#1139 Grand Rounds: Communication

February 26, 2024Scott Benner

Scott and Jenny discuss the need for clear communication between doctors and the people that they care for.

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Scott Benner 0:00
Hello friends and welcome to episode 1139 of the Juicebox Podcast

Welcome back to the Grand Rounds series today Jenny Smith and I are going to be discussing the communication needed between doctors and patients. Nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your health care plan. Don't forget to save 40% off of your entire order at cosy earth.com. All you have to do is use the offer code juice box at checkout that's juice box at checkout to save 40% at cozy earth.com. When you place your first order for ag one with my link, you'll get five free travel packs and a free year supply of vitamin D. Drink ag one.com/juicebox T one D exchange is looking for you. They're looking for US residents who have type one diabetes or are the caregivers of someone with type one to fill out a short survey, T one D exchange.org. Forward slash juice box. When you completely fill out the survey, you're helping people with type one diabetes, and you're helping to support the podcast. It only takes about 15 minutes T one D exchange.org forward slash juice box

this episode of The Juicebox Podcast is sponsored by us med U S med.com/juice box or call 888721151 for us med is where my daughter gets her diabetes supplies from and you could to use the link or number to get your free benefit check and get started today with us met. This episode of The Juicebox Podcast is sponsored by the contour next gen blood glucose meter. Learn more and get started today at contour next one.com/juicebox. Jennifer, welcome back to the Grand Rounds series. Today we're going to talk about communication.

Jennifer Smith, CDE 2:17
Yay, yeah, let's say munication. That's a broad topic.

Scott Benner 2:22
Well, we're gonna we're gonna lean on listeners a little bit for this one actually, maybe a little more so than we have in the past, we have a lot of feedback from listeners about what they wish their doctors would do regarding communication. So I'd like to step through it. Yeah, it's kind of a long one. So we'll jump right in. The first one here says I want my doctor to know that I am an entire person who has diabetes, not a diabetic. And that this is not my entire life. It ebbs and it flows, my controls are normal, and they're okay. And in the end, I need to be treated like a person. And I think that's a good way to start. Because, you know, you and I were just speaking before we recorded and we probably should have just said this while we were recording, so I'm gonna bring it back up. Doctors need to talk to you, like they're real, and understanding how to communicate with people and be human and reflect while people are talking, not just talk at them, but see what they're going through. And respond to that, you know, instead of just yelling orders be more collaborative, I guess is the way I would think about it.

Jennifer Smith, CDE 3:28
Right. And in that collaboration, what you're going to take away, whether you're a doctor, or an educator or a nurse, or you know, whoever is the clinician, that the person with diabetes trying to interact with, they, they need to take that all into consideration for the data that the clinician is looking at, because that data is only truly numbers. And those numbers translate into somebody's life, and why they look the way that they do like you said it might be I've had a really great couple of weeks, everything's been lovely. I had a week off, you know, from my job, I got to relax, I didn't have any crazy, I have to go to school because my kid got in trouble. You know, all the variables that could sneak in, everything was calm, whereas two weeks prior to that, maybe everything was hitting the fan, right? And so, as a clinician, if you're not asking or learning how to communicate on a personal level, you're gonna miss why the information looks the way that it does. If you're really just looking at it black and white people aren't numbers.

Scott Benner 4:40
I don't imagine that anybody listening has never been in the situation where you kind of look up one day and you think I haven't cooked a meal for myself and days. Like I've been eating leftovers or I stopped on the way home or I did something like that. It builds on you. You don't recognize that you're out of your rhythm. Yes, right. And then if you to go look at that weak of blood sugars and say, I see a lot of spikes here, there's some lows. And you know what happened? Right? That what happened? First of all is mind numbing. Like, I don't know what happened, it was two months ago. That's that's the first problem with it. But the second problem is, even if I could remember, you've probably looked at the chart when Oh, that's the week that I wouldn't put two and two together, I wouldn't say oh, that's the week I stopped cooking for myself that week, because right work was hard, or to feel that humanity is important. Because otherwise, what you're saying is, Hey, what did you do? That's how it feels. And you a don't know what you did? And B, you were trying the entire time, like that, I think is the that's where the damage point comes in, is that these people are working really hard. And trying to do well, it's not going their way. Okay. But instead of saying, What did you do, do better? Find out what happened, if they don't know, then just say, look, let's just look at the graph and see what we can do here. You know, like, Let's offer a suggestion, if you don't have a suggestion than asking what happened is almost cruel. You know what I mean? Correct? Yeah, absolutely.

Jennifer Smith, CDE 6:08
Because oftentimes, whether the person with diabetes voices that or not, they are coming in, because there is something that is often not going 100% The way that they want it, they may not know themselves, how to communicate that back to you as the clinician. And so for you to, it's almost finger pointing, and it's a blame scenario, when you're saying, Well, what happened here, pointing your finger at, you know, one, high blood sugar, one really extreme low blood sugar. And again, the person may have no idea three weeks ago, what happened. But if there's a recurring theme, then your job as a clinician is to help figure that out, and give them suggestions. And be able to say, Well, I see that, you know, every three weeks, you've got this big project that you're trying to do with your business. And I can see that this translates into meals that aren't, you know, as timely or a lot of stress that keeps things high. Why don't we try this, I can see that this variable is hard for you to make it better and maybe make you feel a little bit better, better, you know, looking blood sugar's would help in this scenario, let's try this, try this setting change, try, try to, you know, have meals ordered at regular time. So they come to your office or give them a solution that they can start with, I guess,

