Urban Gardening, The Challenges

As more of us people with diabetes are told to eat more fresh produce, our supermarkets know that we are looking for fresh produce. Even then, the produce is several days old and not truly fresh as the grocery chains would like us to believe. Three or more days old are not fresh any longer. What are we to do if we don't live on an acreage and do our own gardening?


I wish I could do just that and be able to garden, but apartment living does not allow this to happen. Even the owner of the building won't allow gardening in the manicured lawns. No one near us will allow gardening and this means traveling to surrounding farms, which even many of them don't want. I finally located one farmer where we can get fresh eggs and some produce during the summer, but not enough to satisfy a family of two. Plus, the selection is limited to what they don't or can't process and not what some of our choices would include. This means no beans, no peas, and many other of my choices of vegetables. Plus many of the selections are past their prime when we are notified to come and harvest.


May I am just used to too many years of good fruits and vegetables harvested at their prime and canned or frozen beyond what we consumed in our daily meals. Mother and Dad always planned the plantings to spread out the harvest and prolong what we had fresh for the daily meals. Plus the canner was always kept busy once harvest started and the prime picking was for the daily meals or frozen.


This article was a pleasant surprise to find; however, many will not gain from this, but still is an interesting article even with the hazards it brings out. The concept of local food and urban gardening is gaining popularity as urban agriculture, with its benefits and obstacles, and is coming to many cities.


“The benefits of urban agriculture are many. Urban gardens are often built on previously unused lots, increasing the beauty and value of the neighborhood. They provide recreation opportunities and a social network for the gardeners involved. Urban food production also means that healthy, fresh produce is readily available to city dwellers.”


The challenges that organizers and growers face need to be understood and conquered if urban gardens are to take hold and even be profitable. Many of the obstacles, planners and growers face include soil contaminants, water availability, and changes in climate and atmospheric conditions.


Of the contaminants found in urban soils, lead is the most prevalent. Even though there is concern about plants taking up lead from the soils, research shows plants take up very little and in fact, it is less than we are exposed to from drinking water. Practices such as washing food before eating and covering soils with mulch can decrease these risks. Finding reliable and safe water sources can be difficult for urban gardeners. Using drip irrigation that will deliver water where and when it is needed can conserve water.

Can You Deal With the Elephants in the Exam Room?

First, it is necessary to identify the elephants that a discussion is hard for providers and patients to talk about with ease.


#1. Sex
#2. Costs of care
#3. Alternative treatments
#4. Advanced directives
#5. Digital technologies


I find I have no trouble in discussing any of the above or more, but studies show that they are often difficult for providers and patients to talk about and many just won't consider talking about them.


The first item above is important for both men and women with diabetes for a variety of reasons. Men often have sexual dysfunction or erection dysfunction quite often and this can affect how they feel about diabetes. In looking for studies, there are a few, but not worth the time because most are less than 10 men. Women have other problems and often dislike having sex because of yeast infections and often dryness making sex painful.


The second item above is very difficult to get providers to talk about because often they are not totally aware of what the actual costs are when providers are employed by the hospital. Hospitals have so many extras that are tacked on to a charge to get more from the insurance companies and/or Medicare/Medicaid. There are at least three free apps, which address health care costs.


The third item above is more difficult for patients because they are afraid of the reactions they will receive from their provider. Once the diagnosis is received by the patient, some will consider having the treatment prescribed by their provider, but others would like to consider complimentary treatment, which may include holistic, neuropathic, or homeopathic regimens. Often they won't discuss these with the doctor because they know from past experience that the doctor will ridicule them and dismiss the treatment. Often they just take the prescription or prescribed treatment and go to another doctor that will provide these.


The fourth item above is probably one of the more contentious topics as many providers just hand out papers to have the patient check the boxes for the advance directives for end of life care to meet federal mandates. In these situations, many patients just ignore these. If they are like me, I have seen physicians, hospitals, and families ignore the wishes of the patient and do what they want done, even with the advance directives on file. I have even seen family ushered out of a parent's room so they can follow their own policies against the directives.


