Tuesday, August 16, 2011

Gestational Diabetes

(Note: I'm posting this story because someone requested it in the comments of my last post. I apologize if it gets long.)

I failed my gestational diabetes screen by two points.

For those of you not familiar with the screen, it’s a test during pregnancy where you drink this horrible, sugar drink and then come in an hour later to get your blood glucose tested. Considering I was seven months pregnant, not showing, and weighed only 116 pounds, I didn’t think there was any chance of my failing the test. I was so overconfident that I had some crackers right before I had the drink, to make it go down easier. (This was allowed, but probably stupid and likely pushed me over the cutoff.)

The cutoff my practice used was 135 and I had a blood sugar of 137. In some practices, a cutoff of 140 is used. And when I looked this up in research studies, in a woman of my age, race, and BMI, it is appropriate to use a cutoff of 140. Or actually, some say the screen isn’t even necessary in the first place in someone like me.

Now if you fail the screen, the next step is a three hour glucose tolerance test. You come in for a fingerstick and if that’s normal, they give you a huge amount of sugar, do a venous draw for blood glucose, then repeat that every hour for three hours. I did not want to do this test.

You are probably thinking to yourself, “Why is she being such a baby? It’s just four blood draws.” That’s exactly what I’d be thinking if someone told me that story, believe me. I’ve had like a billion blood draws in my life and I’ve always thought of it as no big deal… needles don’t bother me.

Except for some unknown reason, my ob/gyn practice gave the most painful blood draws known to man. Now I can deal with short-term pain, no problem, but on two separate occasions of having my blood drawn at this practice, my arm was basically incapacitated. The pain in my biceps was so bad that I was actually awakened during the night due to pain. I could barely move my arm to drive and I had bruises going all the way up to my deltoids. And the pain persisted for over a week. Both times! Their phlebotomist was obviously not the greatest.

So I wasn’t thrilled by the idea of having four of these blood draws in a row at that practice. (The only other place they’d do them was at a hospital a million miles from my office.) My job involves a lot of writing and I was terrified by the idea of my arm being taken out of commission. I was literally in tears at the thought of being unable to function or sleep due to these blood draws--blood draws that I felt were basically unwarranted given the fact that it was so unlikely that I had GD. If I felt the baby were in danger, I’d have done anything, but it seemed more like this test was being done so they could cover their ass.

Anyway, I did try to keep a somewhat open mind. I felt if they had a convincing argument, I’d do the test. I went to my appointment for the 3 hour test at 8:30AM. I did the fasting fingerstick, which was 90. I asked if it would be possible to briefly speak to any OB at the practice about the test before doing it. Immediately the phlebotomy tech looked really put out, and acted like this was a ridiculous request that would take hours to fulfill.

About five minutes later, they miraculously located an OB that was between patients and she came over to talk to me. Except before I even opened my mouth, the doctor’s arms were crossed and she looked really angry at me for taking up 2 minutes of her precious time.

I explained that I was a doctor, that I researched the test myself and that I knew I was extremely low risk. I explained that research showed that with someone my age, race, and weight, testing wasn't indicated at all, or at the very least, a cut-off of 140 was warranted.

Doctor: [snippily] "OUR cut-off is 135."

I then tried to explain to her about how painful the blood draw had been at that office. They clearly went through the vein both times due to the pattern of bruising. I had been awake all night in pain. And then continued to have pain for a week after both times.

Doctor: [snippily] "That's impossible."

So I guess I was lying?

At this point, all I wanted to do was run home crying. Finally, I said I would do the test in fingersticks on my left hand.

Doctor: [snippily] "Fine, so I'm documenting your refusal to do venous draws!"

The phlebotomist was kind of cold to me after that too, possibly since she was the one who gave me the two painful draws. She started ranting about how she didn't know how to document my results. I felt like I had to apologize with every single hourly fingerstick.

