August 12, 2024 • 55 mins
We're celebrating some big news – the Dexcom G7 is finally dropping in Oz this September! 🥳 We'll give you the lowdown on the awesome new features, and reveal a slightly disappointing caveat... This episode also features our first guest: Dr. Aldo Riquelmi, who is a GP and... a diabetes educator! 😱
This was a great discussion about getting more out of your GP visit than just scripts and referrals, and the role GPs can play (if you want them to) in your type 1 care. Aldo acknowledges that the health system is rigid and can be frustrating, but that with the right GP, you can use it to your advantage, and that some welcome changes might be coming in the next few years...
During the show, we had some confusion over whether Dexcom G7 would allow users to silence urgent low alarms. We checked with Google and yes, we will be able to silence all alerts (including urgent low alerts) for up to 6 hours - yippee! Or at least that's how it works in the US.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Music.
(00:10):
Today on Life in Beta, we celebrate the announcement that Dexcom G7 is coming
this September, finally.
And we chat with Dr Aldo Raquelmi, a GP and diabetes educator.
We talk about where GPs fit, or not, in your Type 1 care team,
and the perception of GPs as the gatekeepers of the medical system.
When I moved from England, I was really surprised that people needed to come
(00:34):
in to get a referral and to be referred to a care plan so they can access subsidised
visits. I think the system is very rigid and the system could well be changing in the next few years.
Music.
Welcome back to another episode of Life in Beta, the show where we talk about
(00:54):
the lived reality of type 1 diabetes.
My name is Adam Brockway. I'm the community manager at the Type 1 Diabetes Family Centre.
As always, joining me on the panel, we have Carly Green.
Hey, Carly. Hi, how are you? I'm good. I'm good. Just for reference,
I'm meant to be asking the questions. That's how this works.
It's always spicy. So spicy. And Benjamin Jardine, how are you doing?
(01:18):
I'm doing well. Referee between the sibling rivalries. Yes, that is your job.
Excellent. It's an interesting dynamic, this, because Benjamin is our boss,
and then we sit here and we just kind of like mouth off about various topics for an hour a week.
As I say often, I sometimes wonder at the team I have assembled here.
And as I often remind, we leave our ranks at the
door as soon as we walk out we know where
(01:39):
we stand all right we have exciting late
breaking news don't we we do we do so this episode
we obviously have our interview with dr aldo
riquelme which we are super excited about however breaking news we thought we
just had to throw this in beforehand welcome as a guest sorry there's news love
you bye uh dexcom g7 we have been talking about this since literally before this podcast launched.
(02:08):
Gee, that April release date was a long time, wasn't it? Oh, we got it so wrong.
However, in the last 48 hours, healthcare professionals have been briefed by
Dexcom and we're kind of allowed to talk about things now, which is cool.
So we thought we'd just go over a little bit of what to expect from G7 and a
couple of caveats because it's not all shiny news, unfortunately.
(02:30):
Ah, traditional type 1 diabetes news. Look at all these exciting things,
you can't have it. Exactly. Exactly.
Life with Type 1. So what we do know at the moment is that launch in September.
That's what we have been told. September, it's coming, apparently.
No, not apparently. You can order online as of September. It just may not be
like in-your-face news.
They're just going to allow it to happen. It's going to be a soft launch because...
(02:52):
Because of something. Caveat number one, it doesn't have...
Ndss support yet exactly so you can order it for 110 a sensor yay yay or you can wait until,
dexcom sort stuff out with ndss and then it's the usual 32
50 a month so for those of you who were previously funding your cgms and remember
(03:15):
that period where you felt how am i paying two mortgages at once welcome back
that was me i can't believe it but my hope is that it's not going to be too
long before they sort their thing out.
That's what the reps have said. So let's hope they're right about that.
So why should we be excited by Dexcom G7? Okay. Let's reel off the tech specs here.
(03:38):
I'll try and keep my nerd to a minimum. So 60% smaller than G6.
60% smaller. So Carly's actually got one. Can we just talk about this for a minute?
I have been so excited about the size, like particularly, and they've arrived,
just a little demo kit today to the family centre.
They are so cute and so tiny. It doesn't look much bigger than my T-Slim-like sight on my body.
(04:01):
So it's super flat, super round, super pretty, doesn't take up much real estate on the body.
So if I hold my, like here's mine at the moment.
Look, miniature. Yeah, teeny tiny. So very, very excited.
60% smaller, weighs 3.3 grams, if that means anything to anyone, but yeah, it's tiny.
(04:22):
The other thing I really love about this sensor, 30-minute warm-up time.
Yeah, that's a game changer.
But technically no warm-up time, right? So, yes, so here's the hack.
So it comes preloaded into the inserter, just like G6 did.
The 30-minute timer starts from when it is inserted, from when it leaves the inserter.
(04:43):
So you can put G7, you can put your new sensor on half an hour or more before the last one finishes.
And then when the old one expires, you just tell your pump or phone or whatever
to switch over to the new one and zero downtime. It's up and running, no downtime.
And this is because the transmitter's now inbuilt into each sensor,
just for those who are going, how does that work?
(05:03):
But what will I do when I no longer have those two hours every 10 days where
I remind myself of how terrible it was when I didn't have glucose readings every
five days? Oh no, we can't cry ourselves to sleep. What are we going to do?
We'll have to find something else to moan about.
I'm sure we'll find something. thing. They also have a 12 hour grace period.
Love this. Love this. The Omnipod has an eight hour grace period and that's
(05:23):
just not quite enough for when I find out at midnight that I really need to
change my pod and I don't want to change my pod, but also I don't want to get
up before eight o'clock in the morning.
12 hours. I reckon I can work with it. Should do it. Yep. Yep.
Yep. Yep. No, that'd be great. I had that with a sensor like literally a few
nights ago. I was like, oh,
I'm already in bed. I'm not changing it now. It's cozy in here.
Yeah, so sure enough, 2.30 in the morning, my pump's like, hello,
(05:46):
end of sensor. Yeah, okay, I'll deal with you in the morning. So 10.5 days.
10.5 days, yep. Yep, yep, yep. Innovation, people.
Alerts. So there is a new silent mode where you can silence all alerts for up
to six hours. You can choose how long.
I know when I go on stage or whatever, like for performances,
(06:07):
the ability to just say, do not interrupt me for any reason whatsoever will
be a game changer. I'm excited.
I'm really struggling with this one. I feel like I've got dad hat and person
with type one hat on. Yeah, go on.
Because I know how frustrating it is to have an urgent low alarm go off.
You know, it's the one thing you can't turn off. It's always going to happen.
(06:28):
In the cinema, at work, whatever it is.
There is actually a reason that there's an urgent low alarm, right?
And it's not that you can say, come back to me in six hours and I'll deal with
my hypo. The hypo's not going to wait.
So, you know, I can think of a hundred scenarios, you know, going up on stage,
going to movies where you don't want the alarm to go off. I don't want a hypo anytime.
(06:49):
Probably do want to know about it. So I don't know. I get it. I get it.
Well, it's still going to do an urgent low alarm.
I heard it wasn't. No, it is. And for me, I'm reading this and I'm like,
oh, it's not really much different to what what I do now, because I just go
into alerts and turn everything off.
If you can't sort your facts out, then what can our audience rely upon?
Yeah, we're going to have to get an arbitrator in.
Because my understanding is, so you've got silent mode, and then you have vibrate
(07:13):
mode, which is for all alerts except urgent lows.
So that doesn't make sense. Why would vibrate mode, it vibrates for everything
except urgent lows that are loud?
Well, now I'm not sure whether I'm supposed to care at all, because I've turned
off all the alarms that I can't.
We'll come back and confirm that one for everyone. I was so confident, but now I'm not sure.
(07:36):
Last, it's also more accurate. If you know what a MARD is, mean absolute relative
difference, hashtag nerd alert, G6 was 9% and G7 is 8.2% and lower is better. That's what we know.
Did we find out whether finger pricks are more accurate or less accurate?
Still more accurate is my understanding. Still more accurate.
I don't know how much though.
(07:59):
So, yes, that's G7. So, coming in September, it won't launch with NDSS support,
but that will be coming soon.
Keep an eye on Family Centre socials because we will let you know as soon as
it is available that way.
And we'll be doing an event at some point for those of you in Perth.
And Carly, I have to agree with you on the size thing. I wasn't convinced originally.
And then I sat down for this podcast, looked at the framing of this shot and
(08:20):
realised it looks like I've got a cigarette pack stuck under my arm. It does.
I know that you two have never really gotten on board.
Just you think that I'm a vain female, just not wanting to wear a big thing
on my body. You said it, not me.
Yeah, please don't put words in my mouth. The internet will hate on us from on high.
I just got cancelled for saying nothing. But it's not so much about that.
Like I will happily, you know, rep the tech.
(08:43):
Rep the tech? Yeah. But sometimes you just want to reduce the amount of type
one you wear and have to deal with on a daily basis.
So to have it smaller in all shapes and forms, for me, very exciting.
Very cool. All right.
Enough breaking news. Back to our special guest of honour.
I'm very excited to introduce our first ever guest on Life in Beta.
(09:04):
This is Dr. Aldo Riquelme.
Did I pronounce that right? Well done. You pronounced it perfectly.
Oh, thank you. All right.
The rest's easy downhill from here. Yeah.
Aldo studied medicine in Newcastle in the UK, practices in Midland here in Perth,
specialises in chronic disease management and took that so seriously that he
(09:27):
has gone on to become a diabetes educator as well. So welcome. How's life?
Life is good. Life is busy this time of year for a GP, like winter season. But yeah, life is good.
Is that, I've often wondered about winter and colds Is that just like old wives
tales so to speak What is it about cold weather that actually gives us,
(09:47):
colds? Typically, we get much higher rates of respiratory disease,
common colds this time of the year, also people coming in for their flu vaccine.
So in general, we start getting busier from March onwards, start to quieten
around September, October each year. It's a very seasonal, very cyclical.
So if we need a chronic disease management plan, we should come see you in November,
(10:09):
December, January. Anytime.
Yeah, yeah, it's a bit busier, but you know, we are
used to it really used to it adam i love that you
introduced our guest a special guest to
talk about gps and type one and you just went down a
nerdy rabbit hole do we get respiratory infections more
during the cold i've got this
(10:31):
rash on my leg all day yes so aldo
of all the specialties you could have chosen you chose
gp why gp like what is it that
what is it that called to you about that specialty i really love the
challenge of like having a variety i
think variety is the spice of life but i also i enjoy i think we get the privilege
(10:53):
of gps to develop friendships and continuity of care over a period of time i've
had people that have been coming to see me with their families for more than
10 years and i think there is a privilege and a responsibility to,
see people and be there for them during their ups and downs when life is good
when life is not so good, when they want to be engaged, when they don't want to be engaged.
(11:16):
I think that's quite a privilege and a challenge that we get.
Of course, some people may come to see us over a long period of time.
Some people may choose to move on and that's fine. But I think that's one of the challenges.
And beauties of of this job also i love the fact
that general practice can take you into a lot of
many different directions in your in your career fair
(11:38):
yeah i love what you say there about the ability to build friendships like i
i have never actually thought about putting gp and friendship in the same sentence
but i love that that that is a beautiful thing as you say like see these families
for 10 plus years you see them have kids you see them go through all various stages of life Yeah,
that's right. It's so true. People talk about who's their GP.
