LifeAfterDx--Diabetes Uncensored

A internet journal from one of the first T1 Diabetics to use continuous glucose monitoring. Copyright 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, 2013, 2014, 2015, 2016

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Location: New Mexico, United States

Hi! I’m William “Lee” Dubois (called either Wil or Lee, depending what part of the internet you’re on). I’m a diabetes columnist and the author of four books about diabetes that have collectively won 16 national and international book awards. (Hey, if you can’t brag about yourself on your own blog, where can you??) I have the great good fortune to pen the edgy Dear Abby-style advice column every Saturday at Diabetes Mine; write the Diabetes Simplified column for dLife; and am one of the ShareCare diabetes experts. My work also appears in Diabetic Living and Diabetes Self-Management magazines. In addition to writing, I’ve spent the last half-dozen years running the diabetes education program for a rural non-profit clinic in the mountains of New Mexico. Don’t worry, I’ll get some rest after the cure. LifeAfterDx is my personal home base, where I get to say what and how I feel about diabetes and… you know… life, free from the red pens of editors (all of whom I adore, of course!).

Tuesday, March 31, 2009

Skin deep?

So on to the Navigator. Let us start by judging the book by its cover. The color is a sexy tritium grey. Sparkly. Navigator one. Guardian zero. Guardian is “smoke” colored, a grey-green and not very futuristic looking. Guardian is housed inside a Paradigm case. If you hold it up to the light the bottom is hollow where the driver rod and insulin cartridge would go in a pump. So there is a void of nearly three inches long and quarter-inch high that could have housed an AMPLIFIER to make the damn thing louder. I guess using an existing pump case made sense from a production point of view. Abbott, having no pumps, was free to make their CGM any size and shape they wanted to.

Both CGMs are plastic, and they both look and feel plastic. Neither has the quality feel of… oh, I don’t know… an Apple I-phone or a Presto blood glucose meter. You can make something from plastic without it seeming “plasticity,” if you know what I mean.

Without bothering to read any of the manuals and quick-start cards, I put two triple-A sized batteries in the Navigator and dicked around with the receiver. The purpose of the bizarre shape of the system’s brain becomes apparent as you handle it. It is a rectangle that is concave on the sides and convex on the top and bottom. This actually makes it quite gripable in the hand and is surprisingly ergonomic. It is slightly thicker than Guardian, but not by much. They are the same dimension left-to-right as well, but Navigator is about half an inch taller on the top-to-bottom dimension. Overall, however, Navigator seems much larger when you look at the two units side-by-side.

Navigator features four buttons to guardian’s five. Navigator’s menus, like OmniPod’s, navigate cell-phone-style with the two bottom buttons serving as a back and forth navigation control and the two vertical buttons on the right serving up-down navigation. It is very intuitive and quick to learn. Med-T menus, of course, are a bit more like learning Braille. That said, once you learn it, you can get around a Guardian quickly, it just takes a little longer to learn.

When you wake Navigator up (bear in mind I do not have a sensor hooked up, only time will tell if a glucose status screen remains on all the time or if you have to wake the device up to find out what your blood sugar is) you are at the Glucose CM Screen. Right now mine shows the time, - - -, and an lightning bolt with a slash that I assume means it has no telemetry with a sensor. Once it is hooked up the - - - is replaced with your current sensor glucose level.

From Navigator’s home screen (called Main) there are only five menus (and the damn thing times-out pretty quickly, making you start all over each time it times-out; the machine wakes up at the CM Screen, not where you left it. Growl). The menus are: Glucose, Alarms, Reports, System, and Add Event. Clicking on Glucose takes you back to the main screen. Alarms is where you set your preferences for how loud a beep or how long a vibe you want; and where you choose your various alarm thresholds and sensitivities. More on that tomorrow.

Reports takes us to graphs, stats, event history, glucose targets.

System appears to have controls for hooking up to a sensor and sub menus for changing time and the like.

The Add Event screen lets you add in insulin, food, exercise, and a variety of health conditions. Presumably these will then show up on your download. I was amazed at the variety of health conditions you could enter including--but not limited to--sore throat, stress, allergy, alcohol (no shit), and for the ladies, your Period.

I found the Navigator to be an easy device to navigate around. For comparison a quick reminder of the Med-T menus. The infamous green ACT button takes you to the main menu where there are only three choices: Sensor, Capture Event, and Utilities. Frankly, most of the operations happen in Sensor including all the setting of alarms and starting of sensors. Pressing the ESC key from just about anywhere can take you to graphs, then to two data sets that tell you anything you’d want to know, and more, about the status of the system.

To be fair, I always found the Guardian’s menu and button system less exasperating than the Med-T pumps. I think both Navigator and Guardian are fine in this regard and you’d quickly adapt to either. Navigator one. Guardian one. On this the systems tie.

