When medical providers don't trust you as a diabetic

I’ve used the local dental school as my dental provider for many years. Things have taken an unexpected turn recently and I’m uncertain how to manage the relationship going forward.

I recently was assigned a new dental student to manage my care. I’m used to this situation as I know that there exits seasoned experience of faculty dentists who guide and watch over everything the students do.

The biggest downside for me is that procedures take two to three times longer than a private dentist. I put up with this as I pay out of pocket for 100% of my dental work and I the school needs people like me to educate their students.

Recently, the faculty member came in to talk with me about my diabetes and blood glucose control at a morning visit. He asked me if I had my breakfast and insulin yet. I responded that I don’t eat till later in the day, had not taken any meal dose yet, but my blood sugar was steady in the 90s and I showed my Dexcom display on my watch. It showed a flat 1-hour blood sugar line.

Unfortunately, this did not comfort the faculty person. Later in the appointment, my student warned that this nervous faculty person might be talking to me again about my blood sugar level. I was still flatlining in the low 90s and little to no IOB.

This faculty member had no depth of understanding about the effort I put into my glucose control. He didn’t know that I use a sophisticated automated insulin dosing system and that, unlike most diabetics, I was acutely tuned in to my blood sugar levels.

He apparently held fast to the advice that insulin using diabetics must eat on a regular schedule and take the requisite insulin. His knowledge and understanding was generations behind the times and he did not make any effort to understand the competence I exercised.

This all caught me by surprise. What’s the best way to handle this situation? I tried to inform him early by showing him the glucose display on my watch. To him I was just a patient that risked going hypo on his watch.

The professional ignorance of basic diabetes facts astounds me. The lack of respect towards some diabetics’ knowledge disturbs.

I think there needs to be a partnership between diabetics and medical professionals during procedures that require normal glycemia. I later found out that the school teaches its students that diabetics should be above 100 mg/dL to safely receive treatment. I’m assuming that 150-180 mg/dL would be comforting to them. Even though higher blood sugars promote dental infections and I never target those ranges. Not even in the short range.

I’m at a loss as to how I can bridge this knowledge chasm without implying that they are generations behind in their understanding current day insulin use to control glucose. I fear they see me as a doddering old guy not to be trusted. Is this the effect that my recent stroke has entailed?

By the way, my current 30-day numbers: 97 average, 86% time in range 65-120, less than 1% under 54, and a standard deviation of 19.

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@Terry4 You are a nice, polite person and what I suggest would definitely go against the grain. I am old and blunt. When people disrespect me, then I disrespect them. But respect has little to do with your situation. They are behind times and I would say so. I would also tell them that you have been providing their students with a free mouth to work on for X number of years without any incidence of low blood sugar. Tell them to stick to dentistry and leave diabetes to you.

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I think you should just forget about it and go in flat-lining between 100 and 105. That is what I do anytime I need a procedure that requires anesthesia as the major hospital I use in Boston has a policy that they will not do any procedures unless BG is between 100 and 200. After my last argument with the surgeon over this, he did tell me that he was not concerned about my going hypo, both because of the excellent control I demonstrated but then as an aside he said that there would be a slight rise in my BG as the anesthesia used contains an element that raises BG. Basically, rules are rules.

The problem is that you and I and a few others are the 1 in 100,000 diabetics that can flatline a BG below 100, but we are rare cases and a hospital or clinic can’t tailor a policy for the exceptionally well-controlled diabetics.

If all these providers start dropping their standard to allow patients to be below 100, it is only a matter of time before they have a crisis with a patient going hypo on them during a procedure who looked in control or said they were in control, when in reality they were not.

You could always offer to do a periodic class or lecture on diabetic control, but I doubt that would change anything until the herd (diabetics in general) have far better control than the average diabetic has at this time.

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@Willow4 - your advice makes me feel good but I’m afraid it would produce some unintended consequences. I appreciate your moral support but I’m not yet ready to write off this resource. Thank-you for your comment.

I’d like to say my control was as precise as you imply. I target 83 and my result is often in the 90s but sometimes drifts higher.

I understand that indeed you and I are not part of the traditional standard of care population. Is it too much to ask that the practitioners can discern when we come along (I can supply the dispassionate data!), can they simply use their brains to exercise some reasonable flexibility? Are standards of care inflexible rules?

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My dentist does not know I have diabetes. For me, that’s the easiest way to handle it.

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That’s certainly one way to handle it, although that option is foregone. In retrospect, I could have answered his breakfast and insulin dose question falsely and none of this would have transpired.

The thought just occurred to me that the faculty member was surprised that I was monitoring my blood sugar level continuously and that fact forced his hand to strictly enforce the standard of care.

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This is often the result of our overly litigious society. The hospitals and clinics need to walk a fine line between what is best for an individual patient and keeping the facility out of court when things don’t go 100% as planned.
So, I don’t agree with but, understand a better safe than sorry approach to the general patient population. No facility has the time or patience to research, learn, and accept the very specific needs of an outlier patient.

