American Diabetes Association Complete Guide to Diabetes: The Ultimate Home Reference from the Diabetes Experts

CHAPTER 17

Your Health Care Team

• Diabetes Care Provider

• Visits with Your Diabetes Care Provider

• Diabetes Care Schedule

• Other Health Care Providers

• Communication

• Second Opinions

Your health care team is one of the most critical facets of your diabetes care. Your team includes your primary care provider, and specialists such as a diabetes educator, registered dietitian, eye doctor, podiatrist, pharmacist, and others. Of course, your health care team also includes you.

Sometimes, diabetes professionals will already practice together in a center that specializes in diabetes care. Or your diabetes care provider may routinely work with some of these professionals. If not, you may have to assemble your own group. If your provider doesn’t have a diabetes nurse educator or dietitian on staff, ask him or her to recommend one, as well as other professionals you should have on the team. It may be helpful to think of your diabetes care providers as a team and yourself as the team captain.

Your choice in providers will depend on your personal needs and preferences, as well as cost and insurance coverage for different services or providers. This chapter will give you tips in selecting a primary diabetes care provider and specialists—as well as background about what to expect during your medical visits. You should keep in mind that assembling a team and developing a plan may take some time. Your plan will need fine-tuning along the way. Try to choose providers who are easy to reach and willing to adapt to changes along the way.

Diabetes Care Provider

A diabetes care provider is often an endocrinologist, although it could also be a primary care physician or internist who has experience treating people with diabetes.

Your diabetes care provider is responsible for providing certain basic care, such as a yearly physical exam, complete medical history, and A1C tests every 3 months. What you can expect during these basic care visits will be discussed in more detail in the next section.

Your diabetes care provider should also be available on an as-needed basis to discuss problems, changes in your blood glucose management or other diabetes care, or any other concerns.

Choosing a Diabetes Care Provider

Take the time to select a diabetes care provider who is right for you. You will have your own needs in terms of your health, insurance coverage, and convenience, as well as your preferences in style and demeanor. Keep in mind that your diabetes care provider is your primary contact, so you’ll want to select someone whom you respect and with whom you feel comfortable talking openly.

Schedule an Interview

You may want to schedule an appointment to talk with several candidates before you choose a provider. Some health care professionals may charge an “interview fee,” so be sure to ask about this ahead of time.

Come to your interview with questions you would like answered. Write them down in advance, and don’t be afraid to look at them during your interview. Write down answers to your questions during the interview, if need be.

Sample Interview Questions for Providers

Education

• Where did you go to school?

• Are you board certified in endocrinology or internal medicine?

• Do you hold professional memberships in associations such as the American Diabetes Association (ADA), the Endocrine Society, or the American College of Physicians?

Diabetes Experience

• Do you see a lot of patients with diabetes?

• Are they mostly patients with type 1 or type 2? How many patients like me do you see each month?

Insurance

• What insurance do you accept?

• Are you a provider in my Preferred Provider Organization (PPO) plan?

• If I require a referral to a specialist, do you have colleagues who also participate?

Basic Care

• How often will regular visits be scheduled? What tests are conducted routinely?

• Who covers for you on your days off?

• What procedures should be followed in the event of an emergency? What conditions indicate an emergency?

• How do I know whether I should call you?

• How hard is it to get an appointment?

Other Team Members

• Are you associated with a nurse educator, dietitian, or other health care professionals so that I can benefit from a team approach?

• Are you likely/willing to try new approaches/therapies to diabetes management, or do you prefer to wait until new methods have stood the test of time?

Office Considerations

• Is the office neat and clean?

• Is the staff polite?

• Are you accommodated at your scheduled appointment time or are you kept waiting?

• Are educational materials on display?

• Is there someone you can call with questions or concerns?

Consider Your Needs

After you’ve met with a provider, take time to reflect on the interview. You’ll want to consider how you felt about the physician’s philosophy, demeanor, and experience. Think of yourself as a customer.

Sample Questions for Yourself

• How did the visit with your health care provider feel?

• Were you comfortable with the practitioner?

• Did he or she seem concerned about you as an individual?

• Was the provider willing to work with you to achieve your health goals?

• Did you feel free to express your feelings?

• Did you feel that he or she was listening to you? Were you given sufficient time to get all your questions answered or did you feel rushed?

