Getting into the Groove:  Self Examination of the Academic Detailer Before Meeting the Apparent Over-Utilizing or Mal-Utilizing Test Orderer

Yesterday, I attended a terrific one day course entitled Health Care Leadership:  The Difficult Conversation in Health Care.  It was taught by two legal beagles, The Honourable Judge Heather Lamoureux: Chartered Mediator and Elaine Seifert, Q.C.: Chartered Mediator.  They are the authors of “Resolving Conflict Improving Communications monograph.”  My intention in attending their presentations was to “sharpen my saw” so that I would be better able to communicate with physicians who were either using tests inappropriately or generally over-ordering.  This type of communication can never be a lecture or a confrontation as it would lead to polarization and minimal, useful interaction. 

Our group generated some questions that the initiator of the Difficult Conversation must think about before interacting with the other party.  I list them below:

What are the goals?  What do we want to achieve?

What is the overall plan?

What are the barriers to the communication?

How do we encourage mutual conversation?

Do we have enough time?

Do I have the time and patience to this?

What is my frame of mind?  Am I too tired?  How do I feel?

How do I stand in this situation?

What assumptions am I bringing into this discussion?

What interest groups are involved?

Do I care what this person thinks and feels?

Am I the right person to have this conversation?

What is at stake?

What are the issues?  What is the real issue?

What are my biases?

What is the narrative?

What are the rules?

What are the objective standards?

What is missing in my story?

What does the other person know?

What is the other person thinking?

What are the other person’s feelings?

How do I contribute to the problem?

How have I enabled the behavior?

How has the system enabled the behavior?

Why was this not addressed earlier?

What words do I use that are authentic and will not derail the conversation?

What are the short term and long term plans?  (Need to document these plans - cell phone photo works well)

What is the exit plan including setting up another meeting or bringing in a more powerful individual?

I am sending this list to several of my associates who interact with some physicians who typically order 40 or 50 tests on each patient seen.  

Advice for Purchasers of Drugstore (Do at Home) Hemoglobin A1c tests

People who buy tests from a drugstore should be very careful.  Usually, these tests are not as accurate as those done by hospitals and reference laboratories.  However, “drug store” tests provide you convenience and the ability to get medical test results without being identified to various groups, including insurers. 

Hemoglobin A_1c is a measure of your average blood glucose over the last 2 to 3 months.  If your blood glucose tends to run high, then your hemoglobin A_1c will usually be elevated.  Most doctors use hemoglobin A_1c in patients with diabetes to determine the patient’s usual state of glucose control.  High hemoglobin A_1c can indicate the need for better glucose control.  Too low A_1c may indicate problems with too low glucose (hypoglycemia).  Thus, hemoglobin A_1c can be used to diagnose improvements or worsening in diabetes control.  Very recently, many medical professional societies such as the American Diabetes Association have started to recommend use of hemoglobin A_1c to diagnose diabetes (Diagnosis and Classification of Diabetes Mellitus in Diabetes Care, January 2011; 34:S62-S69, see http://care.diabetesjournals.org/content/34/Supplement_1/S62.full).    There is some controversy over this use (Higgins T, Tran D, Cembrowski G, Wiley C, Shalapay C, Steele P: Is HbA_1c a Good Screening Test for Diabetes Mellitus?, in press, Clinical Biochemistry).  At this time, the US Food and Drug Administration has not approved any manufacturer’s hemoglobin A_1c accurate enough to diagnose diabetes (even A_1c tests that are done by hospitals).  Definitely, the A_1c test that you buy at the drugstore will not meet the accuracy that you need to diagnose diabetes.  If you are thinking about buying one of these tests to diagnose diabetes, think again; see your doctor so she/he can order a high quality test.

A recent evaluation of 3 different consumer-run (drugstore) hemoglobin A_1c tests showed large variation (Little, R, Lenters-Westra E, Rohlfing CI, Slingerland R:  Point of Care Assays for Hemoglobin A_1c:  Is Performance Adequate?  Clinical Chemistry 2011;57: 1333-1334).  Hemoglobin A_1c measurements of each of 3 different consumer meters could deviate erroneously between 0.6 to 1.0% from the real hemoglobin A_1c.  As many physicians use a change of 0.5% in hemoglobin A_1c as a significant difference, these large deviations in these drug store A_1c’s could be erroneously interpreted as real changes. 

Your hemoglobin A_1c will change very slowly in response to changing glucoses.  A 0.6% change in a drug store A_1c’s over a week will more likely represent a defective test, rather than a genuine change.  Thus, should you buy one of these drugstore A_1c tests and do two measurements separated by a week, you should see very little change.  If there is a change exceeding 0.3 to 0.4 %, you should question the measurement.  If you want to reliably follow your hemoglobin A_1c, you need to wait about one month.  Plus, you should have your hemoglobin A_1c measured by an accurate instrument, such as that used by your hospital or a referral laboratory.

In countries with socialized health care, there is no reason to purchase an inaccurate hemoglobin A_1c test.  In countries like Canada and England, physicians will be able to order an accurate test at a reasonably low cost.  In countries, like the United States, the health care customer should not settle for a drugstore A_1c.  Rather, the customer should get their hemoglobin A_1c (usually more than one) from their healthcare provider.  

Eventually, these drugstore A_1c’s will be improved.  Today, save your money and interact with a legitimate health care provider who does not use the tests evaluated in Dr. Little’s article.