Generally, you don't hear people having a general conversation about,
(12:01):
oh, by the way, my cardiologist is blah, blah, blah.
Mind you, in type one land, who's your endocrinologist is a pretty common conversation,
but we are a special breed. Yeah.
So, what I find particularly interesting is that you're a GP and you are also
a diabetes educator of recently, correct?
So, I haven't yet qualified as a diabetes educator, cater but
(12:21):
i've done the course like that could lead into that
i would have to get all these hours of practice to become
credentialed gp is not enough i've done the graduate certificate but like the
reason i i decided to go into it is because i could see that we were getting
so many people being diagnosed with diabetes and pre-diabetes coming through
(12:43):
our doors it's been been feeling like a bit of a,
of a wave that was coming towards us.
And I thought we need to be able to ride this wave, otherwise we're going to sink in it.
We need to be able to have the knowledge and the awareness of how we can help
these people and do what we can in primary care, because the other reality that
(13:04):
we are finding, and I've audited this,
a lot of people that we refer to endocrinology.
And let's say allied health professionals, whether it's diabetes educator or
others, 40% or around 30%, they actually don't make it.
We give them a referral despite informed consent and explaining a rationale
(13:25):
for a variety of reasons, whether it's cost, availability of appointments, etc.
A lot of people don't make it that far. So that means that we have a responsibility
in primary care when we see people to do our very best to give them the tools
and the knowledge that they need to be able to self-manage well and to be able
(13:45):
to manage their condition well.
Have you seen an increase in diagnosis of type 1 diabetes?
Of course, the vast majority of diabetes that we're dealing with in Australia is type 2, around 90%.
What's different about type 1 diabetes is that in type 2, as GPs,
we're actively involved in managing, prescribing, following up, titrating medication.
(14:09):
I think it's fair to say that type 1 diabetes is regarded as a more complex type of diabetes.
Preaching to the converted here. We would tend to agree. Yeah, we might be biased.
So I think the main difference is for someone
living with type 1 of course the
gp will not be your expert source of support i mean we're just talking about
(14:32):
g7 most gps are not aware even familiar with cgm let alone other diabetes technologies
like you know different types of like insulin pumps and all that that
can feel very foreign to most gps unless a gp has type 1 themselves or they
have a family member that have type 1, for most of us, all this technology is
(14:57):
quite foreign to us. So I think the main difference is...
You might need to use us for like your referrals, your care plan, your script.
And of course, not all of your health is about type 1 diabetes.
So there could be aspects where you need to see a doctor, whether it's to do
with your cardiovascular, other conditions, mental health, etc.
(15:18):
Or in brackets, minor illness. We're talking about colds and respiratory infections, etc.
So you might need a GP for that. But I think on the whole, by and large,
we will not be actively involved in managing or making decisions about your
type 1 diabetes treatment.
I think that's fair to say. Apologies, my phone is...
(15:39):
It's not too different from the insulin pump alarms we get from time to time. So we will let you off.
Yeah. So I would imagine that that's what it may feel like to people living
with type 1, that you might see a GP for things like referral scripts.
And sometimes it can feel a bit frustrating to have to go and see your GP just
(16:00):
to get a referral, just to get a care plan, just to get a script.
But I guess there is a role in terms of care coordination and then also engaging people.
People because like you may at
the type one center see people who are
relatively engaged because if people are coming here they already have some
(16:22):
form of motivation or willingness to engage we do see people in primary care
that they're just coming for a script yep and we try and i talk to them about
when did you last have a blood test when did you last see the endo when did
you last see a diabetes educator?
For some people, it may have been years. So we have a role in trying to get
(16:45):
people back onto a road where they're engaged.
And of course, not everyone is managing their diabetes optimally.
Some people are just surviving.
And many people, I'm finding that quite a few people with type 1 out there.
They don't know about CGM or they know about CGM, but they have preconceived ideas.
(17:07):
So we are trying to do what we can in terms of letting them know about these
technologies, trying to engage them with services, letting them know about this
fantastic service here at the Type 1.
We'll pay you later, Otto. Thank you. Yeah.
Yeah, that's interesting. Can I throw in a little question out of interest?
Yeah. Back in medical school when you were studying, what did you learn about
(17:30):
Type 1 diabetes? Like, did that make an appearance in your training? Oh, definitely.
I mean, we were taught about endocrinology and specifically about diabetes and
how that might present the different types of diabetes.
Of course, this is over 20 years ago now.
Of course. Things could have changed, but it's definitely part of the medical
school curriculum and definitely part of GP training as well.
(17:55):
But of course, as you can imagine,
dealing with the whole spectrum of disease and the whole spectrum of the life
cycle the reality is that not
all gps will have an in-depth or up-to-date knowledge about all conditions.
And these days even specialists are becoming sub-specialized right if you look
at orthopedics you're dealing with some surgeons will only do hips or only only
(18:19):
do knees some endocrinologist also becomes sub-specialized so we are finding
that because of the the fast moving pace of.
Evidence and knowledge and technology gps will also have an area of interest
so you have gps who have an interest and more knowledge in diabetes and other
things and then others will have other areas of interest as well but it's fair
(18:41):
to say that diabetes is such an important,
topic these days because it increase incidence that we need to be up to date
especially dealing with emergencies getting the diagnosis right referring from
treatment that that's super Super important.
Yeah. There's so many things I want to deep dive on here.
You've just hit like every marker that I want to talk about today. Yeah, yeah, yeah, yeah.
(19:05):
I think where I want to start, I want to pick up on some language you used and
just test something with you.
Yeah. So what I heard you say is the GP is, I think the words you used were
not actively engaged in the type one medical management, if you like.
What I mean by that is like actively managing in terms of like making, let's say, medical
(19:25):
corrections to your insulin or initiating treatments
to do with insulin in type 1 diabetes so
the reason i want to unpick it actually there's many
reasons i want to unpick it yeah one is because in my
observation the nature of type 1 is such that that's
us it's not the endocrinologist it's not the
gp yeah who is making the day-to-day decisions adjustments management it's the
(19:49):
individual yeah and your point on subspeciality is really interesting to me
because the challenge I always have and what I hear from the community a lot
is that they feel like their interactions with a GP become transactional.
I come in because I need my script.
I come in because I need a referral to go see someone else.
(20:11):
And what is going on in my head in the background is that that's assuming we
kind of say type one is managed by the endocrinologist.
Biologist your respiratory infection is managed
by the gp the reality of
type one is that i can't put
it into a bucket and say i'll save that
up over here and it impacts everything so when
(20:33):
i come and see a gp to talk about my cold type
one is involved it's affecting my blood sugars it's messing up things
that are going on how do people with type one make the
most of their relationship with the gp i think
it's fair to say that i rarely get asked by
someone living with type 1 diabetes about insulin management
(20:54):
most people some occasionally they
might ask but most of the time i think they already realize i'm not the person
to come to when it comes to insulin titration and all these things because they're
already managing themselves or they already know who to go to about these things
they realize the gp is not an expert in that however there's many many aspects
(21:14):
of your health that are not to do with diabetes.
Of course, diabetes may affect it or the other way around, but there's a lot
of other things that you would, or you might benefit from having a generalist
there for support, everyone is different.
So in the person can use that relationship in whatever way is useful to them.
(21:38):
I speak to a lot of people with type one about their GP relationship.
And my sense is it's become transactional over time because what's happened
is the person with type one kind of gets into that space,
which I'm just as guilty of as
anyone of, I know more about type one than anyone I'm going to encounter.
So I get that sense of, it's almost an ego of, I know more than you. So why would I ask you?
(22:00):
And does that then steer towards a relationship where the person won't talk
about things because they kind of think, I know more anyway.
And then do they, does it become, I'm always worried about the person who just
sees their GP as a script mill and never actually has a conversation about what's
going on because I'm a self-manager.
(22:22):
I'm looking after my type one. I know more than you do anyway.
Just give me my damn referral. I think what's happening, and I could be wrong,
what I see is that on the whole, most people that we see with type one diabetes
are a younger population.
So their diabetes might
be the main health issue that
they manage we don't see them that often
(22:45):
in general unless they have other significant medical
problems running alongside and i
guess they're used to self-managing so they might be
more used to you know looking up for information online
trying to problem solve themselves and that
that that's fine we're here if you need us but
i think on the whole we do see less of
(23:07):
them my only concern which i alluded to
earlier and i think there's all sorts of
people out there we do we do occasionally see
people with tab one who very rarely come in not wanting to engage they might
just come for script we try to engage them and then we occasionally might see
(23:27):
them further down the line with severe complications And it doesn't have to be perfect either,
we're not expecting people to have an HbA1c of 7 or 6 all the time,
or have the perfect timing range, etc.
But then there's an undeniable fact that this condition can be associated with
complications in the future.
(23:49):
And then I think one of the main messages I'd like to convey is that.
There's a lot more to health than the diabetes itself. So especially if people
are getting to the age of 40 or above, really important to start considering
things like your cardiovascular risk.
Because of course, that's one of the main killers of people internationally and in Australia.
(24:11):
And sometimes people can overlook that side of things because they have diabetes.
So other risk of like high blood pressure, other risk of heart disease,
are the risk of other chronic conditions beyond the type 1 diabetes.
So what does that relationship ideally look like?
Like if you had the, I use this phrase carefully, perfect type 1 walking to,
(24:34):
like, no. Let me know if you find it.
If you had anyone with type 1 walking to your surgery, but you had the perfect
relationship with them, what would the conversation look like?
What would you be working on together?
How would that work? So it's very, very client centered.
So in general practice, I think in any medical specialty, in any healthcare
(24:56):
client relationship, I think it's patient centered.
But I think there's an element of the consult being also directed by the health professional.
So what I mean is where the person is engaged, is activated in self-management
in terms of having the skills, the knowledge, their willingness to engage,
where they also accept the input from the health professional.
(25:19):
Yeah. So it's like a conversation. So I really appreciate the fact that you
live with this condition, you know how to best manage it, but then as well.
There might be room for adjusting here, there, and there, or having the input
from this person or that person having that conversation.
And of course, coming from a place, when it comes to a GP, I'm not the expert
(25:41):
in managing type one, but this is ways that I can help you and have you thought
about the rest of your health and the rest of your wellbeing beyond diabetes.
I think this type of conversation, I think when it comes to type one,
I think we're more here to support you rather than tell me what to do when it comes to your type one,
(26:02):
but there's a lot more to your wellbeing than type one that I would like you to consider as well.
Right. I, you know, I think it's so easy to end up drawing battle lines as you
were pointing to, you know, someone comes in assuming you're not going to be
able to give me anything that I don't already know.
Then you're setting up a relationship that, that isn't going to work.
(26:24):
And people with type one, I think end up so frustrated that people don't talk
to them about the lived reality, because we do live with it day to day.
It is very difficult to understand if you don't live with it.
But the downside of that is you can get into this bubble of,
I'm the only person that could possibly understand, and no one else can give me any kind of help.
(26:44):
Whereas what you're saying is you've got a different set of skills and knowledge
and understanding and a broader perspective of health.
You mentioned diagnosis, your diagnosis before, Benjamin.
Let's talk about diagnosis. Diagnosis, because this is, I think,
and this is not, you know, I don't have a study with, you know,
X percentage of diagnoses that go down the wrong path or whatever.
