#1162 Grand Rounds: Hodgepodge

March 27, 2024Scott Benner

Scott and Jenny finish up the Grand Rounds series.

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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.

Scott Benner 0:00
Hello friends, welcome to episode 1162 of the Juicebox Podcast.

Today, Jenny and I finish up the Grand Rounds series with something I'm calling hodgepodge because it's kind of all of the questions that were left plus some conversation. If you're a doctor who's listened to this, I hope it helped, please share it with someone else and reach out to me, I'd love to have you on the show. 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. If you're looking for community around type one diabetes, check out the Juicebox Podcast private 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. Don't forget to save 40% off of your entire order at Cozi 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 cosy earth.com and go fill out that survey AT T one D exchange.org/juicebox.

This episode of The Juicebox Podcast is sponsored by the insulin pump that my daughter wears Omni pod. Learn more and get started today with the Omni pod dash or the Omni pod five at my link Omni pod.com/juice box. This episode of The Juicebox Podcast is sponsored by the ever sent CGM and implantable six month sensor is what you get with ever since. But you get so much more exceptional and consistent accuracy over six months, and distinct on body vibe alerts when you're higher low on body vibe alerts. You don't even know what that means. Do you ever since cgm.com/juicebox Go find out. Jenny. This may be our last Grand Rounds episode for a bit you and I

Jennifer Smith, CDE 2:21
oh yeah, I thought we were I thought we were done. So it's kind of a yeah, great buttoning

Scott Benner 2:27
up, we're gonna call it so we know hospital diagnosis, insulin safety foods, CGM BGMs, pumps, humanity, communication management, pregnancy school nurses. And what I have left is just marked on my list as this part will be long. To get means more conversational. And then I'm actually going to do like a wrap up episode that I won't bother you for a while just kind of like go over the the high marks because there won't be any, you know, any conversation back and forth.

Jennifer Smith, CDE 2:57
You're never bothering me. Remember, I

Scott Benner 2:58
know I know don't but we have other things that bother my to do list for Jenny's got other stuff on it, we got to keep moving. Okay. So I have this note here from someone that just says, I wish that they took more of a whole health approach with me, instead of just viewing my diabetes as separate. I wish they understood that everything seems to affect my blood sugar. And the diabetes is more than just my blood sugar being affected. I wish they understood that sometimes you can do everything right, diabetes is still you know, everything doesn't turn out the way you want. Also, I have other health issues, other autoimmune issues, and that also affects my diabetes care. I wish they understood that because it's tiring. I wish they understood that I don't want to come in every three months that's not fun that I hate waiting 45 minutes after my appointment time for them to spend five minutes with me and then not offer anything valuable. Yes, I wish they would run the lab work in the office I wish they would let me have the results without making me make oh my god a second appointment to get the results. And then when I get there, tell me you're so healthy, nothing's wrong. Do you have any questions?

Jennifer Smith, CDE 4:07
That last bit about the labs if I was going to restructure anything in terms of medical like visits regardless of the condition that you're talking about? It would be that if you're coming in for a visit labs will be done ahead of this visit that's on the doctor to order that right I mean the person with diabetes or whatever else needs to be evaluated you know health wise for the person sure they they should have an idea of what is kind of do or what hasn't been looked at in a while but that's really on the doctor to have that order in and then the person knows my appointment is March 1, I need to go in the end of February I need to get the labs done because then the second appointment isn't needed.

Scott Benner 4:54
Discuss that's not right. That's not like a I don't want to say scam but that's not like a billing thing is it trying to Get in there twice? I

Jennifer Smith, CDE 5:01
don't believe so I think it's not proper thinking about what would be most beneficial timewise. And to make the best use of the visit in terms of strategizing, right and talking through what might be some of the things that we do need to address, well look, you know, cholesterol levels, or a one C or vitamin D, they've changed. We've got something that we need to talk about here, right? If you have to come back, and it's really annoying for the person whose life is now interrupted twice, yeah, every

Scott Benner 5:31
three months, right? I'm kind of like baffled by how it's not obvious that a person in the office just takes the schedule every day, I don't know three weeks in advance and call somebody on the phone and says, Hey, Jenny, you're coming in three weeks from now, doctors got the labs here for you. Where would you like me to send off the script? Go ahead and get that blood draw for us? Right, you know, don't come in without that test. Right? It would take not much to do that. And then not much to get people accustomed to it as well.

Jennifer Smith, CDE 6:00
And what do we have today, we have so much automation in systems, that doesn't even have to be a phone call. Yeah, that could be an online, like my chart, or whatever electronic medical health system you're using, that could absolutely be built into that electronic record system that visits here coincide with these type of labs, the note gets sent to the person via email or text or through their online, you know, record portal, they get the notification. And they're the ones that then they have to make the appointment to come in for the labs. But at least it's a notification, it's a reminder to do so.

