Thursday, May 3, 2012

Surprise Ending

In my last post about my endocrinologist, I explained why I had decided not to see him since January, and the interaction that ensued over e-mail with the physician's assistant in his office.

The other day, I received another e-mail, from the physician's assistant at the office, letting me know that the doctor was "very insistent" that I come in to see him, because "as you are aware, pregnant diabetics should be seen every month."

This was puzzling to me, largely because during my first pregnancy, I wasn't seen every month (contrary to that oh-so-patronizing-'as-you-know'), only two or three times that I can remember.  My A1Cs were good, I had a healthy pregnancy and a labor and delivery with very few complications. The Pious One's blood sugar was a little low at birth, but I can hardly believe that a few extra office visits to the endocrinologist would have changed that. My blood sugar just rose unexpectedly during pushing phase, that's all. My doctors looked at my blood sugars every now and then, but only ever made suggestions, and I was basically left to my own devices to make changes to my bolus ratios and basal rates. So I was actually not aware that pregnant diabetics should be seen every month. Is this standard protocol elsewhere? Was my situation in St. Louis really exceptional?

When we moved here during my second pregnancy, I actually thought my local doctor was just uptight for wanting to see me every month, but I tolerated it and went to the appointments. I thought it was possible I might be missing something, and I understood that my doctor here didn't see how well things went the first time. I thought I would show him that I was capable, that I felt comfortable making changes on my own, that my approach involved more than just insulin rates, that there were good reasons for him to trust me with my own health, and that things would probably be fine.

They did turn out fine, so my first clue-in should have been when I went to see my endocrinologist when my Braveheart was 8 or 9 months old and he broached the subject of future childbearing with great disdain.

My second clue-in should have been when I returned three months later and he felt it necessary to reiterate his disapproval of my plan to have more children because, he told me, I don't need more children (of course no one NEEDS children, and if they do, they probably have some kind of co-dependency issues, so I'm not sure why that's a relevant measure).

I'm pretty dense, so I really should have gotten it when I turned up in his office, the Statesman was barely the size of an (no doubt adorable) peanut, and he was actually mad about it. No "congratulations," no "how have your blood sugars been?", no "do you need any help?" Just anger.

I guess I finally did get it when I went in, humbled by a difficult few weeks of blood sugar management, and I was mocked and bullied.

Please understand, dear reader, that I am emotionally over these personal offenses. Not that I think he's right, but I decided that he was a skilled and experienced doctor, and I wanted to see a skilled and experienced doctor when I needed help. So I just planned to tune out when he began to talk about how many children was too many and glean what good I could from our visits. I thought I *might* even be able to convince him that a diabetic could do pregnancy well without a lot of day-to-day meddling help, especially since I've known him for a long time. In fact, he mentioned that, of all his pregnant diabetic patients, he trusted me most (flattery only, apparently, as you will see).

So this pregnancy, as I mentioned, I'm paying out-of-pocket. I'm on Medicaid, which his office doesn't accept, and my open enrollment, last-resort-insurance-for-people-who-are-not-eligible-for-any-group-health-coverage-otherwise won't cover pre-existing conditions until June. I've done Type I diabetic pregnancy twice. I feel very comfortable making changes to my own insulin rates, in and out of pregnancy. Sometimes, when my blood sugars are off, it's not even an issue of adjusting my insulin rates. It's eating habits, blood sugar checking habits, sleeping habits, exercise habits, carb counting habits, and so forth. I make whatever changes I think are necessary, or I try out a new experiment. I'm constantly tweaking and mostly trying to stay on the safe side of 60 and 140. I feel very strongly that I am the final arbiter over my bolus ratios, basal rates, insulin sensitivities, as well as every other kind of habit that I adopt, and I refuse to permit someone else to make those decisions for me. I accept recommendations, suggestions, and discussions, not prescriptions and rules. I personally take 100% responsibility for my A1C and any other lows or highs that come my way.

For those reasons, I don't need to see my endocrinologist for day-to-day blood sugar management. Beyond that, my OB's office draws blood to check A1C and whatever else is needed, they check weight and blood pressure, remind me how important my blood sugars are for baby's health, and so forth. I am fortunate that I have no significant swelling, no pains that are not typical of pregnancy, and really, no complaints at all, except for the large bowling-ball shape that seems to be permanently stuck to my abdomen.

There has been no additional further reasoning from my endocrinologist, in this e-mail or any other, on what about ME and MY HEALTH and MY MANAGEMENT of diabetes needs to be treated with an office visit at the present time. I guess it's possible that diabetics as a group do better during pregnancy when they are seen by a doctor more frequently but...correlation doesn't equal causation? Just because one epidemiological study showed that the number of diabetics who have healthy babies is directly proportional to the number of times they saw their endocrinologist (if such a study exists, I'm not aware of it), it doesn't mean that "seeing the endocrinologist" actually made their babies healthier. Isn't that basic science?

I'm really, honest-to-goodness, wanting to hear about what I'm missing. In a return e-mail, I reiterated my reasons for not coming in, explained that I was healthy and comfortable as measured by my own assessment and that of my OB, and asked the PA to have the doctor call me to explain what he was worried about.

Well, I got a call from my doctor, alright. In the classiest of classy moves, my doctor, instead of trying to persuade me about the basis for his protocol or explaining his concerns about my health, had his receptionist call me to tell me that if I didn't come in for an office visit immediately, I was officially dismissed from the practice for the remainder of my pregnancy.

Dang, that's not a good feeling.

So Jenn and I are really on a roll here with our third pregnancies. I have six weeks to go and no one to bounce ideas off of or help me if my hormones get wacky. I hope you all will still help me out with your tricks, tips, recommendations, and suggestions...!

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