#1125 Grand Rounds: Technology Part I

February 7, 2024Scott Benner

Scott and Jenny discuss diabetes technology. Part one of two. Part two is episode 1026

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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.

Scott Benner 0:00
Hello friends, welcome to episode 1125. This is part one of the Grand Rounds episode for technology part two is it episode 1126.

Today Jenny Smith and I are continuing on with the Grand Rounds series, we're going to discuss technology in this two part episode and the first half general overview of CGM and pumps and in the second half different pumps technology and understanding the differences between them. Please don't forget that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan or becoming bold with insulin. When you place your first order for ag one with my link, you'll get five free travel packs and a free year's supply of vitamin D. Drink ag one.com/juice box. Don't forget to save 40% off of your entire order at cozy earth.com. All you have to do is use the offer code juice box at checkout that's juice box at checkout to save 40% at cosy earth.com. If you're looking for the diabetes Pro Tip series, it runs between Episode 1001 1025. For subscribers to the podcast, those episodes are ad free. For everyone else. There's just a couple of ads episodes 1002 1025 diabetes Pro Tip series from the Juicebox Podcast. This episode of The Juicebox Podcast is sponsored by touched by type one touched by type one.org. And find them on Facebook and Instagram touched by type one is an organization dedicated to helping people living with type one diabetes. And they have so many different programs that are doing just that check them out at touched by type one.org. This episode of The Juicebox Podcast is sponsored by the insulin pump that my daughter wears Omni pod, learn more and get started today with the Omni pod dash or the Omni pod five at my link Omni pod.com/juice box. Alright, Jenny, we are back doing the Grand Rounds, which I guess is gonna get called by default, because I can't think of anything else.

Jennifer Smith, CDE 2:26
I think it's a great name.

Scott Benner 2:27
I love the name until one person online. It took one person to say to me, I don't think every hospital calls it that. And I was like, Oh, I pick the wrong. And but I think it makes the point, right?

Jennifer Smith, CDE 2:37
It makes the point it does. Yes.

Scott Benner 2:41
So today we're going to talk about continuous glucose monitors and blood glucose monitors in the same short conversation here. I guess we'll just start with BGMs blood glucose monitors and go over very quickly, that they're not all the same. And I'm beginning to wonder if doctors offices know that. That makes sense. These are not incredibly expensive items. Most people's insurance, if not all people's insurance are going to be covering a blood glucose meter. Yes, in a world where they're right. That's

Jennifer Smith, CDE 3:16
some kind, it's fair. It's fair, I wouldn't say that they even good insurance companies have sort of a preferred glucose meter. Right. And you may pay more for one that you expect in reviewing is better in terms of accuracy. Insurance will typically cover up a meter. Yes,

Scott Benner 3:36
I just think that it's worth mentioning that this meter that I'm giving you may not be as accurate as other meters, perhaps you should look into it or I don't understand why doctors offices don't begin with here are the top three, right? Because I think there's about three of them that kind of fall in similar space as far as accuracy goes, right? So here's the top three. If your insurance company doesn't cover the test strips for this, then you know, here's a declining list of accuracy. I just don't think that is a conversation that's ever had, I think you Gill, whatever the office leans towards maybe or I don't know how it even works to be honest, true.

Jennifer Smith, CDE 4:11
Years ago, when I was working in office, the standard that would be is that you would get from different companies, you would get sent meters and the meters are not the expensive piece. The meters are actually more of like the freebie that kind of like we would give for newly diagnosed we would give them either Yeah, the prescription and the pay part comes with the test strips, right? So it then depends on what test strips are kind of covered at what cost they're being covered. But most of the offices like I said when I worked in the past would get a good supply from all of the brand name ones not the typical ones, that you're gonna find it like Walmart or any of the pharmacy places that might have the generic brands, but we would get all the way Any ones and we would essentially help to kind of figure out which one would work best for this person size, what other things that they might be working with, et cetera. For

Scott Benner 5:11
my money, its accuracy and being able to read it. That's what I'm concerned with, and blood drops at this point. They're all pretty smaller, like requirements.

Jennifer Smith, CDE 5:21
They are for the most part. I mean, you know, when I was first diagnosed, it had to be this hanging blood. Like this gigantic off your finger? Yeah, exactly. Yes, to get enough. But these days, pretty much they're all about the same tiny, you know, head of a pin sort of size that Yeah. And the other nice thing is that many of the good ones actually allow second drop applications so that if it didn't get enough to begin with, you have a certain number of seconds in order to reapply some additional blood to get enough of the sample.