Guardian has two belt clips to choose from, same as the Med-T pumps. One is a low-profile design popular with many of my female kinfolk. It snaps on nearly flush with the pump. The other style, which I love, is the holster model. This is a plastic hard-shell belt clip with a rotating clip that the pump (or Guardian) slips into and out of with a satisfying CLUNK-CLICK. I find I have the Guardian in-and-out many, many, many times during the day. To me having to UNCLIP it from my belt would be a big hassle. I guess for a pump it wouldn’t matter so much. That said, I use the same style with my out-of-warranty-and-discontinued Cozmo pump.

Navigator’s belt clip is also a holster model, but seems cheesier, not as robust as the Med-T holster. It is also a LOT harder to get the damn thing out too. Now, in fairness, it is brand new….no wait, Med-T holsters are easy to use from day one. It think it is a fundamental design flaw. The Med-T holster is U-shaped, open at the bottom. You can reach down and “flick” the Guardian out of its case quickly and easily. The Navigator holster has a closed bottom with a finger window you can use to push it out. In theory anyway. Also, the Med-T holster rotates for horizontal or vertical wear. Navigator can only be worn horz.

The clip itself is quite large too, holding the receiver out from the body quite a bit. Overall, between the size of the device and the design of the holster, it is not at all comfortable. And I’m a full sized man. It would be miserable for a child.

It also has, as an option, a silicone skin, a’la I-Phone. I’m trying to figure out under just what circumstances I’d use this. I suppose it would be good protection if you carried the receiver in your purse. But then would you hear it? And what’s the point of having CGM if you don’t get in the habit of glancing at it every fifteen minutes or so to keep in touch with your diabetes?

Also in the box the Navigator came in was a rectangular transmitter about the size of a club cracker. It takes a 357 button battery that the manual says will last a month. I googled the battery and it looks like you can score them for ten bucks a pop at battery places, but has them for three bucks; and it looks like if you buy a shit-load of them you can get even better prices. But one more damn thing to buy and carry. I prefer the Med-T rechargeable approach, and it’s curvy seashell transmitter is smaller too. The transmitter is the part of a CGM system that takes up skin landscape, so the smaller the better.

Going back into the distant past of CGM, (which was what, four years ago?) the transmitters were large sealed affairs the size of those things you unlock a mini-van with, and had a cable that attached to the sensor. It would run about a year and cost a fortune to replace. The new Med-T transmitter has a recharging dock powered by a cheepie triple AAA. I plug my transmitter into the charging dock for about 15 minutes while I’m in the shower every sixth day and have never had a problem. Oh, let me be clear about this: I shower every day, but only change my sensor every six. I suppose someone will argue that eventually rechargeable devices cease to hold their charge and at $800 bucks or so to replace, I may wish for a system that cost me a couple of bucks per month in batteries.

The Med-T transmitter is dover-white. The Abbott is battleship-grey. Now God makes us diabetics in a wonder array of colors, but dover-white and battleship-grey are not amongst them. The powers that be at these companies are afraid to choose a skin color that would match most of us (my vote: Indian. Middle of the color continuum. Darker than me, lighter than an African American but better on everyone than dover-white or battleship-grey).

Actually, you may have witnessed the evolution of those stupid things people are wearing in their ears so they can be on their phones 24-7-365. They are becoming jewelry. What a perfect solution to technology that serves a life support function. Simply make it beautiful. Chrome, or gold, or even clear to show the funky circuit boards underneath.

I’d love it if they’d at least stamp them with a medical alert symbol.

The Navigator transmitter also features a plastic arm, or spike, that helps it mate with the sensor. I’m guessing this might break easily and ruin someone’s day.

Med-T sensors come in a sack and can be inserted either by hand or with a re-usable inserter. Navigator sensors come with an appalling amount of land-fill bait. More on that when I put the first one in.

Oh well, nothing about diabetes is land-fill friendly.

Next time: alarms. Options and lack thereof.

Monday, March 30, 2009

The real time shoot-out begins

The dry wind blows a tumbleweed across the dusty street. It is high noon. To the clink of spurs and the creak of leather the two hired guns ease out onto the street, squinting in the bright light, eyeing each other carefully, fingers hovering over the handles of their holstered weapons. Each wait for the other to make a move. The townsfolk scatter for cover.

It is time for a shootout. Diabetes style.

OK, enough fun, it’s time to get down and dirty. I got my mitts on a FreeStyle Navigator. I’m eager to try it out. To see what it is made of. To compare it to the Guardian. To wear the two units simultaneously. To see in real time how they each handle the very same highs, lows, and the occasional fudge-fudge walnut brownie Sundays from the Elephant Bar (in the name of science of course).

And like in any other shootout, there can be only one winner. Of course in a shootout between Med-T and Abbott I’d be very hard pressed to say who is wearing the white hat and who has the black hat.