Just think how nice it is that diabetes is a diy disease and we have the ability to hone our control to each of our satisfaction. We could be under the control of these less than enlightened facilities if we were not diy. We have a tremendous amount of latitude, but I am sure looking for much more could be considered as greedy by some of our overtaxed medical professionals.

I would probably tell him that I am very well educated about type 1 diabetes, and that I take excellent care of myself. I would tell him that I have had diabetes for 63 yrs and am doing well.

I would also tell him that there have been many recent changes in diabetic care. Because of the newer insulins, people with diabetes are no longer tied to set meal times. Diabetics are now encouraged to keep their glucose levels in the non diabetic range if possible. I would offer the names of books where he could further his education.

If he was a jerk, I would just say. Hey, I have had diabetes for 63 yrs. If I didn’t know what I was doing I probably would be dead.

I haven’t had a dentist give me any trouble at all. They might ask about my last A1c, but that is it.

I bet this guy sees lots of poorly controlled diabetics.

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I will use building codes and land use codes as an analogy to what you experienced. These codes do are painted with a broad brush, often make little sense and occasionally are counter productive. Yet we are forced to comply because rules are rules, the process to make an exception for one property owner is expensive and time consuming, and because the rules are enforced in a lowest common denominator fashion. And sometimes the enforcement of the rules is arbitrary, dependent on the whim of an inspector.

That’s just one example similar to that dental practices policy about BG levels…there are probably countless others. It’s easier to just comply with their rule rather than trying to force an exception just for you. Society does not expect us to get worked up about arbitrary rules that are easy to comply with.

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I like to completely turn off my basal right before going into the doctor’s office.

That way when they ask me if I am currently taking any medication, I can say, “Nope. I am not taking any medication right now.”

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Just to be clear insulin is a hormone and not a drug.

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Convicted? No. Never convicted.

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It’s a medication. In English it is a “prescription”; English doesn’t use “drug” except for things that get you high, excluding, curiously, alcohol, coffee and Dance (where quantity counts).

Excellent analogy, at least in the US; US building codes are primarily prescriptive; they describe a way of doing the regulated thing (e.g. disposing of human waste). If you want to build something that doesn’t follow one of the prescriptions you are required to be an engineer and you put your license, and insurance, on the line.

This is not true the world over; it seems to be a function of US law and lawyerism. Follow a restricted set of pre-approved rules and you don’t get sued.

I’ve done house wiring in the UK, where the electrical regulation is interpretative (based on correct interpretation of a set of goals) and the US where it is prescriptive, written down in a 1420 page book of rules (based on the 2008 version). I’ve got away with it in both countries, but I learned more in the UK and my US wiring was entirely Edison wiring with an apparently unnecessary but very carefully maintained ground fault (UK ‘earth’) circuit throughout.

That’s no excuse for the Dentist; @Terry4’s experience strikes me as entirely different; a busybody with a peaked hat saying, “I’m sorry, you can’t do that in here.” A “jobsworth”; it’s more than my job’s worth. A UK phrase from my youth.

I’ve not had problems with paid professionals; they don’t ask questions because they don’t want to be sued. They have no reason to ask about my diabetes beyond questions directly relevant to the their specialty (HbA1c). If they need to know my BG they aren’t going to trust me, or my Dexcom CGM.

They’re happy, particularly when my HbA1c goes down and my condition gets better (retinal) or worse (lots of money in teeth). They don’t need and certainly don’t want to know how I achieved the better results.

Of course this creates a dilemma with PCPs who are expected to look at the whole building, not just the wiring. I honestly don’t know how we can deal with that; I’m using kit that isn’t FDA approved and others are using targets that aren’t approved by the medical establishment as a whole. We are in a hole that will condemn us and might kill us if we climb out, yet it is a hole of our own choice.

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Yes, exogenic insulin is commonly thought of as medicine, but technically not a drug, not because of the negative connotation of schedule 1 drugs.

  • Biologic medication: Biologic medications are large, complex molecules, often made from living cells or tissue. Insulin, Victoza® and Trulicity® are examples of biologic medications that help manage diabetes.

  • Drugs: Drugs are smaller molecules that are made through a chemical process. Metformin, Januvia® and Farxiga® are drugs that help manage diabetes.

https://diabetes.org/blog/insulin-now-biologic-what-does-mean

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Sure that is true for many people with diabetes but I am a type 38. We have negative reactions to what you are saying. It is a rare type. If you want help with other T38’s please give me a call.

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Prescription and drug or prescription drugs are pretty much used interchangeably.

My insulin is listed in my insurance drug formulary.

I think we all understand what insulin is.

Some sort of technical snafu, sorry fixed it best I could on my phone.

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That fixed it, thanks.

The Dentist was a little too pushy with you about your BG but it’s possible that he had an incident in the past where a patient said they were fine started getting a procedure done then half way through went really low requiring intervention. My dentist and ophthalmologist just ask most recent A1C, medications, and for some reason average fasting BG.

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