Scott Benner 5:52
Yeah, yeah. Are mucking it up. So it's not as accurate. Correct. So that to me, that's it just like, explain to them, here's the accuracy. I don't know what your insurance company is going to cover. I mean, even be clear and say, Look, from a purely business standpoint, the game is selling the test strips, like that's where they make money, right? So the meter is your, you know, caretaker meter, and then hopefully, you'll buy our test strips, because you like the meter afterwards. I would imagine there are people listening right now that are thinking, Wait, some of these meters are more accurate than other ones. I honestly 100% believe that that's not a thing everybody understands. And why would you think that? You know, why would you consider one to be less than the other or better. So I think have that conversation. And then on top of that, even if you're giving someone a CGM, which we're going to talk more about, you still give them a blood glucose meter. It's important. And you know, you test your blood sugar, if your blood sugar's really 110. And the the meter says, it's 150. That's a lot more insulin you're about to take, you know, right. And that's just not okay. So

Jennifer Smith, CDE 6:56
all right, it's a safe place that you think that you're starting based on what you're planning to do after this test. And you may be aiming for that, when in fact, you might actually be lower. Or maybe you're actually higher than that. So yeah,

Scott Benner 7:08
it's just important and I want to say to just because you're gonna give somebody a CGM doesn't mean, they don't need an accurate blood glucose meter. So right, you take five seconds to make sure they understand how to use it. Here, I'll ask you a question. You test your finger sometimes, right? Yes,

Jennifer Smith, CDE 7:26
when's the last time more than sometimes,

Scott Benner 7:28
sometimes, when's the last time you cleaned your hands with alcohol before you tested? In 2015, I needed support to start making this podcast and Omni pod was there. They bought my first ad, in a year when the entire podcast got as many downloads as it probably got today. Um, the pod was there to support the show. And they have been every year for nine seasons. I want to thank them very much. And I want to ask you to check them out at Omni pod.com/juice box. My daughter has been wearing an omni pod every day since she was four years old. And she turns 20 This summer, it's been a friend to us along the way. And I think you would enjoy it as well. Omni pod.com/juice box links in the show notes links at juicebox podcast.com to Omni pod and all the sponsors. I don't use

Jennifer Smith, CDE 8:22
alcohol to wipe my finger. There may

Scott Benner 8:24
not be alcohol in this house, actually. So I

Jennifer Smith, CDE 8:27
do use it to clean sites. I do use it to clean the back you know those little ports. And again, we'll talk about CGM, but I do use it to clean that off. But in terms of it's really a degreaser, right? an alcohol swab is kind of a degreaser, you're better off honestly just washing your hands with warm, soapy water, sing the birthday song to make sure that you you know, get as much bacteria off as you're supposed to get off and then wipe your hands nice and dry. And then do the fingers.

Scott Benner 8:56
So here's the question. That health aside, I don't mean like you don't want to open up a hole into your hand while there's bacteria and germs and everything in your hand that I know No, I don't want to do. But for the accuracy of the test. Dirty hands don't matter, right? Well, it depends what they're dirty with. Right? So glucose in your hand sugar on your hands that would interfere with the test. True, but if I was muddy, and I just rubbed my hands real quick and found a clean spot, would I get an accurate test? Jenny's like I don't want to say

Jennifer Smith, CDE 9:25
that? It's a great question. It really is. I mean, I've I've never actually thought about it. Although I will have to say that so in I in college, I used to do Habitat for Humanity and we would do trips out of state for spring break. And there were many times on the worksite it's honestly that it wasn't easy to get to just like running water with soap. So I I would actually just dip it in like my water bottle. Wipe it off. I'm assuming it was clearly I never had any infections. I'm not by any means recommending this as a therapy or an option.

Scott Benner 9:59
I just want to have the conversation. Jenny's not recommending it. Listen, I saw Mark Andrews get catch a touchdown pass a few weeks ago, and I'm telling apply somebody went on the sidelines tested his blood sugar didn't see him stop and wash his hands. So, right? Correct. The reason I bring it up is because I've seen newly diagnosed people kind of crippled by it. Like, oh, I have to test but I don't have a an alcohol swab, or somebody's like, I think I'm low, but I have to go get an alcohol. I'm like, Just test your blood sugar. You're like, yeah, let's get moving here. So anyway, that's my little bit for that. Why?

Jennifer Smith, CDE 10:31
I think as far as accuracy, too, I think that that's something that, unfortunately, unless, as a, you know, we're speaking to, hopefully, practitioners here, too, right. And in terms of their understanding about accuracy, you really do have to read the fine print, this is where you might need to get your reading glasses out and read that tiny little print that comes inside each and every one of the meters that you may be recommending or handing out from your office space. Because if you haven't read that, right, all of the different blood glucose meters on the market, including continuous glucose monitors, they all have marred, right. It's an accuracy rating. And so you'll be able to tell by easily lining those papers up with the little graphs inside of them. Which ones are the better ones to be recommending to your patient? Why

Scott Benner 11:24
do you care which one lives as long as it's the better one and their insurance covers it? Correct? Look, I'm not saying if you have no other options, or you're a cash payer, and it's hard for you, whatever, then take what you can get, you know, the best you can get. But while we're handing them out, it just it seems to me, it seems to me that you probably said that, and a number of physicians probably just in their mind with these meters are different. Like why would you think that their blood glucose meters? Seriously, you know, you would expect that

Jennifer Smith, CDE 11:50
if they're on the market, they've been approved? And yes, they've met some type of accuracy rating in order to actually be on the market. Yes. But there are, as you said earlier, there are three that are pretty much the top tier and align with each other in terms of accuracy. I mean, I have two of the top three. And I will not often but probably, you know, once or twice a month, I'll actually pair them off of each other with the same drop of blood, just to see how they're still, you know, on par with each other

Scott Benner 12:24
remarkably close every time you do it. They

Jennifer Smith, CDE 12:27
are Yeah, very, I would say within about five milligrams per deciliter, honestly, they're very close to each other.

