Endo's- venting

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If you aren’t happy with this particular endo, did you sense that the practice is large enough and has enough breadth that seeing a NP will be productive and the other resources will be useful as well?

One my best and most accessible diabetes resources is a NP who is nominally a CDE/dietician. But really has a lot more depth and is way more accessible than the “real doctors”.

I’ve vacillated between large University endocrinology departments and small-time non-endo docs and back to a big endo practice several times over the past 40 years. The personal connection with a big practice isn’t so great, but especially here in 2022 it’s great to have the deep resources (including experts in pre-clearances and paperwork etc.) of a big endo practice.

After 40 years with T1, and (at least when I had insurance) endo or doc visits every 3 months, any advance (or apparent brush-off) at each individual appointment starts mattering less than the overall and ongoing availability of support.

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Interesting insight, Tim. I think you are spot on with your observations of different types of practices.
Yes, I think NP’s are available there and the receptionist mentioned that my next appointment may be with an NP. As long as they are good, I don’t care. It seems that we want our providers to have a good bedside manner AND skilled at treating us. I think the guy I saw last week was definitely skilled. He was just in a big hurry. Maybe the pharmaceutical meal I saw someone carting in was calling… LOL…

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One thing to consider is the basic practice model of Endo’s generally. They do not have a procedure they can leverage - so they have to see 4 patients an hour to make a living. But this is a complicated process - which makes that difficult. Engaged patients take more time, they run behind, etc… I’m sure you have similar experiences with your primary care. Unlike Radiologists, surgeons, GI specialists, urologists, etc…, they cannot simply master one procedure and maximize their income. Their practices often require a base amount of patient visits. Its more structural than anything, in my experience.

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My nurse practitioner is much better equipped and knows so much more than my endo in regards to real life with diabetes.
She also spends more time with me and I prefer to see her.
Of course she works for the endo so she stays within his guidance. This works for me.

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I’ve had great endos and horrible ones.
They are just like people in any other profession.

I would prefer to have an endo that I know cares about me as an individual.

The reality is that they are few in number relative to the number of patients. The last time I checked there were only 8000 endos in the US. There are 1.6 million people with type 1 and 37 million with type 2. That’s more than 4,000 patients per endo. At 15 minutes per visit that’s once a year per patient.

The most patient person in the world can’t get much done in 15 minutes and if they don’t have a cooperative customer then it’s less productive.

As a present progressive disease, type 2 doesn’t have the immediacy of consequences type 1 does

Those who have type 2 have more time to go through the stages of grief to acceptance. Some never accept it, some accepted but throw up their hands and say there’s nothing I can do about it, and some smart people assume responsibility for managing their condition and do everything they possibly can to preserve their health.

But any delay makes an enormous difference to the speed of progression.

Thoe add to the frustration of a doctor who was already impatient because they haven’t have enough time to care for their patients, just to diagnose them, give them cookbook treatment plans and see them get worse viddlsut by visit.

It’s got to be frustrating to a doctor who would love to waive a wand and cure patients to see them seemingly volunteer to become sicker.

I consider myself fortunate that I have type 1 instead of type 2. I couldn’t ignore the rapid onset of symptoms, I became so weak so fast that I welcomed any diagnosis, any treatment that worked.

I hated that it was type 1 but I accepted it within hours. I had no choice if I wanted to live. I was told that I had fewer years to live , and what I did today would determine how long I had.v Thank God that I had an honest blunt doctor instead of a kindly one who didn’t want to break the news to me over years of visits.

If I had had type 2 with gradual progression of symptoms, even if I had become eventually hospitalized, I know that I would have taken much longer to accept reality and responsibility for doing what I could to manage my lifestyle.

I know that it would have been harder for me to give up favorite desserts that I loved to make and replace them with shallow versions of themselves.

I also know that I would have been more likely to have more consequential damage from diabetes than I have had with type 1.

Instead, because I have been forced to pay closer attention to my health, I am healthier than many people my age who don’t have diabetes. I received earlier treatment for other degenerative conditions much earlier because I sought out medical support early.

So I feel lucky that I have diabetes, that there are doctors and treatments available to me., that I can afford those treatments and can see that they work.

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Most of the time t1 are diagnosed when we are young. My habits weren’t that well defined yet, and I was involved in sports so I was already limiting junk food and sweets.

