Lets Upgrade Health Care Innovation

Jimmy Buffet view

2009-05-15T09:10:00.000-07:00

2009-05-12T10:23:00.001-07:00

Innovation and Policies

2009-03-07T09:21:00.000-08:00

Innovation Workshop Experiment

2008-12-09T13:52:00.000-08:00

This is the MHI workshop we gave today and live broadcast. It was an Experiment and got cut out around first hour, but non-the-less I am excited about the possibilities. Looking forward to your comments. You also may need to fast forward a bit!

Monsters Inc and Simulation: Email from the Wizard

2008-11-12T07:55:00.000-08:00

Below is the post of an email I received from the Society for Simulation In Healthcare (SSIH). I was originally written by Richard Kyle, the Wizard of Simulation since 1997. He has authored a book on simulation in healthcare here.

Here is the email! Would love to hear your comments!

So, just why is the training scene from Monsters, Inc., the best for training the trainers in using simulation?

Because of the massive error in the use of simulation as depicted within this movie: the key, the most essential teaching point "letting a real child through the door" IS NOT IN THIS TRAINING SIMULATION. It is in the movie, but makes zero contribution to the simulation depicted within the movie.

This essential point IS brought out in the TALKING that the boss gives AT the students (it was not a discussion, not a debrief, but a car-wash spray of words). Note that this talking at the students could take place anywhere: a public parking lot, an elevator, in a box with a fox, .... there was little need for a sim facility and no use of sim tools or methods made by the boss. His talk was a classic example of argument by authority, which was rejected in the Renaissance as a defective basis for learning the rules about how our world really works.

If this key point for would-be monsters was actually integrated into the sim, if the student does leave the door open, then a child would come through it, a mock disaster would occur, and the student would directly experience the consequences of "leaving the door open". This direct ingestion of a purposeful experience followed by digestion/integration through focused debriefing is sim-based learning. Presenting monologs within every expensive teaching spaces is not sim.

How does this observation about the sim depicted in this movie relate to you and your use of sim?

Generally
Anytime any authority figure is talking at the students while standing anywhere in a sim facility, then no one is doing sim, then little learning is happening as well, and no one else can use that sim facility for actual sim-based learning. Ever find yourself standing between your students and their synthetic patient (just like to do with real patients) while you talk about those actions that, in fact, could be done by your students on/to a synthetic patient? Is this the best use you can make of everyones' time and this very expensive teaching space? Whenever you observe this kind of low value activity, ask how you could be quiet and let consequences convey the lesson for the day.

Until you observe your students taking action, you really don't know what they can do, and their learning to do is the reason for their being students.

Until you observe your students taking an action, behaving in a certain way, the most you can say is "that topic was scheduled for a class at date/time".

Specifically
The number one teaching point "letting a real child through the door" and having the consequences happen to the student within the sim is a lot like the issue about patient death when the students do/don't prevent something lethal. Perhaps with a student's very first experience within your sim facility, the massive full consequences of the worst outcome (a patient's death, a child coming through the door) just might not be the most effective teaching. Perhaps for newcomers, a better teaching would be to hint those consequences, provide cues that death is oncoming but can be avoided but only if/then X, Y, Z, are done. Leave the patient suspended in air off the cliff for as long as it takes the new student to comprehend the seriousness of the situation, then let the student work out at and perform least one way to pull the patient back to safety. O2 Saturation values well below 90% for long durations of are excellent cues. During the debrief, the instructor must direct the students' attention to the damage to brain tissue from long periods of hypoxia by asking them to .

Curiously
Why do we ever resort to talking at students after they fail to learn what we said at them previously? Seriously, is not this form of repetitive action seeking an alternate outcome the very definition of insanity? Sure, talking at others does allow us to send out a lot of info very quickly, but is anyone ingesting, let alone digesting and integrating the meanings within our words? If lecture was a valuable teaching method, then why would any school have to take attendance?

