2012-03-26

Faithless

I have officially lost faith in modern medicine's ability to treat me as a type 1 diabetic.

Let me start by saying that I am a model diabetes patient. I eat a low-carbohydrate, low-fat diet consisting predominantly of foods with a very low glycemic index. I count my carbohydrates and administer my insulin doses correctly. I work out twice a day, occasionally supplementing those workouts with two 15-minute walks at mid-morning and mid-afternoon. I consistently go to bed between 10:00pm and 10:30pm, and consistently wake up between 5:00am and 5:30am. There is little variation in my routine. I consider myself to be a very easy-going guy who lives a low-stress lifestyle. I don't do drugs of any kind, and my alcohol consumption is extremely limited.

Nevertheless, I experience strange, inexplicable blood sugar swings from time-to-time.

The current treatment paradigm (if my experience with doctors and endocrinologists is anything by which to gauge) consists of an absurd practice of circular reasoning.

This begins as soon as one sits down to speak with one's physician. First, the doctor asks you how you're feeling and how your blood sugar has been. Regardless of the answer you give, the doctor responds by saying, "Well, let's see your numbers." (I don't mind a little small talk to break the ice, but the standards of a good bedside manner would suggest that the doctor not completely contradict the patient's response a matter of pure segue.)

From here, a couple of things might occur: 

Possibility One
If you, the patient, have had some sort of odd blood sugar event recently that you might want to discuss with an educated professional, you might say, "I had a really strange bout of high blood sugar last week that I'd like to discuss with you." To this, the doctor invariably responds by looking at your blood sugar readings and crafting a narrative around the numbers without ever actually listening to the patient's narrative of his/her own experience

The doctor will say, "High blood sugar? Did you count your carbs correctly? Did you take enough insulin? Have you been under stress? Are you sick?"

Of course, if it were that obvious, then the "bout of high blood sugar" would never have been deemed "really strange" by the patient in the first place! But at this point, the course of the interview has been set. At this point, the doctor will ask a couple of questions that will be patently impossible for the patient to answer, something along the lines of "What did you have for a snack six hours before you went high?" Or perhaps, "Do you know anyone who has been sick lately?"

The point of these questions is to provide some sort of prognosis without having to do any work. The point is to cross-examine the patient verbally until there is enough doubt or the memory is sufficiently fuzzy that the doctor can simply hazard an irrelevant guess that the patient is unable to falsify.

For the doctor, the problem is now solved. "Maybe" the patient did something wrong. Next.

Possibility Two
If you are persistent enough and keep good enough records, you can sometimes puncture this absurd rhetorical loop, cover all your bases, and present the doctor with your blood sugar event as it truly exists: a mystery to you. "Nope, doc, I did everything right this time. It's a total mystery."

Here, the physician will tell you that diabetes is a complex disorder with a lot of variables; that sometimes you do everything right and you just miss something somewhere, but that if you just keep trying, you will be able to attain blood glucose control. Then he/she will hand you a set of pamphlets and offer to schedule an appointment with a dietitian or diabetes educator.

Whatever else you can call this "prognosis," it is not much help. Call me crazy, but when I walk into a clinic with a medical question, I expect to receive some medical insight, not a bunch of easy answers or an official checklist to which we must all conform.

What I mean is, that's not medicine. It's not medical treatment. It's not health care. It's just a couple of stock responses to hard, pressing questions. If a doctor is not prepared to provide me with real answers, I would at least appreciate not being lied to, dismissed, and/or made to feel like I am in some way responsible for my blood glucose "shortcomings."

Here's What I Expect
If I ask my doctor why something strange might have happened, I expect a dialogue. I expect the doctor to ask a thorough set of questions about the experience, to take a couple of moments of brief reflection and to venture a guess. 

If the guess seems unsatisfactory to me, I expect the doctor to actually, openly admit that he or she does not actually have an explanation for what happened.

From there, I expect the doctor to send me along with a helpful suggestion or two and then here's the important part...

I expect the doctor to tell me that he or she will look into the issue, read up on it, ask his or her colleagues, and get back to me next time about what the most likely explanation is in his or her professional opinion.

But That Doesn't Happen
It might be a tall order, but on the other hand, when I'm at work and a client asks me a tough question, it is considered highly unprofessional to feed them a line of crap just to shut them up and then go about my day as usual. It is furthermore considered highly insufficient to just say, "I don't know, these things can be complex," and then not follow up with my client later on.

So I am not holding doctors to an absurd, unreasonable standard here. I am simply expecting health care practitioners to adhere to the same professional standards that we all do. And we all do. All of us except doctors.

The point is not that "all doctors are crap," but rather that I find it equally unreasonable for a doctor to treat me this way as I would if a plumber or a car salesman treated me this way. My standard here is universal.

Finally, if you plan on saying, "I have a good doctor, you just have to find the right one," please save your breath. I understand full well that there are good doctors out there. What I do not understand is why there are so few that adhere to the basic principles of professionalism. It shouldn't be so difficult to find doctors who are capable of the bare minimum. I'm not looking for excellence, I'm looking for competency.

And because I see so little of it among health care practitioners, I have concluded that as a group they cannot treat my diabetes. I am better off educating myself and using doctors for what they apparently only want to be used for: To write prescriptions and cite things out of the Therapeutic Guidelines book.

For all needs beyond that, you are better off educating yourself.