I don’t know exactly what the doctor could have done differently. I would have preferred if she gave me an actual explanation of why it was so important for me to have the test, aside from just reiterating the cutoff. Or if she did agree with me the test was unnecessary, she could have nicely explained to me that she had to document a refusal, but admitted that I was very unlikely to get a positive result.

Anyway, three of the four fingersticks weren't even close to the cut-off. The fourth was below the cut-off, but only slightly. I was terrified the entire night that the mean doctor would call me and try to bully me into repeating the test and threaten to kick me out of the practice.

What did end up happening was that I had to call the next day (originally, they promised they’d call me, but apparently they wrote me off) and they got a different OB to speak to me. It wasn't my usual doctor, but it was one I had seen before and liked. He told me that the test was definitively negative. He didn't know what to make of the one borderline number, but said their glucometer tends to run high, and one abnormal value wasn't enough to diagnose GD anyway. He said to me, “I kind of remember from seeing you and from looking at your weight here… you’re pretty tiny, aren’t you? I really don’t think you could have diabetes. That test was probably overkill. Just, you know, eat healthy.”

(I then proceeded to not gain any weight for the next month because I was so nervous about eating carbs, and meat made me ill.)

Even though I guess it worked out in the end, the whole thing left me with a negative feeling about the practice. I felt uncomfortable coming to my visits and I imagined everyone was angry at me. Moreover, guess which OB in the practice was on call the night I went into labor?

So now that it’s all over and I’ve given birth to an average sized baby, you can go ahead and feel free to judge me and tell me that I sacrificed my baby’s health for the sake of avoiding discomfort.

19 comments:

  1. Well,medicine being an art rather than a science when all is said and done, a practitioner should be willing and able to answer questions about cutoffs and procedure...and do it cheerfully and fully. And in my opinion, prior to the test.

    MOST patients that I know google the conditions that they are being tested for and know a little something - which should be a good sign; not an instance of questioning authority, but of trying to be an informed and compliant patient.

    And the bad needle sticks? Just plain inexcusable if it happens on a regular basis...the one time that I had a bad stick was at a blood donation when the tech said (very unprofessionally, but I appreciated it!) "CRAP. I went through your vein. You're going to bruise up and be really sore for awhile! I'm really sorry."

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  2. I think this particular doctor just didn't have a great bedside manner. My husband met her later and thought she was very "abrupt."

    The needle stick thing was crazy though. I've never had such a painful blood draw and so much bruising. I would have said it was a fluke if it happened once, but then when it happened again, I felt like the tech was just terrible.

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  3. I don't see how it is "impossible" for a blood stick to hurt that bad. I have had a few rather painful ones in my time so I know it can happen (they are not giving phlebotimists a lot of training these days but that is a rant for another time). Obviously that OB had issues and maybe needs to take classes on how to improve her bedside manners.

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  4. From the point of view of a non-medic who had gestational diabetes, and a long standing needlephobia and veins which "disappear", they showed very poor practise indeed. Not accepting people's fears or bad experiences and finding ways of overcoming them (including explanation as to the choices and options and why different cutoffs are used, different methods of the same procedure, different people doing it, different locations) means people are less likely to access care which could make a huge difference to health.
    I come from a country where care is free at point of use, and I'd have been giving strong feedback (complaining) if treated that way.
    (In my case, they booked the senior phlebotomist and said they'd have one "go" at my second best vein and if they didn't get a good shot, they'd get an anaesthetist to put a line in instead. Oh, and they were quite happy with me singing campfire songs loudly to distract myself.)

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  5. I know... when I showed people my arm, a few of them told me about similar or even worse experiences.

    I don't think classes are enough to improve anyone's bedside manner.

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  6. From reading your previous Pap post and this one, I think you should consider finding a different Ob (if you still see the same one...). It's not fair to you, and you have rights as a patient! That Ob is the kind of doctor that gives us all a bad reputation. Geez.

