Thursday, March 14, 2019

The Joy of Writing and Insatiable Learning



You never know what an early airport arrival can mean for your soul.

This happened to me earlier today, opening my eyes to a feeling that's been brewing for awhile now and blossoming into a soul-soothing and spirit-lifting revelation ripe with life perspective. Not to mention, inspiration by Bill Gates, Leonardo da Vinci, Dr. Frederick Banting, random airport strangers and paintings of famous past and present Chicagoans sketched onto glass panes at a hotel bar.

Whoa, dude -- deep thoughts! As you can see, the words are flowing my brain is in full gym mode mid-workout on the weights...

My experience began at the airport gate where I arrived an hour before my flight boarding. With a hot cup of coffee I turned to my writing tasks overflowing on my To Do list. Instead of eyeing my smartphone or opening up the MacBook to write, I opted for pen and paper. Sure, I did post on Facebook first because that's what you do in 2019, right? But that's as far as it went. Maybe it was the wide-open window view of the runways. Or maybe I was inspired by how a day earlier, both Facebook and Instagram had crashed and put masses of social media folk into a tizzy.

Whatever the motivation, here was a chance to exercise my under--utilized handwriting skills. In an actual journal.

I scribbled some notes about work and had some fun exploring different ways to write what I needed to on deadline, and then found myself drifting into other thought and jotting down observations about people arriving at the airport gate. This is a whole post in itself about those individuals, but that's for another time...

This airport experience was entertaining and relaxing, but it was only a taste of what would come once I boarded the plane and prepared for the hour-flight ahead. That's where the true inspiration, optimism, hope, and joy of writing transitioned from a creep into a full-waterfall. A smirk into unbridled laughter, if you will.

As we taxied on the runway, I found myself engulfed in a magazine article that focused on the big theme of optimism and hope. It included a whole series of vignettes by prominent folk, and one of those was legendary innovator Bill Gates who shared his belief that “innovation is an art form” that leads to optimism and hope. To get his point across, Gates wrote about his decades-long fascination with Leonardo di Vinci, describing him as a historical figure with an “insatiable learner” who was always hungry to know more. He looked at everything around him in the world, learning as much as possible and then both exploring those ideas in his head and jotting down notes in letters and sketchbooks.

A particular tidbit that Gates mentioned was a letter that Da Vinci wrote to a king in Milan, listing his many talents that included being a designer and engineer of bridges, tunnels, carriages… and at the end, that he also happened to be able to paint.

In reading this, it grabbed hold of my heart and mind and made me sit back and reflect on this as a deep thought, one that I’ve seen before throughout history. Think of Dr. Frederick Banting, who is most well-known for his idea and co-discovery of insulin – aside from that, he was a military man, a researcher on top secret government projects, and a painter himself.

History has always fascinated me, and that’s probably a big push for my falling in love with journalism way back when I was in middle school. Aside from the writing, of course. History teaches us lessons that aren’t just confined to pages of a book or posted online, they tell stories that matter and can translate into lessons in our lives now. To me, looking to history shows us what has come before us and can teach us how we might navigate the future.

It's what goes through my brain right now, as I sit here at a Chicago hotel drinking coffee, writing like there's no tomorrow as the painted faces of 22 Chicagoans watch me from above the bar.



Some are obscure and some more recognizable. Studying them, I recognize roughly 8 of 22, mostly the singers and actors and writers of those featured.  And that starts leading me into another mental rabbit hole, wondering about their lives and what else these individuals may be about beyond what history largely credits them for. This sparks conversation with those around me, and in the end it all goes back to the point:

Insatiable learning.

I want that.

When it’s all said and done, sure many may know me as a writer. Or as a guy who talks a lot about diabetes and wears his T1D on his sleeve. But I want more than that. I want to be remembered for more than just those things that I’m very proud of. A student of life, as it were.

I want to look to the future and find hope, that the world can be better but that I can always work the muscle in my head to think of possibilities and be optimistic.

In some way, I'm thinking about it like a car.

While the point may be to get you from Point A to B, it's more than that too. Driving a car from one place to another also allows you to observe what’s in between those two spots, to explore and see the world around you. There’s an optimism and hope built into that drive, knowing that you can see the world around you and having optimism and hope that you will, in fact, get to where you’re headed.

Focus on that optimism of the drive instead of grumbling about other drivers, road conditions, gas prices, inclement weather, or sunshine reflecting in the rear-view mirror. Know that you get to explore and be a part of the world, on that particular drive on that specific route.