• Did the provider seem likely to tell you what to do or more likely to work with you to reach your goals?

Ask Other Patients and Providers

If the idea of scheduling an interview seems daunting, you may start by asking other patients for recommended providers. For example, recommendations from members of a diabetes support group could be helpful. You may also want to ask other health care providers (whose opinion you trust) for advice. If you like and trust your eye doctor, then you could ask him or her to recommend an endocrinologist.

You’ll also want to consider the location and convenience of the office. Maybe the closest endocrinologist is 50 miles away and you would like someone closer. In that case, you might want to find an internist or primary care practitioner with expertise in treating patients with diabetes.

You can also contact the ADA for a list of recognized providers (www.diabetes.org). Your local hospital or community health organization may also provide referrals. Professional medical societies may provide recommendations as well.

Visits with Your Diabetes Care Provider

Yearly physical examinations are important for everyone as a preventive health measure, but they are especially important for people with diabetes. People with diabetes have a greater risk for developing diabetes complications, including damage to the eyes, kidneys, nervous system, heart, and circulatory system. You are also more susceptible to developing infections. That’s why a thorough examination is needed to make sure your whole body is functioning properly. You’ll also discuss your blood glucose management, so don’t forget to bring your meter, logbook, and any medications you’re taking.

Medical Questionnaire

If you are seeing your diabetes care provider or other health care professional for the first time, you will most likely be asked to provide a medical history. The forms and questionnaires may vary, but all will want the same basic information. It is important to answer honestly and trust that your health care team will maintain confidentiality.

Most histories include questions about the health of your close relatives. Think about the general health and specific conditions that have arisen in your family, especially your mother, father, grandparents, sisters, and brothers.

You will also be asked to provide a general inventory of your past and present health problems, such as back pain, appendicitis, headaches, and depression. Do not deny or hide any illnesses, such as psychiatric disorders or AIDS.

Dig out a record of your immunizations. You may even need to call past health care providers for dates and names of procedures.


Fill Out the Questionnaire in Advance

Ask that that your provider mail a medical questionnaire in advance. That way, you can answer all of the questions more accurately and at a leisurely pace. You’ll want to provide the most complete and accurate picture to get the best health care.


Sample Medical History Questions

• What medications are you currently taking?

• Do you smoke? Have you ever smoked? If so, how much and for how long?

• Do you have any allergies?

• Have you ever been pregnant? What was the outcome?

• When were your last chest X-ray, eye exam, and dental exam?

• Have you ever been treated by a psychiatrist?

• Have you recently lost or gained weight? What was your maximum weight? What did you weigh at the diagnosis of diabetes?

• Have you ever been rejected for health insurance or employment for a medical reason?

• Do you use alcohol or any street drugs?

Some medical questions may be difficult to answer. You may not remember or you may not want to be reminded. Make an attempt to overcome your fears of being judged harshly by what you put on the form. A concerned health care professional will use this information to provide you with the best possible care—not to criticize you. What is important is achieving good health.

Physical Exam

After taking a medical history, your diabetes care provider will give you a complete physical exam. In fact, you need a complete physical once each year.

It will include a close examination of all the parts of your body, from head to toe. Your provider is trained to detect small problems and prevent them from becoming bigger problems and will examine all of the following, and perhaps more.

The Physical Exam

• Weight or Body Mass Index. Talk to your provider about the body weight that you think is best for you and whether you have any difficulty maintaining that weight.

• Blood Pressure and Pulse. Ask what your current readings are and whether these fall within the recommended range. If not, ask what levels are best for you to achieve and how to go about it.

• Eyes. Your eyes will be checked for problems, and you will be asked about any changes in your vision. Make sure to keep your provider aware of any changes that have occurred, even if you are also seeing an eye care specialist.

• Heart and Lungs. Your provider will most likely listen to your heart and lungs through a stethoscope. Sometimes an electrocardiogram or stress electrocardiogram may be performed to detect symptom-free heart disease. Such tests measure the electrical activity and pumping of your heart muscle and can detect many subtle abnormalities.

• Feet. Removing your shoes and socks each time you visit—not just during your yearly physicals—will remind your diabetes care provider to check your feet. You will be checked for dry, cracked spots; calluses; infections; and sores. Using a monofilament to check for sensation, your provider will also look for any loss of feeling that could indicate neuropathy. A tuning fork may also be used for examining changes in sensation.