Scott Benner 12:34
I just last night. So I mean, they're sponsors of the show. But you know, our news is a contour next meter, one of the content x meters, and there's a number of them, but she was bolusing for a blood sugar. And I was looking at her CGM. And I thought, that's not right. I know that's not right. Your blood sugar is not this high. From what she ate, and how much we Bolus. It just didn't make sense to me. I knew her site was working well. So I was like, you just gotta test real quick. And she tested and no kidding like her. I think her CGM had her at 190. And she was 150. So I was like, I knew it. And before we were gonna make another big Bolus. I was like, Don't do that. Again. I'm like, we have to check first. And I have to say I trust that meter pretty implicitly. So pretty great meter. Okay, so but CGM seems good, or do you have more to say on meters? No, I

Jennifer Smith, CDE 13:25
wanted to make a point, though, about what you just brought up in terms of sensing or having a sense of where glucose should be. And as we move into talking about continuous glucose monitors, the accuracy of your blood glucose meter, where you're doing a finger stick and getting a number from, if at any point you need to calibrate that CGM, the accuracy of the blood glucose meter also makes them very big difference in terms of the CGM.

Scott Benner 13:58
I left that out. But that was the last bit of what we did. As soon as that number came up. I was like, go ahead and calibrate the CGM it. Yep. Well said, I know that marketing wise. You know, all the CGM companies like to say like, you know, you don't have to calibrate you don't have to calibrate but you can, if you you know, so why can I if I don't need to sometimes. Right. And you know, and I'm down with that. I know, some people say it'll figure it out and we'll figure it out. But I mean, this is, is four or five days into this thing, her blood sugar. You know, it's she's got her period stuck a little higher using some extra insulin like stuff like that. But I was like, that's not right. And that's, by the way, we're not talking about management right now. But I don't mean that you can figure out what your blood sugar is by wandering out the space. It's a lot of years of experience and knowing what she ate what we Bolus and I think that can't be right. Also how the line moved on the CGM. It just wasn't acting the way I expected it to whichever Which made me think that something was up. Okay, but CGM. Give one to everybody. There. That's my advice. I mean, just everybody, if you've got type one diabetes, given the CGM, I would give type two CGM. I don't know if they're covered by insurance, I think they're incredibly helpful

Jennifer Smith, CDE 15:17
depends on insulin use for type two diabetes. And other factors, obviously, but insulin use the big one. somebody with type two who is on insulin is going to have sort of priority, I guess, in terms of the ability to get one. So but I would 100% mean, if I was going to lobby for something, I would say everybody with diabetes should have a continuous glucose meter. Because that's the only way that you're actually going to see trends based on the variables in your life.

Scott Benner 15:49
Right? I put up an episode today. It's an after dark with this 27 year old girl who said that when she was younger, they told her she was brittle, because her blood sugar's would bounce up and down, up and down. By the way, she's 27. She only had diabetes for 17 years. So it's in the last 20 years. Somebody told her she was brittle. So after I explained to her that that probably isn't really what was happening to her. All I could think was that she had a CGM. Maybe it would have like, struck a chord in or maybe she would have seen it, you know what I mean, instead of just guessing and testing when she wanted to. And by the way, all that led to and this is for the doctors. I mean, obviously timing wise CGM is didn't exist for this person. But not having one being told she was brutal, lead to an eating disorder. It led to manipulating her weight with insulin. It led to this anxiety about food she barely eats now, because of it, you know, all this stuff from just not being able to, like, witness what her blood sugar was doing and make some cogent decisions based on it. Right. So CGM, I mean, listen, Dexcom is a sponsor, but I still I just want to speak honestly here like, you know, I'm not trying to skirt anything. Big difference between g7 and libre three, like, no right

Jennifer Smith, CDE 17:06
now, and that's it's a good point to bring up because I think all the sensors honestly have fair enough similarity and accuracy. What may be the difference person to person is how their body actually interacts with that sensor. Right? I mean, I've said before, I don't know anything about the new Medtronic sensor, the newest one with their seven ATG insulin pump system. I've had people have told me it's a lot better for them compared to previous models. The previous models never worked for me. But Dexcom has always worked very well for me. And prior to going off the market in 2010 ish. I think Abbott used to be called the Navigator. That one was phenomenal. It worked wonderful. I switched to Dexcom it works similar and accuracy now is quite great. The libre as well, I haven't used it in yours. But there are a lot of people that actually prefer that to Dexcom. Right. So there are I think, accuracy. They're similar. But then person to person, you may also have adhesive issues. So don't discard somebody's comments about one system. Because the other systems may work in terms of accuracy, but it may work for other things like adhesives, skin issues under the skin, you know, reactivity and all that kind of stuff.