This blog was originally created to report on Continuous Glucose Monitoring (CGM) back when CGM was just a baby. Since then, we’ve been all over the Diabetes Map together, but now I think it is time to get back to our roots for a time and re-visit CGM.

So before we get started, I want to review the LifeAfterDx ground rules. Like the knife fight scene in Butch Cassidy and the Sundance Kid (Rules? There’s no rules in a knife fight!), the rules are there are no rules. This is an influence free-site. I say what I think with honesty that has been described as both refreshing and brutal.

Right now I am holding a in my hands the much anticipated and much delayed Abbott/FreeStyle Navigator. Well….OK, that’s a lie, ‘cause I’m typing right now. I am metaphorically holding in my hands the FreeStyle Navigator, it is actually sitting on my desk right in front of me.

Now I confess, I did not buy it. And it did not come from Abbott either. The folks at Abbott didn’t even know I had it until this very second (picture the folks in the PR office running around in panicked circles like mice on LSD). This unit came from a Health Care Provider in an undisclosed location (yep, Dick Cheney’s poker bunker). The Provider is a fan of my writing who wanted to know how I thought Navigator stacked up against the other options out there. I’ve actually had the Navigator on my desk long enough for it to gather dust. That’s how long it took me to scrounge up a sufficient number of sensors from various users across the country to wear the system long enough to give it a fair shake; to overcome the euphoria that sometimes comes with new gadgets, or to work through the problems that also sometimes plague new gadgets—a more common experience with Continuous Glucose Monitoring systems.

In the interest of full disclosure, you also need to remember I’ve been wearing a Guardian since, well… forever. I’m used to it. There are a lot of things I like about it. I find it very accurate, but at the same time there is a least one HUGE flaw in the device; and that is its petite little voice. The damn thing is too quiet. CGM alarms are the difference between life and death for me. Literally. I want them loud. Real loud. The original garage-door guardian was not only loud, but had personality too. It made different types of noises for different types of alarms. My co-workers at the clinic learned her language. When my trusty box let loose with a low alarm they’d come running with glucose. When she signaled a high they’d laugh and tease me, “what did you eat this time?”

So, where I was going with this before I got distracted, is that I’m aware I may have a Guardian bias, having worn one so long and having adjusted to it. Still, I decided the best way to compare Navigator and Guardian was to wear the two devices simultaneously. My belt will be crowded with the Cozmo, Guardian, Navigator….thank God I never bother to carry my cell phone.

Before we get started with the shootout, let’s cover the basics for the CGM virgins. If you’ve been with me for a while this will be your refresher course.

First and foremost, Continuous Glucose Monitoring isn’t continuous at all. It also doesn’t read your blood sugar, nor does it replace the need for fingersticks. More on all of that in a moment.

CGM systems, for the most part, share some common elements. They all have a sensor. The sensor is a disposable needle-like miracle of modern technology that is placed under your skin, where it stays anywhere from three-to-seven days. Using assorted Voodoo and Sorcery, this needle magically determines what your blood sugar is without ever consulting your blood at all. Attached to the sensor is a transmitter, whose job it is to send sensor data wirelessly to a receiver. The receiver is the brains of the system and the interface with the user. It has a screen to display a variety of data, has controls to program the system, and contains alarm systems to alert the wearer to dangerous blood sugar levels.

The receivers vary a great deal between makers, in terms of features. All systems also have the ability to download data to a computer, and again, the quality of the software that displays the data varies quite a bit between makes.

The sensor needle actually reads interstitial fluid, basically the water that exists between your cells. There is a close correlation between interstitial glucose and blood glucose, but they are not one in the same. For convenience’s sake, I often will use the generic “blood sugar” when talking about the readings from CGMs even though they don’t really read blood sugar at all. None of the systems are continuous either. They read anywhere between once per minute and once every five minutes. Still, even at once every five minutes we are talking about the equivalent of 288 fingersticks per day. Just as movies are made by rapidly projecting a series of still images at the rate of 24 frames per second; these closely spaced blood sugar checks give us the illusion of continuous movement.

There are currently three companies in the CGM biz with five different systems. The first player to market was Medtronic. They now market three different devices using their sensor. One is a “blind” system that health care providers can place on a patient to monitor 24-hour blood sugar for three days, then download and study the data. Next up Med-T has a CGM system that talks to Paradigm model pumps. It is pretty primitive, having only threshold alarms (alerting the wearer when a certain high or low number is crossed) and the ability to only show a 3-hour and 24-hour graph of the glucose. The CGM uses the pump as the receiver, but in no way interacts with the operation of the pump. Last in the Med-T line up is the Guardian, a standalone unit that features some pretty sophisticated features including predictive alarms that actually work, and the ability to leave the system set on an active real-time graph. Not only can you scope out your current BGL, but you can put that into perspective while viewing your choice of 3-hour, 6-hour, 12-hour, or 24-hour graphs.

