Disagreement With ‘The Plan’

Those of us with diabetes often have specialists involved. Endocrinologists, nephrologists, internists, cardiologists to name a few. For the most part, we trust them and their knowledge. That’s why we go to them. But, have you ever disagreed with their opinion or the plan as they saw it? I have. Disagreeing with the plan does not have to be the issue. How you work out the disagreement is of the utmost importance. I want to share how I’ve worked out a couple of scenarios. Maybe it will help you.

A bump in my diabetes treatment plan

I recall going to a diabetic education center and being told by the nurse that she was putting me on insulin. Yes, she was a certified diabetic educator. No, she was not a nurse practitioner. I hadn’t seen the doctor in charge. And prescribing insulin for the first time was outside the scope of her practice. “Come back next week and we will get you started on it." A big problem here (besides what I just stated)...there was no discussion. I had no voice. I didn’t believe it was time for insulin. I left that education center never to return. I sought out an endocrinologist instead. I hadn’t seen him yet but the appointment was coming up very soon.

A recommendation from my pharmacist

In the meantime, I set up an appointment with my pharmacist as I was struggling with the timing of when to take my meds. She asked why I wasn’t on an ACEI (angiotensin-converting enzyme inhibitor) to protect my kidneys from diabetes.1 I didn’t know. I had read about it but this was the first time I’d heard it from a professional. She felt this was missing from my treatment and suggested I speak to my doctor about that.

Input from my cardiologist

Shortly after that, I met my cardiologist for the first time. I felt connected to him immediately. He was forthright and had a bit of bite to him, he enjoyed a bit of sarcasm. His sarcasm was not aimed at anyone in particular and certainly not at me. To be honest, I can appreciate a bit of sarcasm when it’s about situations, not people. He was also very definite on what he believed was best practice based on the evidence available. When we got down to business, he believed as many do in the connected fields of cardiology and diabetes, that an ACEI medication should be added to my list of drugs to protect the small blood vessels in my kidneys from the harm diabetes can cause. ACEI meds relax the blood vessels and are frequently used to lower blood pressure. They are highly recommended for people with diabetes. I left with a prescription in hand but I didn’t fill it right away.

Why I disagreed with the suggested treatment plan

The problem as I saw it was this...My blood pressure runs on the lower side to begin with. And my glomerular filtration rate, which is an indication of kidney health, was perfect. My diabetes was well controlled. It did not make any sense to me to start a med that would lower my blood pressure. Rather than just jumping on board with both the cardiologist and pharmacist, I waited to see the endocrinologist. My appointment with him was only a week away.

It never hurts to get a second, or in this case third opinion, right? The third opinion, my endocrinologist, was not in support of the ACEI. The new diabetic meds he wanted to start me on will cause blood pressure to lower. Adding the ACEI could tank my blood pressure given I run on the low side to begin with. So for now, that med could wait. At my next appointment with the cardiologist a year later, we briefly discussed why I wasn’t taking the ACEI. He understood and supported the endo’s plan.

Standing firm on what's best for you

At my most recent yearly appointment with the cardiologist, he brought up the subject of the ACEI again. He told me he believed there was still some benefit to being on it. He believed some protection even if very small, was better than none at all and an extremely low dose couldn’t hurt to give me more protection. Although I didn’t say it out loud, I felt there was more benefit with my lifestyle and diabetes management than to add another med. My blood pressure was still in the low normal range. I’d been checking it over the last few months. He made it clear this was his ‘opinion’ and that he would state that in the note to both my endo and family doctor. This time, he didn’t give me a prescription.

Having a voice in your treatment plan

For me, there have been disagreements with what ‘the plan’ should be. In one case, my solution was to change providers. I refuse to be without a voice in my own care. In another case, it was to gather more information from the professionals on my team and make a decision from there. As I see it, the head of my diabetes team is my endocrinologist. He is the one coordinating all the input. Everyone else can offer their input from their field of expertise: cardiology, pharmacy, family practice. And although I appreciate the input of those others, the final decision is between myself and my endo.

Disagreements in the plan or treatment are going to happen. To me, it’s all in how we can work out those disagreements, that is important. And once again, recognizing that diabetes is individual. Sometimes best practice isn’t the best option for the individual.

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