Scott Benner 7:30
something that is clear, concise, and you know, is going to reasonably speaking work to because I think the other problem can be is when you just start like spitballing and they go home, like you knew, you know, hey, the guy said, you want to go home and you you put it into action, it doesn't work, you're like, well, he doesn't know what he's doing. And I'm still lost, and he's gonna yell at me when I go back again. And even if you're not yelling at them, they feel like they're being yelled at. Right? So it mean, I have a pretty big personality. And I still have been in that doctor's office, and I'm like, Oh, my God, like what's going on? Like, you're coming at me? Like, I don't think she was coming at me. And I think I was somewhere deep down. I knew I'm not doing well at this, you know, like, Arden was little I didn't know what I was doing yet. And any kind of feedback felt attacking because I was I was vulnerable. You know, like, I was in a bad spot. I didn't know what I was doing. I was pretty sure I was hurting my daughter. I was starting to think about long term stuff. Short term, you know, was a mess. And then that's where I don't know. Like, that's where that part of the doctors thing is so important. Like, it's how they approach you. It's like coming at a I don't know, it's like to care approaching a stray cat like kind of very slow. Yeah, exactly. I'm here to help.

Jennifer Smith, CDE 8:48
Right. And when you when you first come into that, that office space with the person who has come in, they've made their appointment time, and they made the time to bring in some records and reports and whatever your question to them is, I'm always asked, I mean, this is my no one. But well, how are you? Do you have time to hear how I am? Like I could I can tell you how I am right. But what is important right here. And now for you to know about how I am what are the biggest things and this goes to the person with diabetes. It's what are the checklist things that are really, really important so that when they say, how are you you can say, well, I'm okay, or I'm doing really great, I've changed this, I've changed that, you know, this is looking much better. So there has to be enough communication to really, to really, I guess, give to that question of how are you? And you have to be receptive of it too.

Scott Benner 9:40
Yeah. In my mind, you need to hear people and really see what's going on with them. And at the same time, you need to be a leader, right and not a leader in the way of like, Oh, God, this guy again, but like, you know, like, right, you know, prior to the podcast, and even in the early days of the podcast, I would do like I'd have a lot have phone calls with people where I would just talk to them about their diabetes. And what I learned pretty quickly, is that often, they don't know what they're talking about. They think like, they think they know what's happening. And they're not right now, you still need to listen to them and hear what they're saying. And then I hear what you're saying, you know, and what I think might be. And I never know what to think. Like, how do you know when you're just meeting somebody very quickly, right? You go back to basics. Yes. You just say, look, let's look at your basil first. And let's say that the easiest question I've ever found is away from food or active insulin. Does your blood sugar sit stable? Right? If If yes, where? You know, if that number is 90 I go, Oh, Basil is probably okay. If you tell me Oh, it's very stable at 121 3151 80 I go, Oh, Basil seems weak to me. Let's fix your basil first. And then maybe this will you know, help your meal Bolus is to work better. And I always say like, you know, adjust your basil. Get it right. Be careful while you're boasting and correcting because now you're adding extra basil on these boluses and corrections are gonna eventually need you know, less insulin. Let's get this right first. Give them a path. You know, once you get your Basal right, go back and reevaluate your meal insulin, your carb ratio and your and your insulin sensitivity. And honestly, just telling people that it mostly works for them, you know, like it's but when you start going, I don't know, let's try this at nine o'clock, like, I don't know what you're doing then be entertaining right now make a different problem. So this next person says, you know, it's a long, it's a long story. But basically, they said, I was basically told I'm probably going blind and probably losing my foot, I got very jaded, which really quickly actually did turn into me being non compliant. I stopped going to an endo just went to a GP to get my scripts. And, and I think that the takeaway here was, that hope is just is very important, and that these initial messages over and over again, I want to say initial messaging sets people on path. Contour next one.com/juicebox. That's the link you'll use. To find out more about the contour next gen blood glucose meter. When you get there, there's a little bit at the top, you can click right on blood glucose monitoring, I'll do it with you go to meters, click on any of the meters, I'll click on the Next Gen. And you're going to get more information. It's easy to use and highly accurate. Smart light provides a simple understanding of your blood glucose levels. And of course, with Second Chance sampling technology, you can save money with fewer wasted test strips. As if all that wasn't enough, the contour next gen also has a compatible app for an easy way to share and see your blood glucose results. Contour next one.com/juicebox And if you scroll down at that link, you're gonna see things like a Buy Now button. You could register your meter after you purchase it or what is this download a coupon? Oh, receive a free Contour. Next One blood glucose meter. Do tell contour next one.com/juicebox head over there now get the same accurate and reliable meter that we use. diabetes comes with a lot of things to remember. So it's nice when someone takes something off of your plate. US med has done that for us. When it's time for art and supplies to be refreshed. We get an email rolls up in your inbox says hi Arden. This is your friendly reorder email from us med. You open up the email to big button it says click here to reorder and you're done. Finally, somebody taking away a responsibility instead of adding one. US med has done that for us. An email arrives we click on a link and the next thing you know your products are at the front door. That simple. Us med.com/juice box are called 888-721-1514. I never have to wonder if Arden has enough supplies. I click on one link. I open up a box. I put the stuff in the drawer. And we're done. US med carries everything from insulin pumps, and diabetes testing supplies to the latest CGM like the libre three and the Dexcom g7. They accept Medicare nationwide, over 800 private insurers. And all you have to do to get started is called 888-721-1514 or go to my link us med.com/juice box using that number or my link helps to support the production of the Juicebox Podcast. So this person thought I'm gonna die anyway. Why try? Why

