It turns out the doctor had other things in mind.
Let me back up a bit. Before I get into out interactions, lemme go over what I want in a doctor. I want knowledge, confidence, and curiosity. Knowledge is hard to define in a profession like medicine. To get their licence they have to go through a lot of schooling. It's easy to say that the worst doctor is better educated than most other people. So when I say I want knowledge, I want a doctor that has the know how of his trade quickly at hand, as well as a basic understanding of disease process, medicine, and medical procedures. I accept that he won't have it all at hand at all times. He can research and learn what he needs when it isn't an every day occurrence.
That easily leads into the curiosity aspect. He should be naturally curious about things that don't quite fit into a standard diagnosis. Yes, most things I'll go to a doctors office for will be straight forward. I pee a lot, am always hungry, am always thirst... diabetes. But if there are other things that don't quite fit into that diabetic definition, I want him curious enough to find out. To ensure that the diabetes diagnosis is the correct one. I also want that curiosity to go into the little things I say. I mention that I have 'this' problem and later in the conversation say that I have 'that' problem. Individually they may mean nothing, but when added together they may point to another problem or disease process. In short, I don't want him to be constantly satisfied with the easy straight forward answer. I want him curious enough to get to the REAL answer.
UPDATED 12/14/14
Then there's confidence. I can't express firmly enough how important it is for a patient to be confident in his medical provider's abilities. There will invariably come a time when I will have problems that are not easily understood. Problems that will go beyond the standard knowledge set of any physician. If he portrays the attitude of "What the fuck is going on here? I have no idea what this problem is", then I'll have a harder time believing that he can solve my problem. Even if he gets the right answer, I'll always wonder if it IS the right answer. If on the other hand he acts as though it's a simple matter of getting the right tests and narrowing the problem down to it's core, then I'll believe him and believe it when he finds the answer. That's something that I put into my own practice... I don't show outwardly to my patients when I'm completely thrown off base. I need for them to believe that I either have the answers at hand or will definitely get the answers in a timely manner.
So with all that in mind, my doctors has hit all three of those points.
Let's go back and go through our meeting/physical. Oh, and thank God I scheduled this as a 'physical' and not a 'diabetes' appointment. Physicals are covered under the ACA, and therefore have no co-pay! YAY Obamacare!
Before I even stepped into the office, I had to fill out all the standard paperwork. The one that I paid the most attention to was the list of problems/symptoms. It's very thorough and would obviously lead the doctor to what problems were ailing me. I made sure to check the 'frequent urination', 'constant hunger', and 'extreme thirst' boxes. I checked the family history boxes of cancer and heart disease. I then added things that ARE problems, but not ones I was really interested in addressing. Frequent headaches, frequent backaches, and smoking. Hey.. if I want him to be knowledgeable and curious, I need to provide truthful answers.
The nurse got my vitals. I was happy with the weight (still 270lb!), and pulse (85bpm), but quite shocked by the blood pressure. It was 145/92. Ouch. I know I run a bit high there, but when I check it at work I'm normally in the 130s for systolic blood pressure. After she left, I had a few moments to myself before the doc came in. When he did he was cordial, introduced himself, allowed me to introduce myself (I know he has my info on his laptop, but it's always polite), and he got right to work.
He started off not by going over symptoms or diving right into the physical, but instead asking me what I wanted to get out of this meeting. That, in my mind, is a great start. Maybe I just wanted a quick clean bill of health. Maybe I wanted to talk about something not covered by their worksheets. Maybe I wanted to talk about heat disease. Without doing that one basic thing in asking, he may have completely skipped over what I wanted out of this visit. So I told him about my diabetic concerns, and my thoughts on cholesterol.
He nodded and started right in. He agreed that I'm more than likely diabetic, but he needs blood work before he can go over any treatment options. He needs and A1C which more or less tells him what my blood sugars have been like over the past three months. He'll also need a fasting blood glucose level. I had already had my coffee and breakfast, so that lab work would be scheduled for another day. He said that that blood work would also give us good information to start on a cholesterol treatment if it's even needed.
At that point, I was happy. He addressed my concerns and I was ready for him to perform the actual physical and get out of there. But he went over the entire sheet of symptoms with a fine tooth comb. When I mentioned cancer, he got into the details. Who in my family had cancer, what type of cancer did they have, what was the outcome of each diagnosis. He then did the same thing for heart disease.