Scott Benner 6:37
Yeah, around here, labs are easy, you just me basically just walk into like a quest, or LabCorp or something like that. And you hold your script in the hand. And that's that, or my doctor sometimes just sends it electronically, and you show up and you say, Hey, this is my name. There should be orders in here for me. Yeah, that makes sense. But all the rest of it to get to hear what that person is really saying. Understanding that other autoimmune impacts management that blood sugar is not the whole thing. Like those little like, that seemed like little things, if you really listen to the way this person lays this out, this is the entirety of their struggle right here. You know, like, just if you could just understand these concepts, and not I'm guessing fight me on them all the time, all the way, you make my life better, not just this appointment better.

Jennifer Smith, CDE 7:25
I mean, what I honestly hear is the fact that anyone caring for somebody with diabetes, it's a whole picture look, but what it makes me really consider is that they need to, they need to listen to the variables and really, like listen to all the things that in a day could have impact, including many other health conditions, whether it's thyroid, or it could be any other autoimmune conditions that may have an impact on energy levels, or sleep, or other medications that you're taking that may impact the way that your insulin or other medications for diabetes. There are many, many layers right to evaluate. And it isn't just blood sugar,

Scott Benner 8:09
right? Well, you're some more stuff. today's podcast is sponsored by the ever since CGM. Boasting a six month sensor. The Eversense CGM offers you these key advantages distinct on body vibe alerts when higher low, a consistent and exceptional accuracy over a six month period. And you only need two sensors per year. No longer will you have to carry your CGM supplies with you. You won't have to be concerned about your adhesive not lasting, accidentally knocking off a sensor or wasting a sensor when you have to replace your transmitter. That's right. There's no more weekly or bi weekly hassles of sensor changes. Not with the ever sent CGM. It's implantable and it's accurate ever since cgm.com/juicebox. The ever since CGM is the first and only long term CGM ever since sits comfortably right under the skin and your upper arm and it lasts way longer than any other CGM sensor. Never again will you have to worry about your sensor falling off before the end of its life. So if you want an incredibly accurate CGM that can't get knocked off, and won't fall off. You're looking for the ever since CGM ever since cgm.com/juicebox. Today's episode of The Juicebox Podcast is sponsored by Omni pod. And before I tell you about Omni pod, the device I'd like to tell you about Omni pod, the company. I approached on the pod in 2015 and asked them to buy an ad on a podcast that I hadn't even begun to make yet. Because the podcast didn't have any listeners. All I could promise them was that I was going to try to help people living with type one diabetes, and that was enough for Omni pod. They bought their first ad And I use that money to support myself while I was growing the Juicebox Podcast. You might even say that Omni pod is the firm foundation of the Juicebox Podcast. And it's actually the firm foundation of how my daughter manages her type one diabetes every day. Omni pod.com/juicebox whether you want the Omni pod five, or the Omni pod dash, using my link, lets Omni pod know what a good decision they made in 2015 and continue to make to this day. Omni pod is easy to use, easy to fill, easy to wear. And I know that because my daughter has been wearing one every day since she was four years old, and she will be 20 this year. There is not enough time in an ad for me to tell you everything that I know about Omni pod. But please take a look. Omni pod.com/juice box. I think Omni pod could be a good friend to you. Just like it has been to my daughter and my family. This is gonna be a nice hodgepodge episode I like this person just says I wish they would acknowledge that this takes an entire team, not just me to take care of you know, no one should be discharged from a hospital without all their follow up appointments handled with their diabetes education, registered dietitian, probably a mental health professional this person says continually reassessing readiness to learn a patient coming to you with questions about things they have read or heard. Those people are ready for a deeper dive, right? That's why they're coming to you and saying these things. They want to be more empowered, this is your opportunity to do that for them treat this patient as though they are the primary member of this healthcare team. I like that idea. Like we're a team, but you're the leader as the person with diabetes, right? They should have input on their treatment plan. This is what I have found helpful during the 24 years that I've dealt with this for both my son and now myself. That's good advice. Yeah, if you're I don't have anything to say about that. Other than if you're a doctor, and you were treating the person, like you know, a microphone in the room that just is listening to you and they're not really part of it. I think that's the outcome you're gonna get most times is people feeling disconnected and unheard. But what I

Jennifer Smith, CDE 12:11
also hear kind of behind that is in being heard, you have to analyze from the person and say, Are they ready for the next level? Right? You have to know where they are, what they're talking about, where they're asking to get to, because if they're at no starting step number two, and they really want to know, answers that are really like ninja level. Right? You have to say, Okay, I absolutely, we need to get to that. But we're kind of right here, we need to address this. First, we need to move up here. We need to inch forward and so that you really can grasp what you want to know about. Because that's a level of understanding and application of medication adjustment and whatnot. That you're you're not really a yet with what I see happening.

