June 7, 2013

Why Physicians Dislike Seeing Diabetes Patients

An article in Medscape caught my attention and to see two doctors (one an associate professor of medicine and the other an endocrinologist) discussing diabetes patients is very interesting. Do I think they are in error in their points? Not even, as they present some very valid points. Internist Matthew Mintz, MD, Associate Professor of Medicine at The George Washington University School of Medicine in Washington, DC, who blogs here is one of those doctors that I follow when he blogs. The other doctor is not one I am familiar with and it is Cyrus V. Desouza, MBBS, Chief of the Division of Endocrinology at The Nebraska Medical Center in Omaha. Note: To access the entire article, you will need to sign up for a free account if you do not already have an account with them. I have an account and obtain a lot of good information from Medscape.

This is one of the more positive discussions and deserves consideration. The author of the article, Neil Chesanow (Senior Editor, Medscape Business of Medicine) is the one person that discussed the objectionable aspect in the last paragraph. It is this and I quote, “The more incentivized your patients become to manage their condition and adhere to the regimen you prescribe, the fewer visits they will need to make to your office and the more likely you will be to catch emerging problems before they become serious.”

I was able to correspond with both doctors and they were not in agreement with the above quote. Both felt education is important and with education, the patients would be more willing to take ownership of their diabetes and do their best with the care plan outlined by the patient and their doctor. The error of the article author is also evident when he uses the registered trademark of a Bayer glucometer for the Sanofi-aventis meter that is iPhone-enabled, the iBGStar®.

In my conversation with Dr. Mintz, I brought up the idea of using telemedicine to which he stated, “I do not think; however, that they will obviate the need for face to face contact.” That was my thought as well for using telemedicine as this could help with education, but should not replace appointments with their doctor. Dr. Desouza was not available other than to answer two questions and I appreciate his time to do that.

In the article, Dr. Mintz is very clear about what can happen to primary care physicians (PCPs) when they have appointments with patients with diabetes. Normally he states that in scheduling patients for 15 minutes, many patients with diabetes may have other medical problems requiring more attention than 15 minutes will cover. Then you, as a doctor, are behind schedule and will probably be late in finishing the day.

Dr. Mintz does believe that when patient-centered medical homes and Accountable Care Organizations and their team approach to diabetes care come into existence in the next few years, this will improve the situation, but until then, scheduling will continue to be a headache.

The article lists the following as aids for PCPs in working with people with diabetes.
I will list the points and summarize the discussion.

#1. If Necessary, Upgrade Your Knowledge. Dr. Mintz says, "Expertise is often lacking because medical schools and residency programs don't teach enough about treating diabetes." Clinical literature for diabetes is an intensely researched disease and an admittedly formidable task.

Cyrus V. Desouza works closely with PCPs in the surrounding communities. He also sees basic gaps in clinical knowledge. "Confusion about diagnosing type 1 vs type 2 diabetes may exist," he concedes. "There may be inadequate knowledge of the standard of care. That's improving because of board recertification, but some of it is still there."

#2. Invite a Specialist to Give a Talk. Dr. Desouza advises PCPs to reach out to local endocrinologists for answers. He says a lot of PCPs may not know when it is time to refer a patient to a specialist. Dr. Desouza does take time to reach out to PCPs in the Omaha area that are affiliated with the academic center and give little talks. He feels this is important.

#3. Clarify What You Want a Consultant to Do. Dr. Mintz advises PCPs to be clear when asking for consultations. What does the PCP desire? Does he want the endocrinologist to give a consultant report, a suggestion(s) for the management of a complicated patient, or does the PCP want the endocrinologist to take the lead in managing the complex patient. This is where he says that PCPs are not proactive in what they are seeking.

#4. See if a Hospital Program Can Help. Academic centers and other hospitals often have programs to help,” Desouza says. “In the Omaha area, for example, PCPs can send their diabetic patients to the Nebraska Medical Center when they need help with patient education.” The Nebraska Medical Center has certified diabetes educators (CDEs) for this, or a nurse could assist in titrating the dosage of insulin of a patient who is not meeting ADA guidelines. Patients with complex problems would be seen by an endocrinologist.

"Many academic centers have a case management or diabetes education system with sophisticated protocols and guidelines in place that are not available to PCPs," Desouza explains. Continuity of care is generally better, too, he says, "Because a PCP cannot see that patient every 4 or 5 days or even every month."

#5. Conduct Patient Education in Groups. I am happy to see a doctor actually recommend this. Whether in a hospital setting or a PCP office, educating a small group of patients can be more effective as this will allow the patients to interact. They will be able to learn from each other and this takes the time for education away from the time during the appointment. I will have more on this in my suggestions below.

#6. Build a Social Network of Consultants. This is important enough to quote. Today there are fewer than 6500 board-certified endocrinologists in the United States, according to the American Board of Internal Medicine, and by 1 expert estimate, only about 1 in 6 is practicing full time. "It's a barrier to PCPs," Desouza concedes. "They are hesitant to refer because they know their patients might have to wait a long time to be seen." CDEs are rare too, and not generally available to doctors in private practice. Nor do nutritionists grow on trees.”

PCPs should ask themselves if they would do a better job and stay on schedule more often if, when you had a diabetes-related question, you could go online and receive authoritative advice. This could include questions on testing for diabetic retinopathy, titrating insulin dosages, or adjusting a patient's diet? If the answer is yes, social networking offers a way to build a do-it-yourself support system that may not be available anytime soon.

#7. Get Your Patients Involved Online Too. All too often PCPs forget about a way to make your life easier for their diabetic patients to play an active role in managing their disease. The Internet makes it easy and inviting to do just that. Social-networking websites offer patients with diabetes and other conditions virtual communities in which members can discuss symptoms, medications, side effects, diets, and other details about their health, as well as their favorite apps and devices for measuring blood glucose, counting carbs, etc.

In addition, online weight-loss and management programs for diabetic patients can supplement the care you provide. Many hospitals and insurers now offer them. Medicare also has a good program available.

The following are a few suggestions I would include that some PCPs should consider where they are comfortable in doing this. To supplement number 7 above, prepare a list of websites where your patients can find reliable information. Yes, this will require some time, but the resources are available.

Remote patient monitoring could be done for some of the more complex patients. This will require some extra time for your staff or yourself, but could be worth the effort to learn this now, instead of when required to do this later when penalties may attach for not doing this.

Telehealth or telemedicine may work for some patients that are managing their diabetes very well and only need to be seen for an A1c test or another medical problem, associated with their diabetes or not.

Shared medical appointments are what I was referring to in number 5 above. Select a group of people with type 1 or type 2 diabetes for the same appointment day and then where possible have them meet with office staff for education or use video conferencing where applicable with a CDE or other professionals. Encrypted video applications meeting HIPAA requirements are now available for use.

Peer mentoring or peer-to-peer workers are an area that is often overlooked. Evaluate your patients to find out which are very knowledgeable and would require minimal additional education to be able to work with other of your patients in educating them. Even if you needed to pay for their education by an endocrinologist, this may save the time during your appointments. The CDE's generally will not train them, as this is presently not on their professional list of things to accomplish. Studies have shown that peer mentoring or peer-to-peer works.

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