Scott Benner 18:31
I've seen people who can't wear a certain sensor just doesn't even give them a reasonable reading. And right, who knows, you know, they, I mean, you're not you're never there, but they say I'm hydrated. They say, you know, I did the right things when I put it on and they've tried sometimes for months and eventually abandoned them go to the other company or whatnot, is the sensor from Medtronic called a guardian still did they just keep that name? through it. It's just the newer one, or I wonder if they renamed it.

Jennifer Smith, CDE 18:58
I think it's still the Guardian, I'd actually have to check. But it's it's the newest that works with their seven ATG system. So

Scott Benner 19:06
there's Dexcom libre, Medtronic, there's the Sensi onyx, the implantable one, ever since ever since. Right, right. Yeah. And is that it at the moment?

Jennifer Smith, CDE 19:18
here and I'm trying to think here in the United States. That is

Scott Benner 19:23
it. Yeah. And those are the ones that are that are accurate enough for somebody to dose insulin from them. There's a crap ton of them now that are for like exercise and stuff like that. But yeah, those are not

Jennifer Smith, CDE 19:34
right. Those are not what would be recommended to use for dosing. Oh,

Scott Benner 19:40
Jenny, that was a big word out of you recommended. Okay.

Jennifer Smith, CDE 19:46
Not usually use big words. No, no, I

Scott Benner 19:48
mean it I thought it had a lot of implication when you said it. Maybe I was reading more into it. But no, you're not saying they work but they're not recommended.

Jennifer Smith, CDE 19:55
They're not recommended mainly because they're not you know, There's no indication on them.

Scott Benner 20:02
They haven't gone through the FDA process, right? That they're not going to pair with AI D systems or, you know any of that. Right? And really, you know, for doctors who are listening who might not know, I do think we should dig into it for a second, I'm just gonna let you speak from your own experience. But what is the difference between managing type one diabetes or insulin with diabetes with a CGM or without a CGM? Oh,

Jennifer Smith, CDE 20:28
it's night and day. Really, I mean, as and I think I've said before, in other episodes about the number of times I was doing finger sticks to gather enough information in my day, to make enough decisions about things right, my doctor had written my prescription for 15 test trips a day, just so that insurance would give me enough test strips. And I wanted all of that information at my fingertips are now very happy since about 2005. That I don't have to do that. finger sticks every day. But there's a really good graphic that came out eons ago, when sensors really first sort of started to get a foot in the door. And it gave a graph a 24 hour graph of, I think it was four or six finger sticks on the graph at different times of the day. And then what brought in the visibility of the sensor, kind of what the sensor provides is an overlay behind all of that of the ups and downs from every five minutes of a sensor reading, compared to just the four to six finger sticks values. So I know you've said before, too, you thought you guys were doing really well. When Arden was little right, you'd put her to bed at a certain number. she'd wake up at this number. But then once you had to CGM, you could see that she was going hypo overnight, right? Yeah. And landing in a place that you thought was good. Without the sensor, you didn't know that was happening. I also didn't know where there were problems in the aftermath of my meals, despite doing what is a lot of finger sticks in a day. Yeah,

Scott Benner 22:03
in the time, it took you to say that I with my pen in my hand, and my whiteboard in front of me, wrote down mental health, physical impacts, accuracy, being able to adjust your blood sugar. Well, being able to deal with difficult foods with insulin better being ready to pair with an algorithm. Those are just the reasons that I could think of in two minutes to have a seat salutely. So absolutely. It's not a fancy thing. It's not an extra it's not a nice to have like it really is. In my mind. It should be the first thing like you should get one in the hospital, when you're diagnosed. All these things that you hear people talk about years of diabetes, you know, the things old timers talk about the problems they have, I think many of them are completely alleviated with a with a CGM. Absolutely.

Jennifer Smith, CDE 22:52
And I think in terms of where it should be prescribed in hospital would be great. Because if you've got it in the hospital, you would at least have an education component to what you're seeing, you know, sending somebody home with a prescription newly diagnosed and then they're supposed to slap on this device and make heads and tails out of what they're actually seeing, along with all of these other things that our new variables to pay attention to. That's an overload. It really is. Can it help if they get quick intervention of information after they get it? Yes, and it can make a big difference from the beginning. But it just goes to also demonstrate how important it is that follow up right after diagnosis with all of this stuff being valuable. It's it's just really,

Scott Benner 23:43
even for people who are not like, dialed in super motivated about their diabetes, right? People who are just getting by not paying a ton of attention to it, let them see this number is when I don't feel good. Or this you know, I didn't know I started feeling dizzy at this number, but I still had time to do something about it before I got really low. Like those. I think that showing people those, those little guardrails maybe allows them to retrain their brain over time, to the point where they don't even know they're doing it. You know, until one day someone just says, Oh, I got a beeping it and wherever they ended up setting their, you know their CGM to beat that. I know when I'm 95 Diagonal down, I need like 10 carbs, that's another thing they would know before they would test their blood sugar See 95 And they Oh my god, this is perfect. And then you know, end up low a half an hour later. And that's when the mental part comes in the the instability is like, this is unknowable, and I'm never gonna figure this out. It doesn't make any sense because without that data, it doesn't make sense plus, it helps the doctor you know, it does