• Skin. Your skin will be examined by sight, with special attention to insulin injection sites.

• Nervous System. Your reflexes and your sensitivity to the sharpness of a monofilament or pin or the light touch of cotton or a brush will be checked. If you are experiencing any persistent problems, such as dizziness on standing, pain, burning sensation, numbness in your legs or arms, constipation, diarrhea, difficulty urinating, or difficulty with erections or sexual satisfaction, make sure to mention them.

• Mouth and Neck. Your provider will examine your gums, teeth, mouth, and throat. She or he will feel for swelling in the glands in your neck and ask you about your brushing and flossing habits. The function of your thyroid gland will also be assessed during your initial physical examination.

• Blood. A sample of blood will be drawn to test for glucose levels and A1C. A fasting lipid profile, which measures cholesterol and triglycerides, will be performed to determine the levels of these fats in your blood. Your urea nitrogen and serum creatinine concentrations in the blood will also be measured to assess your kidney function. Your microalbumin-to-creatinine ratio should be reviewed, too.

• Urine. Testing urine for ketones, glucose, and protein also assesses kidney function. People with diabetes are more likely to have urinary tract infections because of the high concentrations of glucose in urine and the loss of the sensation of knowing when the bladder is empty or full because of neuropathy. If you have any symptoms of infection, a urinary culture may also be performed.

• Vaccinations. People with diabetes are more likely to develop complications from the flu or pneumonia. You need a pneumonia vaccine once in your lifetime and a flu shot each year.

• Other Tests. Other members of your health care team may perform some tests. For women, this includes a Pap smear, mammogram, and gynecological and rectal exam. Contraception and pregnancy planning should also be discussed. Men should receive prostate and rectal exams. Both men and women should have their stool samples tested for blood to detect colon cancer. Men may receive a prostate cancer test.

Your examination will also include a discussion of your health, such as a review of your blood glucose measurements, insulin therapy and other medications, eating habits, and physical activity.

Keep your provider up to date on any changes you have made in lifestyle or habits. Maybe you just quit smoking or started an exercise program. If you feel a need to consult one of the other professionals on your team, now is the time to ask about it. If you feel that there are any parts of your treatment plan that are not working, tell your provider. Also keep your provider informed of what treatment options are successful.

A1C Test and Blood Glucose Management

Beyond the yearly physical, your A1C should also be checked every 3 months. Measuring your A1C tells you how well your treatment program is working. You need this test whether you use insulin or not. You may hear your results reported as estimated average glucose or eAG. Estimated average glucose is a different way to report A1C results using the same units as your blood glucose meter (mg/dl). You can use your A1C or eAG results to compare with your own self-monitoring records.

Be sure to discuss your blood glucose readings at every visit. Always bring your logbook, meter, and medications to your exam. If your daily blood glucose tests are in range but your A1C is too high, you and your provider need to discuss ways to better manage and monitor your blood glucose levels. It is important to understand why your tests might show good blood glucose readings when your overall blood glucose measure is too high.

Other Topics

You may be asked about any unusual concerns you may have, such as a sore shoulder or abdominal pain. If you are experiencing any sexual or personal problems, don’t be afraid to bring them up.

Ask about what to do on sick days. Even a mild cold can throw off blood glucose levels, usually by making them higher than normal. Ask what symptoms to be on the lookout for and when you should call your diabetes care provider. What precautions should you take when you feel under the weather?

Changes in your health may result in more frequent trips to your provider. If you’re just starting insulin or are changing your dose and your glucose is out of range, you may need to talk by telephone or see your provider as often as every day for a while, until your blood glucose is in range. If you are trying to manage high blood pressure, you may need to monitor your blood pressure often and keep records of the readings.


Thyroid Test

If you have type 1 diabetes, you have a five times greater risk of also someday developing thyroid disease, which is another type of autoimmune disease. Make sure you have a blood test to detect thyroid disease.


Diabetes Care Schedule

Each person with diabetes has unique health care needs. You may make several office visits a month when you are experiencing difficulties or making changes to your regimen. Or you may go through periods where you only see your provider every 3 months. In any case, it’s good to keep some general guidelines in mind for your schedule.