Scott Benner 13:04
I know for sure. Hey, just because this person says just because someone has bad numbers in quotes, doesn't mean they aren't trying their best.

Jennifer Smith, CDE 13:13
I hate that word. I

Scott Benner 13:14
did. I did too. But like this is the obviously this is this person's experience, right? They feel like I'm coming in there with numbers that somebody's judging is not being good. But I am trying. And I'm trying sincerely like she's like, sometimes I screw things up. But sometimes I just don't know what I'm doing. Sure. Sometimes I just get the math wrong. Sometimes the Chick fil A gives us regular Dr. Pepper instead of diet. Sounds like a personal remembering, yes. When I get to my appointment, I am also not going to remember that two months ago, Chick fil A gave me regular Dr. Pepper instead aside, so don't ask me about that, right? Anyway, this never goes away. There's going to be awful days. And you know, you got to do better at it. It does get easier, but you have to as a doctor appreciate the journey that it takes to go from, you know, being diagnosed, not probably given having, you know, gotten great direction, living through it day to day when you don't know what you're doing, eventually, hopefully figuring right out. And then that Diet Dr. Pepper comes for you. And now this doctor goes, Hey, what happened here? What's this? Right, you know, and that feels terrible after being through that whole thing. And I think

Jennifer Smith, CDE 14:30
that might be the that picking apart component. You know, what happened here two months ago. I think it's the clinicians way to try to get into some type of education about what could have been done differently. It's never really asked in the right way. It's always asked in a sense of the person with diabetes feels like they're being like, blamed. Like what did you do here? Right when the person's like God I have no idea what happened there. In that sense. It's more the broad picture of what are we looking at? What trends what sticks out? And can you remember anything about what kind of sticks out that you didn't really want to happen? And if not, then again, it's more, it's more generalized.

Scott Benner 15:18
This next person makes such a an interesting statement. She says, look, a lot of people in the US and probably other places to struggle to pay for their supplies. I'd love a pump. I'd love a CGM. I really would, but I can't afford it. So now, you know, I'm struggling financially, you're coming to me with hereby these things that you can't afford, I can't afford them. That's hard for me, then I get treated like, Well, I'm not interested in my care, right? And then and this is a quote, then you put me on that? Wait, then the docs are gonna get us all killed with their stupid type two style management that they give people on MDI. Oh, no. So that right, right. So that's, that's this person's comment. So obviously, what happened was somebody said, Hey, get this. And she said, I can't afford that. And they were like, Oh, you're not serious about this, then just, you know, hear some level mirin, you know, beyond. And I will

Jennifer Smith, CDE 16:09
also say that that, then that team, that clinical team doesn't know a lot about the products and what is available for people who have less or don't have good insurance coverage or can't afford, because a lot of the different companies have programs to assist. Yeah. So the doctors should know that. That's

Scott Benner 16:35
the problem with everybody being so siloed all the time, though. Yeah. Like, you know, the doctors, like, hey, get a pump you I can't afford it. They're okay. They just move to the next they don't say, oh, did you know that? You know, this company has an Access Program, or, you know, they have everyone, everyone I've ever been involved with, or heard about has access programs. 100%.

Jennifer Smith, CDE 16:53
And I will guarantee that if they are being visited by a rep from any of the companies, they have been told about the Access Program, yeah. 10 years ago, when I was working with an endocrine practice, our reps that came in consistently gave us information about the access programs and the discounts, and the the, you know, the little discount cards or codes or whatever was available.

Scott Benner 17:18
And some of them are significant, by the way. Yeah, like, I've seen like $500 items reduced to 20 bucks with a coupon, like, you know, so, again, but it's almost only half of the problem. The first part is you should have helped her find out how to do this. And correct when you couldn't figure it out or didn't want to figure it out? Why do you relegate her to like second class status as far as her management goes, and if I'm going to add on one for me, you could have still taught her how to take care of herself with MDI, because plenty of people do it well, but they also know how to use insulin. So then you have to educate like, it's a, you know, it's an if this, then that series, oh, by the way, going back to another thought here. It doesn't mean they would have gotten good direction, even if she could have afforded a pump because this person says I work in an ICU. And my kid has type one diabetes. So I'm aware of this enough that I was paying attention on the day that a person came in in DKA. In their early 20s. The endo had put them on an Omnipod five saw an algorithm based pump. Okay, but they were using libre because Dexcom wasn't covered. So they couldn't do the algorithm. But the person signed up for the whole thing because they wanted the automation.