But anecdotally here at the Type 1 Centre, we hear a lot of stories of diagnoses
(27:09):
that don't really happen, I think, as we would think that they should in an ideal world.
Carly, yours is a bit of a banger. Carly, you've been sitting on this story
for, what is it, six episodes now. Now, for context, Aldo, where I want to end
up with this is how do we make this experience better for people?
That's where I want this to land. But just for some context, Carly, do you want to?
(27:30):
Yeah, I guess every week we hear the stories of how people with type 1 are diagnosed,
and more often than not, it's pear-shaped.
But I guess over the eight years
since I was diagnosed, I've realized how pear-shaped my diagnosis was.
I presented to my GP at the age of 24. there's
no history of type 1 or diabetes or autoimmune I've
(27:52):
got a very healthy family so I
was 24 I was working as a personal trainer and I was also
studying chiropractic on the side so I was very busy I was fatigued all of a
sudden in the space of three days I lost like 10 kilos I was running to the
bathroom every 45 minutes throughout the night like clockwork busting and And
(28:14):
I thought, oh, no, my kidneys are shot.
Like something's wrong with my kidneys. This is the end. Like I didn't even
have tight one on my radar because, you know, we just don't,
right? So I was like, I need to go to the GP.
Went to the GP. They did a urine sample.
And the GP had said, oh, this indicates diabetes. But in order to,
(28:34):
and I'd obviously presented with all the symptoms I've just told you,
to tell whether this is type 1 or type 2, we'll need to do a glucose intolerance test on you.
And I was like, okay, like this must just be the normal process.
So I later find out that's possibly one of the worst things you could do to
someone who's undiagnosed after the first hour.
So for those of you who don't know, a glucose intolerance test,
(28:56):
most commonly given to pregnant women.
It's this green solution of about 70 grams of pure sugar.
So I drank that and I had presented, I later saw on my blood work that I was
sitting around 18 that morning anyway.
But after the first hour, my blood sugar went to 52 and I ended up on the floor of the surgery.
(29:16):
And then next thing I knew, I woke up at Charlie Gardner's hospital here in
Perth and they said, yes, you do have type 1 diabetes.
And I mean, I look at it now and I'm like, yeah, well, you're shit.
But they gave me a dose of long acting, sent me home.
(29:37):
And then I came back the next day and I had a three-hour crash course in injections,
short acting, long acting.
And then just, you know, this is what we know, unfortunately,
about the adult system is you then thrust it out
into the big wide world and it's like we'll see you in three months
good luck and I guess as Adam said I was like how and I'm not the only one who's
(29:57):
had a very pear-shaped story and unfortunately sometimes it is going to go pear-shaped
especially when it's at the more critical end prior to diagnosis but I guess
how can we improve this eight years ago yeah I think things have changed,
I'm really sorry you to hear you had that experience by the way that shouldn't
have happened like that.
But I guess things have changed even in the last eight years in the sense that
(30:20):
we have more information, we have more guidelines, we have more standards and evidence.
For doctors to be aware of and to base our practice on.
So is that more guidelines that have come out in the last eight years?
We're more aware of them, like diagnosis.
And of course, sometimes it can be difficult to distinguish between, let's say.
(30:44):
Type 1 and ALADA or some less common type of diabetes, but shouldn't change the management,
like the urgent management, if you're presenting with osmotic symptoms
and very high glucose levels and there's ketones and all that
we wouldn't miss with that i guess i
felt like i i lost my faith a
little bit in the medical system when i was diagnosed i was
(31:05):
like we know that in australia type ones yeah yeah so prevalent i think what
that illustrates to me as well like i was saying earlier as gps were a lot more
used to dealing with type 2 but that means that that very thing means we need
to be on the lookout for new diagnosis of type 1. Not everyone is type 2.
Some people present atypically as well with type 2, where it doesn't fit the usual pattern.
(31:31):
So we need to always have that degree of suspicion.
Okay, is this a typical type 1? Is it a typical type 2? Does this not fit the pattern?
What is the urgent management? If there's an urgent management that we need to implement now, Hmm.
Yeah, but clearly it requires training on the part of the GP,
like, you know, update courses.
(31:52):
We always have to keep up to date because it keeps changing.
And then we need to have refresher courses about very important topics,
which diabetes, it is a very important topic because we are encountering a lot
of people with diabetes.
And of course, not everyone will be type 2.
There will be some new diagnosis type 1 that we will encounter,
but we won't encounter them very commonly.
(32:14):
Only that's a challenge yes and i guess like
i mean it's we know it's more common now with you
know i think they say it's around 50 50 with adults being diagnosed with type
1 as well as children being diagnosed with type 1 so i guess and it can be challenging
as you say with lada and type 1 and type 1.5 and type 2 that it can be a little
(32:36):
bit hard to distinguish but i guess with more adults being diagnosed,
I guess, as you said, that has to be that.
Yeah, you have to be that, have that level of suspicion and that extra training
and staying up to date because we're getting more and more of diagnosis.
I guess in the urgent management in that situation, we don't have to make the
decision whether it's LADA or TAB1 or like a definitive diagnosis,
(33:00):
but if someone is presenting with high glucose levels,
ketones, osmotic symptoms, I mean, 10 kilogram weight
loss in three days so it was yes to be
honest straight to the emergency department yeah well that's what we would do
we wouldn't mess with that i think that's yeah that's my question you know we've
got to the point where we have there's lots of things to know there's no question
(33:22):
about that and a gp is being asked to learn more and more in these situations.
There's a protocol it's pretty clear what to do this feels like a swiss cheese
problem that it just fell through the gaps because your personal trainer at 24.
Dropping weight like you're going out of fashion. Any protocol on earth is going
(33:46):
to tell you this is a potential type one case. Get them to ED.
Yeah. Scares me. It scares me. What was the question, Benjamin?
There's no question. That's a statement.
I thought you were going with a question. Because I think the thing I'm seeing
is it's not changing. We're still getting these experiences.
I still meet people, must be
at least two or three a month, who have had that experience as an adult.
(34:08):
Old because I think as you say Aldo it's rare
enough right that you're not seeing day-to-day a
presentation of a type 1 newly diagnosed above the
age of 18 where we would have suspected it anyway
but it's not that uncommon to be
fair to have people coming in with very elevated
levels of glucose maybe happens every two
(34:29):
or three months that of course someone who is in brackets
supposed to be type 2 come in with this presentation it is
not that common but it's not rare that we would never see it
maybe every three months or depending on the doctor it's not that that rare
that we need to be prepared to manage that well on that yeah you mentioned sub
(34:52):
specialties before you know you've got orthopedic surgeons who are like yeah i just do big toes yeah.
Whatever yeah um i find it interesting that i don't know if paradox is the right
word that, as you say, even GPs are specializing, you know, like on your profile,
you've got your areas of interest.
But by definition, a GP is a general practitioner and you don't know what you need.
(35:15):
You don't know what it is. So you don't know how to find a GP that specializes
in the thing that you don't know you have yet.
So how do we, as we continue to learn more and more and more about medicine
and the human brain is only so big, how do we tackle this problem of general
practitioner with being able to accurately triage and refer,
(35:36):
et cetera, going forward. Does that make sense? Yeah.
I guess you need to be able to trust your GP. If there's a GP that you know
already that you trust, go to them.
Hopefully, they'll do a good job. I hope so too.
But it's about training and keeping up to date. And, you know,
I think a good GP never stops learning.
(35:57):
And to be honest, I'm not going to be able to know everything about everything.
No, of course not. But common conditions and presentations, especially when
it can be life-threatening, we need to be really on the ball.
I think there's no excuse for that.
So maybe you need to consider as a type one community to maybe contact the RSCGP
(36:20):
or mention that this is happening.
Not as a criticism, but, you know, convey your experience.
And because the other challenge is as GPs, we are supposed to be doing all these
hours of continuous professional development every year, every three years.
But you can choose what you do. Yes. You're right. But you can choose if you
(36:43):
want to go to a diabetes seminar or musculoskeletal seminars.
There are some GPs who are heavily involved in doing skin cancer medicine or,
you know, sport medicine who may never be training in diabetes or respiratory.
You know, I'm training in diabetes education. Maybe I've neglected other things.
Of course. So I won't be very knowledgeable about other chronic conditions.
(37:06):
So one of the tricky things is I need to act within the confines of my expertise.
So in that case if someone comes in and before
giving an oral glucose tolerance test maybe i need to check
with someone or i need to pick up the phone and speak to
the endo registrar that that's what my colleagues who don't feel so confident
in diabetes do in a case of an urgent presentation like that if you're not sure
(37:29):
pick up the phone speak to someone if he's surgeon you know speak to the the
on-call team so we have to be super safe acting within the confines of of our
expertise, if we're not sure,
we need to get expert help.
I have a related question for you, Aldo, off script. I...
Interested in what you think about when someone has been diagnosed with type 1.
(37:51):
So they're going to live with that for life or until a cure comes in five years,
I was told. I've heard five years. Five years, yeah. Where's my cure? Anyway.
Sarcasm. So I'm going to live with that for life. Should I be looking for a
GP who has more knowledge of diabetes or is it more important to find someone that I trust?
(38:11):
What should I be looking for? Completely up to you.
Give me direction out of it. Because the thing is, we were talking about earlier,
okay, as a GP, I'm involved in supporting you, coordinating care.
Being there for you if you have other problems other than type 1 diabetes.
So it depends how important it is to you to have a GP who is knowledgeable about
(38:34):
type 1 or even maybe even lives with type 1. There might be some out there.
It depends on your needs as well and your preferences.
And maybe you have a relationship with a GP that you value and that's more important to you.
Being listened being i think a lot
of people i hear not everyone has a
good relationship with a gp or they struggle to find a regular gp
(38:55):
so for some people that takes priority but that
what's also an important resource is in
any particular practice it could be five or six
or eight gp so there might be some gps okay they have that
expertise in skin cancer if i see them oh why
don't you book a skin check with that particular doctor or that gp has
an interest in like female hormones or that gp has
(39:16):
an interest in asthma so there is a team there and
i think there's definitely i'm not going to
be offended as a gp if you go
and see one of my colleagues that has more expertise in that area i think we
need to be humble enough to recognize okay these are the confines of my expertise
as a as a team of gps in this practice this is the offer this is what we can
(39:39):
offer or even there might be a gp in the community elsewhere that has a particular expertise.
But I do hear you saying, I'm just going to push on this one a little bit,
because what I heard from you is some of that sense of family medicine.
You know, I've built a relationship over time.
I've built, whether it's a friendship or not, you know, I've got someone I can go to.
(40:00):
My real, I guess, worry in the type one space is I don't see that very often.
And I heard you say the same thing. You know, you don't see type ones.
And my gut feel is because they don't value that family medicine approach,
possibly because of experiences of, hopefully not Carly's experience,
but, you know, some experiences of they kind of don't get type one,
(40:21):
but we shouldn't be expecting that, right?
The family GP's role, as you said, is so broad and comprehensive and having
someone you can trust and go and say, I don't know what's going on.
I don't know if it's type one related.
I don't want to assume it is type one related.
There's so many things that we can get support with.
And I'm now thinking of mental health supports, for example,
(40:42):
and the incredible role that a GP has in that space.
You know, an endocrinologist is not necessarily going to think about mental
health supports. The good ones do.
