Early Detection Double Standard

Every year, my doctor does a Pap smear and sends the results off to the lab.  If the results come back abnormal two years in a row, here’s what will happen:

• I will go to a specialist for a colposcopy, in which my cervix will be carefully examined under magnification and vinegar (really) to detect any abnormal cells.  Abnormal cells will be biopsied, and it is quite likely that a tissue sample will be taken from inside the cervix.
• Assuming that the results come back negative for cervical cancer, for the next several years, I will have semiannual Paps done by a specialist until no more abnormal cells are found.  Then I can go back to annual exams done by my primary doctor.

This is all done to make sure that abnormal cells, if present, are found, and to carefully monitor those abnormal cells so they can be excised if they show signs of becoming cancerous.  Early detection is widely thought to be the most important determining factor in successful cancer treatment.  And certain kinds of cancer screenings, such as Pap smears, mammograms, colonoscopies and prostate exams are routinely done on all patients over a certain age regardless of family history of cancer.

On the other hand, every year, I ask my doctor for a fasting glucose tolerance test, and she tells me that on my last routine blood workup my fasting blood glucose was normal and refuses to order the test.  (This year she offered to do another fasting BG, which I declined.  I know my FBGs are OK.)  She acts thus even though I have several risk factors for diabetes, including a family tree absolutely riddled with diabetes.

What happened to early detection?  Is my doctor guilty of malpractice?

Not really, at least not by any standard that would be acceptable in a court of law.  My doctor’s practice is part of a giant teaching hospital affiliated with one of the most prestigious medical schools in the country, and furthermore, this hospital is the home of one of the leading diabetes programs in the country.  And, according to my doctor, the hospital’s definition of diabetes is two consecutive FBGs above a certain number (which is, I think, 126 but may be higher.  I wish I’d written it down).  My FBGs are always well below 100, so no concern about diabetes is indicated.

My doctor is not being negligent; she’s following well-established diagnosis guidelines.

The thing is, I think she’s right and she’s wrong at the same time.  FBGs are a sufficient indicator of full-blown diabetes.  They are just lousy as an early detection standard.

The National Diabetes Information Clearinghouse indicates that the glucose tolerance test is more sensitive for diagnosing pre-diabetes than FBGs.  And the simple reason one would want to diagnose pre-diabetes, according to the same organization, is:

In pre-diabetes, blood glucose levels are higher than normal but not high enough to be characterized as diabetes. However, many people with pre-diabetes develop type 2 diabetes within 10 years. Pre-diabetes also increases the risk of heart disease and stroke. With modest weight loss and moderate physical activity, people with pre-diabetes can delay or prevent type 2 diabetes.  (Source:  National Diabetes Information Clearinghouse.)

It’s all about early detection, kiddos.  The Massachusetts General Hospital Diabetes Unit says, “High levels of glucose are toxic to beta cells, causing a progressive decline their function and cell death.  Consequently, many patients with type 2 diabetes eventually need insulin.”  You don’t have to be Aristotle to derive the syllogism here - those with pre-diabetes who do not receive a diagnosis can expect their beta cells to become poisoned by their high blood sugar levels, eventually leading to full-blown diabetes and possibly even dependence on insulin injections.  Why wouldn’t one of the premier diabetes centers in the country want to detect this early?

I have a lot of ideas about why, most of them sinister:

• The GTT is more expensive than the FBG, and doctors, who are paid by insurance companies, have an incentive to save money.
• Doctors don’t know that lifestyle changes can reverse pre-diabetes.
• Doctors do know that lifestyle changes can reverse pre-diabetes, but, misinformed as to what those changes are, prescribe ineffective low-fat diets.  After years of seeing patients fail to reverse diabetes on low-fat diets, doctors give up on lifestyle changes.
• Doctors not only know that lifestyle changes can reverse pre-diabetes, they even know that carbohydrate restriction is the way to go.  But doctors don’t believe that patients can make and stick to such “drastic” lifestyle changes as giving up bread.
• The research hospitals that set the guidelines for diagnosis and treatment are funded in great part by pharmaceutical companies, and therefore have an incentive to recommend a course of action that results in a medication-dependent population.

To be fair, Jenny at Blood Sugar 101 (formerly called What They Don’t Tell You About Diabetes) offers a somewhat more benign explanation:

• Decades ago, when diabetes treatment was less sophisticated, a diabetes diagnosis was not only a death sentence, it would prevent a patient from getting insurance or even a job.  Since it was thought that nothing could be done to reverse elevated blood sugars, early diagnosis was worthless and could cause financial problems for a patient.  It was deemed a kindness to delay diagnosis as long as possible.  (See Jenny’s article here for lots of fascinating information.)

The drug and insurance company problems seem tough to solve without a gigantic social upheaval.  But surely our doctors can do better!  Doctors do push back on ordering expensive tests, and patient advocacy organizations do lobby Congress to make insurers pay for certain kinds of tests.  It would be the rare insurance company that fails to pay for routine Paps, mammograms, colonoscopies, etc., even though some of these tests are rather pricey, much pricier than a GTT.  And surely doctors can shed the fatalist attitude - sure, many patients would rather jab themselves with insulin than give up their donuts, but that does not mean that every patient would.  I myself grew up watching my mother inject herself with insulin first once a day, then up to four times a day, and even though she became very callous (pun intended) about it, and even though I can submit quite stoically to needles in a doctor’s office, I am too chicken to inject myself.  Anything I can do to avoid that necessity, I will do.  I am surely not the only patient out there who would rather give up bread than poke a needle into my thighs several times a day!

Why don’t doctors give us choices?

It’s all in the presentation.  A doctor can say, “There’s nothing I can do for you but give you a drug,” because he assumes that the patient wants a quick fix.  Or a doctor can say, “I can give you a drug, or you can give up your favorite foods; your choice.”  Or a doctor can say, “I can give you a drug, but if I do that you are going to need more and more medication as time goes on; you will experience side effects that might be bothersome or even dangerous, and it will cost you a lot of money; or you can follow a diet that requires you to give up some foods you might currently enjoy a lot, but it offers you a lot of other delicious, nutritious foods; the diet will keep your condition in check for a long time without side effects, and it may cost you a bit more than what you spend on food now, but it’s cheaper than drugs.”

One more thing - when I was corresponding with my HR department about the company’s support of the American Diabetes Association, he mentioned that he’d personally talked with a number of employees who had been astounded by their diabetes diagnosis, since they’d had no indications whatsoever they were on that path.  Astounded!  Didn’t these folks have the right to know where they were heading, and the right to make a choice on how to proceed based on scientifically sound information?

And finally, if you’re not sick of this topic, please check out this post on Jenny’s Diabetes Update blog.  (Yes, this is the same Jenny who brought you Blood Sugar 101.)  Read the post comments, too.)