Jennifer Smith, CDE 18:29
By God. Did they think that they were getting automated delivery because they had a system and a CGM. And he told them,

Scott Benner 18:39
yeah, you got it. There you go, Oh, my God. It's running around and automated the kids running around and automated and the pumps not talking. And it's not giving any, which is how he ended up in TK. So anyway, scrolling on. I wish they would have told me, I wish they would have known that I would have been willing to go much farther. This is a motivated person. I'm an adult who doesn't mind injections, I would have diluted insulin if I needed to. I would have used vials and syringes, I would have been willing to finger Poke 20 times a day. I just didn't know about any of that. Until I found this podcast. I thought that half unit pens with four needles and six test strips. was all I needed to stay healthy. Wow, how about that?

Jennifer Smith, CDE 19:23
Yeah, that's actually what I was gonna say. I mean, even for somebody who, let's say they really can't afford a CGM, even with all of this stuff. Test strips can be written as a script for plenty a day. Even the generic ones which are good enough to give you enough information to go by through the course of the day. With MDI, you can absolutely make it work. Yeah, no, have somebody guide you through that.

Scott Benner 19:49
But that person statement is more about saying that vial syringes and a couple of test trips a day was all I needed, that means that they were told, shoot this to inject this at a meal, check every once in a while, which by the way, doctors have the funniest way of having you check your blood sugar in this scenario when it's going to be the best, of course. So that yeah, that's always fascinate like, look, you're good. But, you know, maybe you wouldn't think to test yourself two hours prior to see that you're 300 After the meal, and then it came back down again. Right? Right. It's really sad that this person goes on to say, I'm just compelled to send this in, because I didn't realize that I was being set up with bare minimum to survive. Like, I actually thought I was out there just killing it. You don't I mean, that's sad. And

Jennifer Smith, CDE 20:35
in this day, and age, bare minimum, that person's bare minimum was what it was eons ago, when that was the standard, there was nothing different to be able to do. So the fact that people are being told this bare minimum at this point, with the technology and the programs that are available to be able to get and use things appropriately. That's really sad. Yeah.

Scott Benner 21:00
Let's see, I wish my doctor knew that you can have you know, quote unquote, non diabetic a one sees without being consistently low. Every time I have a one C under six, this doctor scours my clarity report looking for lows. And even if I have less than 1% lows, I get a warning about how dangerously I'm acting with a six. I don't even know what to say. I mean, you know, I'm gonna get upset, Jenny, I'm trying not to it's Friday. But if you are a doctor, and you find yourself going, Oh, I've done that. You really need to learn more so that you don't say stupid things to people, this person is having massive amounts of success. And you're yelling at him about it. You know what I mean? That's crazy. Yeah.

Jennifer Smith, CDE 21:43
And the opposite of that. The other really sad thing is that, I wouldn't say endocrinology, but definitely more of the just general medicine, unfortunately, wouldn't even look at a problem with a blood sugar or within a onesie of sick, right?

Scott Benner 21:58
They wouldn't say, hey, maybe five is available to you right now. They just Yeah. Or maybe

Jennifer Smith, CDE 22:02
that's not in the range of somebody who doesn't have something going on with their blood sugar. It is being mismanaged. If you're a one C is six, and you don't have a diagnosis of diabetes. Oh,

Scott Benner 22:13
I see what you're saying. Yeah. Oh, you're thinking people? Oh, I see what you're saying. A regular GP. It's just gonna be like a six. That's fine. That's just Jesus coming for you one day, but it's not a problem today. Don't worry about it. You know, that attitude? I mean, it was like, Oh, yeah. Oh, watch it. We'll watch it. I had somebody the other day. Tell me a doctor told him they were watching. Oh, no, we're watching. We're watching for me to fall over. I had a woman tell me the other day about her thyroid. And she said, I hated my doctor. Tell me we're gonna we're gonna put a watch on this five TSH, I was like a watch. I said, What are your symptoms? My hair's falling out. I'm tired. I can't get rested. My fingernails are breaking. I've lost my sex drive. I like she like rattled off. 10 things. She told the doctor and a doctor goes, We're gonna keep an eye on that. I kept an eye on it already helped me. Right, right. Same thing with a diabetes like a six a one. See how you're alright, that's not too bad. Yeah, this lady says that would really really nice if we stopped acting like talking about the digestion of fat and protein for people using insulin was an advanced topic. Oh, yeah, I have been brushed off and treated as if I was an idiot for suggesting that fat and or protein could be impacting high blood sugars. That's off course. And we'll just say it again. If you're listening, and you think though, that doesn't impact it, you're wrong. So learn more,