Jennifer Smith, CDE 14:43
try right? Why continue to go to somebody who hasn't and in this case, not everybody but in this case they weren't being given anything. Positive, valuable. Yeah, to try positive and valuable and applicable probably to their life. They were Being maybe given some advice about well adjust this here, or change this there? Or maybe it was the don't well don't do this. Why are you eating at McDonald's every day? Or why are you doing right? I mean, don't don't badger somebody into a change that isn't really going to make much different? Yes, for that,

Scott Benner 15:20
I get the idea. So I think what probably happens is that jaded doctors who have seen more than their fair share, you know, in their defense more than their fair share of people who are just not doing well, and it probably seems hopeless. And they probably think let's just jump to the end and try to scare them. And, you know, because I've seen that work with a few people. And by the way, I've actually heard from adults who the scare thing worked on them. Well, yeah. And but more people than not say, scaring me just scared me, or scaring me froze me, or it made me think I can't win, right? It's why everything goes back to understanding how insulin works, because in every situation you find yourself in whether it's somebody who's struggling forever, or just starting out, if you give them these these basic tools to begin with, they have successes that they can build on. Right, you know, and it relieves stress. And I think that, you know, this next statement here from somebody said, I wish somebody just would have told me I could have with insulin moved my anyone say, it's funny, they just didn't have that idea, like I was told, seven, two, good a one say.

Jennifer Smith, CDE 16:26
And also almost that the numbers that they were getting, were as good as it was going to possibly get that it was all about almost a stable point of where their body wanted to sit in terms of blood sugar, and that it was going to sit there. And other variables didn't have any impact on that one of them, obviously being insulin, and that an adjustment that's more precise, could actually move the needle in the direction that you wanted to go. Even without adjusting activity or food or anything else. A lot of times it's the right place to adjust the insulin.

Scott Benner 17:03
And how hard would it be to say, look, the ADA recommends this number, but I'm your doctor, I'm standing in front of you, I don't have diabetes, my one sees probably 4.9, you're not going to probably be able to get that but I bet you we could get you into the sixes. And then work on the fives maybe make some modifications to how you eat. Who knows like, right, if you want to go low carb, maybe we could get you in the forest. Right? But when you say sevens, okay? And the only thing is a quarterly report card, and they hit the seven or even I know it doesn't sound crazy, but 7.9 in somebody's head is still seven. It's still sad. Yeah, like I did it. I'm in the sevens in the sevens. But what's your one thing? Will you tell me?

Jennifer Smith, CDE 17:44
Will I tell you Sure. My a onesie is 5.5. Okay. That's what we want. That was my last one. The one before that was 5.6. So really, I'm I it's there.

Scott Benner 17:54
Yeah, right, right. It's there. Right? It's five you have type one diabetes, it's five, five, it's five, six. You know, you manage that by understanding insulin exercise and diet, boom. Like, you know, if I didn't want to exercise if I was Jenny, but I didn't exercise you probably have a six two.

Jennifer Smith, CDE 18:11
Right? Sure. Yeah, and be using more insulin than I use respond to food differently than I respond. Absolutely. They're those big variables that you do have to understand. But mean insulin is, it's the mover of blood sugar. I mean, right. And if you have it squared away, and you have somebody to guide you, I think, thanks to the podcast, obviously, I think people have a lot better understanding of insulin, and the fear component gets removed and they're willing to do their own trials of changes. But then there are still a good majority of people who are not confident enough about making adjustments and are still going back to their clinical team to make those and because they're not made maybe at most every three months you're left with this idea of again, I'm seven I'm seven one I'm you know, whatever and the doctor says that that's that's in a really great place or it's come down so I'm I'm clearly moving in the right direction and you are but it could be improved even further you could be getting closer to what we would hope for getting in the range of people without diabetes safely. Of course, you

Scott Benner 19:21
know, and people I think generally speaking humans like reaching right they like seeing something out ahead trying for it and succeeding. It feels good it works it I mean, we spend so much time talking about oh, I'm scrolling it's you know your dopamine your D you can give people a dopamine hit with a with a good blood sugar. Like if somebody came in to this conversation right now. And they said Look, you guys are talking about a seven a one c minus 10. I you know, I'd kill somebody for a seven you don't have to kill somebody for something first of all, you just you know, need some changes insulin, yeah, just make some changes in your settings and how you're, you know, timing your insulin. That's it. I mean, honestly, good settings Pre-Bolus your insulin a once he's somewhere in the 60s, you know, it just, it really well be if you're in the 10s, you don't know what you're doing. That's all for a doctor to look at that and say, Oh, I give up on this one. If you knew what I knew, or what Jenny knew you would go, I could fix this tomorrow. I can, you know, like, what are we doing here? So,

Jennifer Smith, CDE 20:23
and the unfortunate thing about those a one C, there is sort of a range, right? A onesies over I think it's over about a nine or a 10 really is a deficit of lots of basil and Bolus, if there's a deficit, definitely. And the person with diabetes may not know what to change the clinician, the one with the degree and all of the, you know, panels on their walls and whatever. They're the ones that should be able to say, Hey, your agency is here. Clearly, there's not enough insulin and you might then start to add insulin to hopefully get those those numbers down. Anytime that a one C is kind of like above where you'd want, let's say it's above seven, but kind of under that 10, then we start looking a lot more at mealtimes. And we start looking at, okay, as you said earlier, if you can float around at a at a stable blood sugar, even if it's 120, right, and you're safe there, then your Basal isn't really the wrong thing. What we end up seeing is these major excursions around meal times, which could be relative, that the dose is not necessarily wrong, that it's the timing, people haven't been taught the right timing of their of their dose, it could be both it could be timing, and that the dose has never been appropriately adjusted. And so those those a one sees as a, you know, just average, could be brought down by attention in a different place.