The fifth and final item above is about mobile technologies. These can improve the doctor-patient relationship, but even then, doctors do not want them around and will ignore their use. Many patients use the internet and this often causes physicians to see this as a threat to them and upsetting the balance of their relationship with the patients. Fortunately, times are changing and with both shared decision making and digital health technology in present popularity, physicians are often forced to deal with this or lose patients.


Now it becomes necessary to state that both providers and patients need standards that medical app developers can follow. If they are reliable and effective digital tools, they can help prevent the elephants from being in the exam room discussion instead of making the elephants presence larger.


While the above discussion may not include all the elephants, often once they are recognized and the provider brings them up with the patient, they disappear and the tension is relieved. Often a partner or a caregiver can be the one to start the conversation and they can be the ones to carry these discussions. Read a doctors interpretation and thoughts about this topic here.

Communications By Any Other Name - Worthless

You may wish to skip this blog. This is because I am overly critical of another blogger. I normally respect this blogger and she has much good to say, but that was not my take on this blog.


Again, I wonder why is it that doctors misunderstand communications. Every doctor has his/her interpretation of patient engagement. Now I will add the term “meaningful use” to patient engagement and say that most doctors are trying to hide behind the two phrases and are not concerned about communications with the patient. To quote Dr. Rob Lamberts, “Communication isn’t important to health care, communication is health care. Care is not a static thing, it is the transaction of ideas. The patient tells me what is going on, I listen, I share my thoughts with the patient (and other providers), and the patient uses the result of this transaction for their own benefit.”


I respect the definition by Dr. Lamberts, but anything in other definitions is bull, and the quicker we as patients understand this, the better off we will be. I covered his blog that Dr. Leslie Kernisan refers to, but do not understand why she had to muddy the waters even more. I will quote Dr. Kernisan to show this: “Here’s my current take:  Supporting patient engagement means fostering a fruitful collaboration in which patients and clinicians work together to help the patient progress towards mutually agreed-upon health goals.” Mutually agreed-upon health goals may not always be in the best interest of the patient.


She says everything but communication as if communication is a term to be avoided at all costs. Then she uses the term to bring people back to patient engagement. I quote, “Communication with patients is, of course, essential to all of this. This is why any innovation that improves a patient’s ability to access and communicate with healthcare providers is proudly labeled as “patient engagement.””


Remember meaningful use, doctors may not meet this if they use communication instead of meaningful use. Then we find out that Dr. Kernisan prefers to quantify patient engagement when she states, “Back to the examples of patient engagement cited above. What are the “right metrics around what constitutes real patient engagement”? Obviously, it will be difficult to agree on metrics if we don’t first agree on the definition.”


Sounds to me she is trying to calculate how to fit this into meaningful use. Tell me this isn't so, doctor! I am even more concerned now and have to wonder what it is about the word communications that doctors are unwilling to accept this, with the exception of Dr. Lamberts.


I become very uncomfortable when doctors use the term patient engagement around me and even more when they use the term in surveys sent out to attempt to get praise for their actions. I refuse to return these and when one doctor called me to find out why I had not returned the survey, I am afraid I was not too polite in my response. I also said that the phrase patient engagement had no standard meaning and communication was definitely not part of my appointment other than keeping my mouth closed except to answer questions.


Of course, the doctor disagreed. I asked him who had set the goals I was to use for my health. When he said we both had, I reminded him that I had not indicated I approved or disapproved of the goals he had laid out. I then told him where I disagreed and why. He quickly asked me to complete the survey and return it. I said I would and I would send one to the administrator and keep another copy for my records. “Click” was the next sound and it was more of a “bang.”


I did return the survey, but he is no longer a doctor on my team and that is by mutual agreement.

Providers Label Patients as Second Class Citizens

I am glad someone is speaking out about what providers and the health information technologies (HIT) are doing to shut us out as patients. If doctors think that their pedestal is tarnished now, wait until patients really understand what they are doing and they may find that there may be some tar and feathers in the next round. Not only this, but also many doctor-patient relationships may come to an abrupt end.