Otherwise, what’s the point? You might as well just leave the car parked in the garage.

So is life. And that insatiable hunger to learn, to explore.

That is what I want in my life. And in particular, in my writing. I want to write not because I have to but because I want to. So that my words can explore, challenge, inspire, ignite.

Even to explore the art of handwriting, which seems like it's becoming a lost art these days of everything-online. Writing on paper feels good. It exercises the mind. Shares as much about you as the words, from how you write to what you cross out and change, to the margins you scribble in to expand on various aspects. Words are art in themselves, as is the process of writing by hand.

And it’s through writing that I have found a place of comfort since childhood, and I aim to find that familiar place again. When you spend most of your time writing on deadlines and because it’s necessary, you can lose the joy of writing and what it meant on a base level. That’s where I’ve been hovering for some time now, seemingly treading water with my words. Rather than diving underwater to explore, splashing around, swimming out into uncharted waters to just see what’s there. There may be new words or phrases, or life experiences to write about.

Again, it comes back to that insatiable learning, that curiosity and interest to expand my horizons. To meet new people or have fresh conversations with old-friends.

Here’s to that exploration of writing and tapping into that insatiable hunger for learning. I may not be Gates, da Vinci or any of those famous Chicago folk, but we all can learn from them and act with intention to just experience and share.

This brings to mind Hamilton the Musical where we're asked (to sing): "Who tells your story?"

Here's to raising my hand to that, with pen in hand wherever that takes me.

Wednesday, March 6, 2019

A Conversation With My Dog About Doctors

The dog and I had a deep conversation recently.

OK, fine. I'll be honest: It was mostly me ranting, with her just watching and listening. Every so often, she'd wag her tail, raise her ears or tilt her head inquisitively. Mostly, the dog was there to listen and offer moral support.

You see, I had a doctor's office visit recently. We've been back for nearly four years now and have had the same Michigan-based HMO policy during that time. It's great insurance coverage and I am very thankful for it, but it's a bit frustrating as to the headaches I must endure as a part of the process.

For instance, the endocrinologist that I've seen for 3+ years now is one of the best. And while he's cool with unofficially being a point-person for my healthcare since 99.9% of it relates to my T1D, it's not official and my insurance requires a Primary Care Physician. That means in order to see my endo or any other doctor who's basically a "specialist," I must have a referral. And they only last a year.

So annually, I must go through the task of going in to see a new PCP to basically recap my general health picture to get these referrals. And per usual, I decline to do anything more like blood-work, lab tests or medication changes because that's all handled by my endo's office. I prefer that everything go through his office, since his name or clinicians are the ones signing my Rx's.

Of course, these Primary Care Physicians aren't pleased with my brushing them off.

I also happen to go to a family clinic about a mile from my home/remote work office, out of convenience; and this particular place is in the same hospital-affiliated network that my endo is. Unfortunately for me in several ways, it's a "teaching facility" which means I typically see 2nd or 3rd year residents who are just going through the motions; I've never once seen the actual doctor whose considered faculty, and I refuse to wait several months for an appointment that I don't take too seriously to start with.

As such, the last time I was at this office to see anyone in person was in late 2017. Last year, I lucked out that the referral specialist agreed to just renew my referrals for my endo and other docs, so I was able to skip seeing a doctor there.

Not so much in 2019, and the in-person appointment was required before anything else. So I sucked it up and made the appointment.

Since I've now just turned 40, I also figured it was time to check off some non-diabetes related health tasks that materialize as you age. Among them, a physical.

After seeing a very nice nurse who went through the check-in health measurements and online chart checks, I was left alone to wait for the never-seen-before doctor. I waited an hour, and in doing so was already missing out on an important work call that had started just before my appointment time.

The doctor finally entered and ignored my extended hand as he studied a paper chart, and this put me in an even-more grumbly mood.

"Wow, you haven't here since 2017? And you have diabetes!"

My response: "Correct. I see an endocrinologist at least a few times a year and work with him directly on my diabetes and most other things. But my referral is expiring soon and my insurance requires that I see a primary care physician, something he isn't able to do officially. So that's why I am hear. To get my referrals."

After dealing with this young doctor's disbelief that I even needed a referral, which is straight up fact for me since 2015 when beginning on this Michigan insurance plan, he moved on.

