Shocked by MD care of my patients

EllieMD · May 5, 2015

Uhh, I would not say the average new grad MD is better equipped to practice than the new grad NP. I was running circles around new grad MDs as a new grad RN in terms of doing things clinically (OH HEY LET'S GIVE 4 YEAR OLD 80MEQ OF K AT ONCE AND NOT CHECK A BEFORE AND AFTER POTASSIUM LEVEL AYUK AYUK......this actually happened to me and I was like *** are you even thinking?).
The new grad MD clearly didn't pay attention during his/her IM/family practice rotations. Educate them and get your patients back in. For patients with type 2 DM that I have only on metformin, I only do fastings 3x a week, if their fastings are good but their A1C isn't at goal, I have them do a few pre-prandial and post-prandials during the week too to see if/when they are spiking sharply. I don't use glipizide/glyburide because I prefer to go straight to insulin rather than wear out their beta cells, but if I inherit a patient on these or they are extremely resistant to insulin I have them check their blood sugars 2 times a day or so.

Sorry to jump in here but the "new grad" MD is completely right here assuming we are talking about a patient who is not on insulin. The current evidence generally supports the practice of NOT doing routine home fingersticks for these patients. See http://care.diabetesjournals.org/content/28/6/1531.full or do a google search to found an array of articles addressing this.

greygooseuria · May 5, 2015

The article concludes that it isn't effective for lowering A1C. I'd argue it provides great data in clinical decision making, especially if the fasting starts creeping up despite therapy with oral agents.

And just because one article says something doesn't mean it should be taken as gospel, considering the ADA recommendations go against your article: http://professional.diabetes.org/admin/UserFiles/0%20-%20Sean/Documents/January%20Supplement%20Combined_Final.pdf and those are gospel for the diabetes management community.

Sorry girl, but I did my masters thesis on diabetes management and I live, sleep and breathe diabetes management. One article is not a landmark study nor is it a sweeping recommendation.

allnurses Guide · May 5, 2015

From UpToDate:

"The effectiveness of SMBG in terms of improving glycemic control in patients with type 2 diabetes (especially those not receiving insulin) is less clear than for type 1 diabetes. Multiple observational studies have evaluated SMBG in type 2 diabetes, with some showing benefit [4,5] and others not [6-9]."

"Monitoring blood glucose is a tool, not a therapeutic intervention. It provides important information with which motivated insulin-treated patients can modify their behavior and improve their A1C values safely by reducing hypoglycemia risk. As an example, SMBG may also be useful for some type 2 diabetic patients who would take action to modify eating patterns or exercise, as well as be willing to intensify pharmacotherapy, based on SMBG results [20]."

"Thus, self-monitoring of glucose may not be necessary at all, or only in unusual circumstances, for patients with type 2 diabetes who are diet-treated or who are treated with oral agents not associated with hypoglycemia. In addition, it may be unnecessarily burdensome in frail older individuals with cognitive impairment or difficulty with fine motor skills from neurologic or musculoskeletal conditions. In such patients, the target for A1C should be somewhat higher (â‰¤8 percent) than for younger and more fit older patients and, therefore, there is little role for regular SMBG, unless the patient is taking insulin."

Sent from my iPhone.

grammynp · May 5, 2015

Thank you so much for your reply. After reading the article you posted, I will change my practice. Though I will make this change per each patient. Many are ready for this change, many are not. In the rural community we do not have any diabetic educators. I teach what I know a

little at each visit. I bought a A1C (fingers stick) for my office and love it.

What bothers me the most is that she refilled there prescriptions for a year. These are mostly one time visits my patients have with her.

I would not even think of making major changes to another providers patients. I would rather have her discuss this with me, so I can learn better management.

Does this make any sense?

Jules A, MSN · May 5, 2015

What bothers me the most is that she refilled there prescriptions for a year. These are mostly one time visits my patients have with her.
I would not even think of making major changes to another providers patients. I would rather have her discuss this with me, so I can learn better management.
Does this make any sense?