But, you know, who's going to look at the person and say, I've seen you six
times over the last year and you're struggling. Can we have a chat?
Or someone being willing to come forward and say, this is hard. So, is that...
(41:06):
I'm hoping for, I'm hunting for, a recommendation we can make to people with type 1.
And I'm hearing a bit of there's a different type of relationship we can have with a GP.
But I don't want to put you on the spot. I guess I would like to say with people
with type 1, if you find a GP that you trust.
(41:27):
That is knowledgeable, that you can feel, listen to, that there's empathy there,
that there's a relationship, value that relationship.
Relationship you can use that relationship in whatever
way you would like to that you need to use it
if you don't go in very often you only
go once a year we're not gonna hold that against you
in general we can be of support to
(41:48):
you in whatever way you need us
and so there's many
types of like patient and gp relationships out there
you know so i think this is an amazing challenge for the the
type one community because actually it's one of the most common
questions we get asked at the family center which gp should
i see who is good with type one and i
(42:10):
think what people are hoping for is that we have a list aldo's
going to get slammed with appointments now but you know that we
have a list of five people who are experts in type one when actually
that may not be what the person is looking for and your
point about you know decide what you want and what
you value and what kind of relationship you want and then
find that because i've kind of decided like i've
(42:30):
got things that i see my gp about and then
i know when it's diabetes related i go see amy my diabetes educator like
i decided that's where this is my point like yeah i was saying earlier do you
really need to see the gp about expert like input about diabetes tab one itself
i'm not sure you even check out
nerd and scripts and referrals i think i think that's the thing is that.
(42:55):
And I'm going to make a broad generalization here. I think the broad frustration
is that I have to go see my GP to get a chronic disease management plan so that
I can go see my diabetes educator, which is where I see the value.
I have to go see my GP to get a script because my diabetes educator can't and
because my endocrinologist costs me $300 and whatever.
I think that's the struggle. But I like what you're saying about choose how you want to use it.
(43:19):
Yes, that frustration might still be there. And I will make a point here.
I will acknowledge that the system can be very frustrating and very rigid.
When I moved from England about 11 years ago, I was really surprised that people
needed to come in just for a referral and they needed to come in once a year
to get a referral and also to be referred through a care plan so they can access subsidized visits.
(43:43):
I think the system is very rigid and the system could well be changing in the
next few years because we are facing an unprecedented shortage of GPs.
And that's predicted to get worse because not as many doctors or trainees in
medicine are wanting to go into general practice.
And then we're also facing some critical shortages in some specialties as well.
(44:07):
So the system might need to be changed where the practice scope for health professional
is a little bit more flexible because at the moment it's very much centered
around the GP where maybe pharmacists and practice nurses are able to prescribe.
And you're not so bound to like those five visits by the care plan that only the GP can do.
(44:29):
I think that system is quite rigid to be fair. So is it, I mean,
we always hear kind of stories about the NHS budget blowing out and it's always
blowing out by a new, the English system I'm referring to here.
But are you saying that in the English system, there's more flexibility,
like you can just rock up, you
say, I want to make an appointment with a specialist and you just do that?
No, you still, so it's a long time ago, but...
(44:50):
In primary care, typically, there would be the practice nurse that would be
running diabetes clinic, for example. Right. You can go straight to see the practice nurse.
Interestingly, the practice nurse, therefore, becomes more experienced in managing diabetes.
And then they consult the GP about complex cases. And the GP is not used to
seeing complex cases, right? So you get that sort of dynamic.
(45:11):
But if you need to refer to a psychologist or a counselor in England,
unless it's changed in the last 10 years, you can.
And you don't have that extra cost. Right. if there's this public system.
So one of the challenges we're facing right now, that people are facing increasing
out-of-pocket costs to see their GP.
And I can understand the frustration, or I have to pay this fee just to get
(45:33):
a referral, and then I have to pay again to see the endo.
So increasing out-of-pocket costs as well to see the diabetes educator,
a lot of health professionals.
That's one of the reasons why we're giving referrals and people are not making
it to the first appointment.
So it's fair to say that Because of the increased out-of-pocket fees,
people are only coming to CS when they absolutely have to, unless they have
(45:57):
a healthcare card, etc., under 16.
And that's always the thing with healthcare, right? It's like,
don't leave it until later, because we can do so much more if we get it early.
But it's expensive. But it's expensive, and yeah, yeah, yeah.
But one of the reasons why that is happening is that there's been underfunding
of general practice primary care compared to hospital system.
(46:19):
A lot of people don't realize primary care general practices,
they actually operate privately.
We get some funding from the Commonwealth, but it's not enough to run our services.
So you would be hard-pressed to find a practice at the moment in Perth that is book billing.
There might be some, but they're dying out.
(46:43):
Money, yeah. Yeah, so it is a challenging time. I do feel for people for the
chronic conditions, especially if they're having to come in a lot.
One of the good things is if you have type 1 and you are young,
you might not actually need to come and see us very often.
I guess what I've been taking away throughout this chat is that the GP is an
(47:06):
integral puzzle piece for us here in Australia. Yeah.
And it's really refreshing, actually, to hear you speak today.
I know we're drumming you with a lot of hard questions.
You're doing an awesome job, Alda. You are, you are. It's really refreshing
to hear the level of care, the care factor in your tone.
And it's so refreshing when you do come across a GP, because my expectation
(47:29):
is not that the GP knows anything about type 1, but my expectation is for that
person to listen and then take what I've said,
care about that, and then take it to the next step.
And I am one who has unfortunately jumped from GP to GP in search of that person.
And I did recently meet a GP.
(47:50):
She knew very little about type 1, but her manner in which she listened to me
and tried to help me and was like, okay, well, this is what I do know.
This is how I can help you. And this is what I'm going to find out to get you
to the next step was like, that is all that I'm after.
You can't expect a GP to know everything. thing and as
someone with type 1 who has to see a gp all the time in
(48:12):
order to get referrals and scripts can we just
talk about why we can't get a script for a whole year for insulin like why
do we what i mean indefinite scripts i'm
like we have this for life like why do we
have to come back all the time yeah so that that might be
changing so there's been some changes in the last year where
like people let's say on high blood pressure medicines
(48:33):
cholesterol medicines can be given in
sq for 12 months but insulin was excluded was
it it was yeah that's right but but
aldo points out that this is watch this space yeah watch
this space because things might be changing interestingly
though that's not the case for antidepressants either no that's
not the case for reflux medications either and not
(48:55):
the case for insulin yet but i don't see why not i
mean people live with insulin they
need it for life so we shouldn't be making
it harder for them to get script right and we did
have this conversation before and yeah what i'm hearing is
yeah there are so there are gps out there who do
care about you and your well-being so i
(49:16):
think it's really important to keep looking until you find the right gp and
then it could be so beneficial to have that gp in your world like for years
to come for so many reasons and then they will get a better level of understanding.
About your care and my advice as well if you find a gp that you feel comfortable possible with.
(49:37):
Maybe have two others in that practice that you feel happy to see.
Because one of the challenges at the moment with the shortages of GPs is if
you need something urgent that week, you might not be able to get in with that
GP that you prefer. That would be your first choice.
So maybe get familiar with another two in that practice or be willing to be
seen for other things by the doctors in the practice.
(50:00):
That makes sense. They're amazing takeaways. And just a reminder to everyone
listening to this conversation that GPs don't set the rules of the game.
I know how incredibly frustrating it is.
And the GP tends to be the gatekeeper, which is why so much of that attention gets put there.
You know, why do I have to get a script? Why do I have to get a referral, et cetera.
(50:21):
I would love to have another conversation another time about the system,
because I think there is a broader conversation here
about the needs of the population are changing
and we're seeing it in gp availability that's
a challenge i think most chronic conditions is
fair to say that there isn't a cure if there was one for type one diabetes on
(50:43):
the horizon like it sounds like it is that would be wonderful sorry i was first
promised one 21 years ago something like that i think the reality is is one
people are living even longer.
They're having more time to develop these ailments. So a lot of people that
we see above the age of 60, which is one of the main demographics that we see
(51:04):
in general practice, have more than three chronic conditions.
Typically, they have high blood pressure, high cholesterol, they may have heart
disease, they may have diabetes, they may have sleep apnea.
It's a bit of a cocktail that you get with metabolic syndrome.
It's fair to say that quite a few of those, there is a potential to reverse them.
But of course we have to work with people and for a lot of people it's not realistic
(51:27):
to expect them to make that sort of lifestyle change so we have to work with
them the system is not perfect but there are ways,
To make the most of that system for people that really need the longer consults.
There are people that we see them, some of them every two weeks. Wow.
Or some more often than that because they need to. So the support is there if you need it.
(51:50):
You just have to know how to make the most of the system.
We'll try our very best to help you, to help those people.
But yeah, it's not ideal. It's far from ideal. And we look forward to the fact,
we were talking about this in a previous episode, Aldo, Aldo,
that people with type 1 are now living just as long as if they didn't have type 1.
So you're going to start seeing a lot more older patients with type 1 and that's right.
(52:13):
We'll be a pain in your neck for much longer. So look forward to this.
I may have retired by then.
Awesome. Well, Aldo, thank you so much for having this conversation with us
today, for being our first Life in Beta guest as well.
We will put notes out if you'd like to go and see Aldo about all things diabetes,
or just GP-related things about diabetes.
(52:36):
If you're lucky enough to live in Perth. We have coming up a couple of events
we want to share with you.
One is our workshop for DIY looping.
The fantastic David Burran is coming over from Melbourne, and we've nabbed him
for a day to have a workshop to set up your own DIY loop.
We're going to have a chat with him about what looping is, who it's good for,
all that fun stuff. And we also have a few extra places on our teen camp,
(53:00):
which happens in the third term school holidays. Again, WA only, sorry.
But there's a few extra places open for that. So have a look at our website
or our socials if you would like to know more.
Just before we go, Aldo, we have one question that we're thinking we would actually
like to ask of all our guests before they go.
If you had a magic wand that could give people with type 1 anything except the cure….
(53:27):
What would you give them? This is going to sound very obvious and very simple,
but I would put a CGM on them.
Oh. A CGM. A CGM for every person with type 1. And why do you say that?
Because it's a technology that
is now subsidized in the last two years or so to everyone with type 1.
There's quite a few people out there who are not wearing a CGM. Right.
(53:48):
And, of course, it's not for everybody, but it gives you a lot more information.
It can empower you to know what's really going on and potentially give you a better quality of life,
that makes sense i remember when i put a cgm on for the first
time it was the beginning of me actually paying attention to diabetes in my
adult life because it wasn't that i didn't want to it was just i didn't have
(54:10):
time to stop and test my blood sugar and hence do something about it whereas
the number was right there i was like oh i'll do something about it because
i can i'll just put in the correction and off we go again i would imagine it
can be liberating for a number of people yeah Yeah,
having a CGM. Again, not for everybody, but that's what I would do.
And that's actually what I do with people that come in and they don't have one
on or they haven't heard about it or they're reticent about it.
(54:31):
Yep. We can actually put one on. Yes, try one.
We can actually put one on and see if they like it and if it increases their quality of life.
It's a really good reminder that we live in our type one bubble and there are
lots of people out there who are not aware that CGM is now subsidized or have just never seen one.
That's right. You can try it out. Try it out. Yep. If you hate it,
(54:54):
worst that happens, don't use it. Yep.