Sim can be an excellent method for the students to learn through their errors in those ways that no one should allow in real life. Learning from the errors of others is the basis of all knowledge used in formal teaching. Now if only learning from those errors of others was as easy as being made aware of them ;)

Richard

________________________________
Richard Kyle
CIV USUHS
Wizard of Patient Simulation since 1997

USU Patient Simulation Laboratory

Thoughts on Patient Simulation

2008-11-07T15:59:00.001-08:00

There is little research about it that is actually useful. In fact, I did an EBP project on simulation for increasing clinical competency. There are many research studies out there related to if people like simulation. Yeah, for the most part, people like simulation. Does it make a difference, beyond skills, but to make more competent practitioners? The initial research is coming out now. At Banner Healthcare Dr. Mark Smith showed a 50% increase in surgical skill rate using haptic based simulation and even just using the Marble Madness on the Nintendo Wii.
In the area of Human Patient Simulation (Simman, Meti) we are still wondering and researching. A review of the literature states that it is at least equal to problem based learning or the status quo in nursing and medicine now. So if it doesn’t hurt, why not use it, the research may show it is better.
I am currently working on a project with the Arizona Board of Nursing, Arizona State University, and Scottsdale Community College to assess competency of nurses whose license is on censure.
Working for Elsevier Publishing I was one of 3 authors on the Simulation Learning System, http://sls.elsevier.com Here we are trying to bridge the gap between nursing lecture and practice all while preparing you for the NCLEX.

There is no doubt, that if nothing else, simulation allows the faculty to identify knowledge gaps, put the nurse in the driver seat, and test new teaching techniques. And if you don’t believe any of it, you have to admit its better then sitting through a 5 hour lecture!

Please contact me with any questions!!!! dan(at)Simovativesolutions.com

Does this remind your of healthcare Administration?

2008-11-05T11:01:00.000-08:00

What similarities do you see??? Is this totally off base??? Does it feel like things continue to be taken away from you??? Thoughts and Comments welcome!!!

Can It Be Done?

2008-11-04T07:25:00.001-08:00

A colleague and I are starting a business related to bringing clinical answers to the bedside faster and easier. We are creating a robust, community driven database that, in time, contain evidence synthesis papers from all diseases and more!

I am posting this blog to ask if the following can be done.

If our company, or any company for that matter, could index enough evidence based practice synthesis papers would it be possible to combine specific data sets to create a picture of a complex patient?

Now that is slightly confusing so let me give a little background. While schmoozing on Twitter i asked what the problems were with services like Up To Date and Epocrates. Several uses spoke about how UTD was great for textbook cases but was difficult to use for complexly ill ones. Epocrates was said to be too slow and not enough detail for some users.

So, if UTD is textbook and a limited number of patients are textbook are we really treating patients as individuals and in the best way?

Of course this is a tough question to answer, but there has to be a better way. If it was possible to index EBP data by population, co-morbidity, treatment, & outcome, would it be possible to cross-connect data to create a clinical picture of an individual patient? I think back to this TED Talk here. When watching this, substitute the pictures with data about patients. Imagine if we could link the data together to create virtual data pictures of complexly ill patient.

No longer would we be treating patients diseases individually, but rather, the best treatments for the whole patient would be discovered and interconnected. The ICU patient with multiple system diseases could have a clinical picture just for them, specified down to the age, co-morbidity's, and outcomes desired. It moves beyond the linear medical model and begins to cross into a holistic approach to care. With enough data, and the addition of genomics, individualized treatment patterns based on gene data as well as clinical diagnosis would be available creating personalized treatment plans for all the individuals on earth.

This idea is VERY exciting for me and if you are interested in helping, or learning more about EBPico LLC please let me know.

But we must remember the initial question. Is a quest like this possible... please twitter me (@nursedan, email me dan(at)simovativesolutions.com, or comment with your thoughts.

Out Growing Blackboard and Angel Course Managers

2008-10-31T12:43:00.000-07:00

The time has come to evolve! The Masters in Healthcare Innovation program at Arizona State University has officially become too robust and innovative for the traditional and proprietary course management system known as BlackBoard.

We are getting to a point now that we need to change too fast, the structure and limited bandwidth for uploads is hindering our ability to share ideas easily and quickly. We are now exploring utilizing free web tools to create our own, makeshift CMS system.

Although still under investigation and refinement, we are looking at FriendFeed as our central hub. Each student will create an account and share that account with the other students and faculty. For sharing up to date information on the students implementation of Innovative Leadership skills we will use Twitter. For presentation sharing, SlideShare. For group meetings and faculty office hours, Skype, and for papers Blogging.

Utilizing these tools we can begin to not only link all the assignments, courses, content, and successes together, but we can also share faster, better, and with the world.

This new direction will be under development in the coming semester starting in January. As we learn and grow this could be a new way to run courses, saving universities millions of dollars. The downside then becomes getting older faculty to adopt a new way of teaching, something that is not always easy.