Then came the part that I was dreading. Smoking. Yeah, it was a pipe dream to think he's skip over that part. Being a health professional myself I know damned well how important it is to quit smoking. But I also know, and shared with him, that the best successes I've had with quitting have come in summer. He didn't feel it was good to wait and wanted to try again now. He was fairly emphatic about it even though he phrased it in with a question "Are you willing to try it now?".
I took a moment to think about it. I wasn't really concerned about trying to quit now. I was more conserned about setting up a good relationship with my new, and hopefully long term, doctor. If I simply rebuffed him it might easily set up an adversarial relationship in his mind. I don't want that. I want to trust him and show him that I trust him. So even though I have little hope that any treatment will work, I agreed to give it a try. He prescribed me Wellbutrin. It's a small doses of 100mg twice a day. I know how Wellbutrin works... well not how IT works, but how the treatment flows. I'll stay at this low dose and have a quick follow up in a few weeks (it's technically an antidepressant so he'll need to check up on my emotional well being). He'll want to give it a month or two, and if it doesn't work, ramp up the prescribed dose. At a minimum, I'll be on Wellbutrin for two months.
Now this is after the fact, but I did look up on people's reactions with Wellbutrin and quitting smoking. It seems that it has a fairly good track record... about 50% of people trying it are able to quit smoking. The biggest problem is that once you stop taking it (about 3 months after you quit smoking), you can easily backtrack back into smoking. I always thought that it worked by taking the edge off of the withdrawal symptoms. In fact it acts partially as a nicotine antagonist. That means it won't let the nicotine into your system. So even when smoking, your body won't be getting it's dose of nicotine. Without the addictive nicotine you will start to not 'need' the cigarette. Plus it IS working to take the edge off of the withdrawal symptoms.
So.. I'll give that a try. I'm not going to make some herculean effort to quite smoking. If it works on it's own, great. If it doesn't, even at a higher dose, then that's fine too. I'll give it another big effort in the warmer months.
He then asked me about my backaches. I've been having moderate backaches for several years now. Sometime while working at that retail hell, I did something to my back. But I let him know that it was currently manageable and never stopped me from doing what I want. I figure if we can get some other health issues under good management, then we can address the backaches later.
I though it would be the same issue on the headaches. I was honest with him though, in saying that they were getting more severe and did occasionally get in the way of my daily activities. I've called into work and delayed actions I want to take because of them. He asked a few more questions and then while looking at his laptop (I'm assuming my vitals were there), he smiled and made a suggestion. It seems that many people have had success in prophylacticly treating migraines with propranolol. Propranolol is a beta blocker... most often used as a blood pressure med. It's not the best at controlling blood pressures, and can't be used as a prophylactic treatment for migranes if you already have good blood pressure. But it might be ideal for me... it can help lower my blood pressure AND prevent some/more/all of my migraines. And yes, he does consider my headaches to be migranes, just not the classical migraine.
Oh, and in case you didn't know, treating something with a prophylactic simply means treating it before it happens. I wouldn't take a propranolol when I get a migraine, I'd take it daily to prevent them.
He was knowledgeable, confident, and curios. In short... I like him as my doctor. For now I'm on two pills daily, twice a day. I'm taking them at fairly odd times so that I don't have to take them at work... 11am and 11pm. After the lab work and my follow up visit with him in two weeks, I'm fairly sure I'll be on some oral diabetic med. I'm thinking Metformin (glucophage), but I know there are other meds out there. I'll be comfortable letting him make that call.
Speaking of lab work... fuck. It has to be a fasting lab work. That means I can't eat or drink for 12 hours before. To be honest, the eating part doesn't bother me. I'm always hungry in one way or another and can simply ignore that part. The not drinking part though... I'm always thirsty. When I smoke, I'm MORE thirsty. It's mostly a feeling of dry mouth, so I think I'll be swishing and spitting quite often in the 12 hours preceding my lab work. It really sucks as I'll have to start this process at work.
Anywho, I'm happy. Like the dental work this past year, I'm on the way to getting healthier. I'll of course keep writing about this.
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Update 12/14/14
Headaches first. It will take quite a while for me to say whether the propranolol is working. My headaches vary quite a bit day to day, week to week, and month to month. BUT... I may have a sign of it working. My Doc wanted me to keep a headache journal, so instead of guessing, I now have data. I've had 3 headaches since starting the propranolol.
The fist was upon me when I woke up. It was bad. a 6 on a 0-10 pain scale. It was bad enough that I didn't wait to see if it would go away, so I immediately took 2000mg of acetaminophen and 200mg of ibuprofen. It took it's damn time, but it eventually went away after about 6 hours. And then it stayed away.