Having a general idea of your diabetes care schedule will help you know what to expect at each visit. Your health care provider may provide you with your own schedule or you can use the schedule below for guidance.

Diabetes Care Schedule

Every visit

• Blood pressure

• Weight

• Foot check

Every 3 months

• A1C test

• Regular visits to your diabetes care provider

Every 6 months

• Regular visits to your dentist

Every year

• HDL, LDL, triglycerides, total cholesterol: for average reading; more often if high levels are being treated

• Kidneys: microalbumin measured

• Eyes: examined through dilated pupils

• Feet: more often in patients with high-risk foot conditions (neuropathy, vascular disease)

• Flu shot

• Review meal plan

• Update with diabetes educator

Every 2 years

• HDL, LDL, triglycerides, total cholesterol: if last reading indicates very low risk.

Once a Lifetime

• Pneumococcal vaccine


Children’s Height

Children whose blood glucose levels are often high sometimes are slow to grow and mature. Height should be measured at every visit, not just the first one. The progress of sexual maturation should also be checked.


Other Health Care Providers

Diabetes is a complicated disease that affects many different organ systems in your body, so it is no surprise that you may need multiple providers as part of your health care team. The type and number of providers on your team depends on your health and needs. Some people may have an endocrinologist, dietitian, eye doctor, and dentist, whereas other people may have eight or more different specialists.

The best resource for recruiting other team members is your diabetes care provider or certified diabetes educator. It is important not only that your provider communicates with other members of your team, but also that team members are able to communicate with each other about any changes that may arise in your diabetes management plan.

It’s a plus if the members of your team are comfortable communicating with each other, which is often the case if they are recommended by your provider. However, you should also pick team members with whom you feel comfortable. Don’t be afraid to shop around a little and find the team members who best suit your needs.


Keeping Everyone Connected

Make sure all your providers have the phone numbers, fax numbers, and e-mail addresses of other members of the team.


Diabetes Educator

A diabetes educator is usually a registered nurse (RN), registered dietitian (RD), or pharmacist (RPH) with a special interest and training in caring for people with diabetes. However, physicians, physician assistants, and other health care specialists may also be diabetes educators.

Diabetes educators often work in locations where people with diabetes are treated, such as doctors’ offices, hospitals, and pharmacies. The American Association of Diabetes Educators can also provide local referrals.

A diabetes educator can answer many of the concerns or questions you may have about diabetes. Diabetes educators may give you background information about the biology of diabetes, teach you how to take insulin or check blood glucose levels, explain how to handle sick days and pregnancy, discuss the effects of various habits on blood glucose levels, and help you learn to cope with stress, and how to choose, set, and reach goals.

In addition to meeting with a diabetes educator, you may also want to participate in a diabetes education program. Your local American Diabetes Association office can refer you to a program that has been recognized as meeting its national standards. This means that it can provide you with quality diabetes education. These programs are covered by Medicare and many insurance plans.

Topics in Diabetes Education Programs

• General information about diabetes and its treatments

• Adjusting psychologically to managing diabetes

• Setting goals and solving problems

• Understanding your meal plan and incorporating it into your life

• Incorporating physical activity into your life

• Checking and recording your blood glucose and urine ketones accurately and using the results to manage your diabetes

• Medications

• Managing sick days

• Preventing, detecting, and treating long-term complications

• Managing diabetes before and during pregnancy


Diabetes Educator Credentials

The initials CDE (for certified diabetes educator) indicate that the professional has experience caring for people with diabetes, has passed a national exam in diabetes education, and is up to date in diabetes care treatments.


Dietitian

A registered dietitian is a member of your health care team who has training and expertise in food and nutrition. A balanced meal plan is critical for anyone with diabetes. You and your dietitian can develop a meal plan that includes foods you enjoy and that will help you balance your food and physical activity.

You may want help in adapting your diet to special goals, such as losing weight, reducing dietary fat or sodium, or complementing a regular exercise program. Your dietitian can help ensure that your diet achieves these goals and that it accommodates your likes and dislikes, culture, schedule, and lifestyle.

It is recommended that you see a dietitian whenever you are having problems reaching your blood glucose targets. It is a good idea to see a dietitian once a year, even if you aren’t having problems with diabetes care.