Jennifer Smith, CDE 24:47
and the you know, we're talking about general medicine, primary care who may be working with more of the type two population. That also means that you now have to do a bit of homework and understanding and live Learning how to read reports, if you are going to prescribe these, being the primary person, this person with diabetes is coming back to, to relay information, you have to know what you're looking at and how to help them, you know, maybe you've talked to them before about not drinking two glasses of orange juice every single morning, hey, this isn't good for your blood, sugar, et cetera. Well, now that there's information and a view of what that actually does, that has to be brought back into the conversation, if that's the point you were trying to make. And sometimes it's just one point at a time, it's one point per visit,

Scott Benner 25:35
it also helps people see the impacts of certain like foods to that they think are like Staples, like great stuff for them, but maybe they'll like, I don't know, maybe the third time they have mashed potatoes, they'll think I you know, that's not worth my blood sugar be in 250. For the next three hours, I'm gonna have, you know, a smaller amount or not eat this anymore, do something different to it, like all kinds of small things. We're always telling people to do the right thing. And then not giving them the tools to do it with, you know, or even the direction to do it with you just say you should eat better. exercise more, what does what does all that mean? You know, like, it's nice to say, but it's not actionable. Right? My brother is a type two, he got a hold of samples of a G six, get G six samples on time, enough to keep him going for like a month. And the significance was huge, like things that a doctor had been saying to him for years that he thought he understood, it turns out, he didn't understand that at all. And he was telling me, he understood, I get what they're saying, you know, and then he wears the CGM for three, three weeks, you know, a month and boom, he understands it.

Jennifer Smith, CDE 26:39
He's like, Oh, that's what happened. That's what

Scott Benner 26:44
they meant. I didn't get it. So anyway, I mean, again, back to insurance, everyone who can get it should get it. And even people who, you know, can't, Medicare, right covers Dexcom, I know, I'm pretty sure for Dexcom, these things are only going to get more and more popular and covered as time goes on, in my opinion, you should start at, we want you to have these things. Let's see if we can get your insurance to cover it. If not, you know what wouldn't be wrong to say to somebody, if your employer is self pay, maybe you should go talk to them. Because they might say okay to this for you, but you have no idea what you can work out. And as a doctor, I think that's the minimum you should understand to say to somebody, right, that's all that's what I got, there. We missing anything with this stuff, and what you want doctors to know about them. I

Jennifer Smith, CDE 27:36
don't think I you know, I mentioned it before in terms of technology really takes some desire to learn about in order to be able to know what you're recommending to your patients. And so, you know, take some of your time, whether it's a class that you take, that you don't really think is purposeful for you that somebody is going to come in from Dexcom, or somebody is going to come in, you know, from Avid or whatever it might be. And you're like, whatever. But you know what you might grasp something from it. There are a lot of actual online tutorials. So you don't even have to go and sit in a class, though, do an online tutorial, but how does the system work? What type of information does it give, and they're all professional based tutorials. So it might take you 15 or 20 minutes, but you know what, now you can better serve your patients, you're actually more informed. And that goes across the board for the technology. Because not only do we have the continuous glucose monitors and the blood glucose meters, but we also have apps and things that sync with them. So from a clinical standpoint, the ability to get that information from somebody and be able to make sense of it and send them some thoughts back or in a visit, discuss that with them becomes even more for facilitating their well being.

Scott Benner 28:55
There should be some continuing education for you. You know, diabetes, insulin, that the technology I mean, come on, like you have to understand how that works. And I don't know how you ever buy a car, and then had the person show you the car, but they didn't know how it works. And all you can do is sit there and think you work here. Shouldn't you know this? Did you know this? Yeah. What do you mean, you don't know what this switch does? You work here, you only sell for cars. You don't know what the switch is? That feeling that immediately removes your ability to trust the person you're talking to? Yes. Right. And, and what Jenny's saying about educating yourself about how these systems work, so you can speak about them is it's not just about that. It's not just about helping the person feel better and not going like Oh, they'll figure it out. You know, it's about them trusting you moving forward. Yes, it really is. You shoot yourself in the foot and it's hard to get back from it. I've had that experience where a physician has said something so bad bonkers, that I was like, Oh, now I know not to listen to them anymore, which isn't fair either. You don't mean like, but it is how it makes you feel. And

Jennifer Smith, CDE 30:08
in today's world of, again, technology, technology being an online driven review system, honestly, shooting yourself in the foot is kind of a bottom of the barrel way of saying it. There's so much feedback that's given in online forums and everything in all different types of professions that you can make one little kind of misstep, and you're getting a bad review. And then it's bad review after nobody coming to you after somebody commenting. It's that it's sort of just snowball.

Scott Benner 30:44
Yeah, you're in business to might be important for people to think that you're a value to them. Yeah. Especially in a world where by the way, people now can go to walk in clinics and get prescriptions if they needed. Even some people have, through their insurance through their employers have access to physicians now. Like, Yeah, everybody's not just going to come to you because you're there. But let's go through real quickly, Jenny, what everybody said, Oh, yes, for CGM, SB gems. My doctor didn't even tell me to watch even a YouTube video. He just prescribed it and left me on my own. So that's such a crazy idea. Here. Take this it does this good luck.

