ACP Internist Blog


Friday, July 21, 2017

Should a type 2 diabetic monitor blood sugars? Maybe not!

In the JAMA, the Journal of the American Medical Association, I read that a group out of the University of North Carolina had actually done a randomized study of whether non-insulin treated type 2 diabetics (usually the adult onset ones) achieved better control of their blood sugars if they did a finger stick test of their blood glucose daily. It turns out that they do not. Blood sugars were not improved in a group of patients who monitored their blood sugars once daily compared to patients who did not monitor them at all. Also combining the blood sugar testing with an automatic message from the machine telling them how to interpret that blood sugar did not improve blood sugar control.

Since 75% of patients with type 2 diabetes are estimated to check their blood sugar and there are over 29 million Americans with type 2 diabetes, and blood sugar monitoring is moderately expensive (though better than it used to be), not checking blood sugars could save billions of dollars a year. But that's not all. The energy used to focus on those numbers, by patients, doctors, and nurses, could be focused on something that might actually matter, like increasing physical exercise or eating a more healthy diet.

To be absolutely clear, this information does not apply to all diabetics. Insulin dependent diabetics, who usually get their disease as children, and absolutely require insulin to survive, do need to check their sugars. For those patients it's vital to know the blood sugar so that an appropriate amount of insulin can be administered to keep sugars as close to normal as possible. Even type 2 diabetics who use insulin often need to know their blood sugar levels in order to adjust their insulin dosages. Some type 2 diabetics take medication and a regular dose of long acting insulin, and it would be interesting to know if they, too, could forego testing.

Checking blood sugars is not simple, though it is a procedure that most people learn pretty quickly. It involves pricking the finger with a lancet to draw a drop of blood, placing the blood on a paper or plastic strip which is then read by a little machine which displays a number. There are talking machines for patients who are blind, there are machines with fancy functions, expensive machines, and cheap machines. You can buy a machine without a prescription at places like Wal-Mart and even buy the test strips over the counter now. It is, however, just one more thing to fit into a busy day and the numbers can make a person feel like a failure if they are high. The monitors require a certain amount of maintenance and sometimes malfunction, leading a person to make unnecessary adjustments or phone calls to health care providers.

This study does have some caveats. Many of the patients in the group that did not test blood sugars had been testing their blood sugars already, so it is possible that they had already gotten valuable information from testing. The patients were told to check their blood sugars once daily. It could have been than testing more frequently would have given better information and been more effective. For instance, if a patient didn't know that their lunch of yogurt and a ham sandwich lead to a higher blood sugar in the evening than a lunch of soup and salad, he or she might not change their diet appropriately.

Despite these issues, this study does indicate that we can safely allow many of our type 2 diabetics to stop routine monitoring. Previous studies have alluded to this, and many physicians are already backing away from badgering patients with type 2 diabetes to check their blood sugars. Nevertheless is remains common and is a way that a patient might misallocate time away from something active and directly beneficial to their health. It is probably time to allow many of our patients to relegate that blood smeared glucose meter to the back of the bathroom cabinet.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

Advice for new third year medical students and soon to be interns

Learning clinical medicine is difficult. It often seems overwhelming. I offer this advice, as I have for many years to students.

Assume that you will be confused and overwhelmed each time you start a rotation. Some rotations take longer before you feel comfortable. My specialty, internal medicine, is usually the most confusing when you start. If you feel like you are drinking from a fire hose, you are not alone. Amazingly, rotation after rotation, students start to feel comfortable in around week three or four.

Maximize your learning from patients. I recommend keeping a notebook (either paper and pen or smartphone app). Each day write down two to four things that you know you should better understand. Often these points were discussed on rounds. Spend a brief amount of time reading about that point.

As an example, today we discussed CKD stages. Several learners (I include interns and residents) suggested that they wanted to better remember these stages. I sent them an article to help their study.

If you do this every day you will not have to cram as much.

Examine as many patients with physical findings as possible. Ask your peers if they have any patients with murmurs or other physical findings. The physical exam can be very useful, but only if you practice it!

Follow up patients after you leave the service. You need to learn as much as possible from each patients. But your learning depends on the feedback of what happens to the patients.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
Thursday, July 20, 2017

Health care reform is still a dog

Back in March, I made some observations about the American Health Care Act, the bill to “repeal and replace” the Affordable Care Act (ACA) that was ultimately passed by the House of Representatives and both hailed and disparaged by the President. Some of the naked political calculus that facilitated the passage of such a truly despicable bit of legislation was the belief that the Senate would somehow rescue the Republican Party from itself and restore something “beautiful.” Well, it is now pretty clear that the Senate bill, cynically dubbed the “Better Care Reconciliation Act of 2017, was no better than what the House threw over the fence.

The bill retained essential “features” of the House version: less funding for Medicaid, fewer constraints on bad behavior of insurers, leaner subsidies for the uninsured to buy insurance, and repeal of the mandate to buy insurance for those with neither employer provided insurance or eligibility for Medicaid or Medicare.

I think Paul Krugman explained pretty well why the current plans to dismantle parts of the ACA don't work. The ACA is based on a few interdependent ideas:
1. For insurance to be useful, it has to have certain features, like broad benefits and inclusion of people with pre-existing conditions
2. To avoid the insurance “death spiral,” everybody has to be in the risk pool. Otherwise, only sick people would buy insurance, thereby pushing up the price and making those who are relatively healthier drop coverage, driving up the price further and driving more healthy people away, worsening the problem
3. To facilitate getting everyone in the risk pool, subsidies are provided to those who can't afford the premium

Remove any one of these and the system collapses. We are likely to end up with fewer people insured and worse coverage for those who buy insurance. As is true of the House bill, the Senate bill did nothing to address the real challenges facing our health care system today, access, quality, and affordability. As the President might say: “Sad.”

What do you think?

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.

Turning up the heat

Today seems like a good day to highlight the association of climate and infectious diseases, not only vector-borne infections like malaria, Zika, and dengue fever that spread with expansion of the vector's range, but health care-associated infections as well.

Phil Polgreen and colleagues here at Iowa recently published two papers on this topic: one in ICHE, also covered in the New York Times, that found the odds of a surgical site infection (SSI) admission increased about 2% with every 2.8 degree Celsius increase in monthly average temperature. The other, in Open Forum Infectious Diseases, describes a seasonal increase in cellulitis during the summer months. Several prior studies have described seasonality of S. aureus, gram-negative rod, cellulitis and surgical site infections—all with higher rates associated with higher temperature seasons or regions (see full reference list from the OFID paper, which includes prior work from Eli and colleagues on gram-negative rod infections).

Daniel J. Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. This post originally appeared at the blog Controversies in Hospital Infection Prevention.

Daniel J. Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. This post originally appeared at the blog Controversies in Hospital Infection Prevention.