Dietitian Credentials

In choosing a dietitian, look for the initials RD (registered dietitian). This indicates that the dietitian has passed a national credentialing exam. Many states also require a license, and you may see the initials LD (licensed dietitian) after a dietitian’s name. Some dietitians are also CDEs.


Meal Plan Tune-Up

If you can answer, “yes” to any of the following questions, then your meal plan may need a tune-up.

• Has it been more than a year since your dietitian reviewed your meal plan?

• Is your blood glucose level or body weight more difficult to manage than usual?

• Are you bored with your meals?

• Are you planning to start or have you already started an activity program or changed your insulin regimen since your last nutrition checkup?

• Have you decided to aim for blood glucose levels that are closer to normal?

• Have you been diagnosed with high blood pressure, high cholesterol levels, or kidney disease?

• Are you planning to or have you recently become pregnant?

• Are you entering menopause?

What to Expect from a Dietitian

During your first visit, your dietitian will assess your nutritional needs, a process that generally takes an hour or more. Follow-up visits usually take 30 minutes. Follow-up visits allow for sharing further helpful information, progress checks, and adjustments to your meal plan. Even though your diabetes management may seem to be on target, don’t neglect periodic follow-up visits with your dietitian.

Topics for Your Dietitian

• How to use meal planning and carbohydrate counting guides, such as those published by the American Diabetes Association and the American Dietetic Association

• How to count dietary carbohydrate and fat and make adjustments to your insulin dose

• How to read food labels

• How to handle eating out

• How to make choices when grocery shopping

• How to handle holidays and other special events

• How to prepare and include foods that are important and meaningful for you and your family

Dietitians may also provide you nutritional resources, such as cookbooks and other reading materials, so that you can learn how to prepare easy, nutritious, and satisfying meals for your whole family.

How to Afford a Dietitian

The best way to afford your visit to the dietitian is obvious: get your health insurer to pay. More and more plans are covering services by a dietitian. Medicare now covers medical nutrition therapy provided by a Medicare-certified dietitian. Medicaid covers it in some states.

Tips for Dietitian Reimbursement

• Call your insurer first. You may have an insurer who provides this benefit. If so, ask what paperwork you will need to submit.

• Only a doctor can refer you to a registered dietitian for medical nutrition therapy.

• Submit a claim after each visit to the dietitian. Include a written referral from your doctor. The referral should not prescribe “nutrition counseling” or “nutrition education,” but language such as “medical nutritional therapy for diabetes management.”

• If you are turned down, resubmit your claim. This time, document how your visit to the RD can save the insurer money. Ask the dietitian for supporting documentation to get the visit covered. For example, you can cite the Diabetes Control and Complications Trial, which proved that complications can be prevented or delayed with near-normal glucose levels.

• If you are turned down, ask for your claim to be reviewed. Many insurers will tell you “no” at first, only to eventually cover some or all of the claim.

• In writing, ask for your disputed claim to be reviewed. Follow up with phone calls. Write down the names and titles of the people you call and the dates when you spoke. It pays to be persistent, so continue to write letters and make phone calls until either you or your insurer decides to pay for treatment.

Exercise Physiologist

It’s hard to know how to start an exercise plan. For example, you may not have been very active in the past or you might want to learn how to integrate a favorite sport or exercise into your diabetes plan.

A professional trained in exercise science and safe conditioning techniques is in the best position to help you design a fitness program. To find a qualified exercise physiologist, ask your diabetes care provider or other members of your diabetes care team.

Exercise physiologists can help you develop a tailor-made fitness program, set realistic goals, and offer tips for staying motivated to stick with your routine. Whatever your goals—to improve cardiovascular fitness, lower blood glucose levels, lose weight, lower blood pressure or cholesterol, or develop muscular strength and flexibility—your exercise physiologist can help you achieve those goals.

Even if you have arthritis, are overweight, have diabetes complications, or have been sedentary and want to become more active, an exercise physiologist can develop an exercise program to accommodate your specific needs. But before embarking on any new exercise program, make sure to clear it with your diabetes care provider. Also make sure that your provider and exercise physiologist are in contact with each other.