On Med-T’s heals was the Dark Horse Dex Com, the second player to win FDA approval, and the first to get a seven-day wear indication. They came to market with a Gillette Razor approach with a relatively inexpensive monitor and competitively priced sensors.

Abbott, who originally expected to be first to market languished for years. They waged a brilliant guerilla campaign of media “leaks” to keep the D-world salivating for the Navigator. I honestly don’t know why it took them so long to win FDA approval. I heard it said they were paying for sins of the past. I also know they took the courageous but fatal path of attempting to get an indication for replacing fingersticks. That was too big a leap of faith for the FDA. Med-T and Dex had applied as “investigational devices.” That made it easier to get FDA approval, but also made it easier for insurance companies to say “no.” Eventually Abbott actually withdrew their original application and started over, eventually winning the same indication the rest of the pack has. It was interesting to watch Abbott change the appearance of the prototype on their web site over the years this process took.

Tomorrow we’ll look at the nuts-and-bolts of the Navigator in its final incarnation, and make some comparisons to the Guardian. But for today I have a final thought: Med-T has given us the Guardian, to protect us, to watch over us. Abbott has given us the Navigator to help guide us. Maybe it’s just a coincidence. Or maybe it tells us something of the nature of the companies, a look into their corporate souls, a sense of their self image and perhaps more importantly; their image of us.

Tomorrow: judging a book by its cover

Friday, March 27, 2009

Coming soon....

The Real Time shoot-out begins.

Pillow talk--medicine style

So the love of my life has a new job. Debbie, mother of Rio and wife to me for more than 20 years, was a disc jockey when I started dating her in the late 80’s. At the time, I was a newspaper photographer, sleeping with a police scanner and running off in the middle of the night to cover fires, wrecks, and assorted human misery. I loved it. God, I was one sick puppy back then. Men, like wine and whiskey, improve with age.

On one of our very early dates I had stopped to buy flowers when the flight-for-life helicopter flew overhead. The girl forgotten, I chased it.

She married me anyway. And I won an award for the picture.

But all of that was long ago. And pre-Rio. Deb hasn’t worked since Rio was born. But it was time; for both our pocket book and for her soul. But guess what? There really aren’t DJs any more. Not many. Most small-town radio stations just pipe in music and DJs from big city operations and add in local ads. A single person can run a small town radio station by sleeping in late and spending most of the day in a bar. It is that automated nowadays.

Deb needed a new career. Her first choice, actually, was rich heiress, but there just weren’t any openings. She applied for several other different jobs without much luck. She’s been out of the job pool for long time, it was scary and nerve wracking for her. And there are a lot of people looking for work now. A lot.

As fate would have it, she seems to have lucked into the perfect thing for her skills, her personality, and her intelligence.

It started with a good deed. I wasted a day recently at the state capitol, manning a booth in the rotunda on the official health awareness day. In past years we screened for diabetes, but politics got in the way so this year I was stuck just talking. It was OK, but not what I call “a good day of medicine.” I define that as a day when I really make someone’s life BETTER. Not to be arrogant, but for me, most of my working days are good days of medicine. There is just sooooooo much need out there and my clinic is in the thick of it. If I can’t make at least one person’s life better on any given day, I probably just wasn’t trying hard enough.

So I was feeling sorry for myself, and thinking if I had spent the day at the clinic I would have had a good day of medicine.

Afterwards, to cheer myself up, I met my buddy Fox for an early dinner and we played with each other’s pumps. She’s wearing Med-T and I’m currently wearing my out-of-warranty Cozmo thanks to supplies donated by readers (love you all!). I was showing her how simple the Cozmo menus are and she was refreshing me on how the Para-pump works (Are you sure you want to bolus? Are you really sure? Are you really sure you are really sure?)

After our taco salads I dropped by another T-1 I know, who is a Nurse Practitioner. Naturally she specializes in treating diabetics. Her practice is growing. Fast.

In fact she was opening an new office in the next town over, near where Deb and I live. “I need a couple of Medical Assistants,” she told me, “I’m looking for really mature, reliable folks. You know anyone over there?”


So now my brown-eyed beauty is wearing scrubs. And a stethoscope. It’s a pretty hot look, I gotta say. Now different practices use MA’s in different ways. There is very little limit as to what skills can be delegated to an MA by law in our state. So MA’s can do some pretty heavy-duty nurse stuff if the practitioner is comfortable delegating to the MA. So in some (smart) practices MA’s do blood draws, run UAs, do triage, assist in procedures, call in prescriptions and all kinds of cool stuff. In other (dumb) practices they answer phones, and maybe take a temperature now and then. A good MA takes the load off the practitioner. More good medicine gets done.

Deb works for a smart practice. Deb gets to do the fun stuff. And she took to it like a fish to water. On one day she assisted the Nurse Practitioner with a pap smear. The next day the MD had one on his schedule. She laid out everything he needed in advance. Without being asked. Being told to get a urine sample on another patient, she automatically went the extra mile and did the dip and recorded the results.