Scott Benner 21:53
And a little trick to figure out if that's the case is if that stability is higher than you want it to be. But like Jenny's saying, it's very stable. If you missed on a meal prior, like she's saying, you might end up at 120 with a perfect basil. And you know, Basil is doing its job perfectly, it's holding you steady. It's not its job to shoot you down. But I tell people all the time, if you see that stability higher, and you're not sure is this my basil, or did I miss on a meal corrected. And when it starts to go down, if it goes down and stays down, you missed on the meal. If it goes down and it comes back up, that could be your Basal being two weeks. Yep, it's a simple way to just check to see what's happening. That's the thing, you should be able to empower people with this, this person says I want my doctor to not be so by the book, I'd love for her to constantly be educating me, let's talk about off label use for medications if we need to, I'd like her not to be afraid to help me change my settings, to empower me to change my settings. And just because I do have a one C that's lower, it doesn't mean that I don't need help ever. Right. And I made a note next to that, when I said you gotta be a guru a little bit. Like it's, I mean, the by the book thing, it's not going to work for this, like you need their variables, you need your information, need the tools, you need the understanding of how to use insulin, they all have to work together, you can't just say, you know, 15 minutes 15 carbs, like that kind of stuff. It's right, it's too bare bones. It doesn't it doesn't do the right things for you know,

Jennifer Smith, CDE 23:17
and it I think a lot of the beginning tidbits of information that are given, they're just a starting place, kind of like the 1515 rule, which is really, really old school, obviously at this point. But it's still being taught because it's a, it's a quick and easy teach. But then you have to end up going beyond that as the clinician when you can say, Okay, I've taught them this, they're using it. But now my job is to say this isn't working, maybe you need less, or maybe we need to consider a change to this. Or maybe we need to, to do this and in the visits with people, then you have to bring that in so that they can see why you're making suggestions, or changes. Don't just give them a directive and expect them to move forward. They need to understand why What are you seeing? What are you seeing that suggesting I should change this or to change that or to think about this differently? Because otherwise you're just sending them out with a map that doesn't apply to their life.

Scott Benner 24:19
I wonder if doctors don't feel almost embarrassed to talk out loud to think out loud. Which would be a shame because it's a large part of how I taught my daughter to take care of herself was just everything that we were doing was spoken. Hey, it's time for you to change your pod. You know, we don't want to leave it on too long. Because you're only supposed to leave your cannula in for you know, about three days. So let's not wait. Let's get that off now. Right. Oh, you know, when we put it on, we'll watch your blood sugar. If it goes up, maybe we'll have to put some insulin in with a new site next time. My daughter doesn't know it. She could not sit down and explain diabetes to you. But she can do it. Right Is it To

Jennifer Smith, CDE 25:00
become habit, because she just knows what to do,

Scott Benner 25:02
because I'm narrating her life around diabetes out loud and not all the time. Like, I don't want people to think, oh my god, this guy up this kid, you know what I mean? Like, they just don't just, you know, like, at times when something was happening, we do it, you know, a plate would come out, I'd go, hey, you know what I'm thinking here, we're going to Bolus you think about how much you think it's going to be. And then we'll compare, you know, and she'd say, I think it's 45 carbs. And I go, Alright, where do you see the carbs? You know, don't don't just guess the number. Tell me where you see it. And then I'd say I see what you're seeing too. But I think you're forgetting the breading of the chicken. So let's throw in like seven more for the reading. And that over there is fried. And so I think you're gonna get a little bump later from from the slowdown and your digestion. So why don't we put a little more in for that, too. And then years later, she just knows how to do it. Like it's not. I think that there's that the doctor brain learns differently. I imagine. I don't know, I don't have it, I have more of what you might call like, an artist's brain. Like, I just, you know what I mean? Like,

Jennifer Smith, CDE 26:05
yeah, I'm a, I'm a talker, when I, when I work with people. And I'm also when I respond to email requests or inquiries about data and whatever. I have very lengthy, like emails and a very lengthy discussion, because I talk a lot. And I want you to go forward with why I'm suggesting a change. Or even if I'm questioning, hey, let's work together. What do you think you know, your life better than I know, I see that we could do it this way. But I also think that we could do it this way. What do you think you'd like to try first, so it gives some options, and it gives them the ability to move forward out of our visit together? To try something without checking back in? Yeah, right away, or without going three months, and then saying, well, it didn't work. I didn't know what else to do. So I just kept doing it.

Scott Benner 26:57
Look, I don't know how many doctors are allowing emails. Now. I guess there's a lot of portals where you can message people. But people need to feel autonomous, like they just really do they need to like and if even if it's a new person, and you're like God, I can't let them make too many changes. They don't know what they're doing. I mean, they can move their Basil 10%, like you don't I mean, like you could, you could give them a little bit of freedom so that they could like trial and error out a little bit. And I'm assuming that the word error doesn't sound right to a doctor. But that freedom that you give them, it's how you get to where you're trying to take them, like you can't shackle them the whole time and then go, I don't know why they don't run, you know what I mean? Like, like giving

Jennifer Smith, CDE 27:36
somebody this dose adjustment, maybe you explain it, but then saying, You know what, try this for two or three days. And if this isn't quite enough, or it's just too much, then we're gonna give you this next option, giving them handing it to them and saying, here, here, here's an option. It's not just you're stuck at this. And you know what, for further collaboration, it's checked back in, send me an electronic message, and let me know, did it work? Did it not work, I am happy to check back in with you to make sure that I give you another suggestion, or to see that it actually is safe to continue changing things. Right.

