Finding Dr. Right
It’s tough to find a good doctor to help manage diabetes. It’s also tough to know if the doctor you have is a good one.
As of some time earlier this month (I don’t know the exact date) I’ve had Type diabetes for 31 years. In those years, I’ve had many different doctors care for my diabetes. Looking back at them, I realize how different each one is from the next. Some are good at telling you that you’re not doing well (or kicking you in the pants when you don’t). Others are good at maintaining the status quo: writing prescriptions and keeping track of various metrics (A1C, height, weight) without ever really knowing you. And every once in a while, you come across a real gem – someone who really can make a difference – who can surprise an old dog by teaching him new tricks. (Yes, sadly, I now consider myself an “old dog”.)
Finding these doctors, however, is a daunting and stressful mission. Sometimes, I’ve found them completely by chance, and other times dumb-luck brought them to me.
I ended up with Dr. Salas, my pediatric endocrinologist, strictly by chance (I mentioned him in my post March 5, 1974). After my parents recognized something wasn’t right, they brought me to my pediatrician’s office, and soon after I was raced to St. Peter’s Medical Center in an ambulance (for a seven year old, that’s kind of cool – and confusing). Somehow, I got paired with Dr. Salas, who ended up taking care of me for the next ten years.
Without any basis for comparison (this was 1981 after all), I can’t evaluate him, but as far as I care, he did everything right and had his intentions were pure. He would always wear a white lab coat, with a circular button pinned to his lapel. It had the word “DIABETES” in all caps, covered by a red circle with a line through it. I knew he wanted to conquer this disease from the start.
Dr. Salas was very particular when it came to A1Cs. I would have to get my blood drawn from the same lab each time, because he believed that different labs did the test slightly differently, and the trends that he would see wouldn’t be accurate. It’s a good thing he looked at A1Cs (the highest, if I recall, was in the 14s), because most of the records that I kept and showed him were false. Considering he was my first, he was a good teacher.
Of course, things happen and sometimes other doctors come into play as well. Once, as a teen, I had a severe low while staying at my grandmother’s house and ended up at the hospital. My parents talked to the doctor at that hospital for quite awhile about me and my diabetes. They were concerned that I had so many sugars in the 300’s, but the doctor said that was OK, that it’s normal for a growing teenage boy to eat a lot and have high sugars. I really liked him for that (I was young, dumb, and naïve back then), but that was far from home and I never saw him again.
After I turned 18 or so, I finally graduated from pediatrics and saw an “adult” doctor. Same hospital affiliation, common progression, different philosophy. Sometimes he took A1Cs with a fingerstick in the office, sometimes he sent them out to a lab. The patients in his office generally either had diabetes or were pregnant. I never quite made sense of why People with Diabetes and People with Babies were grouped together.
In 1997, after moving out (and out-of-state) on my own, I had to find a doctor of my own for the first time. With little to go by, I chose an endocrinologist who participated in my health insurance plan and was affiliated with a well-known (and soon to go bankrupt amid scandal) hospital/healthcare system. I quickly discovered that this guy, young and not well thought-out, was really eccentric. On my first visit, he talked to me about considering pumps, both conventional and implantable (the kind where you refill it with a “big harpoon needle” – his words). He said that, in time, I should switch from Humulin R to Humalog, but then spontaneously decided “What the hell, let’s make the switch now!”. He moved a bit fast for me, but I didn’t know any better, so I stuck with him for awhile.
Until one night when I had a severe hypo and ended up in the hospital (unaffiliated with the Eccentric Endo). While there, I was seen by a resident endocrinologist, and I grew to like him. He was slow and patient with me, and he listened to what I had to say – he didn’t talk down from a pedestal. I’m not sure if it was because he was wonderful or because he was such a stark contrast from my own doctor, but I ended up abandoning the previous doc and going with this one. I continued to see him for several years.
(There was also the guy who admitted at the first appointment that he’s not an endocrinologist but an internist specializing in diabetes. He filled some prescriptions for me, but I never saw him a second time.)