At the end of her first week, we were sprawled on opposite ends of our living room couch, legs entwined, me with a glass of wine, she with a diet 7-up. “Oh-oh-oh,” she said excitedly, waving her hands in the air, her dark brown eyes flashing with delight, “I forgot to tell you, I saw a prolapsed bladder today!”

Wow! That’s sooooo awesome! Ummm….what the hell is a prolapsed bladder?

But it is great because we have separate worlds with a common vocabulary. We each know the cast of characters in each other’s work worlds. We have our own unique and personal spaces where we belong in a common universe.

Yes, it makes for some strange pillow talk of glucose, A1Cs, neuropathy, hypertensions, and prolapsed bladders. But it is a good little world. And I am happy to see her come alive. She glows. Radiant and more sexy than ever.

Hey, baby….put on your stethoscope and come over here….

Wednesday, March 25, 2009

A death in the family

A good friend of mine died today. Actually, my friend was drug outside and executed. Shot in the head. Yep, Smiths Medical today killed the wonderful Cozmo insulin pump.

A tragedy on many fronts. Now less choice among pumps. That means less competition, and thus less innovation.

Among traditional “tethered” pumps it was by far the best of the small pack with two unique features that made it stand out. First, it spoke English, not some convoluted medical device language. The menus were simple to learn, simple to teach. They were straight forward and logical.

But it was the second feature that I love the Cozmo best for, how it calculated “insulin on board,” also called IOB.

IOB matters. It is crucial to how you correct highs. Or lows even, in the case of the newer Model 1800 Cozmo which can suggest how many carbs are needed to save your ass when you are low. All the other players (Med-T, Animas, and the innovative OmniPod) only count correction insulin. This assumes that meal insulin is covered by the carbs you’ve eaten or visa-versa. Uh huh.

OK, will everyone who always counts their carbs right, and has all their insulin-to-carb ratios nailed down perfectly please stand up?

I don’t see anyone standing up.

I’m not either. I “count” my carbs wrong as often as I count them right. I like a pump that keeps track of all the insulin in my system. The stuff used right; and the stuff used wrong.

But innovation and quality are not enough. Health, in America, is all about money. Smiths is vague about why they pulled the plug at both the customer and medical provider websites; but a press release today spells it out better.

First, they say, the diabetes biz is a bad fit for the rest of Smiths. That makes it hard for sales folks to do both pumps and what-ever-the-hell-else Smiths makes and sells. In addition the pump biz requires its own “extensive sales, marketing, reimbursement, insurance and clinical support infrastructure.” Too many people to pay, apparently. That said, 51 folks who had jobs this morning now do not. Hmmmmmmmmmmmm…..hardly seems extensive to me.

Second (the real reason in our Wall Street World) is that “sales and profits for the business have decreased.”

Third, interestingly, CGM seems to have bitten them in the butt. I sure this comes as a bit of a mystery to the thousands of my fellow D-folk who buy insurance Voo-doo dolls on eBay from pure frustration in trying to get CGM covered. Smiths is saying the pump market is changing from “hardware-plus-disposables model” to an “integrated diabetes management model” that would require “significant ongoing investments in continuous glucose monitoring.” They have seen the future, and are afraid of it.

Fourth, they come right out and say the following: “Smiths Medical's shrinking market share has been exacerbated by the aggressive pursuit of market share growth by two large and well-resourced players - Medtronic, which has the largest share of the U.S. insulin-pump therapy market, and J&J.”

And lastly, they are afraid of law suits, and recall that the Cozmo came out the loser in a patent suit filed against them by Med-T sometime back. To be honest, I don’t recall which pump feature it involved. But the press release states “a considerable amount of intellectual property has been established in the diabetes segment, which makes the development of next-generation products very costly, and risky in terms of the potential for future patent disputes.”

The announcement today came out of the blue—a surprise to everyone including the shocked employees I talked to this morning. The ones now out of jobs in the worst job-hunting environment imaginable.

Smiths states their intention to “manage a well-controlled exit from the Diabetes business.” Sounds like an orderly retreat from battle. But unlike the Marine Corps, Smiths is leaving its dead soldiers on the field of battle.

Good bye wonderful friend.
Rest in Peace.
The Cozmo Insulin Pump.
March 25, 2009

Friday, March 20, 2009

Smarty pants

I guess everyone knows I’m a high school dropout. Well, if everyone didn’t know before, they sure as hell know now.

This has rarely if even been a problem for me. Not that I would recommend it as a course of action (and yes, I did go back and get college degree or two later on).

But I’ve decided lately that too much education is a bad thing. Our new Doc likes to drop articles about diabetes on my desk. Being a knowledge-sucking-sponge I do read everything about diabetes I can get my hands on. Usually, I can understand and absorb pretty much anything I read. But I’ve noticed lately that articles written for Docs by Docs have a unique flavor.