Jennifer Smith, CDE 23:34
because it's all about carbohydrate. Yeah, I mean, in there, it is all about carbohydrate. So why would we need to talk about fat and protein? my soapbox to get on is that nobody is guided in how much they need. In terms of portion. Just count your carbs and take your insulin and the other stuff, just eat it? Well, so I can eat a cow. It

Scott Benner 23:57
doesn't affect my blush. Like if you're a physician and you've got somebody in front of you who's type one who wasn't before. It might be you know, instead of just complaining about it on social media or at dinner or whatever, bitching about it in your to yourself when you're driving home in your car that people don't eat? Well, why don't you say hey, listen, this is a great time to go over this. Before type one diabetes, you were killing yourself very, very slowly. You wouldn't have even noticed it happened in probably and then one day you would have been like, Oh, what's that feeling? Then you would have been gone. But now you have type one. So we're going to pay really close attention to what you're eating. This is the part where I tell you that that is six portions not one portion, you know like that. Yeah, like that. You don't need 6000 calories a day. You know, like you know that all this other stuff and you're we're gonna see it now and you're in your in your blood sugar right away like you didn't know before, because you didn't have type one, but now we're looking, what a great opportunity for you to make some adjustments here right and be healthier beyond diabetes. Right? You know, but if I said that to a doctor, and I know that because I've done it that you like, they're gonna say to me people don't listen. Which is like saying, I don't know what it's like it's saying it's like saying that you're a half a mile from a cliff that no one can see. And you know, it's there. And you see people walking and falling off the cliff. But you don't bother telling anybody Hey, slow down. There's a cliff coming cuz some people don't listen to you,

Jennifer Smith, CDE 25:22
or turn the other way. Don't go that way. Let's

Speaker 1 25:27
make an adjustment now. But But the bigger point is that like, well, it's not worth me opening my mouth, because they might not listen to me. First of all, what else are you doing? Isn't that your whole goddamn job? Right? Everyone's not gonna listen. It doesn't mean it's not incumbent upon you to say it. Also, it's will seem disconnected. But parenting, same thing. You don't just get to say it once. And it happens. Oh, no, it's your goddamn lifelong job to stand there and go. Oh, my God. Okay. Put that away. This trash has got to go out. You can't leave that on the floor. Please don't hit your sister. Right? Like, like, you don't just get to say that one time, and it's over. Like, and if you think that, then I don't know what you expected when you became a doctor. You don't I mean, right. Yeah, right.

Jennifer Smith, CDE 26:09
It's much like it. That's a very good connection. It's like being a parent who constantly has to tell your child, the underwear go in the thing right here that on the floor in front of it, it goes in the basket, right? Or we don't leave toothpaste, spit in the sink. We rinse it down right away.

Scott Benner 26:30
We're not going to look at an eight a one C and go, Hey, that's not so bad. Yeah, yeah, it's not so bad if you're on your way to better, but if that's where you're gonna live for the rest of your life, it's going to catch up to you pretty quickly, it just right. There's a lot of repeat, and nobody talks about it that way. And I even listen, I'll go out on a limb here. And I'll even say I understand that socially for the last couple of years. Maybe we've drifted away from being honest with people all the time. Is that a fair way to say that, like, I have been protecting people's feelings a little bit, Jenny is making a face because I know there's a private conversation we had recently that we can't talk about on here. But no, it's still your job. Like you're not supposed to hurt people's feelings. You're not supposed to treat them poorly. But they deserve good information. And they deserve tools. And they deserve direction, like and if you have to repeat it over and over again. You don't just get to say, oh, here comes Scott. He don't listen, I'm not gonna say it again. I'm still paying you. Right? You're my insurance company's pocket do your job. You don't I mean, if I don't listen to you, it's on me. But come on. I don't know. It's very upsetting all this. There's no way any doctors are left listening to this, Jenny.