He started asking about my medications, without looking at the online screen where they had been entered by the nurse an hour earlier. I reminded him of that. While also handing him a written sheet listing the med names and doses. And noting that I didn't need any Rx fills, because my endo handles that all.

[[ The dog, meanwhile in real time, is just looking at me. I can't tell if she even cares about my story, but at least she's listening. ]]

"What's Tresiba?" he asked, and I explained.

"What's Afrezza?" he asked, and I explained.

"You also take Novolog... why are you on so many insulins?" he asked, and I politely brushed him off by reminding him that it's something my endo and I have determined is best.

He then mentioned my endo and wanting to see those records, to which I suggested he give my endo's office a call. Or simply look at the screen since both facilities are in the same hospital network system... and last I knew, the records were being shared. He did that and found the records, from my last visit in November.

[[ At this point in my story-telling the dog hopped up onto the couch and gave a look of concern, before putting her head down and sighing... clearly, we were on the same page here ]]



And this is where it elevated to the next level.

He saw my higher A1C. He noted how my labwork was overdue, for many things including thyroid and kidney function tests. And he connected that all back to what he'd already observed about my lack of primary care doc visits, a higher blood pressure reading despite my current endo-prescribed ACE inhibitor... and generally, my lack of enthusiasm for talking to him in particular.

"I'll be right back," he said, and left the room.

Oh, boy. Now I'd done it. He was only gone a few minutes, during which time I put my socks and shoes back on. He re-entered and didn't sit.

Clearly, the tension had risen.

"You need to change medications," he declared.

Um, no. Even if that's the case, I'm not comfortable with that here. It's a conversation for my endo and I to have, once I can get the referral.

The 2nd-year resident explained the role of a primary care physician to me, noting how important that job is and that he can help explain things to me that other "specialists" may not.

"Listen, I appreciate your job and understand that I'm being difficult here. But I don't need you to explain that to me. While some may, I don't want that from you. It's not why I am here."

He glared at me, dumb-founded.

"You're basically asking us to be a referral mill, something that I'm not comfortable with..."

Then I guess I will be taking my business elsewhere, I stated. Paraphrasing what I told him next: I'm essentially checking off a box here, for insurance purposes. I'll get to managing my health with the appropriate people who know my history and I trust to work with me in that decision-making. Sorry, bud, that's not you. Chances are, I'm never going to see or hear from you again after this visit -- just as it's been every single time I have come here since mid-2015.

What happens if you go to see another doctor and that person tells you to change something, and you need help understanding it?" he asked.

"Then I'll ask that doctor and work it out with him or her. And then let my endo know."

I was actually a bit insulted that this particular young doctor didn't think other doctors, especially those who've been practicing MUCH LONGER than he has, would not be able to make simple recommendations or explain care. That I would need him or this office in particular to explain it to me.

[[ The dog was again perked up, sensing my rising blood pressure,  and inched closer to me and put her head on my leg. That was nice. ]]

After two hours in the office, I was finally able to leave after the young doctor all but threw up his hands and gave me the paper referrals needed to get into my "specialist" physicians. I checked out and left.

Granted, I know that I am being difficult here. That really, I need to put more care into my own health and diabetes management and that -- in the context of this primary care office -- that I should respect their role more. I'm basically gaming to work the system to get what I want.

Still, I didn't feel listened to at this office or by this doctor. And that maddens me. It's also a similar experience I had the last time I was there, and why I hadn't returned in so long.

Maybe now that I'm 40, I can do better on my healthcare. And take it more seriously than I have, to improve my D-management as well as my A1Cs and general health.

I just don't think a primary care physician is what I need for that, and it'll add more headache and stress and push me toward not wanting to take care of myself. I'd like my insurance company to know this, too.

Again, I know it's complaining just to complain here. And that in the end, I've got great insurance coverage that just requires me to jump through hoops. Necessary hoops.



[[ It's a damn shame my dog can't be my primary care physician... she already does more for me than any PCP has in the past three years. Maybe I can teach her to write referrals.... ]]

Oh well. We can dream, right??

Thursday, December 27, 2018

Hello, Gym (aka Improving My Health While Nearing 40)

We joined a gym in late July and my diabetes management habits have been noticeably different since then. Combined with lower-carb eating (roughly half the time), I have noticed a dramatic difference in my blood sugars and overall diabetes management and health.

Sure, there are days when I feel so much more tired. Because workouts can be physically demanding and energy-draining. But most of the time, even after working out and when my muscles are whining, I feel invigorated and more on top of my game.