Picture me on at my desk. I’ve had a “no-show” so I have an hour to kill. I’ve unlatched the seat lock so I can lean waaaaaaaaaaaaaaaaay back in my chair, resting my feet on the top of my desk. I have a fine view of the parking lot out my three windows. I’ve got a pen behind my ear and a highlighter clenched in my teeth. I can’t read without making notes… probably why no one will loan me a book. I’ve got my better-than-sex wireless wave key board in my lap, and the latest article on top of the key board.

The only unusual element of this scenario is the key board. This article is giving me trouble and I find myself Googling new words every few paragraphs. My new favorite word not to use in polite company is “armamentarium.”

No shit, I found this word in an article on the emerging intercrin therapy world. Loosely translated it means “the knowledge, tools, and medicine used by medical professionals” to treat illness. Presumably a descendant of the word “arsenal.” Ohhhhhhhhhhhhhhh, silly dropout me. I would have just said “tool kit.”

Well, this is what comes from being too well educated. Don’t get me wrong, you won’t find a bigger fan of the written word than me. Language can be divinely, elegantly precise. In medicine we really do need to be precise in our communication. We do not, however, need to use words like armamentarium when there are perfectly good options that use fewer syllables.

At my new part-time job as the Molder of Future Doctors’ Brains I have noticed that the medical school experience completely destroys student’s ability to communicate with human beings. Take future-Doc Eva. Her heart is totally in the right place. I’m guessing that earlier in her life she must have been pretty interesting: she has a heart tattoo on her left breast. I caught a glimpse of it when she was learning down to pick up a pen she dropped on the floor. Not that I was looking, or anything.

Eva and I were meeting with a delightful upper-middle aged Hispanic lady who was very hard of hearing. That, by itself makes communication….challenging…on top of the fact she’d probably be happier in Spanish; which neither Eva or I speak. But Eva had also forgotten how to speak the common man’s English.

The poor woman had no clue what Eva was trying to say to her. But culture got in the way and Eva had the white coat on. The patient nodded and smiled and never let on.

As we left I told Eva, Call a low down dirty dog a low down dirty dog.


It’s not hypoglycemia. It is a low. There’s also no such thing as a hyperglycemia, it’s just called high blood sugar.

“OK, I’m not sure where you are going with this, but I’ve already learned to hear you out--so explain.”

When you get out in the real world and are practicing medicine on your own you’ll be lucky to have ten minutes with your patient. You can’t afford to fail when it comes to what you want the patient to know. Keep it as simple as possible.

Eva frowned… “Well, diabetics are pretty smart when it comes to their conditions. I don’t want to look dumb. I worry if I keep things to simple they’ll think I don’t know anything and won’t take me seriously.”

Small risk. But you’ve got the white coat. Better you look like a simpleton than have even one patient walk out of a treatment room confused.

“Your vocabulary is pretty high end,” she accused.

Yeah, well I’m at peace with being a hypocrite. I’m a better tour guide than a role model. Besides, I make up for it by swearing a lot. You can’t do that as a doctor.

Boy am I ever glad I dropped out of Grad School recently. Yes, there was much to learn, but possibly, much to lose as well.

Friday, March 13, 2009

The Fox and the Hounds

So this is a long overdue tale. And because I’ve put off telling it for so long we have to go back in time to the beginning. So first I have to tell you the story of my little sister, Fox. Actually, you hear about her occasionally in the pages of this blog, but I don’t think I’ve ever told you the story of how we met. You see, she is my little sister--but we have different fathers. Different mothers too.

Say, what??? you ask. How can she be your sister if you two share no genetics what-so-ever? Well, we do share a defective gene or two. She, like me, is T-1. Why that makes her my sister rather than my cousin or kinswoman, I’m not sure. It just felt right.

Here is how I met her. Once upon a time, the state diabetes control and prevention program gave us meters and strips. The powers-that-be in the state government decided that I should get enough for 30 diabetics at a time when I had 80 uninsured patients. So I had to be creative. At one point a year or two ago the program ran out of money for a while and I got zero meters and strips for 80 uninsured diabetics. The first I knew about it was when the mob showed up at my office door with torches and pitchforks.

Yeah, we manage crisis to crisis out here on the frontier.

Thus began the mad scramble to find the holy grail of diabetes: affordable test strips. Let us review. There are no generic test strips. The strips can only be used with a matching meter. There are no patient assistance programs for strips. The test strip biz in the US alone is a nineteen billion one hundred seventeen million two hundred thousand dollar per year enterprise. And that’s just how much I personally spend. When we add the rest of you in, it really starts to sound like a lot.

