May 31, 2007
Internal Medicine World Report, September 2006, Volume 0, Issue 0

Patients', Not Physicians', Inertia the Culprit in Diabetes

To the Editor: As an internist who has practiced clinical medicine for the past 16 years, I must respond to the front page article in the July 2006 issue of the journal, "Physicians' Inertia Blamed for Suboptimal Diabetes Treatment" (Vol 21, No 7).

The main points of the article, which summarizes data compiled from several presentations at the 66th Scientific Sessions of the American Diabetes Association, are that physicians' attitudes are to blame for patients' poor blood sugar control, and that routine diabetes self-care is too time-consuming. The data were collected from pharmacy and laboratory claims, and questionnaires completed by diabetic educators and dietitians.

Commenting on the laboratory and claims data, Craig Plauschinat, PharmD, MPH, concluded that "delayed therapy intensification was probably the result of infrequent hemoglobin A1c monitoring," and that "physicians are lulled into thinking they have achieved glycemic control when their patients report that they are feeling better." He then concluded that, "Interventions assisting patients and physicians to recognize and overcome clinical inertia may represent a specific opportunity to improve glycemic control in type 2 diabetes."

While I agree that frequent HbA1c monitoring is an important aspect of diabetes management, "patient inertia" is the most common reason for suboptimal outcomes. Many patients are unwilling to believe they have diabetes, change their lifestyle, initiate medications, or follow up with regular office visits and laboratory tests.

Regarding Dr Plauschinat's second point that a self-reported subjective assessment of "feeling better" implies optimal diabetic control?this is clinically ludicrous.

Analyzing results of only 30 surveys, Jay Shubrook, DO, concluded that self-care measures among adults with type 2 diabetes take more than 3 hours per day. These activities included such things as "home glucose monitoring, record keeping, oral meds, foot care, problem-solving, exercise, meal-planning, shopping, and preparation."

First of all, 30 returned questionnaires is too small a number to yield significant results. Second, the surveys were estimated, included items that are universal to all living and not unique to diabetes, and were not completed by the patients themselves. Third, if the prototypical patient was an adult diabetic receiving monotherapy, this is even more troubling.

In our practice it seems that monotherapy is not the norm in diabetes medical management. It is appropriate for only a small number of patients, and usually only for a limited period of time. The natural history of diabetes is such that over time, optimal control requires multiple classes of diabetic medications in addition to lifestyle changes. For this reason alone, the questionnaire is not realistic.

Dr Shubrook concluded that, "To make the demands more realistic, we need to find ways to combine tasks, or alternatively develop a culture change that all adults can bind self-care into their daily lives."

Indeed we need to make it as easy as possible for our patients to control their diabetes. In our office, patients are instructed to exercise daily. They are referred for nutritional counseling, cardiovascular screening, and annual funduscopic and foot exams. If they do not have wildly fluctuating glucose levels or are not injecting insulin, there is very little benefit to home glucose monitoring. They are encouraged to have optimal lipid and blood pressure control and to have office visits and laboratory testing, including HbA1c, every 3 months.

In our experience, if patients do not achieve optimal diabetic control, it is not physicians' inertia that is to blame. It is our responsibility to make correct diagnostic and therapeutic decisions. It is the patients' responsibility to eat properly, exercise regularly, adhere to the prescribed medication regimen, and have periodic office visits and laboratory and other testing.

In blaming physicians for the failure of patients to achieve optimal diabetic control, the American Diabetes Association is just another example of a mainstream institution abrogating personal responsibility in our "politically correct" society.

?Robert Mills, DO Ringwood, NJ

Diabetes Care: Physicians Must Take a Stand

To the Editor: It was with sadness, but not surprise, that I read the headline of the front page article of the July 2006 issue of the journal (Vol 21, No 7), "Physicians' Inertia Blamed for Suboptimal Diabetes Treatment." The author, Jill Stein, went on immediately to blame doctors, using a 2-pronged attack. First, doctors are giving in to inertia, and second, they have devised programs of self-care for diabetics that are simply too time-intensive.

May I suggest, with some indignation, that a more accurate picture is that doctors are desperately attempting to work within time demands that would overwhelm most people, and that if there is inertia it is only because they have crossed over from desperately attempting to simple despair. My experience with patients with type 2 diabetes is that it is they who suffer from inertia. How many times have we heard this sing-song phrase, "I know I should, doctor. I'll try."

If someone has lived his or her life such that diabetes has become a part of it, it behooves them to dedicate whatever amount of time it takes to straighten things out. The fact that somehow the physician is held responsible for the patient's unwillingness to do this reflects an exaggerated sense of power on our part.

Billions of dollars are spent to develop medications that we hope might act as a better mousetrap for rebellious glucose levels, when "the evidence is overwhelming" (July 2006) that systematic exercise has as much effect as medication on cardiovascular mortality in diabetic patients. Yet this article not only blames physicians for not titrating medication, but in addition, foisting hours of lifestyle modification on these apparently helpless folk.

It is time for American physicians to take a stand on just who is responsible for what, and to honestly define what can be accomplished in a finite amount of time.

?Jocelyn Gunnarsson, MD

Loma Linda, Calif

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