Thanks, Aldo. Thanks for the invite. It's been a pleasure. Thank you so much.
Until next time. Ta-ra. Ta-ra.
Music.
Ta-ra. If you've been listening today thinking that is so relatable,
(55:15):
you should consider joining our online community where over a thousand other
people with type 1 are sharing their experiences, learning and supporting each other.
Head to typeonefamilycentre.org.au forward slash connect.
Music.
(00:10):
Today on Life in Beta, we celebrate the announcement that Dexcom G7 is coming
this September, finally.
And we chat with Dr Aldo Raquelmi, a GP and diabetes educator.
We talk about where GPs fit, or not, in your Type 1 care team,
and the perception of GPs as the gatekeepers of the medical system.
When I moved from England, I was really surprised that people needed to come
(00:34):
in to get a referral and to be referred to a care plan so they can access subsidised
visits. I think the system is very rigid and the system could well be changing in the next few years.
Music.
Welcome back to another episode of Life in Beta, the show where we talk about
(00:54):
the lived reality of type 1 diabetes.
My name is Adam Brockway. I'm the community manager at the Type 1 Diabetes Family Centre.
As always, joining me on the panel, we have Carly Green.
Hey, Carly. Hi, how are you? I'm good. I'm good. Just for reference,
I'm meant to be asking the questions. That's how this works.
It's always spicy. So spicy. And Benjamin Jardine, how are you doing?
(01:18):
I'm doing well. Referee between the sibling rivalries. Yes, that is your job.
Excellent. It's an interesting dynamic, this, because Benjamin is our boss,
and then we sit here and we just kind of like mouth off about various topics for an hour a week.
As I say often, I sometimes wonder at the team I have assembled here.
And as I often remind, we leave our ranks at the
door as soon as we walk out we know where
(01:39):
we stand all right we have exciting late
breaking news don't we we do we do so this episode
we obviously have our interview with dr aldo
riquelme which we are super excited about however breaking news we thought we
just had to throw this in beforehand welcome as a guest sorry there's news love
you bye uh dexcom g7 we have been talking about this since literally before this podcast launched.
(02:08):
Gee, that April release date was a long time, wasn't it? Oh, we got it so wrong.
However, in the last 48 hours, healthcare professionals have been briefed by
Dexcom and we're kind of allowed to talk about things now, which is cool.
So we thought we'd just go over a little bit of what to expect from G7 and a
couple of caveats because it's not all shiny news, unfortunately.
(02:30):
Ah, traditional type 1 diabetes news. Look at all these exciting things,
you can't have it. Exactly. Exactly.
Life with Type 1. So what we do know at the moment is that launch in September.
That's what we have been told. September, it's coming, apparently.
No, not apparently. You can order online as of September. It just may not be
like in-your-face news.
They're just going to allow it to happen. It's going to be a soft launch because...
(02:52):
Because of something. Caveat number one, it doesn't have...
Ndss support yet exactly so you can order it for 110 a sensor yay yay or you can wait until,
dexcom sort stuff out with ndss and then it's the usual 32
50 a month so for those of you who were previously funding your cgms and remember
(03:15):
that period where you felt how am i paying two mortgages at once welcome back
that was me i can't believe it but my hope is that it's not going to be too
long before they sort their thing out.
That's what the reps have said. So let's hope they're right about that.
So why should we be excited by Dexcom G7? Okay. Let's reel off the tech specs here.
(03:38):
I'll try and keep my nerd to a minimum. So 60% smaller than G6.
60% smaller. So Carly's actually got one. Can we just talk about this for a minute?
I have been so excited about the size, like particularly, and they've arrived,
just a little demo kit today to the family centre.
They are so cute and so tiny. It doesn't look much bigger than my T-Slim-like sight on my body.
(04:01):
So it's super flat, super round, super pretty, doesn't take up much real estate on the body.
So if I hold my, like here's mine at the moment.
Look, miniature. Yeah, teeny tiny. So very, very excited.
60% smaller, weighs 3.3 grams, if that means anything to anyone, but yeah, it's tiny.
(04:22):
The other thing I really love about this sensor, 30-minute warm-up time.
Yeah, that's a game changer.
But technically no warm-up time, right? So, yes, so here's the hack.
So it comes preloaded into the inserter, just like G6 did.
The 30-minute timer starts from when it is inserted, from when it leaves the inserter.
(04:43):
So you can put G7, you can put your new sensor on half an hour or more before the last one finishes.
And then when the old one expires, you just tell your pump or phone or whatever
to switch over to the new one and zero downtime. It's up and running, no downtime.
And this is because the transmitter's now inbuilt into each sensor,
just for those who are going, how does that work?
(05:03):
But what will I do when I no longer have those two hours every 10 days where
I remind myself of how terrible it was when I didn't have glucose readings every
five days? Oh no, we can't cry ourselves to sleep. What are we going to do?
We'll have to find something else to moan about.
I'm sure we'll find something. thing. They also have a 12 hour grace period.
Love this. Love this. The Omnipod has an eight hour grace period and that's
(05:23):
just not quite enough for when I find out at midnight that I really need to
change my pod and I don't want to change my pod, but also I don't want to get
up before eight o'clock in the morning.
12 hours. I reckon I can work with it. Should do it. Yep. Yep.
Yep. Yep. No, that'd be great. I had that with a sensor like literally a few
nights ago. I was like, oh,
I'm already in bed. I'm not changing it now. It's cozy in here.
Yeah, so sure enough, 2.30 in the morning, my pump's like, hello,
(05:46):
end of sensor. Yeah, okay, I'll deal with you in the morning. So 10.5 days.
10.5 days, yep. Yep, yep, yep. Innovation, people.
Alerts. So there is a new silent mode where you can silence all alerts for up
to six hours. You can choose how long.
I know when I go on stage or whatever, like for performances,
(06:07):
the ability to just say, do not interrupt me for any reason whatsoever will
be a game changer. I'm excited.
I'm really struggling with this one. I feel like I've got dad hat and person
with type one hat on. Yeah, go on.
Because I know how frustrating it is to have an urgent low alarm go off.
You know, it's the one thing you can't turn off. It's always going to happen.
(06:28):
In the cinema, at work, whatever it is.
There is actually a reason that there's an urgent low alarm, right?
And it's not that you can say, come back to me in six hours and I'll deal with
my hypo. The hypo's not going to wait.
So, you know, I can think of a hundred scenarios, you know, going up on stage,
going to movies where you don't want the alarm to go off. I don't want a hypo anytime.
(06:49):
Probably do want to know about it. So I don't know. I get it. I get it.
Well, it's still going to do an urgent low alarm.
I heard it wasn't. No, it is. And for me, I'm reading this and I'm like,
oh, it's not really much different to what what I do now, because I just go
into alerts and turn everything off.
If you can't sort your facts out, then what can our audience rely upon?
Yeah, we're going to have to get an arbitrator in.
Because my understanding is, so you've got silent mode, and then you have vibrate
(07:13):
mode, which is for all alerts except urgent lows.
So that doesn't make sense. Why would vibrate mode, it vibrates for everything
except urgent lows that are loud?
Well, now I'm not sure whether I'm supposed to care at all, because I've turned
off all the alarms that I can't.
We'll come back and confirm that one for everyone. I was so confident, but now I'm not sure.
(07:36):
Last, it's also more accurate. If you know what a MARD is, mean absolute relative
difference, hashtag nerd alert, G6 was 9% and G7 is 8.2% and lower is better. That's what we know.
Did we find out whether finger pricks are more accurate or less accurate?
Still more accurate is my understanding. Still more accurate.
I don't know how much though.
(07:59):
So, yes, that's G7. So, coming in September, it won't launch with NDSS support,
but that will be coming soon.
Keep an eye on Family Centre socials because we will let you know as soon as
it is available that way.
And we'll be doing an event at some point for those of you in Perth.
And Carly, I have to agree with you on the size thing. I wasn't convinced originally.
And then I sat down for this podcast, looked at the framing of this shot and
(08:20):
realised it looks like I've got a cigarette pack stuck under my arm. It does.
I know that you two have never really gotten on board.
Just you think that I'm a vain female, just not wanting to wear a big thing
on my body. You said it, not me.
Yeah, please don't put words in my mouth. The internet will hate on us from on high.
I just got cancelled for saying nothing. But it's not so much about that.
Like I will happily, you know, rep the tech.
(08:43):
Rep the tech? Yeah. But sometimes you just want to reduce the amount of type
one you wear and have to deal with on a daily basis.
So to have it smaller in all shapes and forms, for me, very exciting.
Very cool. All right.
Enough breaking news. Back to our special guest of honour.
I'm very excited to introduce our first ever guest on Life in Beta.
(09:04):
This is Dr. Aldo Riquelme.
Did I pronounce that right? Well done. You pronounced it perfectly.
Oh, thank you. All right.
The rest's easy downhill from here. Yeah.
Aldo studied medicine in Newcastle in the UK, practices in Midland here in Perth,
specialises in chronic disease management and took that so seriously that he
(09:27):
has gone on to become a diabetes educator as well. So welcome. How's life?
Life is good. Life is busy this time of year for a GP, like winter season. But yeah, life is good.
Is that, I've often wondered about winter and colds Is that just like old wives
tales so to speak What is it about cold weather that actually gives us,
(09:47):
colds? Typically, we get much higher rates of respiratory disease,
common colds this time of the year, also people coming in for their flu vaccine.
So in general, we start getting busier from March onwards, start to quieten
around September, October each year. It's a very seasonal, very cyclical.
So if we need a chronic disease management plan, we should come see you in November,
(10:09):
December, January. Anytime.
Yeah, yeah, it's a bit busier, but you know, we are
used to it really used to it adam i love that you
introduced our guest a special guest to
talk about gps and type one and you just went down a
nerdy rabbit hole do we get respiratory infections more
during the cold i've got this
(10:31):
rash on my leg all day yes so aldo
of all the specialties you could have chosen you chose
gp why gp like what is it that
what is it that called to you about that specialty i really love the
challenge of like having a variety i
think variety is the spice of life but i also i enjoy i think we get the privilege
(10:53):
of gps to develop friendships and continuity of care over a period of time i've
had people that have been coming to see me with their families for more than
10 years and i think there is a privilege and a responsibility to,
see people and be there for them during their ups and downs when life is good
when life is not so good, when they want to be engaged, when they don't want to be engaged.
(11:16):
I think that's quite a privilege and a challenge that we get.
Of course, some people may come to see us over a long period of time.
Some people may choose to move on and that's fine. But I think that's one of the challenges.
And beauties of of this job also i love the fact
that general practice can take you into a lot of
many different directions in your in your career fair
(11:38):
yeah i love what you say there about the ability to build friendships like i
i have never actually thought about putting gp and friendship in the same sentence
but i love that that that is a beautiful thing as you say like see these families
for 10 plus years you see them have kids you see them go through all various stages of life Yeah,
that's right. It's so true. People talk about who's their GP.
Generally, you don't hear people having a general conversation about,
(12:01):
oh, by the way, my cardiologist is blah, blah, blah.
Mind you, in type one land, who's your endocrinologist is a pretty common conversation,
but we are a special breed. Yeah.
So, what I find particularly interesting is that you're a GP and you are also
a diabetes educator of recently, correct?