Now remember that I work at a non-profit clinic. We also have a non-profit pharmacy for the un- and under-insured. As such, we generally get a discount on drugs that can run anywhere between 50% off retail price to 95% off retail price. But in the case of strips, the major players (low-down dirty dogs that they are) generously grant us, no shit, anywhere between 3% and 5% discounts. Off of retail price. Great. Now a strip is 95 cents instead of a dollar. Without insurance, and without a fairy god mother, you cannot afford to check your blood sugar out-of-pocket.

After calling everyone I know we finally found a cheap strip. Ten cents each. No free meters, we had to buy them. And they were really ugly. They looked like Russian Garage Door Openers. From 1975. And the accuracy of the strips was…..dicey. And the software only let me download ten patients. Ever.

It got me over the crisis, but was no solution. Then we discovered AgaMatrix. Yeah, the folks that make the I-podesque WaveSense meter with its high-tech red blood cell-counting strips that are twice as accurate as the other major players with an amazing 10% strip-to-strip variance rather than the FDA approved 20%. They actually offered us a REAL discount. But their meter required coding and I was sick of coding problems.

Even so, I chatted with their corporate folks, who told me a self-coding meter was only months away. They generously supplied me with a ton of samples of the older WaveSense for evaluation. And they sent a rep all the way to the wilds of New Mexico to meet me.

Now the first question I always ask the Ken and Barbies who visit me from drug companies is the same: Are you diabetic?

First place winner for bad answer: “No, but my dog is.”

So imagine my surprise when the rail thin, pretty, and intense (down boys, she’s taken) meter rep responded to my opening question with “Yes.”

I sat up with a shock and knew in a flash that something unusual had just happened. Two Type-1s had just met in the wild.

We tested the WaveSense and my Peer Educator gang loved it. We compared a wide variety of readings with our in-house Hemocue, which is lab-grade accurate. The bottom line was that these strips work. Really work. They were much tighter than anything else I’d seen or tested before.

The day after the FDA approved the self-coding version, called the Presto, a FedEx package arrived at my office. I opened it and out fell a blue meter the size of a small deck of cards. Here I was in the mountains of New Mexico and I was one of the first diabetic educators to hold the latest technology in my hands. AgaMatrix didn’t even have boxes or manuals for it yet.

Very cool. I emailed and thank you and added that they needed to send 8 more so my Peer Educators wouldn’t fight to the death over who got the one and only Presto.

But now I had a problem on my hands. Well, come to think of it, I always have a problem on my hands. But I had thousands of the not-so-great strips still in house. We could sell them for $10 per vial of fifty; and the Presto strips would be $15 per vial of fifty. How would the Patients react to the extra five bucks?

In the end I decided to run a comparison test. I made up posters with both meters on them and posted them at key locations in the clinic. You know, in my office, at the pharmacy window, in the bathrooms….

Nearly universally, my patients jumped on the Presto band wagon. Some because of the feature set, a backlight for instance. Some because they’d had issues with Brand X. Seems like about every twenty strips or so you’d get a crazy-assed reading. I had warned folks to retest anything that seemed unlikely, but it was still a hassle. And although I don’t know this for sure, I think most changed because they found the little blue meter to be sexy. Ya got diabetes. Ya gotta test. Might as well have a meter you feel good about. And the meter is sexy, filling Amy’s “I-pod factor” requirement. The lancing device is the second best out there (after the one that comes with the OneTouch Mini—two inches short and one-handed operation) with 8 different depth settings. The software, while not Abbott’s Co-Pilot, is pretty damn good. More on that in a sec.

So with all my under- and un-insured patients on the Presto, I found myself using the Presto’s ZeroClick software a lot. It isn’t perfect, but there is a lot to be said for it. One nice thing is that the cable is USB instead of those maddening nine-pin serial ports used for most meters.

I have what looks like a dead octopus on my desk. It is a tangle of wires to connect every meter known to man to the sole serial port on my tower. I’m constantly plugging, unplugging, plugging again, bumping the power cord, crashing the computer and then using a lot of Anglo Saxon English that really shouldn’t be used in front of women and children. (The other day six-year-old Rio told me that school gives him a ficken’ headache).

Now some meters need to be ‘on’ to download. Others ‘off.’ Sometimes different models of a given brand go one way or the other. Presto meters just need to be plugged in. The software doesn’t even need to be spooled up. Just plug it in and BOOM. The software opens, if that meter has been downloaded before it knows which patient in belongs to and the data is sucked out of the meter and dropped into the right folder. You can even merge data from multiple meters for those folks who have a work meter, home meter, car meter.

So recently I said, screw this. I’m putting everyone on Prestos. Starting with my 60 Medicare diabetics. So I called Fox, Hey little sister, how are you? Ummmm….hey, I was wondering if you could, you know, like, send me sixty meters………tomorrow?

