At my latest visit to my primary care physician he flattered me.
He was impressed that in 3 months I had turned around a newly diagnosed case of diabetes through diet and metformin, the commonly prescribed med to control blood glucose levels in patients like me with type-2 diabetes.
I dropped 25 pounds.
My fasting blood glucose fell from 140 mg/dL to 90 mg/dL, from full-blown diabetes to a normal level.
My A1C went from 7.8% to 5.9%, from diabetes to just above normal in the pre-diabetes zone.
He declared me his "best diabetes patient ever." Maybe it was hyperbole, but he seemed genuine in his sentiment. It made me feel good.
Encouraged by my new status as a best ever patient, I told him what I intended to do next.
I said I intended to lower my glucose to normal levels. My ophthalmologist and podiatrist and two dietitians suggested I do this and said I might be able to go off metformin.
I seem to be tolerating 2,000 mg of metformin fine. I do experience nausea and lack of appetite at times. No one knows why. Maybe metformin? Maybe my low-carb diet?
My doctor's reaction was startling: his neck turned red and I thought I saw a bulging vein as he took notes on his computer. Without meaning to do so, I struck a nerve.
"Don't do that," he insisted.
He said 5.9% was great and I ought to aim to maintain at the pre-diabetic level.
He said I could create other health problems if I slipped too low. I aimed for normal, which I thought ought to be the goal. But I was surprised by what my PCP told me.
His philosophy is that as humans get older they are destined to develop diabetes.
Is He Right?
His fatalistic view may be right. I think he has seen many of his patients in this middle- to upper-middle suburban income area fail to control diabetes. He said he can't easily teach his patients how to count carbs and use calculators.
He favors a simple approach with moderation AND medication with perhaps a greater potential to succeed. A half loaf, rather than my no loaf approach. (I haven't had regular bread since I was diagnosed -- though I hear the siren call of an Italian sub or a burger on a bun. I have burgers sans buns. I did have one hot dog on a bun. I'm not perfect.)
He said I ought to enjoy myself and have the occasional pasta or pizza. He feels glucose control fails when strict rules are applied.
He told me previously I should expect to be on metformin for life.
Maybe he's right, but so far, I am comfortable with what I am doing. My wife and sons have joined me on a low-carb lifestyle. I loved pasta. But it turns out I like mock-pasta made from spiralized zucchini and butternut squash. It looks like pasta after being sautéed or even microwaved and covered with a low-carb tomato sauce. I loved pizza. But I like home-made pizza with crusts made from almond flour or riced cauliflower and topped with cheese and mushrooms.
I have been with my intern for nearly 10 years. For the most part, he has done well by me. He has referred me out when I had questions he couldn't answer, such as a DNA test showing I was a poor responder to Plavix (clopidogrel), after a STEMI in 2005. In that case, my community cardiologist had put me on the then relatively new drug, which I stayed on for a record-setting eight years before my new academic preventive cardiologist asked why I was still on Plavix.
Time for a Change?
Why did I change doctors? My original cardiologist told me he was aware of the poor responders to Plavix and that there were alternatives. He said I should stay on Plavix and he'd change drugs when "you have your next heart attack." Yikes.
The episode with my current internist left me perplexed. I have heard horror stories from other patients. But I feel I have had more than my share. I wonder if there is something in me as a patient that prompts unusual exam room exchanges.
For example, here is something that occurred more than a decade ago with a family physician who was my primary care doctor back from the '90s through the turn of the century. I liked her. The lib in me liked the fact that I had a female African-American physician.
Then something happened. Maybe nothing that happens in an exam room would surprise you.
But try this.
My long-time FP suddenly became very solicitous and asked me all sorts of questions about my family. It was a new approach, but seemed reasonable. That's what FP are supposed to do, right?
Enter the Twilight Zone, at least as far I was concerned. Bring up the music.
She pointed to her white lab coat and said see this? It was a silver cross. She said she considered her medical practice part of her ministry. My eyebrows started to go up. Alarms went off. Holy Moses, Jesus Christ.
She asked me if I knew the seven names of God in the Old Testament. I had to admit I didn't. She asked me to learn them and recite them the next time I came in.
Then, she informed me that Jews like me -- I am not particularly religious and had not previously discussed religion, mine or hers -- may be the People of The Book, but evangelicals like her know more about the OT.
I was very uncomfortable.
I decided I needed to bail on the practice, but the Ten Commandments of HMO rules held me in place. (I'm out of that HMO now.)
I learned a lesson. I complained to the practice manager. I was amazed to find that she took my side and said they wanted to keep me in the practice, Could I see their medical director. I did. That's my current doctor. I told him what had transpired. He said his colleague sometimes gets like that. He asked me if I would have a problem having an Arab Christian as a doctor.
I said no. But in my view, storm clouds are gathering again as I bump up against his beliefs about treating T2D.
Not Just Yet
I am sticking with him for now. I like him and I like him being affiliated with a nearby hospital in case something comes up.
I still want to see if I reach a normal range with my A1C and then we'll continue the conversation. I may have to find a new captain on my health team. Maybe not.
I am mulling: Should I stay at a 5.9% A1C? I am close to normal. Maybe I can reach 5.2% or even lower?
Should I try to get off metformin?
My urologist notes that metformin seems to lower the risk for prostate cancer, another of my weak spots. Metformin also is being explored for life extension.
Should I start trying to a new physician?
Or maybe find a diabetes expert to manage my diabetes?
What is your opinion on what I should do next on my medical journey?
I'd like to hear from you.
You can post here or write me at howard.wolinsky@gmail.com
Read the beginning of A Patient's Journey here.