Talking to your Diabetes Care Team

Talking to your Diabetes Care Team

Summary

A diagnosis of diabetes can be frightening to patients who know a lot about diabetes as well as to those who know little about the disease. Asking a physician and other medical professionals the right questions about diabetes care can help patients obtain the information they need to manage their condition correctly and confidently.

Recommendations from diabetes organizations and government agencies call for people with diabetes to visit their physicians four times annually or more often when necessary, such as during pregnancy or when having trouble controlling glucose (blood sugar). This is a substantial investment on the part of the patient in time, effort and finances. Preparation can help patients to get the most out of these visits.  

Self-education is particularly important today, when a job change or a sudden switch in health insurance plans can require a patient to find a new physician. Patients should take an active role in informing their new doctor about their medical history. When patients keep and update their own records, this can assist physicians in understanding individual needs and circumstances. The more knowledgeable patients are about their diabetes care, the better equipped they will be to manage the disease and handle sudden changes.

About talking to your care team

More than ever before, people with diabetes are being required to take an active role in managing the care of their disease. As health insurance plans continue to restrict or change coverage, patients need to become educated and vocal advocates to ensure they receive the best possible care from all the medical professionals involved.

There are several important aspects to maximizing treatment options and being an effective self-advocate. They include:

  • Knowledge about general diabetic issues. Patients should understand the most recent diabetes-care guidelines and new treatments. Some of these guidelines change frequently. For instance, blood pressure guidelines have recently become stricter for patients with diabetes because high blood pressure is implicated in many diabetic complications. As another example, the International Diabetes Federation in 2005 tightened its recommended targets for the glycohemoglobin test, though individuals’ goals may vary depending on their condition and their physicians’ advice.

    In addition, patients should know financial information, such as what their insurance plan does and does not cover (e.g., glucose meters, test strips, antidiabetic agents, insulin, flu shots, insulin pump).
  • Personal health information. Patients should keep comprehensive and current records of their glucose (blood sugar) levels, other blood tests, urine tests such as ketone testing and microalbuminuria testing, blood pressure readings, diet, exercise, foot care and other self-management routines.
  • Advocacy. Patients need to take charge of their own care by keeping track of treatments and telling providers about what is working and what is not working.

General guidelines

There are many aspects to becoming an effective self-advocate for diabetes care. Some general guidelines will help patients keep their treatment plan on track. They include:

  • Learn as much as possible about diabetes. Patients who understand how diabetes is affecting their health (including all possible symptoms and complications) can work better with health professionals to keep track of the condition and to identify the cause of symptoms.
  • Choose a physician carefully. Patients should find physicians who have insight into diabetes care and who can recommend other specialists when necessary. Endocrinologists specialize in treating diabetes and other disorders of the endocrine system. Ideally, patients will choose a lead physician who works with other specialists to provide a “team care” approach to treating diabetes. Members of this team might also include:
    • Certified diabetes educator or nurse educator
    • Registered dietitian
    • Ophthalmologist
    • Dentist and dental hygienist
    • Pharmacist
    • Exercise physiologist
    • Specialist physicians as needed
    • Therapists (physical, occupational, speech, psychological) as needed
  • Select the best, most flexible insurance plans. Whenever possible, patients should choose insurance coverage that allows them the flexibility to see all the physicians required and get the care they need.
  • Be active in the treatment plan. Patients are their own best advocates. They should read and learn the care recommendations and guidelines provided by reliable sources, and by agencies and organizations such as the National Institutes of Health, the Centers for Disease Control and Prevention and the American Diabetes Association. Then, they should ensure that their physician and health insurance provider are willing and able to provide such services. If not, patients should consider changing insurance plans and/or physicians.
  • Do not take “no” for an answer. When an insurance company refuses to pay for a service, patients should write to the company and explain why the service or procedure is necessary. It may help to include research that supports the case and a note from the physician about the necessity of the service. In addition, it may be necessary to explain that paying for coverage of a test or procedure now may help prevent the need for insurance to cover more expensive care later.
  • Be prepared to pay some out-of-pocket expenses. Increasingly, health insurance companies are either cutting back on the services they cover or passing on a larger share of the cost burden to patients. Patients should be ready to pay for some aspects of diabetes care, including education and visits to experts who are not in the insurance provider’s network. There may be other sources of financial support available to eligible patients, such as Medicaid or financial assistance from governmental or private agencies.