Now I want to be clear about the facts that while Fox is a Fox, and that she is one of our tribe, those facts have nothing to do with my adopting the Presto meter. That’s just icing on the cake. I realized, late, that as a matter of good ethics you should support those that support you. Especially in a collapsing economy. You should also support those firms that do the right thing. And you should not support firms who don’t or won’t do the right thing.

So that’s why I’m supporting the Fox rather than the Hounds. I’m doing everything I can do to help AgaMatrix because they are the only meter company doing the right thing. They sell a top-flight strip a price that lets a patient afford them at cash pay. They give non-profits a good break. They have managed to get their product into Wal-Mart, at a price that is around half that of the major players. That, and they have a damn fine product. Good intentions with a crappy product get nowhere with me. Oh yeah, and I really like seeing a diabetes company making an effort to hire diabetics. Much rarer than you would expect.

I’m rooting for the Fox. And I kind of think the Fox just might eat the Hounds for lunch.

Friday, March 06, 2009

The doctors and me

Doctors don’t like us. Sorry, but it is true.

I go to a lot of medical seminars. And thanks to being a middle-aged white guy, I’m often mistaken for a doctor. No doubt it is my suave good looks and extensive vocabulary. OK, you can stop laughing now. But being mistaken for a doctor lets me hear things that real doctors would not say if they knew there was an undercover diabetic in the room. (Cue the James Bond theme song).

And I’ve noticed over the last few years that many doctors manage to use the word “diabetic” like a curse word. So how can I demonstrate this with the written word so that you can understand the tone, the inflection, that I hear far too often? Harsh. Biting. Like spitting out wine that has turned to vinegar.

Hmmmmmmm….OK, so if someone told you that Dr. X said, “I find these diabetic patients to be very taxing.” Well, now that sounds harmless enough. Maybe even honorably honest.

But it is the way “diabetic” is said that makes the difference.

What is the most vile, disgusting, gross thing you can think of? Yeeeeeewwwww, there’s a bunch of used condoms on the picnic table! Yeeeeeewwwww, there’s a leech crawling up your leg. Yeeeeeewwwww, there’s ….. Well, hopefully you get the idea.

That is how a great many doctors say “diabetic.”

But now, as if I don’t already have enough to do, I’ve been given a chance to do something about this. Not about the used condoms; about the attitudes of doctors.

I was recently drafted by an enlightened doc at a university hospital. His job, among other things, is to train “Residents.” Residents are not people who live at a hospital. Well, actually, come to think of it, they pretty much do. But I’m talking about proto-Doctors in their final phase of training.

Hearing on the grapevine that I was not making enough money in the first place, and am now making even less, he hired me to drive half way across the state two days per month to help him out. The job description was a little vague, but the pay was good.

I figured I’d be working with patients. Wrong. I’m working with the Residents. My first day on the job I was sort of a fifth wheel out-of-place observer. In every way. I work at a clinic where I know everyone by name. All the staff are on first name basis (of course two of them have the same first name: Doctor).

Now I was in a place with hundreds of employees. Maybe even a thousand. It is daunting. Thrilling. Scary. All at the same time.

So what the heck am I supposed to being doing here exactly? I asked my new boss at the end of the day. “You’ll figure it out,” was his response.

It wasn’t until I was driving home the first day that my mission dawned on me. It took a while to sink in. I was replaying the conversations, observations--everything I said, heard, felt, did-- on the way home when it hit me. Suddenly a light came on. Oh crap, I bumped the stupid dome light button!

Then, slowly, a theme emerged. Something I heard three different Residents relate to their preceptor. I’ll paraphrase, as they all pretty much said the same thing: “So the patient hasn’t done anything we asked them to do on the last visit, so I had the complications talk with her.” Picture a self-satisfied smirk. An inquisitor who just lit the bonfire at an old-fashioned witch burning.

I flipped open my cell phone and dialed. You want me to teach the children (his word for the Residents) what makes diabetics tick.


So I guess my next business card will read “Diabetes Ambassador.” My new part-time job is to make the next generation of doctors different from their forbearers. Not to view us as disobedient children; but as complex living organisms who have to exist in an even more complex social environment.

So today, two weeks after my epiphany, on my second day on the job, a young proto doc was complaining that a patient was still eating too many tortillas. After he finished his rant I said out of the blue, I've got a coupon for a free sex change. Would you like to have it?”

Shocked silence.

Awkward laugh. “What??”

Would you like to be a woman instead of a man?

“No…of course not…wha…why…why did you ask that???”

Because it is easier to change your gender than change your diet. You are asking too much. You are using threats and fear to affect change. That might work for a little while, but it is not sustainable. You need to understand your patient. You need to motivate, not intimidate.

Long silence while this set in. “So how do I….?” And we had a great chat. Not diabetic to doctor, or doctor to diabetic, or even peer to peer; but person to person. I love, love, love patient care. But this is a very cool gig.

I really do love Docs. Maybe I’m the right guy to make them love us back. What do you think?