We intend to share our successes and learning moments in blog form. If you have suggestions about tools that may be of use to us, please email me.

Hopefully, this will be creating a new way to conduct class and share information. Transparently.

web 2.0 tools and the busy healthcare practitioner, a workshop!

2008-10-23T08:58:00.000-07:00

After teaching a technology in healthcare class, travelling and chatting with healthcare professionals, and meeting nurses online, I have determined that we need to do a better job of introducing healthcare workers to the WEB and its 2.0+ activities.

I know this is nothing new, Webicina has started this trend with a great site training Docs how to utilize web tools for better practice and communication. Something that is VERY needed and will hopefully propel our practitioners out of the middle ages of pencils and charting notes on napkins (although napkins do spark good ideas).

Here in Arizona, we are hosting a workshop introducing web 2.0 tools to busy healthcare practitioners. HERE are the details. It will be held at the downtown campus of Arizona State University. It is geared for the novice technophobe who needs a little intro to the way the world is changing through web tools. I highly recommend educators in healthcare attend!

If you know anyone who needs an introduction to how we can use Twitter, Blogs, Clinical decision managment tools, and other web 2.0 tools and beyond send them to the above website.

Or contact me.

Presentation on Policy and Innovation

2008-10-11T15:30:00.000-07:00

Here is a presentation I gave for the DNP students at Arizona State University College of Nurinsg and Healthcare Innovation. They loved it and identified with being innovators, and having trouble getting their ideas to stick. Guess thats why we are reading MADE To STICK and WIKINOMICS are ways to communicate their ideas.

Enjoy

Caring For The Innovator, Caring For Innovation Powerpoint For Dnp Course

View SlideShare presentation or Upload your own. (tags: health policy)

A quote, too close to home.

2008-09-21T17:02:00.000-07:00

Working in the hospital I work in, and being the person that I am (an Innovator, positive deviant, leader, and complexity science advocate) the following quote described the current situation in my work life.

"Incompetent leadership has been the inability to tolerate or place trust in individuals who show initiative or who are in anyway unconventional'

This quote comes from an article entitled Chaos & Evolution in Nursing Research.

I will not go into details as I do not want the offending parties to be further ground or attacked, but my hope is that this quote reaches enough people that it will inspire others to look outside of their comfort zone to tap the collective wisdom of those individuals who are innovators, change agents, and altogether unconventional. The quote that goes well with this is,

"When an employee in a health care agency behaves "unpredictably" and is considered inappropriate or unreasonable, perhaps it is the administrations view of the system that is not appropriate!

As you lead and participate in change, keep these quotes in mind as they are the backbone to caring for the innovator and caring for innovation.

Complexity in Healthcare

2008-09-18T17:56:00.001-07:00

I have been reading the book Out of Control by Kevin Kelly about complexity science and the future. Although not stated out right, many of his analogies apply to healthcare.

One that hit home was the idea that anything in balance is dead.

Kelly shows us this concept through the analysis of planets atmospheres in the solar system. Any planet whose atmospheric elements are in text book equilibrium can sustain no life. But earth, earth is a stable instability of gases, and, of course, life thrives$

In complexity, stagnant and equilibrium is death. When movement stops, even to the cellular level, death occurs.

And what our our hospitals thriving on? Stability!

Policies and procedures provide a stagnant environment that takes enourmous energy to change, the AMA and other professional organizations are steeped in the traditions of a past paradigm, and the knowledge workers at the point of care have extreme difficulty in adopting new practices (17 years for research to reach the bedside). So what does all this mean...

Stagnation.

So to hit it home a little closer. The IOM reports that over 100,000 people die each year from medical error. But is that surprising when the system is working towards stability?

My questions are: what would happen if a hospital, clinic, practitioner office moved to a complex adaptive system model?

What if the policy was to find and utilize the best evidence to make a clinical decision?

What if there was a system out there to provide the best evidence to the practitioner, the patient, and the system so policies and procedures were then obsolete?

What kind of healthcare would happen then?

I'm an Author..Finally out of Stealth

2008-09-16T09:09:00.000-07:00

Hello all,

I have been in stealth mode while working on a simulation project with Elsevier Publishing the past year, and finally, I can talk about it.

the SIMULATION LEARNING SYSTEM

This is the first of its kind in human patient simulation education support for nurses. The product features a WORKING EMR, 30 med surg scenarios, Multimedia resources for learning, and provides a step-by-step guide to setting up, conducting, and debriefing simulation!