Questions about insurance plans

The rules regarding health insurance coverage have grown increasingly complex over the years. Patients with diabetes should ask the appropriate human resources professional about the following aspects of their care:

  • Co-pays and deductibles. What are the out-of-pocket costs to patients, and how do they differ when visiting in-network or out-of-network physicians?  What coverage is provided for eye care, foot care and dental care? 
  • Diabetes education and associated care. Does the patient’s insurance coverage include diabetes education, weight-loss and fitness programs and counseling with registered dietitians? If these aspects are not covered, can they still be applied to any deductibles?
  • Supplies and equipment. Are glucose monitoring equipment, test strips, syringes and drugs such as insulin, glucagon, antidiabetic agents and antihypertensives included? Is there coverage for an insulin pump, insulin pen, jet injector or inhaled insulin and related equipment? What about diabetic footwear or other recommended equipment?
  • Mental health counseling. Are visits to therapists and diabetes support groups covered?
  • Pre-existing conditions. Patients with diabetes should ask how this condition will affect their coverage when joining a health insurance plan.
  • Diabetes issues related to pregnancy. Pregnant women who have diabetes must see physicians more frequently and have additional tests when compared to nondiabetic women. Patients should ensure the insurance plan will cover this extra care.
  • Surgeries and procedures. What coverage may be available for a pancreas transplant, kidney transplant or other organ transplant? What about experimental treatments such as an islet cell transplant or implantable insulin pump? What sort of inpatient and outpatient rehabilitation is available if a foot or leg amputation or other surgery is needed?

Questions to ask physicians

Choosing the right physician may be the most important decision a person with diabetes makes in establishing an effective care program. Patients should choose a physician who is knowledgeable and flexible. Endocrinologists specialize in diabetes and other disorders of the endocrine system (glands).

Some patients may prefer to select a primary care physician who is also a certified diabetes educator (CDE). Certified diabetes educators are licensed multidisciplinary health professionals who teach people with diabetes. To gain this accreditation, a provider must pass a test and earn recertification every five years.  Most CDEs are nurses who have acquired the additional appropriate training. Many endocrinologists work together with CDEs associated with their practice, forming a comprehensive diabetes healthcare team.

Above all, patients should feel comfortable with their physician, especially in asking questions and expressing concerns about their care.

When selecting a physician, patients should ask the following questions:

  • Does the physician have special training in diabetes?
  • Does the physician treat many patients with diabetes?
  • Is the physician available every day of the week? If not, who covers for the physician in cases of emergency?
  • Does the physician accept the patient’s insurance coverage? Are there any additional fees associated with visits and tests?
  • Is the physician part of a team of experts (including registered dietitians, educators, therapists and others) who can provide comprehensive diabetes care?
  • Will the physician create a sick-day plan for the patient and give specific instructions about how and when to address problems such as hypoglycemia with treatments such as sugar consumption or a glucagon injection?

People with diabetes should take time before the initial visit (and subsequent appointments) to think about questions they would like to ask their physician. They should also bring along any records that may be helpful to the physician, such as a chart of glucose (blood sugar) readings or a food diary. A list of current and past medications with the specific dosages is also valuable. A valuable tool can be a daily diabetes log, covering matters such as symptoms and questions, that a patient can maintain and bring to medical appointments. It might help to call ahead and ask the physician about which things to bring to the visit.

Topics that a physician is likely to address during an initial visit include:

  • Family and personal medical history. A physician is particularly likely to be interested in any family history of diabetes. Patients should assemble a family medical history chart that provides a history of illnesses in their family (parents, grandparents, aunts, uncles, siblings), as well as dates of birth, death and ages when a particular illness or injury has occurred.
  • Use of drugs and supplements. Patients should tell their physician about prescription and over–the–counter medications and supplements they are taking. It may be helpful to collect all pill bottles in a plastic bag to bring to the appointment.