If all that bothers you is that she did 1 year refills I'd let it go. Although I don't do refills that long it isn't making "major changes" or actually any changes at all. It sounds like you learned something about finger sticks from discussing it here which is a positive.

My relationships with my physician peers are far to valuable to risk alienating them over something insignificant. My advice? Be thankful she was willing to cover for your vacation and unless you really have a practice question, with the intent of learning something from her rather than criticizing her handling of your patients, I wouldn't do anything more than thank her for covering for you.

EllieMD · May 6, 2015

Thank you so much for your reply. After reading the article you posted, I will change my practice. Though I will make this change per each patient. Many are ready for this change, many are not. In the rural community we do not have any diabetic educators. I teach what I know a
little at each visit. I bought a A1C (fingers stick) for my office and love it.
What bothers me the most is that she refilled there prescriptions for a year. These are mostly one time visits my patients have with her.
I would not even think of making major changes to another providers patients. I would rather have her discuss this with me, so I can learn better management.
Does this make any sense?

I completely understand what you are saying and I really think the cost vs. benefit varies by patient. I'm impressed that you have a fingerstick A1C machine. I actually have DM 1 and my endo does not have one which drives me crazy. I don't need the feedback at my appointment but I imagine most of his patients do and it would be really helpful to discuss in person.

allnurses Guide · May 6, 2015

We started to use fingerstick A1C testing in-office and it has been a great help, though we struggle getting reimbursement for the test strips from some insurances.

Sent from my iPhone.

SHGR, MSN, RN, CNS · May 12, 2015

As far as MD vs NP care of diabetes patients, it is shocking how little instruction MD students get on the topic. From what I have seen, NP students get more training in DM care and are better at patient teaching and support, which is crucial.

EllieMD · May 13, 2015

As far as MD vs NP care of diabetes patients, it is shocking how little instruction MD students get on the topic. From what I have seen, NP students get more training in DM care and are better at patient teaching and support, which is crucial.

Just to address this, I have a minimal understand of the NP curriculum but MD students typically get at least 8 weeks of class room based endocrinology instruction, the majority of which is focused on diabetes. Additionally, diabetes is integrated into pharmacology and all other topics taught during the first two years. As someone who has DM, it became a running joke among my classmates the frequency with which diabetes was brought up. All MD students need to pass both Step 1 and Step 2 of the USMLE which requires extensive knowledge of both the diagnosis and treatment of DM. Additionally, a medical student will be directly involved in the treatment of hundreds if not thousands of patients with DM during the 2 years of clinical rotations (averaging 40+ hours/week). So it would be near impossible to graduate from med school without a pretty extensive knowledge of DM. Then during residency the MD will learn about DM as it relates to his/her specialty or gain more experience in managing it if she/he is in a primary care specialty.

greygooseuria · May 13, 2015

Book knowledge does not equal being able to educate patients thoroughly about their condition and achieve compliance, though.

SHGR, MSN, RN, CNS · May 13, 2015

EllieMD, that is great that your program is focusing on DM and its care. In my work with family medicine residents, I was told by many (recent graduates of different medical schools) that their coursework on the subject was minimal. They do of course see it all the time in primary medicine residency, sometimes working with faculty stuck in outdated practice patterns though...

EllieMD · May 13, 2015

EllieMD, that is great that your program is focusing on DM and its care. In my work with family medicine residents, I was told by many (recent graduates of different medical schools) that their coursework on the subject was minimal. They do of course see it all the time in primary medicine residency, sometimes working with faculty stuck in outdated practice patterns though...

That's more than a little scary! My general experience as a patient and a physician has been that both NPs and MDs not directly involved in diabetes care do lack an understanding of current treatment options. Our fast track where I work is staffed by NPs (that is how I ended up on this forum) and they tend to have lots of questions for me regarding my pump and CGM. MDs should graduate from medical school with a solid understanding of diabetes care but it is a major problem if that is not happening. The USMLE is supposed to ensure that so it is very concerning that residents are not comfortable with the DM education they have received. That said, I personally prefer the use of CDEs for diabetes education because that is what they are trained to do and they tend to have longer appointment windows to provide more in depth education and support.