I am one of 3 authors on the project and am very proud of the hard work that Elsevier and the other contributors have put forth. This product is truly AMAZING. I was a skeptic at first, believing simulations should be created by the schools to match the curriculum. After seeing the SLS I am convinced otherwise.

This will cut faculty prep time significantly, provide resources for student learning, and change the way Lecture and Simulation mesh inside nursing schools.

This has the potential to change the way simulation is conducted, and standardizes scenarios for better learning outcomes and better student experiences.

I welcome comments and thoughts.

Its Been A While

2008-09-15T10:35:00.000-07:00

Well, its been a while since I last posted. I am 3 weeks into my PhD in Healthcare Innovation at Arizona State University and have already filled up 150 pages of notes. I had loathed the thoughts of Nursing Theory and Philosophy classes, but as I read the articles I am finding that Innovation and Complexity are hidden through and just need a little push to get them out in the open!

I am also working with a business partner on creating the next revolution in healthcare knowledge utilization. This project is currently in stealth mode, but will become public in the next few months. Nothing like this has ever been done before, and we are excited about the possibilities of changing healthcare knowledge forever!

Well, it off to read more theory!!! Being a skeptic on how theory would have ever related to my practice as an Emergency Department RN, I am now realizing, having the basis of theory allows one to see the bigger picture and look at the systemness of healthcare. I will be blogging more on that in the future.

Time to put on the headphones and read away!!!!

I earned my Masters

2008-08-05T13:50:00.000-07:00

I am now officially done with my Masters in Healthcare Innovation (MHI) from Arizona State University College of Nursing and Health Care Innovation...

Next Steps: I have been accepted into the PhD in Nursing and Healthcare Innovation, working on the INNOVATION track, as opposed to the nursing focus.

This is exciting... Dr. Dan RN by the time I am 31 years old!!!!!

We are Batman

2008-08-05T13:48:00.000-07:00

We are batman

So I just finished watching Batman Dark Knight. To warn you this is one of those passionate flight of ideas Blogs I am famous for… OK… so its perfect… Batman is our symbol for MHI (Masters in Healthcare Innovation) and Bruce Wayne is our symbol for the graduates.

The entire movie is a fight between innovation leaders (Batman & The Joker). Batman with his vision of a better Gothem (healthcare) and Joker with his sights set on benefiting on the broken system. Who wins??? Well I will not spoil the movie but I will try to address some of the characteristics that are portrayed so elegantly in the movie.

Lets start with Batman. If you saw Batman Begins you will know that Bruce Wayne was once part of the problem of Gothem… A rich man making money on the suffering of others. After experiencing a life altering interaction with crime, he reevaluated himself and embarked on a journey to understand how the broken system became broken and the people living in the trenches. Sound like the MHI program… I think so!!! So as he trained to one day fight the broken system he realized it was time to break away from the old ways a become something bigger…. He chose to become a symbol (Batman) something that people can believe in and follow. In other words, Batman is the innovation leader fighting for good change.

So what do I mean by good change. Again, you gotta see DARK KNIGHT, but Batman has defined his values and sticks to them. He adapts his techniques, his equipment, his approach, and his logic to the situation. He garners support from the change agents and does not take ownership of the innovation. You will see in the movie near the end what I mean about not taking ownership!!! He uses his tools to both fight the system and crime to accomplish the goals. He works towards a vision of a better Gothem and does not let friend nor foe stand in his way. He realizes that he is the key to making change and even those close to him do not always understand his motivations. He eventually translate it.

Can you see the tie ins… again… you gotta see it….

But what about Bruce Wayne. Where is his side in all of this. Bruce still plays the part of the broken system but uses his power for good now. So it could be argued that we MHI’rs as individuals are Bruce Waynes. He still has to live in the city filled with crime, he still must deal with the day to day work that is part of the routine, but he is working to change it and understands that he must still both create change and operate in the system he is changing at by night. MHI as a whole is the symbol known as Batman. Ok… need to get thoughts on that… but first lets go to the joker.