Once an initial relationship is established, patients should be sure to take an active role in subsequent visits by closely monitoring their examinations and asking relevant questions. Potential issues to be addressed include those surrounding the following topics:

  • Glycohemoglobin test (HbA1C). Measures a patient’s glucose control over the previous three months. When was the last time the test was performed? What were the results, and what do they indicate? How often does the physician plan to perform it in the future?
  • Lipid profile. Measures the level of cholesterol and other fats in a patient’s bloodstream. When was the last time the test was performed? What were the results, and what do they indicate? How often does the physician plan to perform it in the future?
  • Home glucose monitoring (self–testing). Patients should discuss how often to use their glucose meter and should know their target blood glucose levels.
  • Dietary guidelines. Patients should have a clear, detailed meal plan that tells them how much food they can consume, in what categories (carbohydrate, protein, fat) and other specifics, such as whether alcohol is allowed. It may be appropriate to request a physician’s referral to a dietitian for nutrition counseling. 
  • Foot examinations. Foot problems are a common and potentially serious complication for patients with diabetes. People with diabetes should have their feet examined during every visit to a physician. A comprehensive foot exam, including assessment of sensation and circulation, should be performed every year, or more frequently if there are any risk factors. In addition, physicians should show diabetic patients how to care for their feet. For more information, see Foot Care & Diabetes.
  • Eye examinations. People with diabetes should be sure to have dilated pupil examinations at least once a year. Dilation allows an ophthalmologist to detect damage that has resulted from diabetes. Patients with conditions such as diabetic retinopathy, glaucoma or cataracts may need to see an ophthalmologist more often.
  • Blood pressure. High blood pressure increases the risk of heart disease and stroke, primary causes of death in people with diabetes. Elevated blood pressure can also lead to or worsen other disorders, such as kidney disease and glaucoma. It is vital that patients consult with physicians about appropriate blood pressure readings and treatments that can control blood pressure.
  • Microalbuminuria testing. This urine test can detect small amounts of protein in urine (proteinuria), an early sign of diabetic nephropathy (kidney damage). When was the last time the test was performed? What were the results, and what do they indicate? How often does the physician plan to perform it?
  • Ketone tests. Samples of urine or blood can reveal levels of a waste product called ketones that are dangerous if they build up. Home urine tests and certain glucose meters can assess these levels. How often and under what circumstances should the patient perform ketone testing?
  • Other endocrine diseases and autoimmune disorders. Some diabetic patients may be prone to other endocrine or autoimmune conditions. For example, people with type 1 diabetes are at increased risk for Hashimoto’s thyroiditis and Graves’ disease. Should the patient have a thyroid blood test?
  • Musculoskeletal disorders. Diabetes increases the risk of a wide range of rheumatic and orthopedic problems from gout to osteoporosis. Should the patient have a waste product test, bone density test or other screening test for such conditions?
  • Cardiac stress test. Some experts are now recommending that diabetic individuals, especially elders, have comprehensive stress testing to detect silent forms of heart disease.  Is this recommended for the individual?

The American Diabetes Association recommends that various tests be performed with the following frequency:

  • Each visit
    • Weight
    • Blood pressure
    • Foot examination
  • Every three months
    • Glycohemoglobin test
  • Annually
    • Lipid profile
    • Dilated pupil exam
    • Dental exam
    • Microalbuminuria/proteinuria test
    • Complete foot examination

Patients with certain risk factors may be advised by their physicians to have such tests performed more often.

Questions for specific providers

Some questions may be relevant only to specific providers. Patients should keep in mind the following information for the following professionals:

  • Nurse educator or certified diabetes educator (CDE). This is someone who helps patients learn about their diabetes and how to treat it. Patients should find out whether a prospective educator is certified.

Once they have selected an educator, patients should generally follow the lead of the educator but should not hesitate to raise any questions or concerns. Questions for a diabetes educator, working with an endocrinologist or other lead physician, may include matters pertaining to glucose monitoring, other self-tests such as ketone tests, medication, lifestyle changes and unusual symptoms such as dizziness or fatigue.

  • Registered dietitian. During the formation of a meal plan, patients should tell their dietitian about medications they take to control their diabetes. Patients should also share their personal food preferences, and it may help to bring in a food diary that records details of meals over a period of time.

    Once a meal plan has been established, it will be reviewed from time to time. Lifestyle interventions, such as exercise and quitting smoking, may also be recommended by a dietitian. Patients should express any concerns they may have about their diet.

  • Ophthalmologist. Patients should ask prospective eye doctors about the percentage of their patients who have diabetes, and whether the physician performs laser retinal surgery (photocoagulation)photocoagulation for diabetic retinopathy). In addition to a dilated pupil exam and funduscopy, will the patient receive other eye tests such as perimetry (visual field testing), tomography (measurement of pressure inside the eye), pachymetry (measurement of the cornea’s thickness), gonioscopy (inspection of each eye’s drainage angle) and fundus photography?