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  7. Dr. G: My current OB is actually a very nice lady and I like her a lot, so I wouldn't switch on the basis of not liking one doctor in the practice. Plus I hope not to need to see an OB/GYN again anytime soon and get most of my care through my PCP.

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  8. This is the kind of treatment you were subjected to, and you are a physician. Imagine if you were not?

    This kind of treatment is one of the reasons women choose midwives.

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  9. Anon: I can certainly now understand why women choose midwives. I was so disgusted by this experience. Plus I had to wait close to an hour for my two minute OB checks, which always felt very rushed. I selected my OB because out of all the doctors I saw during my OB checks, she was the only one who actually took time to explain things to me during our visits.

    If I had a midwife, I might not have had to wait an hour to push while fully dilated because the doctor was stuck in a surgery.

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  10. Fizzy, your experience sounds awful, on top of being pregnant and not just a regular patient. Sometimes things are just harder for us, pregnant people (I know you're not right now, but I am). I think I would cry if I was in your shoes. All of my tests so far have been borderline (but luckily a few points under), I am also on the skinny side, and my OB has been gracious most of the time in giving me "the benefit of the doubt." Just like that other OB doctor was who called you back about your results.

    That said, I also agree with you that one negative experience with a physician shouldn't necessitate going to a different practice or choosing a midwife. I think there are plenty great OB female and male doctors (and midwives), we just have to find them! :)

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  11. With both of my pregnancies, I failed my one hour screens. I am also on the petite side (5 feet tall). I'm not sure it is fair to have me drink the same amount of glucose has a much larger person - I don't eat as much as they do (I hope). Anyway, total sympathy about the 3 hour test, having done it twice -- it sucks.

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  12. I agree with other commenters: based on the last two posts, you should think about a new OB practice if you ever get pregnant again! Still, I hate to generalize, but I've met far more "toxic" docs in OB/GYN than in other specialties. I always find it odd. The majority of OB/GYNs with whom I have interacted (as a med student and through 3 full-term pregnancies) have been women, who are supposed to have better communication skills, higher pt satisfaction, etc. And they work in a field where most pts are healthy and, in the case of OB, happy to be in the office/hospital because they are pregnant or delivering. Why are they so bitter as a group? It mystifies me. Maybe some of the very pleasant OB/GYNs amongst our MiM writers can shed some light on the specialty. In truth, I loved OB/GYN--the mix of medicine and surgery, the healthy, happy pts, the continuity of care, the intensity of being a part of childbirth--and might have considered it seriously as a specialty, but was so put off by the toxicity of the residents and faculty I worked with, especially (unfortunately) the women, that I quickly ruled it out.

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  13. K: Exactly... I thought I deserved the benefit of the doubt. I'd barely gained any weight in my pregnancy and I was thin to begin with. Considering I just barely failed the test (likely due to those damn crackers), it seems like it wasn't worth yelling at me over.

    Tempeh: This was actually the first unpleasant experience I've ever had as a patient seeing a female ob/gyn. And I've seen many... and till now, they've all been lovely. I've seen a couple of male ob/gyns who were really toxic, but this was the first female. But as a *med student* my experience was totally different. This OB reminded me of the women I worked with during my med school clerkship. And yeah, that does seem to be a common experience.

    Anyway, I'm not planning any more kids, so it's not really worth switching. I'm going to see my PCP for my annuals.