So the JOKER!!! He is an innovation leader as well. I know, its hard to believe, but we have talked about this in class. We has innovation leaders can use our power of change for evil… That is the choice that the Joker made. He created chaos for the reason of chaos. There was no vision, he describes himself as a rabid dog, just “Doing” and not thinking. He is a lost yet effective leader. He can manipulate his followers to do his bidding and his fatal flaw is the fact that he took ownership of his change and innovation. He began to expect his change would always carry out the way he planned. That cost him, his ownership brought him down.

So, we are Batman, and Bruce Wayne, and we are trying to fix Gothem while living their too… and sometimes, we have to fight Jokers and give up ownership to keep the symbol of change and good alive in those with less power to change the world. Its perfect!

OK… now you all have to go watch it! You will see the tie ins… its advanced innovation at its finest!

MHI Newsletter Shakes New Ground

2008-05-12T13:13:00.001-07:00

I wanted to include a link to the Masters In Healthcare Innovation at Arizona State University college of Nursing and Healthcare Innovation newsletter. See below... please subscribe and forward as appropriate.

Paste into browser:
http://archive.constantcontact.com/fs094/1101985890950/archive/1102003174591.html

Or click this hyperlink
ASU MHI Newsletter & Signup

Jules Verne and Healthcare Innovation

2008-04-22T12:01:00.000-07:00

So I admit I am somewhat of a nerd... I was watching the Discovery Channel today and saw a show about Jules Verne. It got me thinking about the Masters In Healthcare Innovation program I am currently studying.

Jules was initially a shunned stockbroker. Repeatedly denied credability due to his outlandish ideas and science fiction. But as history has shown, he predicted the submarine, flying machines, space travel, dictators, world demise, and diseases. He was a true innovator, before the word innovation was buzzing the world.

So how does this relate to Healthcare Innovation. In much the same way Verne was shunned, the MHI students at some point feel the same way. They are the groups of people that don't fit the traditional mold of the healthcare industry. They have ideas, see things differently, and predict changes, well in advance of them happening. Verne found comfort in a group of friends called "The Eleven without Women". The MHI classmates, though with women, provide a similar support structure. A place where the walls of tradition are broken and ideas flow and are accepted without the context of the bottom line or power struggles found in actual hospital politics.

I found on fact very interesting in watching this show. Verne consulted with physicists, mathematicians, visionaries, and designers and calculated the trip to the moon, the weight of the lander, and the power needed to break gravity almost exactly. Decades before NASA was formed Verne calculated within 2 miles the landing spot of the astronauts returning from space in the ocean!!!! That is innovation!!!

So what is the morale of the story. Pay attention to those people you work with who question the status quo and work to change to world. They may be right on! Although questioning is a needed part of innovation.... shooting down ideas with out a pilot is not.... Give it a chance and you may predict the next revolution in healthcare!!!!

Dr. Nurses changing the flow!

2008-04-20T21:18:00.000-07:00

After a long break I am back to stir up the blogosphere....

There has been a lot of talk lately on the Dr. Nurses. I have read blogs, mostly by physicians, questioning the value of these healthcare providers. I find that interesting and at the same time not surprising.

I find it interesting that a group can feel overwhelmed (primary care crisis) yet when the market produces comparable answers it seems some are a bit wary. But what is causing this sudden kick up of blogs and discussions? It is fear of a role change? Is it loss of power? Is it something completely different? Is it just curiosity? Nurse practitioners have been around for a long time, yet the new DNP programs have created quite a stir....

Personally I think it is a good thing. The crisis will not be solved by physicians alone. Not only do DNP provide needed services, they are a member of the team. They can reduce the demand on practices and according to research they have equal or better care outcomes. They are not a replacement for docs, they are a member of the team.

It is not surprising that this questioning of change is occurring. Healthcare is steeped in tradition, and fearful of change. The only way to change healthcare is to begin to look outside of healthcare for answers. I have posted about Disney, Auto, and other industries and how they can have influence healthcare. Living in a silo fixes nothing.

I am interested in discussing what industries can help change healthcare???? Please post your thoughts!!!!

Update- Plans

2008-04-10T15:22:00.000-07:00

Hello all... sorry for not posting the past week, I have been hard at work finishing some projects for my masters program.

I am going to a Design Awards Dinner tonight at the Desert Ridge Marriott where the author of Wisdom of Crowds, James Surowiecki will be speaking at the KeyNote. Should be a fun experience and a good networking event. I will write a blog tomorrow about the experience.

More innovation soon to come!!!

I GOT PUBLISHED!!!

