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Question:

From Florida, USA:

My 10 year old son was diagnosed with type 1 diabetes when he was six. We have learned everything we could possibly want to know about diabetes. Don't get me wrong; I do not think I know everything about diabetes. There are always new things to learn. I want to know why we have to see the doctor every three months? We do have the A1c test done every three months, but I have been scheduling his visits about four to five months apart. His last two A1c tests were 6.1 and 6.4. I feel we are doing a good job with helping our son keep his blood sugars at a good level. When we go to an appointment, the doctor asks us his levels on the pump, how much insulin he is on and so forth. We asked him when would our son need to be tested of certain problems and he said most type one diabetics don't seem to have problems until they have had if for five years. He would not recommend any testing until he's had diabetes for five years. Why do we have to go every three months? It does not seem like we get much accomplished at these visits.

Answer:

You have asked good questions and I admit I may be biased in my approach. Please accept my attempts at a bit of humor and seriousness.

The American Diabetes Association and other organizations associated with the care, education, research, etc. of type 1 diabetes recommend quarterly A1c determinations. Ignoring for the minute that not all A1c assays are the same and have the same normal reference ranges, are you really comfortable that you know what to do (if anything) if the next A1c is 7.1? You currently are following the trend (6.1 to 6.4). If you needed a referral to your endocrinologist, then you might want to call to be seen; if your doctor's practice is anything like mine, there might be a two to four month delay in being rescheduled for a follow-up (but missed) appointment, depending on the nature of the problem.

Your child is not a machine. There is, hopefully, more to diabetes management and your doctor's approach than simply the rote "what are your levels, what are your rates, what are your boluses, what are your activities, what are your meals?????" There are psychological and social impacts of diabetes. There is the counsel of getting the flu shot; there is the "reminder" to wear medical identification and the reminder for the increasingly-independent 10 year old to check for ketones when ill and with elevated glucose readings.

There are the opportunities to learn about new science and research about diabetes for the patient and possibly family members AT RISK of developing diabetes. There are the updates on Diabetes Camp. There are letters to be written to schools and coaches, etc. to explain the child's "special needs" and the application of a 504 plan. There are the updates on new insulin pumps.

Indeed, maybe you have a wonderful handle on all this! I truly hope that you do. I have many patients who have learned tons and do not need frequent sessions with me, my nurse, my dietician, my social worker, my CDE, etc. I see those patients every four months or so, despite the ADA recommendations.

Your son has had diabetes for almost four years now. It is true that, STATISTICALLY, diabetes complications and co-morbidities (those other health problems that occur commonly with, but are separate from diabetes) usually don't appear until after five years elapse from diagnosis. And, the complications are less likely if control is good. With puberty, maybe a couple of years away for your son still, these complications are recommended to be screened for ANNUALLY. Do you track when the last eye exam was? Or, the kidney screening? Or, the screen for thyroid or celiac disease? My patients do not. But I do it for them. And statistics mean ZERO for any INDIVIDUAL child. (After all, what was the statistical likelihood that your son would develop diabetes?)

So, I do not at all disagree: if your comfort level for diabetes is good, your knowledge base good, your son's comfort and knowledge bases are good, then you may not at all need to be seen quarterly.

If you do not get much out of your visits, then maybe you need not go but be prepared to get the A1c tests done "somewhere." (And who is going to order them and review them? Who is going to refill that Glucagon kit or glucose meter strip prescription?). Or, maybe your team needs to take you to another level? Or, maybe you aren't letting your Diabetes Team know that you need even more data to take to the next level.

I am not trying to be cynical or defensive here, but if you called your lawyer and got 15 minutes of time, you would be billed. I guarantee it! If you call your doctor on the phone for 15 minutes to relay an issue or an insulin adjustment or medication refill, he likely could NOT bill you. What a bargain! Does your doctor deserve to be paid for his/her time? (I am NOT AT ALL SAYING that this is the reason to go to the doctor, but I'd wager there are many times you have conferred with your doctor and got no bill; allow this person to see your son as a child who has diabetes and not a diabetic child.)

DS

[Editor's comment: In addition to the doctor's comments, as a parent of the child with diabetes, I would like to point out that the doctor also has an important role addressing the issue of lipoatrophy. Also, since clinics often download blood sugars from meters these days, the doctor can advise the parents or patient on insulin adjustments. They are able to look at trends, rather than the overall A1c, to see where changes could be made. And, finally, a diabetes specialist should look at your child's growth and development to see if there is anything unusual. BH]

DTQ-20051208144602
Original posting 26 Dec 2005
Posted to Other

  
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Last Updated: Tuesday April 06, 2010 15:10:04
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