Adrian Gropper, MD writes about Health IT Week – the Consumer Health IT Summit. He does not pull any punches and his blog should upset a few great doctors that understand the importance of communication. The rest probably are clapping their hands heartily and saying Amen.


Dr. Gropper says that the Health IT week demonstrated a double barrel strategy first to keep patient information segregated from provider information. Then by rebranding HIPAA as “Meaningful Consent” with no input from patients, this makes patients second-class citizens in Meaningful Use Stage 2 interoperability. Providers and regulators are working together to see that is stays that way.


Normally providers and IT people make comments, but they are strangely quiet after this blog. They seem to know that some patients read many of the blogs and they are careful not to disclose their opposition to Dr. Gropper telling all. Dr Gropper and several providers have laid out some of the background in a good discussion.


“The segregation of patient information from “provider” information is the current federal regulatory strategy. It’s even more so in the states. By making patients into second-class citizens, the providers can avoid open scrutiny, transparent pricing, and independent decision support.”


“Federal regulators then create a parallel system where information is delayed, diluted, and depreciated by lack of “authenticity”. This is promoted as “patient engagement”. For regulators, it’s a win-win solution: the providers support the regulation that enables their price fixing and many patient advocates get to swoon over patient engagement efforts.”


What is even more troubling is this. “The Model Notice of Privacy Practices legitimizes the practice of provider-to-provider health information exchange under the HIPAA Treatment, Payment and Operations (TPO) exemption. TPO is used by providers and health information exchanges to avoid patient authorization for sharing of private information.” This smacks of patient privacy being violated with no concern.


Another point made by Dr. Gropper is the intentions for emails between doctor and patient. Apparently, most providers, regulators, and HIT companies wish to keep emails out of the hands and use by patients. Dr. Gropper states that the regulators are making most emails an organization-to-organization system. This is part of the regulations for Meaningful Use Stage 2 certification.


This means that the original intent of Blue Button Plus, having secure communications between patient and provider, will be lost and transparency will be lost. This will also mean that hospitals and providers can avoid giving patients an independent decision support portal and a key independent communication channel.


Without transparency and independent decision support, the tools for reducing health care cost become limited. The market-based (as opposed to Medicare for all) foundation of ObamaCare cannot highlight unwarranted and overpriced services as long as the providers of those services maintain control of our personal information. This seems a merely politically expedient. If we accept an impotent Blue Button Plus and HIE exclusion via TPO we may be headed for a regulatory failure even larger than the sub-prime mortgage crisis.


Patients need to sharpen their skills and knives for the battle ahead. It won't be pleasant for all concerned.

Statins May Indicate Reduced Dementia

These two studies raise more concerns than they solve. Why are larger doses of statins needed to reduce the risk of dementia. At the same time, other studies are finding more muscle and joint problems with the increased dosage of statins and more cases of type 2 diabetes.


This also raises the issue of which statins were being used by patient numbers, possible ethnic variables, and the correct dosage to cause the reduced dementia. I therefore agree with Professor Jose Gonzalez-Juanatey, University Hospital, Santiago de Compostela, Spain, who said, "These new data suggest that high-potency statins may reduce the incidence of dementia in patients with atrial fibrillation and in elderly patients. Nevertheless, before we can know for sure that statins may prevent dementia, a clinical trial confirming these findings is mandatory."


At the same time, Seth S. Martin, MD, Johns Hopkins Hospital, Baltimore, Maryland, who is conducting a systematic review of the literature on statins and cognition/dementia, said, “These current results fit in well with existing studies.”


This leaves things unsaid and especially what conflicts of interest have not been disclosed. While some statistics are shown for the different statins in the press release, no patient numbers are matched to the statins and an attempt to obtain to details of the two studies was unsuccessful. So I am left wondering who funded the study?


I am less concerned about these two studies having some solid evidence and the information not being cooked by Big Pharma than I was about the information I used in this blog. However, I remain concerned about conflicts of interest.