My diabetes data (and habits) show it's working:
  • Insulin Use: During the height of my gym-workouts over the past several months, I noticed that I was using roughly a third less insulin than before -- both my Tresiba basal dose decreased every 24-36 hours, and my monthly box of Afrezza inhaled insulin is lasting noticeably longer and even impacting how often I need to refill my Rx for it.
  • BG Range: Yes, my average glucose has dropped from the low 200s into the high-100s. It's a work in progress, coupled with the fact that I am still experiencing a lack-of-willpower at times in the evening when it comes to snacking. This has been my biggest weakness over time, eating more carby snacks without adequately measuring them -- leading to higher BGs overnight that need corrections in the middle of the night, or even first thing in the morning. Progress, though... I am working on it and trying to limit my evening snacking, as well as weave in veggies and lower-carb snacks instead.
  • 'Lower carb' eating: As noted, we've been pushing toward lower carb for quite a while now -- probably close to a couple years. But over the past six months, I've made a point of being more disciplined on my eating style. By no means do we believe carbs are evil, and we enjoy them quite a bit. We no longer by certain snacks and foods, because (as mentioned above) I have a lack of discipline and willpower and it's better to not tempt myself by having easy access to a food item. There is a lot more produce in hour house these days, though sometimes we buy too much and it spoils. We've been weaving larger portions of veggies into our dinners, which are generally lower-carb about 66% of the time -- (just to name a few examples: organic turkey & brown rice stuffed peppers; squash boats and "zoodles" where you can use zucchini or squash instead of pasta; brussel sprouts, salads, and cauliflower pizza). Of course, there are times we just cave or don't care, and that's what I would say accounts for about a third of our dinner-time choices.
  • Alcohol: Many in the D-Community may recall I'm a fan of beer, especially microbrews. When I travel I like to enjoy a local craft brew and generally I sign on to the #DrinkLocal mantra. However, craft beer is often more nuanced with higher carb counts and potentially even sweeter. So while I still do enjoy microbrews, what's most often in my fridge at home is a lighter beer variety. You may generally find a bottle of the low-carb Michelob Ultra or a Labbatt Blue Light lounging around in there. While a day may come I decide to eliminate beer (and alcohol?) pretty much entirely, that day has not arrived and my health has given me no sign it's necessary as of now.
  • A1C, Not Yet: This isn't a clue for now, since my last appointment in the summer was too soon after these larger lifestyle changes took place and I haven't had another appointment where it's been a full 3 months to warrant a new A1C test.
With all of that being said, there's quite a ways to go.

Why Now?


We're paying quite a bit of money for the gym and at times for the lower-carb food choices, but it's worth it to us.

We have been talking for a few years now about joining a gym, but just had not pulled the trigger on that. Sure, we added some dog-walking and other small exercise components to our daily and weekly routines, but it wasn't anything scheduled and more often we slacked on actually doing what we said we would.


As we both head closer to age 40 (I'm nearing that in February 2019!) it became clear that we needed to make more of a concerted effort to improve our health. On the diabetes front, this has always been on my mind. But over the recent years, I've noticed -- aside from my general "beer belly" growing a bit larger -- that it was more difficult to make long walks, navigate large conference centers, or make the trek up and down parking garage stairs. I would get easily winded. On top of that, my niece and nephew (currently ages 6 and 4) take up my attention more often, and simple things like picking them up, playing "airplane kids," or chasing them around the house/yard gets more tiring.

I swam for four years in high school and a bit recreationally in early college, but that is pretty much the last time I can proclaim to have taken part in any competitive sport or exercise routine. And any workouts or gym experience is now 20 years in the rear-view mirror. Along with any muscle strength that would've been gained back in those years.

So, nearing 40, the time to do something different arrived.

The gym we chose is a half-mile from our house, so on nicer days I have the option of easily walking there as part of my warmup and cool-down.

We've been pretty good about getting into the gym at least a couple times a week, at least up until the holiday arrived. With work travel on my end, some "real people sickness" and the holiday-time, we slacked a bit in November and December. But we're working to get back into the routine.

On days when I didn't make it into the gym for whatever reason, we also have a small amount of equipment at home to use. I've also made it a point when traveling for work to make use of the smaller hotel gyms available.

