Dear Dr Endo,
You’ve done a great job helping me manage my diabetes and I don’t doubt your credentials one bit. But recently I read with alarm an unsettling news report which was headlined: 100,000 ‘received wrong diabetes diagnosis’. The report went on to reveal that a research study had found “substantial evidence” that people in the UK are being “miscoded, misclassified and misdiagnosed with diabetes” on GP (general practitioner or family physician) lists.
One of the experts behind the report, Professor Simon de Lusignan from the University of Surrey, conceded that around 50,000 people were diagnosed with diabetes but did not have it, and another 50,000 were classified with the wrong type.
This means some people were been told they had Type 2 diabetes when in fact they have Type 1, and vice versa! The damning report says “the most widespread misunderstanding” among health professionals was changing somebody’s diagnosis from Type 2 to Type 1 when they go on to insulin.
A misdiagnosis could have a considerable impact on my life as the guidelines for insulin use in Type 2 are very different from those in Type 1. And what happens to diabetics who aren’t familiar with these things and follow the doctor’s advise faithfully.
But before I strike off Britain from the list of countries I’d like to visit, I must say this problem is not limited to the UK. In fact, like diabetes, it may be a global epidemic. Indeed, I have read many reports of doctors being clueless when it comes to treating diabetes.
Back in February, I had written about an Australian diabetic who died because emergency room doctors were ignorant about treating hypoglycemia. And stories like these have only strengthened my belief that in the age of ‘superspeciality’, our medical schools are producing graduates who miss the wood for the trees.
This, of course, has been borne out by a study published in the American Journal of Medicine which shows that there is currently an imbalance in the training of primary care physicians. The researchers say that despite the fact that 90 percent of doctor visits are outpatient, most medical schools focus on inpatient situations. This leaves future primary doctors unprepared to deal with chronic disease like diabetes.
Dr. Stephen Sisson, who led the study, said: “When I graduated from residency here, I knew much more about how to ventilate a patient on a machine than how to control somebody’s blood sugar… The average resident doesn’t know what the goal for normal fasting blood sugar should be.”
After administering a test commonly used to gauge the knowledge of medical students to a group of first-, second- and third-year residents, Dr Sisson discovered to his horror that ALL the first-year residents were poorly prepared to treat chronic illness. (Fortunately, knowledge improved somewhat among community hospital residents over time.)
Dr Sisson concluded that this is happening because training for all residents is particularly poor on outpatient diagnosis and management of diabetes, lipid disorders, dizziness, anemia, and alcoholism. The culture at university hospitals, where specialists often assume leadership roles in resident education, is not hospitable toward primary care, where specialized medicine is emphasized over a broad education in general internal medicine, he says. (You can read my report on this study here.)
My poser is: If family physicians don’t know what needs to be done, how are they going to guide us patients?
Alas, poorly trained family physicians are not the only problem we diabetics face. If I were to be hospitalized and be cared for by ‘specialists’, I’d fare no better.
Recently, a UK national audit found that 37% of diabetic inpatients are subject to medication errors by doctors and nurses, including being given the wrong dose of drugs or at the wrong time. More than one in four (26%) medical charts contained errors about prescriptions and a fifth contained one or more errors on how medicines were being managed in hospital. The errors related to drugs, including insulin as well as tablets, to keep blood sugar under control.
The report pointed to “significant issues” concerning the use of insulin drips in hospitals. Some 13% of diabetic patients had been on an insulin drip for the previous seven days but 8% of drips were considered “inappropriate”. Overall, 10% of insulin drips exceeded seven days and 12% were considered “inappropriately long”.
In more than a quarter of cases (26%), the transfer of the patient back on to insulin injections “was not managed appropriately”, the audit said. Those who had undergone surgery were more likely to have been given an inappropriate drip and more likely to encounter problems when going back on to injections.
The audit also discovered that over one third (37.1%) of inpatients with diabetes experienced at least one medication error, a quarter (26%) of their charts had prescription errors and a fifth (20%) had one or more medication management errors.
My understanding is that insulin overdoses can result in potentially fatal hypoglycemic episodes (‘hypos’) and insufficient insulin can lead to diabetic ketoacidosis (DKA) which, if left untreated, can also prove fatal.
For too long many of us diabetics have experienced poor care at the hands of physicians and in hospitals. And if we were to swap stories, I’m sure Karen, who’s hosting the second Diabetes Blog Week, would need to organize another event devoted to horror stories. In the meanwhile, what do I do?
Given the fact that many family doctors do not have enough knowledge to effectively advise diabetes patients (borne out by many studies), and visits to a specialist like you involves long waiting periods and longer commutes, I personally support the concept of diabetes self-management education (DSME). And guess what, doc? IT WORKS!
Indeed, in case of emergencies, like hypos, I’d rather have my family members tell the doctors what to do or I’d carry a note detailing the measures to be taken ‒ in case I have passed out ‒ in my wallet along with my card that identifies me as a diabetic. If it offends the health professionals in the emergency room, so be it.
No offence to your profession, doc, but it’s my life!