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Old 20-08-2018, 17:25   #1
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Health Care & Diabetes

We're liveaboards and move around quite a bit, and I know that others here do as well. I'm hoping that someone can tell us if there is a Doctor/Clinic that will cater to this group.

My wife has diabetes, which she has managed quite nicely with just long term insulin. Her midwestern doctor wants her to come in quarterly and doesn't want to consider remote testing and conversations over the phone rather than in person. This is a real problem since you have to have a script to get the insulin.

Any suggestions?
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Old 20-08-2018, 17:41   #2
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Re: Health Care & Diabetes

In the US, google "direct primary care physician" and your area. Alternatively called DPC, sometimes called concierge medicine (though this latter term generally refers to a more expensive practice).

In this practice model, you typically don't use insurance. Rather, you pay a physician a monthly fee (often referred to as a membership fee) for somewhere between $40 and $100+ per month. Note that a lot of these DPC practices have been networked (e.g. Medlion); I would aim for someone independent/less expensive.

You should be able to find a physician with whom you can establish near home base. Insulin is typically available everywhere, though planning is obviously appropriate.

A reasonable physician would agree with her checking her A1c with a kit you can buy without a script from Walmart for about $20 (these are reliable).


PS:
Her midwestern doctor wants her to come in quarterly and doesn't want to consider remote testing and conversations over the phone rather than in person.
I would recommend another physician regardless of life circumstances.
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Old 20-08-2018, 17:50   #3
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Re: Health Care & Diabetes

You don't give your wife's age. Insulin-dependent diabetes can have long term effects on internal organs, blood flow, ocular health, (eyes) and more, with aging ramping up the potential effects. Her physician likely wants to moniter the effects, and take whatever actions are needed to minimize the potential damage. On the flip side, the quality of life you may enjoy cruising can offset the benefits gained by sticking close to shore, and access to more comprehensive medical services. You may have to find a way to strike a balance between enjoying cruising and having access to quality medical care. I can't offer any real advice, but, there are likely any number of diabetics out cruising the oceans, but, as stated, age and time of onset of the disease will have to play a part in any decision you make. Cheers, and I hope you cruise for years to come.

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Old 20-08-2018, 18:06   #4
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Re: Health Care & Diabetes

She is 67 and onset was about ten years ago. Is there a point of age where one needs to stay close to home?
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Old 20-08-2018, 18:48   #5
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Re: Health Care & Diabetes

Quote:
Originally Posted by carlylelk View Post
She is 67 and onset was about ten years ago. Is there a point of age where one needs to stay close to home?
For well controlled diabetes without other medical problems there is no real activity restriction at any age. It would be unreasonable for a physician to say that she needs to "stay close to home" unless something else is going on assuming that her diabetes is well controlled and has been that way for a while (year plus?) without having any low sugar spells. If there were low spells, this would have to be reviewed (almost always caused by patient skipping/losing meals, not following the treatment plan).

If there were unexplained low spells, I'd be concerned (rare). If there were multiple explained low spells (e.g. "I forgot to eat")....well....I would wonder if this person should be left alone anywhere.

It sort of sounds like she was never given good education about this, or, was only given the initial scare speech and never the more realistic one.

The biggest problem with people who have type 2 diabetes on insulin is that they do not look at themselves as a diabetic on insulin. They initially were started on pills, probably with only modest daily awareness that they really, really need to start acting like a diabetic (e.g. thinking about their meals, calories, activity level). They just plop the pills and sooner or later have to start insulin.

Recall that the average type 1 diabetic was so afflicted as a child/adolescent. Likely hovered over by a hawkish mother, that type 1 diabetic leaves the nest at age 18 with the full capability between their brain, insulin, and glucometer how to be their own pancreas.