So, I haven't yet qualified as a diabetes educator, cater but
(12:21):
i've done the course like that could lead into that
i would have to get all these hours of practice to become
credentialed gp is not enough i've done the graduate certificate but like the
reason i i decided to go into it is because i could see that we were getting
so many people being diagnosed with diabetes and pre-diabetes coming through
(12:43):
our doors it's been been feeling like a bit of a,
of a wave that was coming towards us.
And I thought we need to be able to ride this wave, otherwise we're going to sink in it.
We need to be able to have the knowledge and the awareness of how we can help
these people and do what we can in primary care, because the other reality that
(13:04):
we are finding, and I've audited this,
a lot of people that we refer to endocrinology.
And let's say allied health professionals, whether it's diabetes educator or
others, 40% or around 30%, they actually don't make it.
We give them a referral despite informed consent and explaining a rationale
(13:25):
for a variety of reasons, whether it's cost, availability of appointments, etc.
A lot of people don't make it that far. So that means that we have a responsibility
in primary care when we see people to do our very best to give them the tools
and the knowledge that they need to be able to self-manage well and to be able
(13:45):
to manage their condition well.
Have you seen an increase in diagnosis of type 1 diabetes?
Of course, the vast majority of diabetes that we're dealing with in Australia is type 2, around 90%.
What's different about type 1 diabetes is that in type 2, as GPs,
we're actively involved in managing, prescribing, following up, titrating medication.
(14:09):
I think it's fair to say that type 1 diabetes is regarded as a more complex type of diabetes.
Preaching to the converted here. We would tend to agree. Yeah, we might be biased.
So I think the main difference is for someone
living with type 1 of course the
gp will not be your expert source of support i mean we're just talking about
(14:32):
g7 most gps are not aware even familiar with cgm let alone other diabetes technologies
like you know different types of like insulin pumps and all that that
can feel very foreign to most gps unless a gp has type 1 themselves or they
have a family member that have type 1, for most of us, all this technology is
(14:57):
quite foreign to us. So I think the main difference is...
You might need to use us for like your referrals, your care plan, your script.
And of course, not all of your health is about type 1 diabetes.
So there could be aspects where you need to see a doctor, whether it's to do
with your cardiovascular, other conditions, mental health, etc.
(15:18):
Or in brackets, minor illness. We're talking about colds and respiratory infections, etc.
So you might need a GP for that. But I think on the whole, by and large,
we will not be actively involved in managing or making decisions about your
type 1 diabetes treatment.
I think that's fair to say. Apologies, my phone is...
(15:39):
It's not too different from the insulin pump alarms we get from time to time. So we will let you off.
Yeah. So I would imagine that that's what it may feel like to people living
with type 1, that you might see a GP for things like referral scripts.
And sometimes it can feel a bit frustrating to have to go and see your GP just
(16:00):
to get a referral, just to get a care plan, just to get a script.
But I guess there is a role in terms of care coordination and then also engaging people.
People because like you may at
the type one center see people who are
relatively engaged because if people are coming here they already have some
(16:22):
form of motivation or willingness to engage we do see people in primary care
that they're just coming for a script yep and we try and i talk to them about
when did you last have a blood test when did you last see the endo when did
you last see a diabetes educator?
For some people, it may have been years. So we have a role in trying to get
(16:45):
people back onto a road where they're engaged.
And of course, not everyone is managing their diabetes optimally.
Some people are just surviving.
And many people, I'm finding that quite a few people with type 1 out there.
They don't know about CGM or they know about CGM, but they have preconceived ideas.
(17:07):
So we are trying to do what we can in terms of letting them know about these
technologies, trying to engage them with services, letting them know about this
fantastic service here at the Type 1.
We'll pay you later, Otto. Thank you. Yeah.
Yeah, that's interesting. Can I throw in a little question out of interest?
Yeah. Back in medical school when you were studying, what did you learn about
(17:30):
Type 1 diabetes? Like, did that make an appearance in your training? Oh, definitely.
I mean, we were taught about endocrinology and specifically about diabetes and
how that might present the different types of diabetes.
Of course, this is over 20 years ago now.
Of course. Things could have changed, but it's definitely part of the medical
school curriculum and definitely part of GP training as well.
(17:55):
But of course, as you can imagine,
dealing with the whole spectrum of disease and the whole spectrum of the life
cycle the reality is that not
all gps will have an in-depth or up-to-date knowledge about all conditions.
And these days even specialists are becoming sub-specialized right if you look
at orthopedics you're dealing with some surgeons will only do hips or only only
(18:19):
do knees some endocrinologist also becomes sub-specialized so we are finding
that because of the the fast moving pace of.
Evidence and knowledge and technology gps will also have an area of interest
so you have gps who have an interest and more knowledge in diabetes and other
things and then others will have other areas of interest as well but it's fair
(18:41):
to say that diabetes is such an important,
topic these days because it increase incidence that we need to be up to date
especially dealing with emergencies getting the diagnosis right referring from
treatment that that's super Super important.
Yeah. There's so many things I want to deep dive on here.
You've just hit like every marker that I want to talk about today. Yeah, yeah, yeah, yeah.
(19:05):
I think where I want to start, I want to pick up on some language you used and
just test something with you.
Yeah. So what I heard you say is the GP is, I think the words you used were
not actively engaged in the type one medical management, if you like.
What I mean by that is like actively managing in terms of like making, let's say, medical
(19:25):
corrections to your insulin or initiating treatments
to do with insulin in type 1 diabetes so
the reason i want to unpick it actually there's many
reasons i want to unpick it yeah one is because in my
observation the nature of type 1 is such that that's
us it's not the endocrinologist it's not the
gp yeah who is making the day-to-day decisions adjustments management it's the
(19:49):
individual yeah and your point on subspeciality is really interesting to me
because the challenge I always have and what I hear from the community a lot
is that they feel like their interactions with a GP become transactional.
I come in because I need my script.
I come in because I need a referral to go see someone else.
(20:11):
And what is going on in my head in the background is that that's assuming we
kind of say type one is managed by the endocrinologist.
Biologist your respiratory infection is managed
by the gp the reality of
type one is that i can't put
it into a bucket and say i'll save that
up over here and it impacts everything so when
(20:33):
i come and see a gp to talk about my cold type
one is involved it's affecting my blood sugars it's messing up things
that are going on how do people with type one make the
most of their relationship with the gp i think
it's fair to say that i rarely get asked by
someone living with type 1 diabetes about insulin management
(20:54):
most people some occasionally they
might ask but most of the time i think they already realize i'm not the person
to come to when it comes to insulin titration and all these things because they're
already managing themselves or they already know who to go to about these things
they realize the gp is not an expert in that however there's many many aspects
(21:14):
of your health that are not to do with diabetes.
Of course, diabetes may affect it or the other way around, but there's a lot
of other things that you would, or you might benefit from having a generalist
there for support, everyone is different.
So in the person can use that relationship in whatever way is useful to them.
(21:38):
I speak to a lot of people with type one about their GP relationship.
And my sense is it's become transactional over time because what's happened
is the person with type one kind of gets into that space,
which I'm just as guilty of as
anyone of, I know more about type one than anyone I'm going to encounter.
So I get that sense of, it's almost an ego of, I know more than you. So why would I ask you?
(22:00):
And does that then steer towards a relationship where the person won't talk
about things because they kind of think, I know more anyway.
And then do they, does it become, I'm always worried about the person who just
sees their GP as a script mill and never actually has a conversation about what's
going on because I'm a self-manager.
(22:22):
I'm looking after my type one. I know more than you do anyway.
Just give me my damn referral. I think what's happening, and I could be wrong,
what I see is that on the whole, most people that we see with type one diabetes
are a younger population.
So their diabetes might
be the main health issue that
they manage we don't see them that often
(22:45):
in general unless they have other significant medical
problems running alongside and i
guess they're used to self-managing so they might be
more used to you know looking up for information online
trying to problem solve themselves and that
that that's fine we're here if you need us but
i think on the whole we do see less of
(23:07):
them my only concern which i alluded to
earlier and i think there's all sorts of
people out there we do we do occasionally see
people with tab one who very rarely come in not wanting to engage they might
just come for script we try to engage them and then we occasionally might see
(23:27):
them further down the line with severe complications And it doesn't have to be perfect either,
we're not expecting people to have an HbA1c of 7 or 6 all the time,
or have the perfect timing range, etc.
But then there's an undeniable fact that this condition can be associated with
complications in the future.
(23:49):
And then I think one of the main messages I'd like to convey is that.
There's a lot more to health than the diabetes itself. So especially if people
are getting to the age of 40 or above, really important to start considering
things like your cardiovascular risk.
Because of course, that's one of the main killers of people internationally and in Australia.
(24:11):
And sometimes people can overlook that side of things because they have diabetes.
So other risk of like high blood pressure, other risk of heart disease,
are the risk of other chronic conditions beyond the type 1 diabetes.
So what does that relationship ideally look like?
Like if you had the, I use this phrase carefully, perfect type 1 walking to,
(24:34):
like, no. Let me know if you find it.
If you had anyone with type 1 walking to your surgery, but you had the perfect
relationship with them, what would the conversation look like?
What would you be working on together?
How would that work? So it's very, very client centered.
So in general practice, I think in any medical specialty, in any healthcare
(24:56):
client relationship, I think it's patient centered.
But I think there's an element of the consult being also directed by the health professional.
So what I mean is where the person is engaged, is activated in self-management
in terms of having the skills, the knowledge, their willingness to engage,
where they also accept the input from the health professional.
(25:19):
Yeah. So it's like a conversation. So I really appreciate the fact that you
live with this condition, you know how to best manage it, but then as well.
There might be room for adjusting here, there, and there, or having the input
from this person or that person having that conversation.
And of course, coming from a place, when it comes to a GP, I'm not the expert
(25:41):
in managing type one, but this is ways that I can help you and have you thought
about the rest of your health and the rest of your wellbeing beyond diabetes.
I think this type of conversation, I think when it comes to type one,
I think we're more here to support you rather than tell me what to do when it comes to your type one,
(26:02):
but there's a lot more to your wellbeing than type one that I would like you to consider as well.
Right. I, you know, I think it's so easy to end up drawing battle lines as you
were pointing to, you know, someone comes in assuming you're not going to be
able to give me anything that I don't already know.
Then you're setting up a relationship that, that isn't going to work.
(26:24):
And people with type one, I think end up so frustrated that people don't talk
to them about the lived reality, because we do live with it day to day.
It is very difficult to understand if you don't live with it.
But the downside of that is you can get into this bubble of,
I'm the only person that could possibly understand, and no one else can give me any kind of help.
(26:44):
Whereas what you're saying is you've got a different set of skills and knowledge
and understanding and a broader perspective of health.
You mentioned diagnosis, your diagnosis before, Benjamin.
Let's talk about diagnosis. Diagnosis, because this is, I think,
and this is not, you know, I don't have a study with, you know,
X percentage of diagnoses that go down the wrong path or whatever.
But anecdotally here at the Type 1 Centre, we hear a lot of stories of diagnoses
(27:09):
that don't really happen, I think, as we would think that they should in an ideal world.
Carly, yours is a bit of a banger. Carly, you've been sitting on this story
for, what is it, six episodes now. Now, for context, Aldo, where I want to end
up with this is how do we make this experience better for people?
That's where I want this to land. But just for some context, Carly, do you want to?