Jennifer Smith, CDE 27:39
I really hope that they're, I mean, you know, if I was a clinician, I guess I just I mean, I know my personality. I am very much if you've got something, and I don't know much about it. And I could do better than I would rather sit here and be like, out I was really wrong. Like man, like, you know, I can do better. I can clean this up. I can turn this around, I can do better for whatever the job is that I have. I can do better. Right? But that's an that's the attitude. I think anybody who's in healthcare should really have what are you in this for? Are you in this to improve people's lives,

Scott Benner 28:15
I did a recording this morning with a anesthesiologist, who has been diagnosed with type one later in life. She's had it now for about five years, she came down to talk about what an anesthesiologist should know. And I'm actually going to make it part of this series, which I was terrific, right. And she's lovely. And we had a great conversation. But at one point, she said this thing that I hear people say all the time, she you know, she goes well, you know, there's a lot of burnout in health care. And I'm like, yeah, there's a lot of burnout in factory work, too. But you don't get to like not run the crane and pick up the piece of steel and put it where it goes. Because you're just sick of it. You don't you mean like I actually said to her, these are my words, Jenny. I said, if if people work for me, you motherfuckers would be upset because I'd fire y'all. Like Like, I don't I don't want to hear i I'm burned out what? You make over six figures. go on vacation. Like Like, I don't know, take a walk smoke weed, leave me out of it. Do your job anymore.

Jennifer Smith, CDE 29:12
Make changes in your organization. If you're burned out, that means that something in the organizational structure of your day to day

Scott Benner 29:20
schedule, how you're beating you up? Yeah, correct. Yeah,

Jennifer Smith, CDE 29:23
beating you up so much that you're feeling burned out. And absolutely, that needs to be taken care of. But it doesn't mean that the people then that you're taking care of in your practice. Yeah.

Scott Benner 29:33
Do you know that during that recording, I turned to a browser window, I opened up chat GTP don't laugh for a minute, okay. And I said, please tell me what an anesthesiologist should know about how insulin pumps work and what how they should manage them during surgery, and it spit out something that I read back to her and she goes That's all accurate. So, my point to her was, if people keep making the same mistakes over and over again, we just need one person to write down the rules, maybe start an email chain, right? Like every day, you guys get an email to remind you about people with type one diabetes and pumps. And this is it or people who come in with, I don't know, like, you know, hypertension, like, here's the thing to remember. And she said, some people don't read their emails, I'm like, what what point is there going to be like, what are we going to hold people to account to do their job? You don't I mean, and I get there's human failings, which I don't even mean in a pejorative way. Like I understand there are limitations of people. But as an organization, I get if Jenny's tired on a Thursday, or if I'm in a bad mood last week, or something like that, but just the whole organization take a dive, like, like, how does that happen? And it just seems like, I mean, I hate to say this, it just seems like laziness to me. I mean, am I being harsh? look good? You know, just, I think what I said to her was, she's like, well, people have to come in and advocate for themselves, which I don't know how doctors don't hear. That should be insulting to them like that. I'm so bad at my job, someone has to come in and remind me of what it is when I get there that I'm supposed to be doing. Yeah. But I said, like, I don't go get four new tires and remind the guy when I dropped off my keys to put the lug nuts back on, I just assumed that's going to happen. Like, do you mean, like, do I have to assume a doctor's not gonna follow through? Or do the thing like, come on? Doesn't make any sense to me at all? So yeah,

Jennifer Smith, CDE 31:27
I mean, I think in general ordering and those kinds of things. I think a lot of it is so already organized within a lot of the electronic medical kind of charting and whatnot, that things get checked off pretty easily, and may not be something that gets revisited then. Right?

Scott Benner 31:48
Yeah. Actually, thinking about that electronic aspect of it. This was something I brought up to, I didn't quite say it this way, then. But I, I'm thinking to say it now, if you're a doctor, and you have some dreams of your kid, being a doctor, the way you're doing your job, right now, you're making the profession, it's not going to work the same way, they're going to put, they are going to put a chat bot in charge of the medicine, and you're going to be a technician making the same dollar everybody else is making. So if you like your $300,000 a year, and you want your kid to have it to maybe do a job that makes us all think this is a profession that should keep going in this direction, because right now it feels like you're being overpaid, to give me an eight, a one C and have me out of here in my mid 50s. Like that's how it feels, if I have diabetes, right?

Jennifer Smith, CDE 32:29
Well, and with the way that things are going, you know, with AI, quite honestly, there are going to be algorithms that now take some of that job out, right. At some point, there will be algorithms that evaluate glucose trends that evaluate insulin pump data, and give some feedback. And then at that point, like you really do become kind of just a prescriber. Yeah,

Scott Benner 32:56
you're a technician, right? You're not You're not a doctor anymore. You're the person that understands all the words enough to like, point me in the towards the right room where I gotta pay and stuff like somebody

Jennifer Smith, CDE 33:05
with diabetes myself, I would rather have a very personal conversation with a person and get their feedback. Sure, it would be lovely, if a computer could just spit out, Hey, I see these problems, fix this, change this do this. That would be nice. But for some of those variables and things that you just can't teach personality, right? To a computer, it's