2008-03-31T13:08:00.000-07:00

IN the April/June issue of Nursing Administration Quarterly look for the following article! Its my first of many to come, man this is exciting!

Caring for Innovation and Caring for the Innovator

Caryn Unterschuetz, BSS, RN; Paula Hughes, BSHS, RN, CHES;
Daniel Nienhauser, BA, MBA; Daniel Weberg, RN, BSN, CEN;
Lauraine Jackson, RN,BC

Nurs Admin Quarterly
Vol. 32, No. 2, pp. 133–141
Copyright c 2008 Wolters Kluwer Health Lippincott Williams & Wilkins

Exclusive Social Networks....good idea?

2008-03-29T10:43:00.000-07:00

Recently I have seen several blogs on exclusive physician-only social networks. Sites such as Sermo and Ozmosis adn Tyromed have popped up creating a place for physicians to share ideas and collaborate. My question is, is this a good idea?

Do exclusive sites like this serve to generate new knowledge, new ideas, and new innovation....OR do they silo thoughts into the doctor world, lost forever? I cannot honestly answer that because I am not a physician and cannot access the sites... SO am I feeling left out... Not likely. I do wonder about the effect of theses sites though. Do they continue to widen the gap between docs and other specialties like nursing, respiratory, administration, nurse practitioners, and PA's?

Wouldn't sharing case studies and collaborating with the health care team only serve to create better outcomes?

I understand the need to create a site that the general public cannot access.... Although patients do have a say in the world of health care, an open site like that only serves to breed another MySpace. But a collaborative website that includes all health care workers and promotes a professional exchange of ideas and collaboration seems like a better idea.

Keep your eyes open, as a site like this will be beta testing soon!!!! I will update more as this occurs!!!

Damn Army!

2008-03-28T08:05:00.000-07:00

I almost had a heart attack today when I read this story. The Army has awarded a $900,000 contract to DRC (a patient simulation training company) for ONE YEAR.

For those of you who know me I too have a simulation consulting company as well. Simovative Solutions LLC! I have done some work with schools of nursing and am now working with a publisher to create the next innovation in simulation learning.

Although it can be lucrative

I can only hope to get $900,000 for a year contract... You think the Navy needs sim?

Brainstorming auto vs medicine

2008-03-24T16:56:00.000-07:00

What can the auto industry teach us about good practice in medicine? Just ask your local mechanic.

I just took my Honda Civic to the mechanics for a tune up prior to an emissions test. The CHECK ENGINE light was on and I knew that was not a good sign. I entered the office early in the morning and was promptly greeted with a smile. The man behind the counter asked, "How can I help you?" Try getting that customer service at the ER, docs office, or clinic.

I responded with my story about the cars engine light and the man pulled out a quote sheet! He spent a few minutes calculating the diagnostic test and provided me with a number. From there I had a choice... I could take or leave it.

What a concept. Upfront pricing model... Can you see this working in medicine? You go into the ED, doctors office, or clinic and give your story, from there they tell you a estimated cost of procedure and tests, and THE PATIENT CHOOSES! AMAZING concept!

Now I can see some thinking about the extra time in quoting a price, and the type of reimbursement, and lost business, but think about the culture change. If you are told it will cost x amount of dollars to deal with a chronic disease, wouldn't more do preventative oil changes to make sure the engine runs smooth.

Better yet, what if an insurance company used this as the philosophy. It may even create a bit of honesty and patient teaching in medicine.

ANYWAY, back to my car... SO I went home after dropping it off, and a few hours later I got a call. A very nice man on the phone told me they had inspected the cause of the light and it was regular 100,000 mile checkup stuff... a belt change, a little leak in the water pump, and change the spark plugs. I again was updated on the price.

How does this apply medicine... So you agree for the labs and xrays to be taken... then, after the results are back, the doc updates you with some of the needed repairs.... Again, the patient is steering the boat.

"Yeah I will take angiogram and the stent, but I will try and control my type 2 diabetes with diet and exercise, I heard metformin has a few side effects, how does that sound?" asks the patient

Doc responds, "well, you HGB A1c is still in the mild elevation range, we can try that and see what happens, just be sure to check in with me in a month for a retest, and please see a dietitian for a follow-up and diet guide."

See, collaborative care....

SO how does this story end... well, I picked up my car and had opted to get the full repair. Figure that was a good investment as I cannot afford a new car at the moment... I think prevention is the key to long car life, wonder why its so hard to get patients to think the same about their body!