The second was a far more mild headache. It was only a 2, but frustrating enough that I still took 1000mg of acetaminophen. It didn't go away for a full 10 hours.
The third was a very bad headache. I woke up with it and it was a 6. I took the 2000mg of acetaminophen and 200mg of ibuprofen... and it got worse. It went up to an 8. I repeated the medication 4 hours later and it did nothing. I called off work as with that type of headache I can't concentrate. Hell.. I had trouble driving. It lasted almost all day. All in, I had that headache for about 13 hours.
Now why would I say it's working when I have one of my worst headaches? Well that first one didn't come back. Normally when I have a bigger headache like that, I'll take my meds and will reduce the headache, but it will come back and I'll have to take the meds a second time. I didn't have to do that. The second headache, while not nearly as bad, didn't get worse. Normally when I take my meds and they don't have an effect, it just gets worse and worse. The third headache... well, yeah that was very very bad.
I'll keep up on the journal and present it to the doctor and see what he thinks next Monday.
The labwork. Fasting sucks, but I'm pretty good at timing it. I wanted a full 12 hours of fasting so that I'd get good results. As the lab opens up at 7 am, I wanted to start my fast at 7pm. That puts me right in the middle of a shift at work. I take my lunch break at around 4pm, so that was the last time I ate. From 7 pm to arriving home and going to bed at midnight, I had only a few sips of water. When I woke up at 6:30, I immediately shit/shower/shaved and went off to the lab. Again with only a few sips of water.
I was more thirsty than anything. Eating wise I had only 'missed' one meal; the one I'd eat when I get home from work. I did find out that I could have been drinking more water. The doc DID say that I should avoid all eating and drinking though... I'd say that they should be more forthcoming with the 'but you can drink water' thing. Giving a urine sample after drinking almost nothing for 12 hours is a royal pain.
The results of the lab work? Well I haven't gone over all of it, but I did get the part I was most curious about... I'm diabetic. VERY diabetic. There are two measures for diabetes. A fasting blood glucose reading and an A1C reading. The fasting blood glucose measures how much sugar is in your blood after not eating anything for at least 8 hours. A normal, non diabetic, person will read between 70 and 100. The A1C more or less reads what your blood glucose level has been over the past 3 months. A normal, non diabetic, person will read between 4.5 and 6.
My fasting blood glucose level was 255. My A1C was 9.6.
Ouch
Even without me coming back in (that's scheduled for next Monday) he prescribed me 500mg of metformin a day. I'll admit I figured I'd be on a higher dose than that. At work I treat diabetics that are on 2500mg of metformin a day. Even from what I've researched, I figured the starting dose would be 500mg twice a day. But I have to step back and remember that I'm the patient. I'm not the doctor. I'll talk to him about it on Monday.
When the nurse called me and gave me the lab results (along with the prescription for the metformin), she also mentioned that I would have to have a second set of labs done. Fasting labs. To be honest, I was so taken aback by the A1c and fasting blood glucose that I don't recall if it was for more labs or some of my previous results weren't available. She didn't give me my cholesterol results, so maybe that got messed up. But then again... I don't recall cholesterol tests requiring fasting.
Anywho, I wanted to get it done and over with so I started my fast at work on Friday. This time I allowed myself more water. I got to the lab Saturday morning a few minutes after they opened and was shocked to see a full 13 people in line. This wasn't going to be quick. I signed up on the list and took my seat.
Remember that bad BAD headache I told you about earlier? Well... that was the day. I was trying my best to sit still and NOT have my head hurt. At one point I looked up and saw people that arrived after I did getting in. I considered going up to the receptionist and asking why I was being skipped over, but to be honest my head was throbbing to badly. If I got any answer that was less than satisfactory I would have blown up. So I waited... and waited... and waited.
I waited for an hour and a half. When my name was finally called the waiting room was empty save for me and one other person. I took my seat, gave my name and told them that my doctor had forwarded my lab order yesterday. The receptionist looked through her paperowrk and couldn't find it. I urged her to call the doctor's office but it was closed.
I had fasted for nothing. I had sat in that damned waiting room with my head throbbing for an hour and a half for nothing. No lab order, no labs. I'm still rather angry about that, but I can't find out why it happened until Monday. And NO, I'm not going to fast tonight in preperation for lab work tomorrow morning. They can explain why they didn't forward the lab order and then ensure me that it will be there before I try fasting again.
Till later.
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