Back in 2016, I had just moved to a new city and it took me five months to get an appointment with a well-known hospital affiliated diabetes clinic. In the meantime I started using the automated insulin dosing system, Loop.
On the day of my long awaited first endo appointment at a new clinic, a winter storm prevented my doctor from showing up. Instead the clinic offered for me to see the head of the clinic.
I played it with a simple explanation of my understanding of how the system works and how its helped me, especially when sleeping. To back up my claims, I pointed to the data that the clinic downloaded from my CGM. I also printed hard copies of my 14-day and 30-day Dexcom Clarity Ambulatory Glucose Profile (AGP) report.
I don’t remember my exact numbers but my glucose variability was low and my average BG was in the 100-110 mg/dL range. My time in range (65-140 mg/dL or 3.6-7.8 mmol/L) was more than 80% and my time low around 3%. Over 2/3 of my “hypoglycemia” was in the upper end of the low range, what I would call the “alert range.”
The doctor listened carefully and asked appropriate questions. He took his time looking over various Dexcom reports on his screen. To his credit, he did something I’ve rarely experienced with endos: he didn’t feel obliged to give me the standard hypo warning.
My point of care A1c came in at 6.0%. I now realize, due to iron deficient anemia, my actual glucose exposure was likely equivalent to a 5.5% A1c. In any case, I was pleased that he didn’t feel the need to over-react to a lowish A1c alone to warn me about dangerous hypoglycemia.
I think I was likely the first patient he had seen in clinic using an automated do-it-yourself insulin dosing system. He measured his comments carefully and maintained a neutral position with regard to DIY Loop. He neither complimented nor criticized. I could tell from his body language and questions, however, the he was impressed with the level of glucose control I got from this new technology.
I think the key to keeping skeptical doctors off of your back and gaining their support is to use data to show that your better control from looping does not come at the increased risk of severe hypoglycemia, < 54 mg/dL or 3.0 mmol/L. I’ve needed to remind subsequent doctors at this clinic that I don’t consider “alert value” hypoglycemia (55-70 mg/dL or 3.1-3.9 mmol/L) with the same gravity as severe hypoglycemia. I’ll often treat alert hypoglycemia with one glucose tab or one ounce of juice.
I also made it clear that through extensive personal experience and observation, I knew that my threshold of physical hypoglycemia symptoms started at 65 mg/dL (3.6), not the standard 70 mg/dL (3.9) that most clinics use. I pointed out that gluco-normals spend a good deal of time in the 55-65 mg/dL (3.1-3.6) range, particularly during the period right before waking up in the morning. I much prefer to compare my glucose control to healthy non-diabetics, not some arbitrary standard decided by professional associations.
With my recent dive into educating myself about hypothyroidism, I lost some respect for my diabetes docs. They seem much more driven by rote and inflexible adherence to standards of care. My clinic, however, does an excellent job of supporting my continuing need for a long list of diabetes supplies and that is no small thing.
In summary, I would approach the doctor in a matter-of-fact manner and bring lots of data to support your case. This is a test for your doctor. If you learn that this provider over-reacts and fails to consider your case in a individual fashion, then you’ll know how to handle your communication going forward. If the doc freaks out about using a system not certified by the FDA, then I don’t think there’s much benefit in arguing. Smiling and nodding can be effective in this situation.
If the doctor is supportive and open to new ideas, then I would consider that a plus. S/he should treat you like an individual case, listen to your questions, and give appropriate answers.