Patients should be ready to report details to the physician that include their level of glucose (blood sugar) control, blood pressure and any complications related to diabetes or other conditions they may have. They will also want to ask how they can reduce their risk of diabetic retinopathy, glaucoma, cataracts and other eye diseases.

  • Pharmacist. Patients should bring their medications with them when they go to the pharmacy with questions. It is also crucial that pharmacists know about all of the prescription drugs, over-the-counter drugs and supplements the patient uses if they are to provide information about possible drug interactions. Individuals should ask whether any medications or supplements they are taking can affect their glucose levels.

  • Dentist. People with diabetes are at increased risk for gum disease and should be sure to inform their dentist of their condition. Patients should ask about the best methods to prevent gum conditions. Diabetic heart patients may need to take antibiotics when undergoing dental work.
  • Exercise physiologist. Exercise is a cornerstone of most diabetes treatment plans. A physician may refer a patient to an exercise physiologist, trainer or other expert. Patients may want to ask about the individual’s experience in working with diabetes patients, about which types of exercise are recommended and which may need to be avoided, about the interaction of exercise and blood sugar, and about exertion and heart rate.

There are many other medical specialists that diabetic patients may need to see occasionally or regularly. These include:

  • Podiatrist. Some people with diabetes will need to see a foot doctor, as foot problems are a common and serious diabetic complication. Patients should ask prospective podiatrists about how many patients with diabetes they treat, how often a complete foot exam is needed and what it will include, what treatments may be needed for serious conditions such as ulcer or Charcot foot, what foot care the patient should perform at home, whether the patient can perform nail care or needs to have the podiatrist do it, and whether diabetic shoes, socks, inserts, skin thermometers or other products are recommended.

  • Gynecologist/obstetrician. Yeast infections and sexual dysfunction are common in diabetic women. Women with diabetes who are pregnant, or are considering pregnancy, will need to see a specialist with experience in high-risk pregnancies and diabetes-related pregnancy issues. This applies to women with type 1, type 2 or gestational diabetes or other forms of diabetes.

  • Urologist. Many diabetic men experience sexual dysfunction, including impotence. In addition, men with diabetes face the same common prostate disorders that other men have.

  • Cardiologist. Many people with diabetes will need to see a cardiovascular specialist because they have atherosclerosis, diabetic angiopathy and high blood pressure. Patients may wish to ask whether cardiac tests such as a stress test should be routinely needed, what their blood pressure is and should be, what their cholesterol levels are and should be, how often cholesterol testing should be performed, whether cholesterol drugs or antihypertensives are needed, what diet and exercise plan is recommended, and how to quit smoking.

  • Neurologist. The nerve disease diabetic neuropathy is a common complication of diabetes. Patients need to know how often they should have a neurological exam and specific tests such as electromyography, nerve conduction velocity studies and quantitative sensory testing, and what their options are if treatment is needed.
  • Nephrologist. Kidney disease (diabetic nephropathy) is a serious complication of diabetes. Patients are advised to ask about the merits of microalbuminuria testing, proteinuria testing, glomerular filtration rate and waste product tests to detect and monitor renal damage, whether dietary changes will help (e.g., reduced salt or low protein), whether medications such as ACE inhibitors or angiotensin-II receptor blockers are advised, and about the need for dialysis or a kidney transplant if end-stage renal failure is approaching.

  • Dermatologist. Skin conditions often develop with diabetes. Patients may wish to ask about treatment options and prevention methods such as skin care.

  • Therapist/psychologist. Patients with diabetes face many issues that can create extra stress or lead to depression. A therapist or psychologist may be able to recommend methods or counseling to help deal with stress or other mental health issues at work, home and school.

  • Rehabilitation therapists. There are a variety of circumstances where diabetic patients may work with a physical therapist, occupational therapist or speech language pathologist. For example, patients may receive outpatient therapeutic monochromatic infrared as a treatment for neuropathy, inpatient instruction in using adaptive equipment such as a shower bench after a leg amputation, or speech therapy after a stroke. Patients may wish to ask about the therapist’s level of experience in addressing diabetic issues, how long therapy may be needed and what treatment methods and assessments will be used.
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