As an adult, I really don’t have a hard time with eating sweets or carbs. It’s when I take insulin for a certain number of carbs and it’s the wrong dose. Even when I took the same dose for the same food a day earlier.

I was very sick when I was diagnosed. No one explained anything to me the day I was diagnosed. They put me in bed, gave me a large dose of 20 units of regular insulin. I woke up feeling better thinking I could go home now that I was better.

They the nurse laughed at me and told me I’m here for a few days and to get used to the restrictions.

I often wonder how I survived those days with NPH insulin and finger sticks that just gave a range of possible sugar like 180-220.

I would crash all the time. I was never able to properly time my NPH insulin. Somehow I’m still here 35 years later.

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We really do have much better insulins and technology to help with diabetes than years ago. It had to be really difficult for people back then and it is a blessing that many survived the earlier days without any long term damage.

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You touched on some really, very true good points!!!

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Same for me, but with additional 20 years prior to NPH using 1 daily injection of Lente, and urine testing in test tubes.

Yes, me too, MM1. Dx type 1 1959. Amazing that we are doing so well.

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It’s weird how it goes. After nph and regular, I switched to ultralente and humalog. I had decent control for the first time.
Until they discontinued ultra lente and I started pumping.

I went straight from nph/reg to pump, Minimed 505 or 506 I think, in late 80s. Continued to MM 523 before switch to Tandem in 2020.
I have kept Lantus or Levemir on hand for pump backup, but only used once.

I didn’t change to a pump because I needed better BG control, I’m doing it because I need to make it more reliable than relying on another person most of the time

I had no problem using Novolin. Before I started using a CGM my A1C was 6.7. After using CGMs for a month it dropped a 5.9 while I was still using Novolin.

Over the years I learned that if I ate predictable meals my job of insulin management was easier. I became very good at correcting BG 4-6x/day.

Old fashioned human synthetic insulin is actually a better match to the needs of our bodies than the short-term analogs are. Analogs are used for pumps not because they are better for bodies, but because of the diffusion lag. If there were a simple, reliable and safe way for pumps to inject insulin directly into the bloodstream, then regular human synthetic insulin would be the preferred insulin.

When I was switched to a t:slim and Novolog I discovered that they were not well suited to handle gastroparesis without software like Control IQ.

A minimum of 1/3 of all persons with long term t1d developed gastroparesis.

Gastroparesis often produces a second surge in blood glucose more than 2 hours after the first one. It essentially looks like two separate meals every time you eat. A Tandem extended bolus does not match that BG curve and the mismatch grows worse if you restrict the extended bolus to 2 hours.

The diffusion lag of human synthetic insulin is a good match to blood sugar rise from gastroparesis. The first peak is slightly undermined and the second one is slightly anticipated.

There’s only one practical way to handle this mismatch manually using fast acting insulin. It doesn’t matter whether you use a single bolus or an extended bolus.

After every meal you observe the peak, and when IOB drops too low to possibly reach target correct, watch for it to approach target and correct for any under or overshoot. I know it’s possible because I’ve done this for a couple of weeks.

After the first week I figured out that Control IQ could do what I was trying to do manually, but better. I had to wait for a peak and endure it’s effect or guess how much to correct. Control IQ doesn’t have to wait. It can start to dampen the rise before it slowly reaches a high peak and act with a partial correction before a fast rise gets high.

It’s not perfect, it’s an improvement. It acts sooner than I could and mitigates rises and falls in a way that would require a lot more attention and time on my part than I can afford .

It’s like driver assist. it makes the work easier so when your attention is required, you’re not as tired from the mechanics of driving.

Glad you found what works for you. Assume you are using Novolin R (regular) ?

I used Pump with Regular for many years before the faster novolog and humalog came out. Doing great with Control-IQ and Novolog. Glad we have choices.

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I was using Novolin R and N.
Now, I’m using Novolog because Medicare will only cover with the pump is certified to work with, unless I can convince an endo to fight them for regular.

It’s a pain in the butt to try to match the curves of gastroparesis Novolog with extended boluses and timing. I’m hoping that Control IQ can handle it better than I when I get upgraded next month.

But, based on my experience with bad sites , it may only have a chance to do that 70% of the time. :-c

Even if we had a pump that delivered into the abdominal cavity, insulin would work much faster. The early minimed implanted pump worked that way with regular insulin and had really good results.
The problem was with battery running out and cannula getting clogged. No one wanted surgery every other year so they dropped it. Now I understand they are redirecting g the idea again.

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