Type 2 diabetics too rarely adopt this type 1 world view that pretty much every kid with type 1 has figured out by age 18. Type 1 folks generally have nothing to say to their doc about their diabetes, and vice versa. I'd encourage more education/understanding about the diabetes......it really should be seen as an annoyance that slightly increases risk for other problems later that only need to be checked once every year or two (aside from the lab testing).


For reference: https://diabetesed.net/wp-content/up...ds-of-Care.pdf
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Old 20-08-2018, 18:52   #6
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Re: Health Care & Diabetes

Quote:
Originally Posted by carlylelk View Post
She is 67 and onset was about ten years ago. Is there a point of age where one needs to stay close to home?
is she really a type 1 diabetic?
or a maturity onset type 2 diabetic being treated with insulin?

if she is the latter she may find that with weight loss and exercise the cruising life style will reduce her insulin needs to a level where some pancreatic function returns ,allowing treatment with metformin,daonil etc.

insulin is available everywhere and in many places without a prescription from a pharmacy if you speak to the pharmacist.

failing that all hospitals will have some sort of diabetic clinic.

a local doctor will also write a prescption if asked.

the problems you may have will be getting penfill cartridge refills many places still use U100 in vials administered by syringe.

also the specific brand that she uses,lilly and novonorsk are big suppliers throughout the world so fast and slow acting insulin like nova rapid and levemir will be available,but unavailability might require changing brands if buying locally to another generic slow and fast insulin.

synthetic insulin is also fairly stable to temperature so packed properly fedex or dhl might also be an option from the US.
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Old 20-08-2018, 19:24   #7
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Re: Health Care & Diabetes

I appreciate the advice but I was hoping for a reference to a clinic or practice on the east coast that would be tailored toward mariners.
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Old 21-08-2018, 08:46   #8
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Re: Health Care & Diabetes

I am a midwestern Endocrinologist. I suspect your current Dr's hesitancy is liability risk and doesn't understand cruising boaters. However as a fellow sailor I hope you find someone. If she is stable without significant complications or CV disease I wouldn't have problem with 6 mo to yearly follow up. I suspect you can buy insulin without a prescription. In Canada you don't need a script for insulin and is 1/10 of the price. Be careful to neither cook or freeze the insulin. I would also have DAN insurance policy and you should have glucagon on board. Maybe I should keep my luscence current when I retire and go cruising.
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Old 21-08-2018, 09:07   #9
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Re: Health Care & Diabetes

I am an Internist & Nephrologist. I have used a family physician on St John's USVI named Scott Hartshorn, MD. He is a few blocks up from the customs house in a large shopping center. He is kind, compassionate and intelligent. He is a good doc. Look him up if you need help while in the Virgin Island.
There is a good clinic that is part of the Peeple's Hospitals on Tortola that takes walking patients. Not cheap but a great resource for care on Tortola, BVI.
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Old 21-08-2018, 12:46   #10
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Re: Health Care & Diabetes

I do know insulin has a long shelf life if kept refrigerated.
I do not know the temperature ranges or how long it will keep.
Knowing that, one could keep an inventory onboard to last for some time into the future.
Several months for sure.
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Old 21-08-2018, 14:16   #11
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Re: Health Care & Diabetes

I'm diabetic, and a boater and pilot (airplanes). Diabetes should never keep you from what you want to do if your blood sugars are controlled AND YOU HAVE THE RIGHT DOCTOR.


So, first your wife needs to tell her doctor to get with her program (he works for her) or fire him.


I have a "concierge" private doctor who happens to be the president of the county Independent Physicians Association. You might check their web site for help finding a doctor whose services are more in line with your wife's needs. Board of Directors | IPALC - Physicians of Lee County They might help ...



If her A1Cs are good, unless there are other issues, she should only need to do labs twice a year assuming her self-testing is stable.