When I moved to New York, I again had to find an endocrinologist. Without any trusted people to ask for referrals, I turned to a combination of my insurance-network list and Google (Warning: if you’re searching Google for doctor recommendations, don’t. What you’ll find is mostly useless – one of the rare instances where the top-ranked Google results are least relevant). There seemed to be a highly-rated doctor close-by, she’d had some gold stars and other awards I’d never heard of, so I figured I’d check her out. Alas, she wasn’t taking new patients, but another endo in her practice was.
During our first meeting, we sat at opposite sides of his desk while he folded his hands and asked “So, what can I do for you?” Umm… I have Type 1 diabetes and just moved to the area and…. For a diabetes specialist to ask a T1 patient why he’s come to see him seemed peculiar to me. His personality was, well, missing. But looking back at the six or seven years I’d seen him, he’d done more for me than I’ve given him credit for. He’s the one that transitioned me from NPH to Lantus. He’s the one who decided I’d probably be better on Novalog than Humalog. He determined from my labwork that I should be taking Synthroid. He’s also the one who started me on the pump (actually, his nurse/CDE did most of that work).
But every visit seemed to be the same monotony. He would focus on lab results and my sparsely-populated logbook (too much focus on isolated incidents, in my opinion). He had me dictate my basal rates and bolus wizard settings. Small talk always included questions about my job and about hockey, even years after I’d left that job and hung up the skates. If I had questions or concerns of my own, he never really addressed them. Every time I left his office, I’d be stuck with a feeling that I’d just wasted some precious time and a co-pay. Yet, technically, I’ve probably made the most progress while under his care.
An aside: My wife works for a pharmaceutical company. Although not in sales, she has tagged along on a few “rep rides”, where the sales reps drive around and visit several veterinarians (she’s in her company’s animal health division). She observed, and told me, about the relationships that the reps build with their clients.
So it struck me: who could best assist me in maximizing the benefit of my insulin pump? I surely didn’t know the answer to that, but I knew who did: Medtronic. I called their toll-free number and got in touch with local sales reps. They gave me a list of some doctors, and told me which are “good” with the pump, which are more old-fashioned, and which are at the leading-edge of exploiting everything that the pump can do.
And that’s how I met Dr. Melfi. No, not that one (though Tony Soprano’s psychiatrist does live close-by). This Dr. Melfi is the endocrinologist that I’ve been seeing for the past year or so, and he (unintentionally) puts the others to shame. One of his first questions to me was: “what are your goals?” I was stunned. He never set targets for me; he asks me what I’m hoping to achieve. While some may interpret this as lackadaisical, I find it empowering and trusting. It also tells me that he looks at each patient uniquely, with a unique set of objectives and aspirations. Though we’re all Type-1’s (he doesn’t work with Type-2’s), he doesn’t have us all running the same marathon toward the same finish line.
Then he asked for my pump. I had no idea what he was doing with it, but a nurse disappeared with it outside the room, and when she came back, she also had pages upon pages of charts and tables that put even the best of log-book-keepers to shame. Every carb-bolus. Every fingerstick result. Every correction. Every change in basal rates. It was all there in vivid color, the last two-weeks history staring back at me in a way that I had never seen it before. Then he took out his pen and identified some trends that I’d never seen before. He quickly identified (and discarded) the anomalies – the days when I was completely off-track. (A few months later, after I had started using a CGM, those trend-lines appeared on the graphs as well).
While my previous endo had me navigating the menus to recite my basal rates, and constantly nagged me about not keeping complete logs, this one had it all right in front of him. For all the gripes I may have had about Medtronic in the past, I have to say that CareLink Pro, the doctor’s version of the web-based pump-data-retrieval system we use at home, is AWESOME. Awesome, in all caps – bolded, and italicized.
Dr. Melfi also told me about super-bolusing (I’d read about it online, but never had a doctor bring it up before!) and gave me bite-sized, manageable tips on how to bring my A1C down to where I want it. And, for the first time ever, I actually look forward to visits with my endo. I’m scheduled to see him in a week and a half, and it can’t come soon enough.
It took a long time, but I’ve finally found Dr. Right. And since I have no plans to move ever again, I’m planning to stick with him for as long as he continues practicing. And to think, all these years I’d been going with less-than-ideal care. I just didn’t know.