Jennifer Smith, CDE 31:22
Right. Yeah, I know. I mean, when I and I don't know what you guys had when you first got the one because you only started with Dexcom. You never used anything else. Right? Correct. Yeah. So I'm assuming that you got some education given that Arden was a child? Yes.

Scott Benner 31:40
But it felt like they were building the plane as they were flying it because it was so early on. You know, it's like you were learning together in the office with somebody which I appreciated. They, they were like, look, it's new. We don't really know. Right, which I thought that was great. Because we'd also had an experience in the past, where we were told not to use an omni pod. Because I forget, what did they tell us? Or they said Your daughter's to lean for that. And oh, and I was like, I don't know what that means. But we're getting this anyway. And so we got it. I mean, I went with Omni pod originally, because of the just the generally the tubeless nature of it seemed, for a number of reasons like the way to go. It took two years for the endocrinologist to pull me aside one day and say, We want you to know that because of RT and success on Omni pod. We're now writing prescriptions for Omni pod to younger kids that we weren't before. And I said, Why did you tell me all those years ago like not to use it, and in a very quiet tone, the person said to me, it was newer, and we weren't comfortable with it. So we didn't want you using a device we didn't understand. So it had nothing to do with how lean Arden was it had to do with they didn't understand it. They didn't want to take the time to learn it. And so they weren't going to they were going to just push me towards another device. And

Jennifer Smith, CDE 32:55
or they had experience with what was already on the market. And in comparison, which wasn't a fair comparison. They were able to say she may be too lean, she may not do well with this or whatever. And again, their comfort level and I find this not as much now but years ago honestly, many offices had a comfort level weren't talking just about insulin pumps with one particular pump. Yeah, that's what they maneuvered everybody toward this pump. Because we know this pump Oh

Scott Benner 33:29
yeah, that was a whole day of somebody saying to me animus ping animus ping, which by the way doesn't exist anymore?

Unknown Speaker 33:34
No, it wasn't good pump.

Scott Benner 33:35
I was on it. Everyone I've ever spoken to says they love it. Absolutely. But Arden is also used Omnipod for she started on a pump when she was four. She's 915 artists been using Omnipod for 15 years. So I think we did okay, but that point of understanding what you're talking about, so that you can actually talk about this person says they should know that CGM 's are extremely important at diagnosis, not knowing exactly how insulin affects you. And all of the other factors that go into managing sugars are very helpful in determining all of your personal factors. Yes. And I wrote a note after that, they just said, Look, patients shouldn't even have to ask for CGM. You shouldn't make a person. They don't know anything about diabetes. You don't I mean, now you're asking them to choose what they're supposed to be. You know, using they don't have any idea this person's like, You got to tell me, you know, she goes on to talk about, about catching loads how important it was, especially for their child. And then this other person says, I'm, uh, I was diagnosed at 29 I needed this the same for the same reasons, right? And then oh, this is interesting. This person had a libre back when back when they were scan only you had to hold the device up to the libre to get that number. And the physician told them that they were scanning it too frequently. You have you ever heard somebody say don't look at it so often.

Jennifer Smith, CDE 34:51
Yes. Yeah. From a mental health standpoint. I think that there are there are some people obviously who they you Use it. Not quite to their health. But as almost an obsessive, I have to check, I have to check. I have to know where I am. Oh, it's going down. Oh, it's going up. And there's a difference in that versus I need to see where I am because I have this planned. And I need to see what my action is right now. For the coming, you know, plan? Yeah,

Scott Benner 35:21
the best way I've ever found to make people comfortable there is to tell them, Look, let's set more reasonable alarms. And then don't look. Unless the alarm sounding. That's it, but we can't make your high alarm 250. Like, you know, we can't do that,

Jennifer Smith, CDE 35:35
right? Because then you're gonna miss the mark. And that's going to make you hyper vigilant, again,

Scott Benner 35:39
not gonna be the point. And for a doctor who says, Oh, if I don't make it to 50, the thing will be beeping all the time, I would say to you, you might want to go listen to the Pro Tip series, because it doesn't need to be beeping all the time. It doesn't need to be going high all the time. There's simple ways about using insulin that will help you right, so Okay, agreed. All right. Thank you very much. Yes, of course. Let's do this. Let's move into pumping. But if it doesn't fit here, I'll split it up into two different episodes. That way I have it here. But I can maybe put in its own if it needs to be is that okay? That's fine. I have about 15 minutes where you're going to go through the people's questions. And if we have to come back later and finish up we will. So cool. I wish they would have explained the difference in detail between t slim and Omni pod. Oh, isn't this interesting? In the new device world. This person doesn't even mention Medtronic. They were extremely vague and our toddler is on Omni pod. And so you made this point already in the CGM episode, but you need to understand what these things do. This is Omni pod, this is how it works. Here's why it might be better for you or you are here's what I'm even seeing from people who are using it. This is what the T Slim is. This is what control IQ is like. Do you think that it's possible that doctors just like tube, no tube, you think they're like, it's that simple.