(27:30):
Yeah, I guess every week we hear the stories of how people with type 1 are diagnosed,
and more often than not, it's pear-shaped.
But I guess over the eight years
since I was diagnosed, I've realized how pear-shaped my diagnosis was.
I presented to my GP at the age of 24. there's
no history of type 1 or diabetes or autoimmune I've
(27:52):
got a very healthy family so I
was 24 I was working as a personal trainer and I was also
studying chiropractic on the side so I was very busy I was fatigued all of a
sudden in the space of three days I lost like 10 kilos I was running to the
bathroom every 45 minutes throughout the night like clockwork busting and And
(28:14):
I thought, oh, no, my kidneys are shot.
Like something's wrong with my kidneys. This is the end. Like I didn't even
have tight one on my radar because, you know, we just don't,
right? So I was like, I need to go to the GP.
Went to the GP. They did a urine sample.
And the GP had said, oh, this indicates diabetes. But in order to,
(28:34):
and I'd obviously presented with all the symptoms I've just told you,
to tell whether this is type 1 or type 2, we'll need to do a glucose intolerance test on you.
And I was like, okay, like this must just be the normal process.
So I later find out that's possibly one of the worst things you could do to
someone who's undiagnosed after the first hour.
So for those of you who don't know, a glucose intolerance test,
(28:56):
most commonly given to pregnant women.
It's this green solution of about 70 grams of pure sugar.
So I drank that and I had presented, I later saw on my blood work that I was
sitting around 18 that morning anyway.
But after the first hour, my blood sugar went to 52 and I ended up on the floor of the surgery.
(29:16):
And then next thing I knew, I woke up at Charlie Gardner's hospital here in
Perth and they said, yes, you do have type 1 diabetes.
And I mean, I look at it now and I'm like, yeah, well, you're shit.
But they gave me a dose of long acting, sent me home.
(29:37):
And then I came back the next day and I had a three-hour crash course in injections,
short acting, long acting.
And then just, you know, this is what we know, unfortunately,
about the adult system is you then thrust it out
into the big wide world and it's like we'll see you in three months
good luck and I guess as Adam said I was like how and I'm not the only one who's
(29:57):
had a very pear-shaped story and unfortunately sometimes it is going to go pear-shaped
especially when it's at the more critical end prior to diagnosis but I guess
how can we improve this eight years ago yeah I think things have changed,
I'm really sorry you to hear you had that experience by the way that shouldn't
have happened like that.
But I guess things have changed even in the last eight years in the sense that
(30:20):
we have more information, we have more guidelines, we have more standards and evidence.
For doctors to be aware of and to base our practice on.
So is that more guidelines that have come out in the last eight years?
We're more aware of them, like diagnosis.
And of course, sometimes it can be difficult to distinguish between, let's say.
(30:44):
Type 1 and ALADA or some less common type of diabetes, but shouldn't change the management,
like the urgent management, if you're presenting with osmotic symptoms
and very high glucose levels and there's ketones and all that
we wouldn't miss with that i guess i
felt like i i lost my faith a
little bit in the medical system when i was diagnosed i was
(31:05):
like we know that in australia type ones yeah yeah so prevalent i think what
that illustrates to me as well like i was saying earlier as gps were a lot more
used to dealing with type 2 but that means that that very thing means we need
to be on the lookout for new diagnosis of type 1. Not everyone is type 2.
Some people present atypically as well with type 2, where it doesn't fit the usual pattern.
(31:31):
So we need to always have that degree of suspicion.
Okay, is this a typical type 1? Is it a typical type 2? Does this not fit the pattern?
What is the urgent management? If there's an urgent management that we need to implement now, Hmm.
Yeah, but clearly it requires training on the part of the GP,
like, you know, update courses.
(31:52):
We always have to keep up to date because it keeps changing.
And then we need to have refresher courses about very important topics,
which diabetes, it is a very important topic because we are encountering a lot
of people with diabetes.
And of course, not everyone will be type 2.
There will be some new diagnosis type 1 that we will encounter,
but we won't encounter them very commonly.
(32:14):
Only that's a challenge yes and i guess like
i mean it's we know it's more common now with you
know i think they say it's around 50 50 with adults being diagnosed with type
1 as well as children being diagnosed with type 1 so i guess and it can be challenging
as you say with lada and type 1 and type 1.5 and type 2 that it can be a little
(32:36):
bit hard to distinguish but i guess with more adults being diagnosed,
I guess, as you said, that has to be that.
Yeah, you have to be that, have that level of suspicion and that extra training
and staying up to date because we're getting more and more of diagnosis.
I guess in the urgent management in that situation, we don't have to make the
decision whether it's LADA or TAB1 or like a definitive diagnosis,
(33:00):
but if someone is presenting with high glucose levels,
ketones, osmotic symptoms, I mean, 10 kilogram weight
loss in three days so it was yes to be
honest straight to the emergency department yeah well that's what we would do
we wouldn't mess with that i think that's yeah that's my question you know we've
got to the point where we have there's lots of things to know there's no question
(33:22):
about that and a gp is being asked to learn more and more in these situations.
There's a protocol it's pretty clear what to do this feels like a swiss cheese
problem that it just fell through the gaps because your personal trainer at 24.
Dropping weight like you're going out of fashion. Any protocol on earth is going
(33:46):
to tell you this is a potential type one case. Get them to ED.
Yeah. Scares me. It scares me. What was the question, Benjamin?
There's no question. That's a statement.
I thought you were going with a question. Because I think the thing I'm seeing
is it's not changing. We're still getting these experiences.
I still meet people, must be
at least two or three a month, who have had that experience as an adult.
(34:08):
Old because I think as you say Aldo it's rare
enough right that you're not seeing day-to-day a
presentation of a type 1 newly diagnosed above the
age of 18 where we would have suspected it anyway
but it's not that uncommon to be
fair to have people coming in with very elevated
levels of glucose maybe happens every two
(34:29):
or three months that of course someone who is in brackets
supposed to be type 2 come in with this presentation it is
not that common but it's not rare that we would never see it
maybe every three months or depending on the doctor it's not that that rare
that we need to be prepared to manage that well on that yeah you mentioned sub
(34:52):
specialties before you know you've got orthopedic surgeons who are like yeah i just do big toes yeah.
Whatever yeah um i find it interesting that i don't know if paradox is the right
word that, as you say, even GPs are specializing, you know, like on your profile,
you've got your areas of interest.
But by definition, a GP is a general practitioner and you don't know what you need.
(35:15):
You don't know what it is. So you don't know how to find a GP that specializes
in the thing that you don't know you have yet.
So how do we, as we continue to learn more and more and more about medicine
and the human brain is only so big, how do we tackle this problem of general
practitioner with being able to accurately triage and refer,
(35:36):
et cetera, going forward. Does that make sense? Yeah.
I guess you need to be able to trust your GP. If there's a GP that you know
already that you trust, go to them.
Hopefully, they'll do a good job. I hope so too.
But it's about training and keeping up to date. And, you know,
I think a good GP never stops learning.
(35:57):
And to be honest, I'm not going to be able to know everything about everything.
No, of course not. But common conditions and presentations, especially when
it can be life-threatening, we need to be really on the ball.
I think there's no excuse for that.
So maybe you need to consider as a type one community to maybe contact the RSCGP
(36:20):
or mention that this is happening.
Not as a criticism, but, you know, convey your experience.
And because the other challenge is as GPs, we are supposed to be doing all these
hours of continuous professional development every year, every three years.
But you can choose what you do. Yes. You're right. But you can choose if you
(36:43):
want to go to a diabetes seminar or musculoskeletal seminars.
There are some GPs who are heavily involved in doing skin cancer medicine or,
you know, sport medicine who may never be training in diabetes or respiratory.
You know, I'm training in diabetes education. Maybe I've neglected other things.
Of course. So I won't be very knowledgeable about other chronic conditions.
(37:06):
So one of the tricky things is I need to act within the confines of my expertise.
So in that case if someone comes in and before
giving an oral glucose tolerance test maybe i need to check
with someone or i need to pick up the phone and speak to
the endo registrar that that's what my colleagues who don't feel so confident
in diabetes do in a case of an urgent presentation like that if you're not sure
(37:29):
pick up the phone speak to someone if he's surgeon you know speak to the the
on-call team so we have to be super safe acting within the confines of of our
expertise, if we're not sure,
we need to get expert help.
I have a related question for you, Aldo, off script. I...
Interested in what you think about when someone has been diagnosed with type 1.
(37:51):
So they're going to live with that for life or until a cure comes in five years,
I was told. I've heard five years. Five years, yeah. Where's my cure? Anyway.
Sarcasm. So I'm going to live with that for life. Should I be looking for a
GP who has more knowledge of diabetes or is it more important to find someone that I trust?
(38:11):
What should I be looking for? Completely up to you.
Give me direction out of it. Because the thing is, we were talking about earlier,
okay, as a GP, I'm involved in supporting you, coordinating care.
Being there for you if you have other problems other than type 1 diabetes.
So it depends how important it is to you to have a GP who is knowledgeable about
(38:34):
type 1 or even maybe even lives with type 1. There might be some out there.
It depends on your needs as well and your preferences.
And maybe you have a relationship with a GP that you value and that's more important to you.
Being listened being i think a lot
of people i hear not everyone has a
good relationship with a gp or they struggle to find a regular gp
(38:55):
so for some people that takes priority but that
what's also an important resource is in
any particular practice it could be five or six
or eight gp so there might be some gps okay they have that
expertise in skin cancer if i see them oh why
don't you book a skin check with that particular doctor or that gp has
an interest in like female hormones or that gp has
(39:16):
an interest in asthma so there is a team there and
i think there's definitely i'm not going to
be offended as a gp if you go
and see one of my colleagues that has more expertise in that area i think we
need to be humble enough to recognize okay these are the confines of my expertise
as a as a team of gps in this practice this is the offer this is what we can
(39:39):
offer or even there might be a gp in the community elsewhere that has a particular expertise.
But I do hear you saying, I'm just going to push on this one a little bit,
because what I heard from you is some of that sense of family medicine.
You know, I've built a relationship over time.
I've built, whether it's a friendship or not, you know, I've got someone I can go to.
(40:00):
My real, I guess, worry in the type one space is I don't see that very often.
And I heard you say the same thing. You know, you don't see type ones.
And my gut feel is because they don't value that family medicine approach,
possibly because of experiences of, hopefully not Carly's experience,
but, you know, some experiences of they kind of don't get type one,
(40:21):
but we shouldn't be expecting that, right?
The family GP's role, as you said, is so broad and comprehensive and having
someone you can trust and go and say, I don't know what's going on.
I don't know if it's type one related.
I don't want to assume it is type one related.
There's so many things that we can get support with.
And I'm now thinking of mental health supports, for example,
(40:42):
and the incredible role that a GP has in that space.
You know, an endocrinologist is not necessarily going to think about mental
health supports. The good ones do.
But, you know, who's going to look at the person and say, I've seen you six
times over the last year and you're struggling. Can we have a chat?
Or someone being willing to come forward and say, this is hard. So, is that...
(41:06):
I'm hoping for, I'm hunting for, a recommendation we can make to people with type 1.
And I'm hearing a bit of there's a different type of relationship we can have with a GP.
But I don't want to put you on the spot. I guess I would like to say with people
with type 1, if you find a GP that you trust.