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  14. First of all, let me say that the way you were treated was *not* appropriate or nice in any way, and I certainly don't support the way in which your practice physician snipped with you (maybe she was on call and 10 patients behind, maybe she was told you were refusing a test, who knows? Still, not good). However, gestational diabetes is not merely a matter of weight gain or how small you are in pregnancy. All women, to some small degree, are somewhat insulin resistant in pregnancy. Sometimes this crosses over into diabetes in pregnancy, no matter if you are 100 or 400 lbs (of course, the more risk factors, the higher possibility of developing diabetes). If you fail the test, you *should* have further screening, but one off number does not diabetes make. There is actually some good research supporting moving from a 1 hour/3 hour glucola to a 2 hour standard glucola for all. An alternative in our practice to the glucola is 2 weeks of fasting and post-prandial blood glucose monitoring to monitor trends. I happen to be the "diabetes nazi" in our practice, and was trained with a cut-off for a one hour of 130 (gasp!) More patients rule into the 3 hour test group, but when I was in my prior practice I had a heck of a lot less fetal macrosomia than in my current group, which uses the 140 cut-off. Anecdata, FWIW. You shouldn't have to be fasting for the 1 hour glucola, crackers or not, should not have made a significant difference. Big slice of chocolate cake? Maybe. :)

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  15. I completely agree with Tempeh. My best friend is an OB and I know a lot of the OB residents at the hospital I delivered at. Almost all are women, and they are the some of the bitchiest and condescending people I've ever met. It actually made me feel like I just had to check my heart/emotions at the door when I was having my baby because they were so cold, weird, and just bitchy about everything. Definitely not a "miracle of life" group and that was really frustrating and disappointing to me. Oh, and the way they talk about work/patients outside of work is truly, truly awful. God forbid if you have any complaints, are overweight, hairy, or remotely different in any way if you're delivered by one of them.

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  16. Dr. Whoo: If someone had said the right things to me, I likely could have been talked into the test. I'm fairly easily influenced.

    However! :), I still think that the test was unwarranted. I had a BMI of 19 pre-pregnancy and only gained net 15 pounds through the entire 40 weeks. Nobody could tell I was even pregnant till 7-8 months. Can you honestly tell me even anecdotally that you've seen a woman like that deliver a macrosomic baby?

    (And I DO think the crackers could have made at least a 2 point difference. An hour after the 100g glucose load, my fingerstick was only 120 :)

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  17. I've been thinking about this post all day. While I sympathize with you, I think you might have chosen the wrong time to bring up your concerns...the day of the test. It wasn't an emergency and you could've followed a gestational diabetes diet until you discussed it with your doctor. One week wouldn't have impacted your baby's size ans since you felt so strongly about being a false positive in the first place, you could have waited. I've been there and I convinced my OB to do the 3 hour test without "wasting my time" on the 1 hour test because I have a stong family history of gestational diabetes and type 2 DM. Lucky me, the 3 hour one was negative but "barely."

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  18. Gestational Diabetes is also one of my passions because it is true preventative medicine. Treating it effectively can reduce the risk of c-section, pre eclampsia and shoulder dystocia. I also have had many 'skinny' patients with gestational DM. I agree that you were not treated very nicely, but also as anonymously mentioned before me, that was probably not the best timing to discuss the matter either.

    Say you were in the middle of rounds and the nurse pulled you in a room to answer another doctor's patient's question. Said patient, who you didn't know from Adam, states he was refusing care and wants to ask you questions about it, how would you respond?

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  19. Anon and RH+: You make an excellent point except for 2 things:

    1) I had the screen done during my OB check, so my next appointment wasn't for another 3 weeks. If I waited that long, then waited to schedule the test, it would have probably been over a month before the issue (if there was one) was addressed)

    2) Since I only joined the practice when I was pregnant, the practice actually refusesd to assign me a specific OB (I selected one at the end). So actually, I didn't have an OB at that point. Each visit, I just saw whatever doctor was available, and they encouraged this since there was an equal chance of getting delivered by any doctor. So there wasn't a possibility of talking to *my* doctor who knew me so well, because such a doctor didn't exist through no fault of my own. None of them knew me, really.

    So given that situation, there wasn't much I could do beyond asking to speak to whatever doctor was available. Maybe this was an irritating experience for the doctor, but if it was, maybe they should have assigned pregnant women specific OBs so I could have had someone I trusted to talk to about the situation.

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