Jennifer Smith, CDE 36:55
Could be practice to practice, quite honestly, it could be that simple. It could also be, these are the pumps, they all deliver insulin. And I think they're trying to save people from some of the very little tidbits of information that make you different. But I also think that that's really important. From an individual need perspective, really good pediatric practices, I know often will have like pump exploration days, where they'll have you know, all of the different pump options come. And you can walk around almost like a fair, right, you can explore talk to the representative, you can feel it, pick it up push buttons, get kind of an idea of what it would look like feel like you know, you can even like clip it on and see what it would be like to kind of have it dangling on your pants or whatever. But those are all really important things when you as a clinician are recommending something, don't recommend based on your preference. That's the bottom line, you have to really consider what does the person need to know if they are a swimmer? And a competitive swimmer? Well, you might tell them a little bit more about why one may be more optimal than another. But it's still up to them to make the decision.

Scott Benner 38:16
I think they should blend information to like I mean, the person who comes out to explain the device to you is the salesperson, right? So like, you know, okay, here's these are the highlights of the pump, that's great. But also go do some research on your own, and talk to users and get their feedback. And go online and hear what people are saying there. And then blend that together. When you're talking about don't just like you're not a salesman for T slim or for Omnipod you're you know, you can't just go by what the pamphlet says the pamphlets, its marketing, right? So right. I'm not saying that one of them is hiding something or something like that. But it's not going to give you a full understanding of it by just reading the brochure. I mean, that would be like making a decision based on my ad. Like if you hear an ad for something, these are the highlights. You should now go figure out the rest of it. Like you know, don't make a decision based on this. I think that's incredibly important. And it goes back to that thing you said during the CGM. It's like you have to educate yourself on how these things work. And especially with the algorithms now. It's not just the I mean, honestly, before the algorithms pumps were, they were just basic,

Jennifer Smith, CDE 39:23
basic delivery that makes it easier than taking

Scott Benner 39:27
injections. The idea behind going from MDI to pumping is that with pumping, you gain control over your Basal insulin. You know, you could set up extended boluses squarewave Bolus, things like that. You can vary basil Yeah, right. You know, you could temporary basil your insulin completely off if you wanted to, if you were in a situation these are things you can't do with MDI. But it wasn't some like insane leap. Like it was just here's the extra things you to me. It's amazing and it's incredibly helpful. But now you're gonna go from those Is to these algorithms, they all are aiming for the same thing, but doing those things differently. And you should know the differences. It just makes sense to me. Because when I stop and think about, where are doctors going to struggle in the coming years with algorithms? I think of it's like little things like fat and protein becomes really important. Right? Like, you know, because a doctor is gonna, like, say, oh, no, the thing does it. But it doesn't. It doesn't know, the thing doesn't know that there's a bunch of fat and the carbs that you told him about at one o'clock and 90 minutes later, your blood sugar's gonna start going up. And then people are like, Well, what should I do? Should I wait for the thing to do it? The thing is gonna take, I mean, honestly, hours to make another decision. And to

Jennifer Smith, CDE 40:44
clarify, will the thing do it? It'll do it? Well, yeah. But as you just said, it'll take hours of time, because all the systems are based on with their algorithm are based on an sort of an extended time of action of our rapid acting influence, which are not rapid. It's a horrible word, whoever came up with that word for today's insulin, yes, it's faster than what I used originally, but it's not rapid, as fast

Scott Benner 41:11
as the word makes it sounds correct. If the algorithm is thinking on a, I don't know, on a six hour timeframe, then your blood sugar shoots up an hour after you eat. And five hours later, the algorithms gonna be like, Oh, we should probably be more aggressive with this, you know, that happens to you at two meals, well, then this, I don't know what good the algorithm is to you at that point, like, you know, if your blood sugar in the 200. Now, if it's holding your blood sugar at 200, and eventually gets it back down, I see the doctors argument, this is way better than these people were doing before. And it is yeah, and I understand that, but a tiny bit of a tiny bit of understanding how insulin works. And a tiny bit of understanding how the algorithm works could lead you to tell them, here's a secondary Bolus maybe we could make that would help us, which the company isn't going to tell you about, because they're not legally allowed. That's not how that works. Like the FDA doesn't allow insulin pump manufacturers to direct you about how to use insulin. That's just the thing that they're not allowed to do. What you're

Jennifer Smith, CDE 42:09
getting into is the idea that, and we've been talking about all along is that as a clinician, you have to educate yourself. Right? There are so many things that you learn as somebody with diabetes, because of the huge benefit of continuous glucose monitors. And when you fold that continuous information of what your glucose is doing, into a system that can now dose insulin, along with that, you have to know how to look at the data to help somebody best make decisions for their life. I mean, we started MDI, it is what it is you could Bolus 16 times a day and sort of mimic what you think you need to do. Sure, go ahead, but it's not going to have precision, conventional pumping. Next line, you've got some smart features, but who's the driver, the person, the person drives the the use of those precision parts of that technology. And then algorithms bring it even further. But not far enough. Our algorithms are not AI, right? They're not learning. They're not saying Oh, every Friday night pizza is coming in, you got to be ready for this. It's not there yet. So the smart driver is still the human. And the human needs the right information in order to be able to navigate blood sugars in a target range that's going to keep them healthy, long term,