(41:27):
That is knowledgeable, that you can feel, listen to, that there's empathy there,
that there's a relationship, value that relationship.
Relationship you can use that relationship in whatever
way you would like to that you need to use it
if you don't go in very often you only
go once a year we're not gonna hold that against you
in general we can be of support to
(41:48):
you in whatever way you need us
and so there's many
types of like patient and gp relationships out there
you know so i think this is an amazing challenge for the the
type one community because actually it's one of the most common
questions we get asked at the family center which gp should
i see who is good with type one and i
(42:10):
think what people are hoping for is that we have a list aldo's
going to get slammed with appointments now but you know that we
have a list of five people who are experts in type one when actually
that may not be what the person is looking for and your
point about you know decide what you want and what
you value and what kind of relationship you want and then
find that because i've kind of decided like i've
(42:30):
got things that i see my gp about and then
i know when it's diabetes related i go see amy my diabetes educator like
i decided that's where this is my point like yeah i was saying earlier do you
really need to see the gp about expert like input about diabetes tab one itself
i'm not sure you even check out
nerd and scripts and referrals i think i think that's the thing is that.
(42:55):
And I'm going to make a broad generalization here. I think the broad frustration
is that I have to go see my GP to get a chronic disease management plan so that
I can go see my diabetes educator, which is where I see the value.
I have to go see my GP to get a script because my diabetes educator can't and
because my endocrinologist costs me $300 and whatever.
I think that's the struggle. But I like what you're saying about choose how you want to use it.
(43:19):
Yes, that frustration might still be there. And I will make a point here.
I will acknowledge that the system can be very frustrating and very rigid.
When I moved from England about 11 years ago, I was really surprised that people
needed to come in just for a referral and they needed to come in once a year
to get a referral and also to be referred through a care plan so they can access subsidized visits.
(43:43):
I think the system is very rigid and the system could well be changing in the
next few years because we are facing an unprecedented shortage of GPs.
And that's predicted to get worse because not as many doctors or trainees in
medicine are wanting to go into general practice.
And then we're also facing some critical shortages in some specialties as well.
(44:07):
So the system might need to be changed where the practice scope for health professional
is a little bit more flexible because at the moment it's very much centered
around the GP where maybe pharmacists and practice nurses are able to prescribe.
And you're not so bound to like those five visits by the care plan that only the GP can do.
(44:29):
I think that system is quite rigid to be fair. So is it, I mean,
we always hear kind of stories about the NHS budget blowing out and it's always
blowing out by a new, the English system I'm referring to here.
But are you saying that in the English system, there's more flexibility,
like you can just rock up, you
say, I want to make an appointment with a specialist and you just do that?
No, you still, so it's a long time ago, but...
(44:50):
In primary care, typically, there would be the practice nurse that would be
running diabetes clinic, for example. Right. You can go straight to see the practice nurse.
Interestingly, the practice nurse, therefore, becomes more experienced in managing diabetes.
And then they consult the GP about complex cases. And the GP is not used to
seeing complex cases, right? So you get that sort of dynamic.
(45:11):
But if you need to refer to a psychologist or a counselor in England,
unless it's changed in the last 10 years, you can.
And you don't have that extra cost. Right. if there's this public system.
So one of the challenges we're facing right now, that people are facing increasing
out-of-pocket costs to see their GP.
And I can understand the frustration, or I have to pay this fee just to get
(45:33):
a referral, and then I have to pay again to see the endo.
So increasing out-of-pocket costs as well to see the diabetes educator,
a lot of health professionals.
That's one of the reasons why we're giving referrals and people are not making
it to the first appointment.
So it's fair to say that Because of the increased out-of-pocket fees,
people are only coming to CS when they absolutely have to, unless they have
(45:57):
a healthcare card, etc., under 16.
And that's always the thing with healthcare, right? It's like,
don't leave it until later, because we can do so much more if we get it early.
But it's expensive. But it's expensive, and yeah, yeah, yeah.
But one of the reasons why that is happening is that there's been underfunding
of general practice primary care compared to hospital system.
(46:19):
A lot of people don't realize primary care general practices,
they actually operate privately.
We get some funding from the Commonwealth, but it's not enough to run our services.
So you would be hard-pressed to find a practice at the moment in Perth that is book billing.
There might be some, but they're dying out.
(46:43):
Money, yeah. Yeah, so it is a challenging time. I do feel for people for the
chronic conditions, especially if they're having to come in a lot.
One of the good things is if you have type 1 and you are young,
you might not actually need to come and see us very often.
I guess what I've been taking away throughout this chat is that the GP is an
(47:06):
integral puzzle piece for us here in Australia. Yeah.
And it's really refreshing, actually, to hear you speak today.
I know we're drumming you with a lot of hard questions.
You're doing an awesome job, Alda. You are, you are. It's really refreshing
to hear the level of care, the care factor in your tone.
And it's so refreshing when you do come across a GP, because my expectation
(47:29):
is not that the GP knows anything about type 1, but my expectation is for that
person to listen and then take what I've said,
care about that, and then take it to the next step.
And I am one who has unfortunately jumped from GP to GP in search of that person.
And I did recently meet a GP.
(47:50):
She knew very little about type 1, but her manner in which she listened to me
and tried to help me and was like, okay, well, this is what I do know.
This is how I can help you. And this is what I'm going to find out to get you
to the next step was like, that is all that I'm after.
You can't expect a GP to know everything. thing and as
someone with type 1 who has to see a gp all the time in
(48:12):
order to get referrals and scripts can we just
talk about why we can't get a script for a whole year for insulin like why
do we what i mean indefinite scripts i'm
like we have this for life like why do we
have to come back all the time yeah so that that might be
changing so there's been some changes in the last year where
like people let's say on high blood pressure medicines
(48:33):
cholesterol medicines can be given in
sq for 12 months but insulin was excluded was
it it was yeah that's right but but
aldo points out that this is watch this space yeah watch
this space because things might be changing interestingly
though that's not the case for antidepressants either no that's
not the case for reflux medications either and not
(48:55):
the case for insulin yet but i don't see why not i
mean people live with insulin they
need it for life so we shouldn't be making
it harder for them to get script right and we did
have this conversation before and yeah what i'm hearing is
yeah there are so there are gps out there who do
care about you and your well-being so i
(49:16):
think it's really important to keep looking until you find the right gp and
then it could be so beneficial to have that gp in your world like for years
to come for so many reasons and then they will get a better level of understanding.
About your care and my advice as well if you find a gp that you feel comfortable possible with.
(49:37):
Maybe have two others in that practice that you feel happy to see.
Because one of the challenges at the moment with the shortages of GPs is if
you need something urgent that week, you might not be able to get in with that
GP that you prefer. That would be your first choice.
So maybe get familiar with another two in that practice or be willing to be
seen for other things by the doctors in the practice.
(50:00):
That makes sense. They're amazing takeaways. And just a reminder to everyone
listening to this conversation that GPs don't set the rules of the game.
I know how incredibly frustrating it is.
And the GP tends to be the gatekeeper, which is why so much of that attention gets put there.
You know, why do I have to get a script? Why do I have to get a referral, et cetera.
(50:21):
I would love to have another conversation another time about the system,
because I think there is a broader conversation here
about the needs of the population are changing
and we're seeing it in gp availability that's
a challenge i think most chronic conditions is
fair to say that there isn't a cure if there was one for type one diabetes on
(50:43):
the horizon like it sounds like it is that would be wonderful sorry i was first
promised one 21 years ago something like that i think the reality is is one
people are living even longer.
They're having more time to develop these ailments. So a lot of people that
we see above the age of 60, which is one of the main demographics that we see
(51:04):
in general practice, have more than three chronic conditions.
Typically, they have high blood pressure, high cholesterol, they may have heart
disease, they may have diabetes, they may have sleep apnea.
It's a bit of a cocktail that you get with metabolic syndrome.
It's fair to say that quite a few of those, there is a potential to reverse them.
But of course we have to work with people and for a lot of people it's not realistic
(51:27):
to expect them to make that sort of lifestyle change so we have to work with
them the system is not perfect but there are ways,
To make the most of that system for people that really need the longer consults.
There are people that we see them, some of them every two weeks. Wow.
Or some more often than that because they need to. So the support is there if you need it.
(51:50):
You just have to know how to make the most of the system.
We'll try our very best to help you, to help those people.
But yeah, it's not ideal. It's far from ideal. And we look forward to the fact,
we were talking about this in a previous episode, Aldo, Aldo,
that people with type 1 are now living just as long as if they didn't have type 1.
So you're going to start seeing a lot more older patients with type 1 and that's right.
(52:13):
We'll be a pain in your neck for much longer. So look forward to this.
I may have retired by then.
Awesome. Well, Aldo, thank you so much for having this conversation with us
today, for being our first Life in Beta guest as well.
We will put notes out if you'd like to go and see Aldo about all things diabetes,
or just GP-related things about diabetes.
(52:36):
If you're lucky enough to live in Perth. We have coming up a couple of events
we want to share with you.
One is our workshop for DIY looping.
The fantastic David Burran is coming over from Melbourne, and we've nabbed him
for a day to have a workshop to set up your own DIY loop.
We're going to have a chat with him about what looping is, who it's good for,
all that fun stuff. And we also have a few extra places on our teen camp,
(53:00):
which happens in the third term school holidays. Again, WA only, sorry.
But there's a few extra places open for that. So have a look at our website
or our socials if you would like to know more.
Just before we go, Aldo, we have one question that we're thinking we would actually
like to ask of all our guests before they go.
If you had a magic wand that could give people with type 1 anything except the cure….
(53:27):
What would you give them? This is going to sound very obvious and very simple,
but I would put a CGM on them.
Oh. A CGM. A CGM for every person with type 1. And why do you say that?
Because it's a technology that
is now subsidized in the last two years or so to everyone with type 1.
There's quite a few people out there who are not wearing a CGM. Right.
(53:48):
And, of course, it's not for everybody, but it gives you a lot more information.
It can empower you to know what's really going on and potentially give you a better quality of life,
that makes sense i remember when i put a cgm on for the first
time it was the beginning of me actually paying attention to diabetes in my
adult life because it wasn't that i didn't want to it was just i didn't have
(54:10):
time to stop and test my blood sugar and hence do something about it whereas
the number was right there i was like oh i'll do something about it because
i can i'll just put in the correction and off we go again i would imagine it
can be liberating for a number of people yeah Yeah,
having a CGM. Again, not for everybody, but that's what I would do.
And that's actually what I do with people that come in and they don't have one
on or they haven't heard about it or they're reticent about it.
(54:31):
Yep. We can actually put one on. Yes, try one.
We can actually put one on and see if they like it and if it increases their quality of life.
It's a really good reminder that we live in our type one bubble and there are
lots of people out there who are not aware that CGM is now subsidized or have just never seen one.
That's right. You can try it out. Try it out. Yep. If you hate it,
(54:54):
worst that happens, don't use it. Yep.
Thanks, Aldo. Thanks for the invite. It's been a pleasure. Thank you so much.
Until next time. Ta-ra. Ta-ra.
Music.
Ta-ra. If you've been listening today thinking that is so relatable,
(55:15):
you should consider joining our online community where over a thousand other
people with type 1 are sharing their experiences, learning and supporting each other.
Head to typeonefamilycentre.org.au forward slash connect.
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