Scott Benner 33:31
starting to seem like you can't teach personality to a lot of physicians either. So but I sorry, I know being smart is tough, probably all little like, you know, awkward and everything, but it's but but listen, I'm pretty smart. And I've got a personality, like, just try harder. I'm not saying I think computers should just become doctors. I'm saying that I think we're gonna get forced in that direction. Right? Because the physicians aren't giving enough pushback. Otherwise you're not it's they feel like union people who are like add spine. We don't want to be in a union anymore, like you want to hold on to your union, or do you want it to go a different way? And I think you're right, though, I think that moving it to a computer knowing the actual answer, but you still needed to come through a person. It's another Kenny that's another example of maybe we maybe that doesn't need to be a doctor, maybe it needs to be an actual person who is good at connecting with human beings and understands the medicine just enough to be a bridge for that. There's a guy on here one time, his name Sam fold. And Sam is the general manager of the Philadelphia Phillies. Wow. But he also played baseball for like nine years professionally. But he also went to what like pretty much almost an Ivy League school for economics. So he was a very interesting and different blend of intelligent and baseball player. And the reason he's the general manager the Phillies now is because the first job they gave him was to be a bridge between the analytics and the guy holding the bat. Sure, and now I'm not wondering if this isn't the same Same way, this is gonna go one day, like we knew you don't I mean, we need a, we need a person down the middle who understands both sides, they don't need to be a nine year trained physician to agree that chat gfpt got this one, right or whatever that's gonna happen in the future. And as crazy as that sounds to people, and Jenny knows that I'm doing this, but it's a very slow process, and it's in the background. But my last, the last thing I want to do with this podcast is leave behind a chatbot that has taught itself off of the entirety of the 1000s of hours of the podcast. And I'm already having these amazing experiences where I'm just teaching it like the Pro Tip series. And by teaching I mean, you're just feeding it into it, you're hard pressed to ask it a diabetes question, it doesn't have a good answer to just from learning from listening to all of our conversations, you, me and all the other people who come on here, it's really, really fascinating, like, so I think I can leave something like that behind. If I can do that. I'm assuming a hospital can figure it out. Of course. Yeah. So this is my last thought. I'm going to put it in this episode. And let's talk it through for a couple of minutes. And then we'll be on our merry way. And thank everybody for listening to the Grand Rounds, episodes, etc. While you and I were recording this, I jotted down in my notes, follow one patient a month to learn Oh, and we didn't really go over it. But I found myself thinking that every doctor should just find one patient that has a glucose monitor and is interested in helping and say to them, Hey, can I follow your CGM for a month? Could we text once in a while, I might text you and say, Hey, tell me what just happened. Now, when your blood sugar did this? Or did you just eat it feels like you just ate and or, you know, I saw you ate but you didn't get high. What happened here just a month, I swear to God, one month, I know nobody's gonna do this. For me, he's gonna tell me it's a HIPAA violation or some crap, I don't care. I'm telling you, if you followed one person a month, and you did it for a year, you would learn a lot, you could be on this podcast next year putting me to shame talking about diabetes. So and anybody you would learn so much in just just that one idea, and it's so doable. It's free. And it would take a limited amount of effort on the doctors part part and on a patient's part. And you all know one patient who's cool that you could approach about this, you know what I mean? And it

Jennifer Smith, CDE 37:21
also teaches you an awful lot about the actual product,

Scott Benner 37:24
right? Yeah, you might learn how it works, you

Jennifer Smith, CDE 37:27
might actually learn some of the ins and outs of that particular CGM, or some of the ins and outs of that particular pump and what you thought it would do. And then when you actually see it performing in the here, and now real time, you can say, Well, God, that recommendation I've been giving

Scott Benner 37:47
what the hell I'm talking about, I saw my daughter's graph today. Just her graph. I looked at it, I thought, Oh, she ran out of insulin. And it's her day off. It's her sleeping day, right? Because this is their one day off a week from school. And I was like, there's no doubt in my mind. She is asleep. And she ran out of insulin. I knew in 15 minutes by looking at a graph. I called her up, I woke her up was like, Hey, is your pump empty? And she goes, Oh, thank you. And she was just like that. I knew that from looking at a graph. And you'd be amazed at what you'd learn. If you just follow along for a month, right? And then let them go and then go pick somebody else. Now we'll do it with a kid or talk to their mom, like, you know what I mean? Like, I swear to God in a year, you would, you'd be a genius at this. And it wouldn't cost you anything, you wouldn't have to go to a meeting on a Saturday, like all the stuff that I hear, you know, and you maybe you wouldn't feel so burned out, Jenny, if you were actually helping people and not walking around all the time feeling like, Oh, nobody listens to me. And this sucks. And why am I bothering? So? I don't know. All sounds like common sense to me. But they'll say,

Jennifer Smith, CDE 38:53
Oh, that's a common sense. You bring up something that many people are not unique.