Exercise Physiologist Credentials

Look for someone who holds a master’s or doctoral-level degree in exercise physiology or a licensed health care professional with graduate training in exercise physiology. You may want someone certified by the American College of Sports Medicine to ensure that your exercise physiologist has the skills necessary to design a safe, effective fitness program to suit your needs.


Mental Health Professional

In addition to creating physical and metabolic problems, diabetes affects a person’s thoughts and feelings. Sometimes these feelings can become overwhelming. Mental health professionals can help people deal with some of the personal and emotional aspects that are inevitably associated with diabetes. Mental health professionals include social workers, family therapists, psychologists, or psychiatrists.

Types of Mental Health Professionals and Credentials

• A social worker should hold a master’s degree in social work (MSW) and have training in individual, group, and family therapy. Social workers can help you cope with many concerns related to diabetes, including problems within the family, coping with workplace situations, and locating resources to help with medical or financial needs.

• A marriage and family therapist should hold a master’s or doctoral degree in a mental health field and have additional training in individual, family, and marriage therapy. These therapists can help you with personal problems in familial and marital relationships and with problems on the job.

• A clinical psychologist usually has a master’s or doctoral degree in psychology and is trained in individual, group, and family psychology. You may visit a clinical psychologist to help you through a particularly stressful period over the course of several weeks or months or on a longer-term basis to work through depression, anxiety, or other problems.

• A psychiatrist is a medical doctor with training in the relationship between physical well-being and mental health. Psychiatrists with expertise in treating people with diabetes can help you understand how the physical problem of diabetes can also affect your mental health. Psychiatrists prescribe medications or hospitalization for emotional problems, if needed.

If you feel that you need some help coping with the emotional burden of diabetes, don’t be afraid to talk to your diabetes care provider, who can recommend an appropriate health care professional.


Children with Diabetes

Having a child or teen with diabetes can be a challenge. Make sure your child’s health care team includes a mental health professional. This team member will work with you and your child to identify the developmental, behavioral, emotional, and social issues confronting your child and to offer support and help for the whole family.


Eye Specialist

Eye care is a priority for anyone with diabetes. You can preserve your eyesight by keeping your blood glucose level close to normal.

An eye specialist monitors changes in your eyes, especially those changes associated with diabetes. He or she then determines what those changes mean and how they should be treated. For example, changes in the tiny blood vessels that supply your retina—the part of the eye that detects light and thus visual images—could be an early sign of diabetic retinopathy. If left untreated, diabetic retinopathy can lead to blindness.

Your diabetes care provider will look at your eyes during the course of your yearly physical examination, but you also need to have them more thoroughly examined by a trained eye specialist. Your eyes need to be dilated for this exam.

Eye Exam Schedule

• If you are an adult, have a thorough eye exam (including dilation) at the time of diabetes diagnosis and yearly thereafter.

• If you are 10 or older and have type 1 diabetes, you should have a comprehensive examination 3–5 years after you are diagnosed with diabetes and yearly thereafter.

• Also, if you notice any changes in your vision or you are planning a pregnancy, you should be examined.

When to See Your Eye Doctor

• Your vision becomes blurry

• You have trouble reading

• You see double

• One or both of your eyes hurt

• You feel pressure in your eye

• You see spots or floaters

• You lose vision

Choosing an Eye Doctor

The right eye doctor is an important aspect of your health care team. You may want to schedule an interview with a potential eye specialist before choosing one. Here are some questions and topics to discuss.

Interview Questions for Eye Specialists

• Do you see many patients with diabetes?

• Do you have experience treating patients with diabetic retinopathy?

• Do you perform eye surgery? (This is usually limited to ophthalmologists.)

• Are you a retina specialist? (This is important because eye disease in people with diabetes affects the retina, the part of the eye that detects visual images.)

• Will you send regular reports and keep in touch with my diabetes care provider?


Types of Eye Specialists and Credentials

Ophthalmologists are medical doctors (MD) qualified to treat eye problems, both medically and surgically.

Retina specialists are ophthalmologists with further training in the diagnosis and treatment of diseases of the retina.

Optometrists are trained to examine the eye for certain problems, such as how well your eyes can focus. While they can prescribe corrective lenses, they do not perform laser surgery to correct retinopathy.


