other hand, there is no evidence supporting an A1C under 7 for Type IIs, and there is some evidence of harm with the stricter glycemic control.

I'm 100% with Dinosaur on this one. Probably metformin would be the next step at the next appointment for the patient, but snowing him with 3 meds was completely inappropriate.

At Wed Aug 13, 06:49:00 PM, Anonymous Anonymous said...

Family med resident:
Did you closely read this thread?
The man had HgBA1C's great than 7 FOR TWO YEARS. How long do you propose to wait? Three years, five years, the patient's first MI or fem-pop bypass? I am all for giving a patient a grace period to give diet/exercise a chance to work. Two years is not a grace period, it's medical incompetance. Look at this joker's latest thread. One line says it all "Diabetes is the ultimate lifestyle disease". So therefore since it is a "lifestyle disease" ole dino here can abdicate his role as a doc (editorial comment: I've been managing diabetes at least as long as this quack). A word to the wise FP resident, read the guidelines and listen to your attendings. The only thing you should get from this blog is HOW NOT TO BE A DOCTOR.

signing off, I can't deal with this moron anymore.

At Wed Aug 13, 10:31:00 PM, Anonymous Anonymous said...

The "guideline robots" out there should do a little research about how little evidence there really is behind those guidelines. There is very little improvement in microvascular complications in pushing HbgA1c from 8 to 7 and absolutely no improvement in macrovascular complications such as CAD or PVD. In fact the almost universal weight gain caused by everything except metformin may do even more harm in the long term. I'm totally with you Dino. Bogus guidelines are destroying medicine.

At Wed Aug 13, 11:22:00 PM, Anonymous Anonymous said...

Why don't you pubmed the subject, you are a little out of date.

At Thu Aug 14, 02:09:00 AM, Blogger Nurse K said...

Dino--I used this calculator to determine the avg glucose---I guess the AccuCheck people don't know what they're talking about, but some random OB site does?

At Fri Aug 22, 10:32:00 AM, Anonymous Anonymous said...

I'm awfully confused, considering this.

I feel like doctors just read magazines to get their information. Diet, exercise, lifestyle management, and it being largely within the patient's control, my ass.

At Tue Aug 26, 01:53:00 AM, Anonymous Anonymous said...

I've had a patient admitted to me with severe hypoglycemia after a similar episode. Good thing the Expert found my care wanting! The Lower the Better!

To an anon: maybe your vaunted guidelines need some better evidence before being set in stone. I remember when the big push for low A1Cs in TYPE 2 patients started: when TYPE 1 patients were found to benefit. Since then any shred of possible support to the idea has adhered, but anything outside the party line (ACCORD) is explained away. Many of these Commandments, er, guidelines, have been a confident assertion of wishful thinking from Mount Ivory Tower.

To FM resident: You give me hope!

Dino, I'm with you on this.

At Thu Aug 28, 10:55:00 PM, Anonymous Anonymous said...

Well now anon an N of 1. Anymore anecdotal evidence? So you let diabetics walk around with glucoses in the 200 plus range and HgBAiC's of 8, 9 or whatever just because they "could" have a hypoglycemic episode. You are an idiot. Please do tell where you practice so I can have my patient's moving to your area avoid a moron like you. I practice in the real world using today's medicine. I am not some ancient passed by fool who lives on myths and anecdotes. Go back to residency fool.

At Sun Sep 07, 12:16:00 PM, Blogger Unknown said...

Honestly, I'm apalled by the lack of basic professional courtesy that has been displayed by some of the commenters out here. The exact mode of management of this patient's diabetes is debatable, but courtesy to a fellow "man of the steth" is not.
Whatever happened to decency in our professional disagreements. If physicians were to squelch discussion by calling each other quacks, morons, or fools we would still routinely be giving everybody Lidocaine post MIs, and avoiding beta blockers like the plague in CHF. Please, for the sake of the profession, don't use the cloak of annonymity on the web to do away with courtesy and demean yourselves.



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