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The Importance of Early Diabetes Awareness

4/11/2019

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By: Maddie Barbe

As a third year podiatric medical student, I have already seen my fair share of patients who have lost parts of their limbs to varying degrees. There are an estimated 1.9 million Americans living with amputations at any given time, with about half being non-white. Often times, those patients who have undergone amputations seem the most educated about managing the diabetes and its sequelae. But it is imperative that diabetes management awareness take place early with diagnosed patients. So, how can we reach patients earlier to educate them on diabetic amputations?


  • Numbers: an estimated 68,000 Americans undergo amputations within a year, with a significant share of those being related to diabetes and peripheral vascular disease.
  • Prognosis: once undergoing an amputation, there is a high 5 year mortality rate, estimated as high as 50%.
  • Symptoms to watch out for: In a study by Reiber (1994), she found that patients who had undergone amputations at VA Hospitals had previously experienced numbness (57%), lack of pain (42.5%), claudication (62.3%), ulceration (84%).
  • How to decrease risks: emphasize returning for routine diabetic foot assessment, using diabetic shoes if they qualify, wearing shoes around the home, checking their feet every day out of the shower for calluses or pre ulcerations, sugar control, smoking cessation…
  • Sequelae: risks for cardiovascular disease, obesity, joint issues, depression, need for more proximal or contralateral amputation goes up once a patient has undergone one amputation.
  • Share some good news: amputations peaked at 185,000 per year in 1996. Diabetic amputations have since dropped 67% through prevention efforts and medical management. So, having diabetes with those additional risk factors is not a death sentence. If the patients take steps to decrease risk and see doctors when possible, they can dramatically decrease chances of undergoing amputation.

    It is worth spending extra time with diabetic patients, especially those with additional risk factors, about the risks of amputation and how they can help prevent them.

Numbers and data from Amputee Coalition’s Roadmap to Preventing Limb Loss in America.

About the Author: Maddie Barbe is a member of the Class of 2020 at Temple University School of Podiatric Medicine. She serves as Director of Outreach with FootAid.

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Catching the Silent Nod

10/14/2018

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By: Elizabeth Oh

Doctor: "Why haven't you been taking your medications properly?"
Patient: "I don't know"
Doctor: "It says right on the paper work - Take twice a day."
Patient: *silence
Doctor: "Do you understand?"
Patient *nods yes
 
A far too common scenario. 
A plea from a doctor to a patient about taking the proper steps for healing.
Frustrations and tensions are in the room.
Too many assumptions made on both ends. 
Looming emotions shooting across both minds.
 
...Did you catch it? A possible reason? 
 
Answer: The patient could not read and was ashamed to share.
 
To assume that in our "day and age" and with the "internet at our finger tips", that the rates of illiteracy may be low is a heavy understatement. During my time volunteering in local clinics abroad and in the states, I've noticed on a personal account that there are many individuals out there that simply can not read. Turns out, the research also supports this observation...

According to an NPR article, one in six adults in the United States have reading skills below a 4th grade level. Among this group, 66% adults were born in the United States while 34% were born abroad. 
 
In a recent study published in July 2018, illiteracy was one of the death predictors in a Brazilian cohort (Inuzuka, et al) 
 
According to the United Nations Educational, Scientific, and Cultural Organizations (UNESCO), there is Globally at least 750 million youth and adultsthat still cannot read and write while 250 million children are failingto acquire basic literacy skills.
 
So now that you, the global warrior that you are, are now more aware of illiteracy, you want to ask: 
Now what? 
Are there tools developed yet to establish a bridge for illiterate patients?
Sadly, I have to say- It is in the works.
 
But... I do have personal recommendations for those that are not comfortable at all. 
Disclaimer: My recommendations stem from my personal adjustments after seeing my immigrant parents do the silent nod during their primary care visits and is in no way a well-studied approach (since there is none at this moment).
 
Approaching a suspicion of illiteracy:
 
1. Be attentive to your patient's reactions and body language
are they nodding more than asking questions? 
 
2. Ask them if they can read or if they have trouble reading the given material. 
Usually when addressed, it is easier to say no. 
 
3. Be open to using different visual aids as materials to communicate properly to your patient.
If you can, try to draw out something and explain what is going on and why their medication will help them. 
 
4. Have them repeat back what you'd like them to do. 
This is important. Don't forget this step as this affirms that the message is interpreted properly or poorly to the patient.
 
As a technologically advanced society, I believe we've relied too much on the printed document given at the end of each visit. As a team member that plays any role with someone's care, 
we must be aware of the silent nods that exist and the potential chasm of communication that could be reduced between doctor and patient- abroad and in our Westernized clinics. 
 
I hope this read was helpful and if you have any questions, please send them my way!

About the Author: ​Elizabeth Oh is  a member of the Class of 2020 at Western University of Health Sciences College of Podiatric Medicine. She is also the the APMSA Alternate Delegate for the Class of 2020 and the student liaison to the American Board of Podiatric Medicine.
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Medical Malpractice Concerns

For those providers who are forced to face malpractice concerns in their practice in the United states a few things should be understood:
  1. “No malpractice claim has ever been filed against any American health care worker providing humanitarian services without charge in the developing world.”(1) The malpractice risk is almost nonexistent as long as the practice is limited to the indigenous population and that care is provided free or at minimal charge.
  2. The only documented malpractice against american physicians in the developing world is the care of “western” patients in “for profit” health centers and hospitals.
  3. There is a small civil liability noted in the developing world. This only involves traffic accidents and accidental injury and death when American health care workers are involved in an incident in a non-medical capacity.
  4. In 2003 a study was done that found that not one volunteer or missionary agency provides malpractice insurance, as coverage of this type in simply not available.
“To summarize, Americans travel and carry their malpractice mentality with them even though malpractice is not an issue in the country where they are traveling. The malpractice liability is in providing care for Americans traveling or living overseas, and charging for those services. There appears to be minimal to no risk in providing free medical care to the indigenous population in poor countries while doing “voluntary” or “humanitarian” service.” (1)
​

1. W. “Ted” Kuhn: Medical Malpractice in the Developing World. Global Medical Missions, Winepress Publishing, 2007 
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