Podiatrist

Foot care is especially important for people with diabetes because they are prone to poor blood circulation and nerve disease in the extremities. In addition, people with diabetes are likely to develop infections that often appear in the feet. Even small sores can turn into serious problems quickly.

People with diabetes should see a foot doctor called a podiatrist. Your diabetes care provider or podiatrist should check any foot sore or callus. Don’t try to treat any foot problems yourself.

Podiatrists treat corns, calluses, and foot sores to prevent more serious problems from developing. They can also show you how to correctly trim your toenails and how to buy shoes that fit properly. To find a podiatrist, ask your diabetes care provider for a referral, or check with local hospitals or your local American Diabetes Association office. During your initial visit, ask what percentage of his or her patients have diabetes.

Get early treatment for foot problems! Call your doctor or podiatrist if you have any of these problems: an open sore (ulcer) on your foot; a cut or blister that is slow to heal; any infection in a cut or blister; a red, tender toe; any change in feeling, such as pain, tingling, numbness, or burning; and any puncture wound, such as if you step on a nail or thorn.


Credentials for Podiatrists

Podiatrists graduate from a college of podiatry with a Doctor of Podiatric Medicine (DPM) degree. They also complete residencies in podiatry and can perform surgery and prescribe medication for your feet.


Pharmacist

A pharmacist has a wealth of information on medicines: what’s in them and how they interact with each other. Pharmacists are highly trained professionals who must know about the chemistry of the products they dispense and what effects, both good and bad, medications have on the body. Therefore, they can also give advice on whether and how any medication you take for your diabetes or other conditions could or will affect your blood glucose levels.

It is important to find a pharmacy you like and to stick with it. This way, the pharmacist can keep an accurate and up-to-date profile of your medical history, allergies, and medications.

Pharmacists do more for you than fill your prescriptions. They alert you to the potential common or severe side effects of any drug you are going to take. With each new prescription, they can review your medication profile to see if any of your current medications might interact with your new prescription.

So, in addition to asking your diabetes care provider, you can ask your pharmacist to recommend over-the-counter medicines for colds or other minor illnesses. For example, if your pharmacist knows you take a sulfonylurea, he or she may recommend a cold medicine with little or no alcohol to avoid any possible interaction between the two medications.


Pharmacist Credentials

Pharmacists are required to have their PharmD degree. They must also pass an exam in the state where they practice pharmacy.


Dentist and Dental Hygienist

People with diabetes are at higher risk for gum disease and mouth infections. To prevent gum disease, see your dentist or dental hygienist every 6 months for a thorough teeth cleaning. Make sure your dentist knows that you have diabetes, and ask him or her to observe your brushing and flossing techniques to make sure you’re doing all you can.

Call your dentist if you find any of the following: your gums bleed when you brush or eat; your gums are red, swollen, or tender; your gums have pulled away from your teeth; pus appears between your teeth and gums when the gums are touched; any change in the way dentures or partial plates fit; any change in the way your teeth fit together when you bite; or persistent bad breath or a bad taste in your mouth.

Some medications may cause dry mouth, so tell your health care provider, dentist, or hygienist if you experience this problem. They can offer suggestions.

Dermatologist

High blood glucose can cause dehydration, which causes dry skin. Diabetes also increases your risk of developing skin infections, especially if your glucose levels are often above normal. For instance, staphylococcal skin infections can cause itchy spots on the buttocks, knees, and elbows.

Your best weapon against dry skin is to keep your glucose within your target ranges through healthy eating, exercise, and medication. If you develop a skin problem, you’ll need to see a skin doctor—a dermatologist. Your diabetes care provider or local ADA office can provide a referral for a dermatologist, if needed.


Dermatologist Credentials

Dermatologists are medical doctors (MD) with special training in skin disorders.


Communication

You’ve chosen your health care team. Now what? Your diabetes care provider may already use a team approach and may already be in contact with other team members. If they are not already in touch, make sure all team members know about everyone else on your team.

Ask your health care team to consult with each other whenever appropriate. Be sure that they have each other’s phone numbers, e-mail addresses, and mailing addresses. If you are making any lifestyle adjustments—quitting smoking, starting a weight-loss diet, or taking up jogging, for example—make sure you notify all team members.

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Remember, your health care team is there to help you manage your diabetes. They can provide a wealth of information and the resources you need to make the decisions that affect your health. But you are the one who ultimately makes the decisions and puts your health care plan into action.