Scott Benner 28:11
I think also, if you don't believe that conversating with people can lead them to understanding things that you should, I'll tell you this little story. So Jenny, and I have made all these different series together. And the feedback overwhelming, I'm talking about overwhelmingly like hundreds of 1000s of millions of downloads, right? And people come back, I listen to this my one season the sixes, blah, blah. And I even to the point where I sometimes think, what the hell did we say in there? You know, you mean, so like,

Jennifer Smith, CDE 28:40
what really hit for that person, like God, like,

Scott Benner 28:44
I don't think I know that much about it. So I did this thing recently. And it's gonna come out on my social media at some point. But I chat GTP like AI has gotten to the point now where it's fascinatingly good at breaking down conversations. So behind the scenes, I'm feeding the transcripts of everything you and I have done together into AI, and I'm telling it just one simple thing. What are the key takeaways for people living with type one diabetes? And it writes in bullet points, my brain doesn't write in bullet points, but it does. Wow, that's cool. It's so good, Jenny, that when I put it in front of you, you're gonna think you wrote that list yourself. Or you're gonna think I wrote it, or you're gonna think we wrote it together. It's really technically

Jennifer Smith, CDE 29:28
we kind of did. All we're doing is feeding information and something is putting it together and very concise.

Scott Benner 29:35
It literally can read through it and filter out all the bowls. And just come back with this is what was spoken about. I'll tell you this, we you and I did an episode called setting Basal insulin, the math behind Basal insulin or something like that. You can ask the transcript, what your Basal insurance should be based on your weight and a couple of other things. And it just from our conversation knows the answer. It figures it out for you. That's insane, right? But here's the plan. Here's my bigger point. I know I'm helping people with this conversational style. But I also know there are some people who don't enjoy this conversational style, right? So I'm finding a way to give that information to them the way they want it, doctors have to do that, too. You can't talk to people the way you learn, right? I'm sure all your engineer patients are probably thrilled with you. You don't I mean, like, seriously, but if I came in and you started bullet pointing me to death, I don't know what to do. If you told me right now to take three thoughts that I understand and write bullet points about them, I guarantee you, I'd write them out in a paragraph instead, right, and then I'd have to stop and break the paragraph apart, and then reward them. So they look like bullet points, because my brain doesn't work that way. It's really something I

Jennifer Smith, CDE 30:41
mean, what you're kind of boiling it down to is what I feel about. Educating the way that I do is getting to know a person, I understand that I have a little bit of a different way to do that. And you know how we work with people. But in an office space, time is really the constraint, I get that. But because I have the time, the nice thing is that I could tell you what impacted someone's blood sugar in one way compared to another's, because I know them, I don't know them just their name. I know them, I likely know the siblings in the house. And I know that this child goes to a grandparents house, you know, four times a week, and they're served these things versus at home, it's different. And so those are some of the things that also go into management, that may not be a setting change. And that you have to be able to learn in order to educate, or to be able to teach a strategy that's applicable to that one person. I know that I teach differently, a little bit differently for each person I have the opportunity to work with, because I meet them where their need is.

Scott Benner 31:55
I think if a doctor hears you say that and thinks I can't do that, I think yes, you could. You can you just need more practice talking to people. I swear to you just call me like get on the podcast, and we'll chat. And just after an hour, you'll be like, Oh, I can just conversationally talk about diabetes, and people understand it. That's crazy. I'll do that. You know, it's it's so doable. Jenny, this person here says, If you don't know something, just tell me you don't know. Yeah, honestly, would be the bedrock of our of our relationship. And I actually just interviewed someone recently who had that story, she asked a question about her pump, to her doctor. And instead of Bushcare, were sending her to go and go watch a YouTube video. Which, by the way, there are a lot of comments in here from people like do not go tell me to watch a YouTube video, like Teach me how to do the thing. Okay, so if you were the doctor don't know how to do it. I mean, hey, why don't you take a weekend? You know what I mean? Cuz kind of your job. Be honest. And so anyway, this doctor says, I don't know, I'm gonna find out and come back to you. And then they actually followed through and did it? Yes. And it was a big deal for this lady. You know, that would be a

Jennifer Smith, CDE 33:10
that's a big deal for me. I mean, I have fired essentially, or just not gone back to clinicians through the history of my adult life as choosing my own clinical team. Because I got the sense very much that they couldn't answer my question, they kind of be asked around not knowing how to tell me that they didn't know. And so I was just like, Okay, I'll find somebody else.

Scott Benner 33:35
I wished my doctor not only knew how to tweak, you know, my diabetes, about my lifestyle, like, have like a, she actually says here, I wish you had a primo list of referrals, mental health, you know, nutrition, stuff like that a CD, they actually knew what was there was willing to work with you. And listen, I'll say this, I know a number of doctors privately. Don't just say like, oh, there's a guy over here. I know the girl in this practice, and you know, they're crap. And you send people to them anyway, because they're part of the system or something like that. You just create another problem. Again, say, you know, I don't know anybody that's going to fit that bill should ask around a little bit, or call some offices, ask some leading questions. How do you guys deal with this? You know, like, pick on your own? But yeah, this person's like, you know, please just help me find other practitioners at times. If you can't do it, just say, I don't know, let's get you to this person.