Scott Benner 43:32
we made a significant adjustment last night to get Arden's blood sugar down. We didn't wait for the algorithm to do it. We were like, No, I know what to do here like to get this down and did not cause a low or anything like that afterwards. I think maybe I'm just as you were talking, I thought maybe doctors should do ride alongs with people who have type one, right? Because you always hear my endo is terrific. They have type one diabetes, like people say that all the time. Like I hate to say it, but my endo is better because they have type one my nurse practitioner knows, I mean, listen, you have type one, right, like so. I do. Wonder if that's not doable. I wonder if doctors couldn't just like, live a day with a patient every once in a while. Just I mean, honestly, that's how you if you lived here for a week, you wouldn't, you'd know everything you needed to know.

Jennifer Smith, CDE 44:17
But I wouldn't even say to go there. If you are a doctor who is prescribing these, an easier ride along really would be take the product, put it on your body and use it as if you were somebody with diabetes as if you were following the directions that you're giving people to walk out of your office with. Right? Yeah, you know, look up your carbs. Check what is happening before you go for a run, look at your data and know it's not going to reflect shifts like somebody with diabetes has, but it'll get you in the mindset of all of the considerations along with using this piece of technology that is delivering insulin, which is not a silly medication. Even

Scott Benner 45:05
like, maybe this is the right along idea. Maybe it's Can't you just follow one of your patients for a week? Like, can you get somebody like get there? They say, Look, I'm trying to learn more about all this, would you help me? I'm gonna follow your CGM. I know that sounds crazy. But for a few days, just text me, I just ate this, it was this many carbs like that, like, here's how much insulin I put it, it wouldn't take you long to like, go, okay, I get this. And now you've had this, you take this thing you take time, one time. And now you can take what you learned and give it to everybody. It's just none of you are going to do that. I know when I said let me just tell you right now, that's the best idea I've ever heard. So if you're a doctor trying to help people with type one, following a type one, knowing what they when they ate it, and how much insulin they got, then watching their CGM, you would understand in no time at all what was happening. And you'd be able to not only just help that person, but you'd be able to transfer that knowledge on to other people. So anyway, you would I'm 100%. Right about that. I'm not I'm not backing down off of that, quickly, if this person says hey, if you're having issues with like a glucose monitor, or a pump or something, it would be lovely if the doctor would help us when we need help with our insurance, oh, writing letters of medical necessity, things like that, you know, don't just give people a script and then go, Oh, it didn't work out. That's tough. There are times they need you to step up. I would also say that giving somebody an arbitrary amount of time before they're allowed to have a device, I don't think makes a ton of sense,

Jennifer Smith, CDE 46:37
is ridiculous. It needs to be individualized. Yes. Yeah, I

Scott Benner 46:40
mean, I get that my assumption is, is that they've had this experience with insurance companies. And they know that the insurance companies deny in the beginning, but that's also you can get around that, and you know it. So you know, people are begging for insulin pumps, just telling them Oh, it has to be six months, or the practice has a rule. You have to be on MDI for a year, correct. You know, I mean, a year Jesus, you can't figure it out, you know,

Jennifer Smith, CDE 47:04
yeah, I was gonna say that, that's often what it actually boils down to is a protocol that's within the practice, or within the department or whatever, that says, you have to meet all of these pieces. And typically, it takes six months. So we're gonna say, within about six months, then we can start working towards getting you a pump. Yeah, but again, that everybody is so different in their life, and has so many different variables and needs, that you really have to throw those protocols out. And you have to say, well, you know what, this person definitely needs a weight, there is a lot going on here, this person could definitely have it within the next month, because they need it and they, they get it, they're at a higher level of learning, or they've reached certain, you know, points of education that are already important. So individualize. Okay,

Scott Benner 47:58
thank you, Jenny. I'm gonna leave a voice note here for both of us. So when we come back and re record again, we're going to talk about why insulin pumps are so important. What they do for people, they're not just replacements for injections, and what value they'd get out of pumping and what value they'd get out of an algorithm. And we're gonna actually like continue this conversation next time you're back. Fantastic. Thank you so much, of course.

A huge thanks to Omni pod, not just my longest sponsor, but my first one Omni pod.com/juice box. If you love the podcast, and you love tubeless insulin pumps, this link is for you. Omni pod.com/juice box. A huge thanks to touched by type one for sponsoring this episode of The Juicebox Podcast. Check them out on their website touched by type one.org or on Facebook and Instagram. If you're looking for community around type one diabetes, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, but everybody is welcome. Type one type two gestational loved ones. It doesn't matter to me. If you're impacted by diabetes, and you're looking for support, comfort or community check out Juicebox Podcast type one diabetes on Facebook. To continue this conversation jump now to Episode 1126. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com