To work together as a team, you must be able to communicate with your fellow health care team members. It’s not always easy to communicate, especially when you’re feeling nervous, worried, or under pressure. Sometimes people can feel intimidated by health care professionals. However, just remember that they are there to help you. To best help you, they need to know what is on your mind. Only you can tell them how you are feeling and what special concerns you might have.

Tips for Talking with Providers

• Plan for your visit. Write down questions or concerns you want addressed. Bring your blood glucose logbook, a list of your medications, and anything else your diabetes care provider needs to know.

• Share the conversation. Begin the visit by telling your provider what you hope to accomplish and what you want him or her to know. Your provider cannot read your mind or guess what problems you may have.

• If the vocabulary becomes too technical or the concepts too complex and you don’t understand, speak up. Ask for an explanation of anything you don’t understand. Don’t worry about feeling “stupid” or worry that this is something you should already know.

• Write down any information or instructions. It is important that you thoroughly understand everything that your health care professional is telling you.

• Consider bringing a spouse or support person to sit in on the visit.

Your emotional health is critical to your well-being. Let your provider know if you are struggling. Don’t be afraid to bring up sexual or personal topics. Your team members are professionals and are prepared to help you deal with even the most sensitive topics.

Don’t be afraid to discuss money. Health care professionals realize that financial worries can contribute to patient anxiety, and most will be willing to discuss payment options. Tell your provider if you are having trouble paying for your medications or diabetes care supplies, even if you are not asked.

If you don’t feel comfortable with any member of your health care team or feel that you are not communicating effectively, consider interviewing other professionals until you find someone with whom you feel at ease.

Second Opinions

No matter how much you trust your doctor and other health care professionals, there may be times when you would like a second opinion. This could occur when surgery, long-term medication, or other treatments that will drastically affect your lifestyle are recommended. You may also want a second opinion if your health care provider says you have a problem for which there is no known therapy or your provider calls the problem you have incurable.

Check with your insurance company to determine whether medical costs for a recommended procedure are covered. Also ask whether they cover the cost of a second opinion and whether they pay only their own recommended consultants. Some insurance companies insist on a second opinion before they will fully cover certain treatments.

When searching for a physician to provide a second opinion, first ask your physician or a health care professional you trust. Look for a doctor who is board certified in the field in which you are seeking information, such as cardiology, surgery, or endocrinology. One option is to call the appropriate department of a major medical center or teaching hospital and ask for the name of a specialist in the field.

Sometimes insurance companies require a second opinion. Ask your insurer what costs for the recommended procedure are covered and whether they will cover the cost of a second opinion. Also ask if they pay only if you see one of the consultants they recommend.

Be sure to tell the physician about your diabetes. If the problem is diabetes related, or you suspect that it is, call the American Diabetes Association for the names of specialists in your area (see Resources). For problems not related to diabetes, try calling the appropriate department of a major medical center or teaching hospital and asking for the names of specialists in the field.

Questions to Ask When You Get a Second Opinion

• What is the diagnosis and how was it determined?

• What treatments are available and which are most effective? Most risky? Most commonly used?

• What treatment do you suggest and why?

• What is the success rate for this treatment?

• Is the condition reversible?

• What are the potential side effects and complications of the treatment and how likely are they?

• Is the problem or treatment likely to affect my blood glucose levels?

• Will the treatment require hospitalization? For how long? Will I need follow-up care?

• Are there any additional costs associated with this treatment, such as repeated blood tests, physical therapy, or postoperative nursing care?

• Is this an experimental treatment? Will I be participating in research? Will I be part of a placebo/control group or will I receive treatment?

• If this is the case, you may need to evaluate the potential risks and make sure they do not outweigh the benefits. If this is a research protocol, are more conventional treatments available should this one fail?

Team Approach

Assembling your health care team will not happen overnight. It can take time and persistence to find the right people to take care of you.

You’re not alone. Your primary provider and diabetes educator are excellent resources for finding specialists in various fields of diabetes treatment. After all, treating diabetes is a team effort and you may need several experts to help keep things running smoothly.

As in all matters of our health, you are the most important advocate. Trust your instincts and try to choose providers who have your best interests at heart.



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