Jennifer Smith, CDE 34:28
And sometimes that takes from the clinical or you know, the physician angle that that means that even if you can only refer to people within your organization, then know the people that you do need to refer to, right know the mental health specialists in your organization, get to know a couple of them. Who would you really click with who really would be great and who was kind of iffy and totally wouldn't be somebody for diabetes to talk to right. Get to know kidney specialists get to know good cardiologists get to know your system. I'm because I guarantee that there's not just, there's often not just one practitioner to refer to. And if you get to know those different teams, you'd have a better list that you can easily pull out or look up on your notes on your phone and say, you want to see this person, you could see this person, but they're not my first choice. Why? Who cares? It's important for the person that you're telling.

Scott Benner 35:25
And if you don't think that's important, this person says, Look, I'm a researcher and a reader. So I ended up clashing with my doctor who just wanted to take complete control and not empower us at all. If you're a doctor is like, that's how I want it, like, I'm gonna crack the whip, and everybody's just gonna do what I'm gonna say, this person said, I switch practices because of that. On top of that, she was told that her and her daughter would difficult patients. Yeah, for wanting to understand how to take care of themselves, they'll think about the psychological ramifications of that. If you're like, not everybody can speak out, here's a person who spoke up, right. And but most people aren't head down. A lot of people are head down, right? If you dominate them, they'll take that, and they'll never stick up for themselves ever. And you will be directly responsible for the poor health outcomes that they have. And you won't think so you get around at a party and tell your tell your friends, what a great job you're doing for everybody. But this is how these people could feel.

Jennifer Smith, CDE 36:20
Yeah, I think it kind of goes along with a lot of I wouldn't say a lot, but maybe half of the time I hear from parents, especially where their pediatric practice really wants to do the load of the adjustments. They really don't want the parents stepping in and adjusting and doing things in between the visits, which may not be close enough together, as their child is growing. And all those changes are happening. It's not soon enough. Now there are really awesome practices that have a lot of close, you know, I guess communication, but then the other ones do a lot of hand slapping, I did you change this? I would you adjust that. I told you not to do this, or you know, that doesn't help and long term. If the child is in the room, hearing those comments, they're also now learning that they don't have any voice in their own health.

Scott Benner 37:16
I don't know what I'm doing. And maybe worse, my mom doesn't know what she's doing. Right. I think that's a thing I see all the time, especially when we speak in public Jenny, and, you know, I, you know, I'll go to the parents and all, you know, a license stuff out for them. And then you go to the kids, and you're like, hey, you know, I told your parents and stuff today, and maybe they'll and the kids are like, my mom does not know what she's the devil coming out and say it like, she's tried three things. My one seesaw seven, maybe that's the most just the most terrible thing is taking the a child's you know, confidence in their parent away, you know, like, what's gonna happen at the end of this series, Jenny, and I gave it away a little bit here. But there's going to be an episode where I'm just gonna read the takeaways for everybody. And I'm gonna go over them with other people in like, kind of bonus episodes or supporting episodes for this series. In the end, as a doctor, empathetic kind. If you don't know something, figure it out. Teach people how to use insulin know how to talk about that very fluidly. It's all you have to do. Like, like it just, there's not much more to it than that, then let it be a conversation and give them give them power. Now look, do you have some people who, you know, you're like, Listen, if I give them power, they're gonna kill themselves in five seconds. Like, I'm, I'm not saying sure those people, you know what I mean? But those people can also be helped with basic tools, and a little bit of like, carrot and stick. Like, there's nothing wrong with saying, Hey, you're a 10. No problem. I think in six months, we could be in the eights. Like I'm going to help you get your settings right, then you do a couple things for me, we'll come back do another blood draw, we get you down to the AIDS. Now we're off to the races. I don't see why a year from now you couldn't have a six a one say, like, give people something to work towards? Like, we're basically just ants, Jenny. Humans are not good without a task. No, they're not. No, you gotta give him something to do. You know,

Jennifer Smith, CDE 39:15
right. You know, and from, from the doctor standpoint, too. I think when we're talking about diabetes, you're talking about a specialty. Right? You're talking about beyond just general practice. You've chosen to go into something that requires you to keep up with the changes that are happening. And this is very specific. And you might be you might end up being an endocrinologist who has nothing to do with diabetes and then that's great. That's your practice is not specific to that but if it is, you should be able to answer a question about a device. You should be able to keep up with what medications what is changing how to use it, who to use it for, you should be a able to answer questions, because you've chosen to specialize, it would

Scott Benner 40:04
be like if I climbed into a Nissan ultimate, it said driving school on the side of it, got behind the wheel looked over at the person in the other seat and said, which one of these makes it go? And you said, I don't know. I don't know. Well, then what am I paying you for?

Jennifer Smith, CDE 40:18
Right? Absolutely, I just I don't understand. If you've chosen, as I said, if you've chosen to specialized, you need to know your specialty.

Scott Benner 40:29
Jennifer, there is no doubt in my mind, that if I wanted to make a living a different way, I could offer private courses to doctors. And I think in three hours teach you how to take care of your patients. I know you could do it, too. There's a lot of people that could do it. But my point is, if that could be done for you, you could probably do that for yourself. You know, like you don't like go like find out that one of the things I'm always fascinated by, if someone comes in the office, they figured it out, they get their agency where they want it, they've got these great stable graphs. And the first thing that happens is Doctor yells at them out of fear. You're too low, you're gonna have a seizure. What about saying, hey, what didn't you do? Right? Could you tell me what you just did? Because I got to be honest with you. I didn't see this coming. Right? It happens all the time. And if they say something like, I listened to a podcast, don't yell at them and say the internet's not a good place for you to learn. Because your doctor's office hasn't been a good place for them to learn. They're trying to figure something out. So in the end, Jenny, meet people where they are, give them agency, and for God's sakes, think before you speak. Yes, leading a sentence in the wrong direction leads 15 minutes into the wrong direction. Start Strong.

