Doctors and A1c's

Simply because insulin dependent diabetics are taking medication all day every day that can drive their bg still lower… so while a bg of 60 isn’t actually truly a problem in and of itself, a bg of 60 in a person who’s lost natural bg regulation ability and is using medications that can drive it still lower very easily is considered worrisome, rightly so. Concepts like these go back all the way to the earliest tenants of medicine where providers pledge to “first, do no harm”

But the point still needs to be impressed on clinicians that we aren’t all teetering on the edge of an having an acute issue just because we practice tight control…

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I think clinicians are overly hypo-phobic, especially when they can not discern the difference between a patient with high variability and an obvious higher risk of hypos from the patient that shows up with 25,920 glucose data points (288/day X 90 days) and demonstrates with prodigious proof that the clinician does not need to reflexively make this warning. It erodes their credibility.

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I agree that they can be overly hypophobic… and that this disconnect can be frustrating. A good provider certainly will distinguish between someone with tight control and someone with out-of-control hypoglycemia…

I still respect their perspective though, having been both raised by and married to medical clinicians… their foremost responsibility in counseling any patient who’s using insulin and experiencing hypoglycemia is to warn them of the dangers of it… that’s their job, whether we like it or not

I really don’t believe that most doc’s are hypo-phobic but the establishment is. It is the constant pressure of those over seeing them that bring on their caution. The litigious nature of our society makes them tow the line, lord help one of them if they step out of the standard practices and something happens to just one patient.

They do what they do because of the CYA effect

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Warning a patient (low A1c w/ < 5% hypo) to raise their A1c from 5.5% to 6.5%, without considering via data that shows their actual hypo risk, harms patients. It raises the patient’s long-term complication risk without gaining any benefit.

The doctor’s instincts toward caution may work well many times but they just need to open their eyes and actually examine the data before them.

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I wouldn’t agree, in a general sense, that the data supports that statement. 5% hypo still introduces risk. 1 single severe hypo can kill someone. The data that an a1c of 5.5 vs 6.5 will appreciably improve outcome is sketchy at best—- that said, I personally believe it will… but I can’t expect my personal beliefs to alter the medical advice I’m given

That would be great in a perfect world. But a doctor must survive. They must cover their butt.

I for one have no issue with being given this kind of general advice. I can smile and say sure as I disregard what he or she has said. If it keeps the doc out of hot water I see no harm.

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I understand this, Gary. It makes sense to me but, as a patient, I narrowly wish to see my medical needs met. I am highly aware of the pressures on the doctor, the mind-numbing and needless insurance second-guessers, the short time available to spend enough time with the patient, and the incredible complexity of the glucose metabolism all combine to make an endocrinologist’s (and any doctor’s) job hard.

I’m sympathetic to those pressures but I will not stand for lapses in critical thinking skills. They need to look at the data, then decide to warn the patient only if the data supports it, not on some visceral hunch.

The data proves that when people’s blood sugar drops dangerously low it can be a health emergency and can even cause death. You can’t present a doctor with data showing that yours is doing that 5% of the time every single day and expect them to say nothing. For them to say nothing would be blatant malpractice… you’re an intelligent person, it’s your job to put what they say into the context of your life… it’s still their job to say it though

If you don’t want to hear it, maybe a better approach would be to not even present the data… I don’t, because I don’t want to hear it…

The two percent rule is in play here, 2% of the people screw it up for the rest of us. If not for 2%ers there would be no crime, there would be no wars. There would be no patients willing to sue a doctor for everything he is worth just because he failed to utter some irrelevant warning. Even though the lack of warning was not the problem but it is outside of the standard to not warn the doctor will be just judged as inadequate because he broke with standard practice.

Sometimes I think the smile and nod tactic is the best one to use with your diabetes doctor. That way, they keep writing the Rx’s.

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Thats the tactic i use. :grinning:

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After reviewing my lab work with A1c of 5.7% (at the time), my endo took one look at my standard deviation on my Dexcom Clarity report and said everything looked great. She said she worries much more when she sees people with an A1c in the 6-6.5% range with high standard deviations.
I ended up switching docs due to other, legitimate concerns, but I think there’s a decent number of endos out there that personalize treatments based on assessed risks.
My current endo took a very similar approach when he evaluated my A1c and Clarity Report. I think using a cgm can give an endo a lot of comfort when treating a patient with a lower A1c.

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Great to read that some endos are starting to understand the meaning of the data. Low variability is the key to safely lowering average BG and A1c’s.

Mine, at my first consult with them saw my a1c which at the time was 5.5 and said he’d like to see it w little lower but only if I can do it without experiencing hypos… I’d consider 5% of my life spent in hypo territory far, far too much and would expect to receive appropriate warnings about the risks associated with it from my doctor if I was doing so…

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Do you mean 5% below 55 mg/dl? or 5% below 70 mg/dl?

Here’s the ambulatory glucose profile of a gluco-normal person. Note the time spent “hypo” (<70 mg/dL) at 5.2%. Is this person at risk?

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It is definitely a CYA standard. I was trying yoga some some joint issues and had never done yoga before and of course fainted in a heated room. I told my doctor and because I fainted, it was reported. Fortunately it didn’t get filed with DMV or was filed but with side note in heated room during yoga. But I had a talk with my endo about this situation. If a person with diabetes is having some major lows and tells their doctor about it, they legally should report it to DMV. But I told her, if I tell you this and you report it and I lose my license, i’m done because I need my car. So that means, when we are having some issues, i can’t you for fear of being reported? What a crazy, screwed up system. She agreed and thankfully, I learned to never say I lost consciousness or needed help but was having so low issues. She said that a doctor could be liable if one of their patients had an accident. Kinda scary, isn’t it?
So I don’t report is I were to ever lose consciousness and I understand why doctors can be conservative with numbers.
Thankfully my current endo looks at time in target and my SD.

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I think a significant difference here is what happens when a gluco-normal person goes low vs a Type 1 goes low?

Which I think gets back to the point as:

So, I would consider a BG of 50 in a Type 1 to have very different practical meanings as compared to a BG of 50 in a gluco-normal person.

People who don’t use or spend time around chainsaws have near zero % likelihood of chainsaw injuries. People who use them all day every day should be properly trained and cautious in their use, and if they are having close calls 5% of the time should probably be counseled on the subject

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