Scott Benner 39:00
Story. When you think of this series, we have a couple of minutes before you have to go. Did you enjoy making this? Do you think it of course, do you think it hit the mark? Or do you think that doctors would listen that and be like, Don't bash me because they call it doctor bashing if you're critical of them?

Jennifer Smith, CDE 39:13
Well, you know, and I think if you have an open mind that you would start listening to this to begin with, or you feel like you are missing something. I would expect that you're going to gain something out of this, even if it's just one episode that really hit and you're like, oh, yeah, that makes sense. Yeah. And depending on what type of physician you are, you know, emergency department or, you know, a specific, you know, specialty like endocrine or whatever it might be. I would have again my personality. Yeah, I would have been very, very excited to be able to hear something that I could have gotten something out of even even if it made me feel like ah, I'm clearly not hitting the mark here. I can do better than this. Right? Yeah,

Scott Benner 39:56
I hope so. I really do. I hope also that they heard that Really, if you have a type two using insulin, it's enough of the same game that you could use some a lot of the same concepts to help those people because I, you know, you are going to hear some people say, well, type ones are such a small portion of the of the population, I can't put that much effort into learning for this many people, but a lot of what you're gonna know and help a type one with, you could help us type two with as well. And that's it. You know, if mass appeal is your is your game, then? You know, there you go. Absolutely. Yeah, I mean, until they start putting GLP into the water, I guess which will be.

Jennifer Smith, CDE 40:33
Personally, I really hope that I have to filter all my while. I'm

Scott Benner 40:37
not advocating for that I am what I, what I actually think is it's funny, I'm in between on that idea. I'm seeing GLP has helped people with type one and type two diabetes all over the place. And I am for whatever makes you healthier. But at the same time, I think we're going to eventually do the thing where we skip over the value in this thing, and then just start mass, giving it out to everybody to try to avoid the problem to begin with. Which is I mean, maybe is a reasonable answer, but I don't know. It's it's so far in the future. It just it always scares me that when something's easy, we stopped thinking about it. You know what I mean? So, anyway,

Jennifer Smith, CDE 41:13
no, I think the series was, I think it was needed. And for whoever grabs it and really listens to it and can step back from an ego and say, I can get something from this. I don't agree with this. But I do agree with that. Or I can you know, take something away from this. I think it was important.

Scott Benner 41:30
I do too. I my bigger hope. And my bigger my my more reasonable expectation is that we're hitting people who are younger and just in med school or thinking about going to med school and maybe you're gonna this is going to be a thing that helps the next generation of people maybe more than this, but I hope not. I hope everybody got something from it. Anyway, I always enjoy working with you and doing these things. So I can't thank you enough for helping me. Of course, you know, I

Jennifer Smith, CDE 41:55
always enjoy it as well. Thank you

Scott Benner 42:02
a huge thanks to Omnipod not just my longest sponsor, but my first one Omni pod.com/juice box if you love the podcast, and you love tubeless insulin pumps, this link is for you. Omni pod.com/juice box. I want to thank the ever since CGM for sponsoring this episode of The Juicebox Podcast. Learn more about its implantable sensor, smart transmitter and terrific mobile application at ever since cgm.com/juicebox. Get the only implantable sensor for long term wear get ever since.

If you're ready to level up your diabetes care, the diabetes Pro Tip series from the Juicebox Podcast focuses on simple strategies for living well with type one. The pro tip episodes contain easy to understand concepts that will increase your knowledge of how insulin works and so much more. My daughter has had an A one C between five two and six for since 2014 with zero diet restrictions, and some of those years include her in college. This information works for children, adults, and for the newly diagnosed and for those who have been struggling for years. Go to juicebox podcast.com and click on diabetes pro tip in the menu or head over to Episode 1000 of the Juicebox Podcast to get started today. With the episode newly diagnosed we're starting over and then continue right on to Episode 1025. That's the entire Pro Tip Series, Episode 1002 1025. If you or a loved one was just diagnosed with type one diabetes, and you're looking for some fresh perspective, the bold beginning series from the Juicebox Podcast is a terrific place to start. That series is with myself and Jenny Smith. Jenny is a CDC es a registered dietitian and a type one for over 35 years. And in the bowl beginning series Jenny and I are going to answer the questions that most people have after a type one diabetes diagnosis. The series begins at episode 698. In your podcast player, where you can go to juicebox podcast.com and click on bold beginnings in the menu. 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