Jennifer Smith, CDE 41:38
I wish to my point, don't point fingers do not

Scott Benner 41:41
point fingers at people like it's we're in this together and give people I can't believe I'm going to say this. You have to give people their flowers to when they do well. You got to like and it can't feel phony. You got to really mean it. You know, this is amazing. I know how much hard work this took good for you. I think there's more keep going. Right? And

Jennifer Smith, CDE 42:02
it doesn't have to be with what you what you see as where you would want them to be. If you've got somebody you've been working with who is so fearful of Lowe's that they run blood sugar's at 250 or 300. And now, your work together whatever education they've provided themself, now they're averaging a blood sugar around 190 or 200. That's a give them flowers. That's not a well, we really want to be lower than this. Oh, no, no, no, they've achieved something like, let's keep the ball rolling, right, you have to give them good positive reinforcement, regardless of what your down the road, like goal is for them. My

Scott Benner 42:44
daughter's first endocrinologist was brilliant. I could tell by talking to her. She never helped me once with diabetes. Just stood in the room smart, and said smart things and

Jennifer Smith, CDE 42:56
didn't help it that didn't translate into helping you. Oh, no,

Scott Benner 42:58
no, no, I was in a panic. You know, it might have been easy to say things like, hey, if your blood sugar is too high, you might not have enough insulin, I would have gone. Oh, that makes sense. Thank you, you know, Jenny, there's a note here from you that says Please don't look at a static number and then say everything is great.

Jennifer Smith, CDE 43:19
Right. And I wonder if I don't know if I gave context to it. But I think that I think that I was possibly talking about a one C two there. Because it is it's we understand that a one C is just an average, you really do have to get into the whereas the agency coming from what are the kind of the data points that are pointing to this because then you have more room as the clinician to say, Gosh, you came in your agency is now you know, 5.8, and it used to be 6.8. And in my mind, that's lower than I want it to be. But gosh, that a Wednesday is really stable. Look, you have like less than 1% of the time low, you have a standard deviation that's like those, those little pieces that go up to make that one standard value. That's really important to

Scott Benner 44:10
look at. I'm gonna run through a couple of things here at the end for people, I wished my doctor was a resource for other resources. Tell me, why did I have to this person says directly? Why do I have to find this podcast on my own? Listen, there are plenty of doctors and I want to say thank you to all of them that recommend this podcast every hour of every day. The Facebook group, which gets 150 new members every four days is overwhelmingly they have to answer a couple of questions. It's a private group, right? One of those Where did you hear from this from my physician from my doctor from my hospital? Like it's a fair amount of people. So thank you to all of you doing that. Obviously, I don't think we're talking to you. But you know, for everyone else, if you don't know, send me somewhere that might know and don't do that thing of like, well, I don't know what you're going to hear when you get there. Because the thing that's happened thing now is bad. So, no, I don't know like what could go wrong now maybe he wants he's nine and a half. I'm on the fast track here. You know what I mean? Like, good, go try something like whatever happened to like, I don't know get out there and do something like sometimes just doing anything and seeing a little bit of a positive return is enough to supercharge and get you going again, even local support networks, people are asking here like, please know where I can go meet other people. My teenage daughter just hears you're doing Oh, this is I think we've covered this in another one. But there are people who are looking for more, okay, so don't just look at their six five, a one C and go You're doing great. Because they might want to do better. And they'd like to hear from you. I mean, they know they're doing six fives. Great. They know they're doing great. So there's a double edged sword there. You could lull somebody into complacency. But what this person says specifically is when my daughter hears that, then I go home and try to say to her, Hey, listen, we should try Pre-Bolus. In five minutes longer. She goes, Hey, doctor said we're doing great. So yeah, you took away her desire to try to help herself. There's a way to say you're doing well. But there's always room for improvement. So here's some ideas like that kind of stuff. Right? Real quick. They don't make us feel bad about my agency Don't say things like, well, it's okay, this time, please don't use guilt as a communication tool. And then here says this is some feedback from somebody else. It just kind of gave me like a stream of consciousness that I want to kind of end here with she said, relationships, person to person person, the diabetes, clear relationship expectations, level setting, meet people need to feel safe. freedom to express things is very important. psychological safety is a big part of how you can get these visits and your relationship to work in everybody's favor. That's kind of where I'm at today with communication. If you have a minute, I'm going to share something with you, Jenny. Okay, go ahead. Anything you want to say or finish with before I jumped to the end? No,

Jennifer Smith, CDE 47:07
I was actually going to add one thing to that list is the be supportive of the caregiver. Be supportive of a caregiver, I talk a lot about like parents as the caregiver for kiddos, and be supportive in the way that you would be willing again, this goes along just communication, hear what they need, and also hear what they've tried. And if the child or the teen is in the room, be supportive of the efforts of what the parent is really trying to do. So again, you you may have some things to share with them. But really try to prop them up with all the effort they've been putting in. And if they come to you with questions, being able to again, communicate back in a way that they can understand how could this work? Could this be something that would be better, just really support them?