Also of note: For the past year or more, I've noticed my left shoulder is much more tense and sore. To the extent I can hardly put a long-sleeve shirt or jacket on without a bit of trouble. While it's possible this is a diabetes-related complication known as "frozen shoulder," I'm not 100% convinced of that and my personal trainer seems to think it's just a rotator cuff issue. So we have been doing specific stretches and exercises to battle that... and I've noticed it has helped a little bit. This may be a sign of age and even the need for a new bed and mattress, but that's TBD. At least the bands help and for now, I'm happy with this.


Our personal training sessions end soon, but we have a gym membership through 2019 so we'll be in there multiple times a week getting our workouts on.

Here's to a healthier year as we move into our 40th birthdays.

Tuesday, August 7, 2018

Letter Abut Limiting My BG Test Strips

My third-party supplier has recently tried to limit test strips for those using a Dexcom CGM system. In fighting this policy, I penned this letter. While I've been able to get more strips as prescribed, my hope is also that this letter leads to deeper consideration at the policy level by this Michigan company.
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August 6, 2018


Michael W. Hoskins
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J&B Medical Supply
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Wixom, MI 48393

Dear ------- and J&B Medical Supply:

I am writing this in response to recent letters received from J&B Medical starting on July 24, 2018, regarding the allowable amount of glucose test strips for those who also use the Dexcom G5 continuous glucose monitor (CGM) as part of their diabetes management.

Per your letter, “all regular diabetic testing supplies are included in the coverage of your Dexcom G5 sensor.” And further, due to the Dexcom G5 being classified as a non-adjunctive therapeutic CGM that can be used for treatment decisions, J&B Medical has decided on a policy level to only ship a maximum of 4 boxes of test strips for every 90 days in order to calibrate the CGM twice a day.

On an individual level and at a broader policy level, this blanket limitation on test strips contradicts my physician’s prescription for what is medically necessary.

Per Dexcom’s G5 User Guide, “The sensor glucose reading can be different from your expectations and symptoms. In this case, wash your hands and take a fingerstick blood glucose measurement with your BG meter to confirm your expectations and symptoms.”

In my situation, my endocrinologist has prescribed the following: 4 test strips a day, or 360 total for a 90-day prescription (compared to your suggested 180-day supply for those three months).

There are several reasons for this, as documented in my physician’s chart notes:
  • This amount accounts for not only my two required calibrations per day with the Dexcom G5, but times when I do not use my Dexcom G5 and other situations such as illness, lost data signals, and backups for hypoglycemia/hyperglycemia when clinical data shows the Dexcom G5 is not as accurate.
  • On average of 2-3 times per week, I experience “compression lows” as a result of rolling over and sleeping on my Dexcom G5 sensor. As a result, when I receive a Low alert via CGM, this requires me to confirm the CGM data with a fingerstick to ensure accuracy.
  • Additionally, the Dexcom G5 is FDA-approved for seven days of wear – or 28 days for a box of four sensors each month. That means there are at least 6-8 additional fingersticks per each 90-month period not factored into this J&B policy on test strips.
Clearly, the FDA and subsequent Medicare classification does not require a Dexcom G5 to be used instead of fingersticks. Instead, both federal agencies state that a patient may use the Dexcom G5 instead of fingersticks to make treatment decisions. Additionally, both the product manufacturer and the federal agencies recognize that accuracy may vary on the Dexcom G5 and that additional fingersticks may be necessary or preferred at times – such as those noted above.

Take my glucose readings today – my properly-calibrated Dexcom G5 that has been in place for three days displayed 226 mg/dL, while a fingerstick showed 177 mg/dL. Had I dosed insulin off the CGM reading, I likely would have dropped into the dangerous hypoglycemic range. This discrepancy is not an uncommon occurrence.

While some individuals may decide with their physicians’ guidance that two test strips a day is sufficient when using a Dexcom G5, that is a patient-physician choice and should not be one dictated by an insurance provider or third-party supply distributor.

In speaking with Blue Care Network of Michigan during the week of July 30, the insurer verified that my coverage includes both the Dexcom G5 CGM as well as any additional test strips for fingersticks that my physician determines is medically necessary; as long as a Prior Authorization is obtained, the coverage is provided.

I am sending this response letter to J&B Medical to have on file. Along with any submitted prescription and additional physician notes on file, I trust the Prior Authorization for test strips will follow what has been determined to be medically necessary – for my own diabetes care, as well as others who may also be using these products for their own healthcare.

Thank you,

Michael W. Hoskins