The best doctors know that they are your advisors and are there to help you live a healthy life of your own choosing.
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Old 21-08-2018, 15:35   #12
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Re: Health Care & Diabetes

Your doctor doesn’t know anything about diabetes that every other doctor in the world doesn’t know. He won’t talk to you on the phone because he can’t bill your insurance for that.
He is obviously not interested or concerned with you, your needs, your lifestyle or accommodating you in any way.
If you have Medicare and or insurance, you can walk into any walk in or emergency clinic anywhere every few months and get seen, get new lab work, new prescriptions and be on your way.
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Old 21-08-2018, 19:02   #13
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Re: Health Care & Diabetes

Medicare pays for a doctor to do quarterly check-ups for diabetics. Think your doctor is more interested in the money he gets for a visit rather than your wife's health. My current physician used to have me see him biannually but either Medicare or our supplemental insurance made a big cut in the reimbursement for the checkups. He went to a quarterly appointment schedule to make up the difference when I turned 65.

Sorry I can't help with a physician reccomendation as I've done my sailing between quarterly doctor appointments. Call around and explain your cruising life. Hopefully you'll find a doctor that will work with you. Know when we went to SoPac many years ago was able to get prescriptions for a whole bunch of drugs for our medical kit from a doctor who sailed. He actually stocked us up with samples that went a long way to keeping the cost down.

I'm insulin dependent and have been diabetic for more than 30 years. Have done a solo Transpac and a delivery from SF to Oceanside, CA as well as multiple times spending a week to a month on the boat. When I've spent more than a week straight on the boat, I lose weight and have to cut back on the insulin dosage. How do we say this diplomatically?? Is she not as svelte as when you married her, know I'm not?? Weight is definitely a factor in insulin dependency and insulin in normal living makes it really hard for me to lose weight and very easy to gain. As soon as I'm off the boat my weight balloons at least 10 pounds. If she is successful in keeping her A1C below 7 cruising should be no problem. Don't think getting insulin is a problem in a lot of places. Know that the hotel we stayed in in Bangkok replaced my insulin after they accidentally froze it which supposedly ruins it. No doctor visit, just me being pissed as I clearly told them that it couldn't be frozen. The pens were also way cheaper than in the US.

As far as insulin maintaining it's potency unrefrigerated, it will go at least a month in Hawaii temperatures. When I was going to do the TransPac experimented leaving it on the counter and it still worked after a month. From what I understand, it gradually loses its potency if not kept cool but takes awhile for it completely lose it's potency.
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Old 22-08-2018, 04:45   #14
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Re: Health Care & Diabetes

You may also want to look into a ketogenic diet. I am not yet cruising, and mostly a lurker here.... But I am a type 2, adult onset, diabetic. With Keto, I have lost 70 lbs., no longer on metformin, B/P meds cut in half, blood sugar is controlled and my A1C's are in the low 5s. Not to mention that once my blood sugar was controlled, numerous other "ailments" improved (distance vision, skin conditions, energy levels, etc.).

Keeping this diet may be problematic while cruising, really not sure on that one....
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Old 22-08-2018, 13:23   #15
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Re: Health Care & Diabetes

"If you have Medicare and or insurance, you can walk into any walk in or emergency clinic anywhere every few months and"
I don't think so. Medicare is limited to care within the US, AFAIK. Cruisers may not be in the US. (Although we've got those clever eleven "insular possessions".)

Many doctors put "practice management" above "practicing medicine" and most are pretty lousy practice managers in any case. If the wife is *stable* and managing her condition, there's no reason to stick with a problematic doctor. If the doctor was being honest they might have said "If you want to remain under my care, I need to see you every 90 days because I don't think ...whatever". When a doctor just says "Here's what you must do" with no options? That's a sausage factory, a patient processing mill, not a doctor. Plenty of real doctors out there.
The Walmart A1C tests are not really A1C tests. They used to sell a real test kit from Bayer, but last I heard they dropped those, and went to a "test card" that you have to spot with some blood and mail off for processing. Real A1C test kits are still out there, and if the wife's stable, plain blood sugar testing would work just as well. That's certainly available all over, and shelf-stable.
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