Scott Benner 48:05
That's a perfect way to end, I was going to share one of the takeaways with you. So from Episode The second episode of the Grand Rounds series is called diabetes diagnosis. And I asked an artificial intelligence to give me the key takeaways from that episode. And it said doctors and regular primary care settings may diagnose diabetes due to the rarity of the condition and the similarity of symptoms to other illnesses. misdiagnosed excuse me, it is important for patients to clearly communicate their symptoms and concerns when contacting their doctor's office. misdiagnosis or delayed diagnosis can lead to complications such as diabetic ketoacidosis. Doctors should be proactive in ordering appropriate tests such as blood work in your analysis. When patients present with symptoms that could be indicative of diabetes. Patients should not be dismissed or ignored when they expressed concerns or symptoms that could be related to diabetes. education and guidance on diabetes management should be provided to patients at the time of diagnosis, including information on insulin use, blood sugar management, and the impact of diet and exercise on their blood glucose levels. Doctors should be aware of the impact of their words and actions on patients mental health and well being. Collaboration between primary care and diabetes specialist can ensure comprehensive and effective diabetes management. Patients should be directed to reliable sources of information and support such as diabetes education programs and online communities. And doctors should continuously update their knowledge and skills and diabetes management to provide the best care for their patients. That's what AI picked out of your mi conversation. Isn't that fascinating?

Jennifer Smith, CDE 49:36
Well, and what it actually it's what's interesting about it is that it it sounds like the summary that you'd get in like a research project. We looked at all these things in 3000 participants in this study and these are the key takeaway points in order to be able to provide somebody with diabetes, the right care. That's what it sounds like.

Scott Benner 50:03
I'm also almost I'm being boastful a little bit here if I'm being honest, because you and I, you're a lovely person who comes on my podcast. I mean, like, We're not sitting in the same office talking to each other for a month about what we're going to do, you and I pop on when you have free time and free time is in quotes, right? Like when you you jump on here and I go, Hey, Jenny, we're going to do that Grand Rounds thing. Let's do what happens when you're diagnosed in your doctor's office today, and you go, okay, and then we chitchat for five minutes about our lives, then we have a conversation that when you asked a I provide key takeaways. That's all it said. That's what he came up with. My point is conversationally, is a good way to get out good information, right? Absolutely. That's how people's brains hear storytelling, not you reading a bullet point list of them. So Right. Also, by the way, in this is pretty far off. But that's not all i Sai. What I said was provide key takeaways in English, Spanish and Hindi. Wow. And it did that. So I finally found a way I think people are always asking for this template in Spanish is a big one. And the podcast has become very big in India, there's a ton of dialects so I don't I just picked the one that I think is the most kind of central, sure to imagine these key takeaways in other languages for diabetes, Pro Tip series for bold beginnings for that kind of stuff. Gonna be nice. So Scott, he's on it in 2024 door.

Arden has been getting her diabetes supplies from us med for three years, you can as well, US med.com/juice box or call 888-721-1514. My thanks to us med for sponsoring this episode. And for being longtime sponsors of the Juicebox Podcast. There are links in the show notes and links at juicebox podcast.com. To us Med and all the sponsors. A huge thanks to the contour next gen blood glucose meter for sponsoring this episode of The Juicebox Podcast, learn more and get started today at contour next one.com/juice box. I have one thing to tell you. But I'll do it after the music close.

So I waited until 50. People found this on their own to say it out loud. But I've added a thing if you're listening in Apple podcasts, you can actually subscribe to the podcast pay a fee. Now the whole podcast is free. So don't now you're like, Well, why would I do that? Scott, if it's free. If you pay the fee, which I think is like 599 A month or $59 a year I think that's about it. If you do that you will get currently you will get the bowl beginning series without ads and you will get the diabetes Pro Tip series without ads in it. And so far one episode that has all the curses at it. Now, why did I wait until 50 people signed up on their own to bring this up. I wanted to make sure it would kind of pay for itself. This is not like a money. I'm not gonna make any money on this. Because the editing on like pulling ads out of old episodes and you know making episodes with curses in it. It's gonna cost money in editing. But anyway, now there's 50 People, I'm going to tell you about it because if I can get if I can get 50 more people to do it. I can add a another series without ads. And we can start offering episodes once in a while that have all the curses in them. So if I go crazy in some episode, we're cursing all the time, and we can afford the editing. I know that sounds weird that it would cost money to not edit out a curse but I have to edit the episode for the regular show. And then that basically means it has to be edited twice to leave the it's not important. This is just it's what it is. It's an added expense. Anyway, if I see this pop up, another 50 People 100 People something like that, then I'll be able to turn to the editor and say listen every time you get one with a bunch of curses in it, give me two edits give me the Kersey and the non Kersey in that way the people who are paying for the subscription can hear the cursing. And as that builds up a listenership that will also afford me the ability to take ads out of some of the more popular series and offer them to the subscribers as well. Anyway, there's no pressure to do this. But you can if you want. Besides what I mentioned, you get I think you get each episode like 18 hours earlier than normal. And ad free bull beginnings ad free Pro Tip series and some random cursing here and there. Anyway, do it. Don't do it. Please, it's entirely up to you. But it's a great way to help me pay for more content. So if you're up for it, you'll see it right there in your apple podcasts that if you're looking for community around type one diabetes, check out the Juicebox Podcast pro COVID facebook group Juicebox Podcast type one diabetes, but everybody is welcome type one type two gestational loved ones, it doesn't matter to me. If you're impacted by diabetes and you're looking for support, comfort or community, check out Juicebox Podcast type one diabetes on Facebook. Thank you so much for listening. I'll be back soon with another episode of The Juicebox Podcast. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com