Endocrinologists and “Choosing Wisely”

When comparing the “Choosing Wisely” pronouncements of the Society of General Internal Medicine (SGIM) with the American Association of Clinical Endocrinologists (AACE) and their educational arm, the American College of Endocrinology (ACE) both are out of line to my way of thinking, but the AACE/ACE is more reasonable.

To review, the SGIM stated, “Don't recommend daily home finger glucose testing in patients with Type 2 diabetes mellitus not using insulin.” The AACE/ACE states, “Avoid routine multiple daily self–glucose monitoring in adults with stable type 2 diabetes on agents that do not cause hypoglycemia.” If for no other reason than many oral diabetes cause hypoglycemia, this is less threatening to people with type 2 diabetes. Plus they left themselves some wiggle room with the words multiple daily. The members of SGIM clearly stated no daily home finger glucose testing unless on insulin.

Obviously, Dr. Alan Garber was not made part of the selection committee or we would be relying on only the A1C results and be completely in the dark. The ACE president, Daniel Einhorn, MD, medical director of the Scripps-Whittier Diabetes Institute, La Jolla, California is a lot more thoughtful and maybe more patient oriented. He said of “Choosing Wisely”, “The whole Choosing Wisely campaign is to alert physicians to be thoughtful and for patients to also question when something is ordered or suggested."

Dr. Einhorn explained how the endocrine societies came up with their recommendations. "The list reflects the observation of a group of experts who've seen people order certain tests that are just not necessary. Other items could have been chosen, but these were felt to be perhaps the most common mistakes made. The recommendations are likely to evolve over time as more is learned." I do not appreciate being termed a common mistake just because I have diabetes.

Dr. Einhorn is right about vitamin D. Many doctors do use the incorrect test for vitamin D deficiency. Many doctors use the 1,25-dihydroxyvitamin D when they should use the 25-hydroxyvitamin D test. This test is less expensive and valuable for vitamin D deficiency. The 1,25-dihydroxyvitamin D is correct for use in patients with hypercalcemia or end stage kidney disease.

Diabetes Management under a Physician Shortage

In the next few years, what are we, as diabetes patients going to be able to do? There is going to be a physician shortage which we have been hearing about from doctors and their professional organizations. Even teaching professors are talking about this and a few patients. How long are we going to be forced to wait between appointments and think about how much time the doctor spends with you now. This can only be worse and your questions may not even be answered.

Ann Bartlett, who writes at Health Central dot com has an excellent blog on July 17 that deserves your attention. She is a type 1 and in this blog writes for all people with diabetes. Because of what she writes about the numbers of practicing endocrinologists, I will disagree with her statement that everyone should see an endocrinologist at least once a year. Some people will do very well in the early stages of diabetes, especially those with type 2 diabetes that do not need to lose weight or that are able to manage their diabetes with nutrition and exercise. Many people do probably need to lose some weight and are capable of doing so.

Where I do agree that people with type 2 needing to see an endocrinologist are those people with complex diabetes and often comorbidities requiring more attention than a primary care physician (PCP) has time to devote to the patient. Many of these patients are in the need of insulin therapy, but the PCP has not kept abreast of the knowledge required and so won't prescribe insulin. Instead, he has stacked one oral medication on top of another and in some unusual cases, the patients are taking up to four different oral medications. Too many and most of the time they still are having trouble maintaining good A1c's.

Ann is right when she says, “Third-party insurance providers, the big bad boy of this debate, are finally hearing the bell toll, and need to start offering fair reimbursement to doctors for services rendered.” Unfortunately, with the Centers for Medicare and Medicaid Services not expanding their payment to PCPs and endocrinologists, the rest of the insurance industry will not step forward and help, as they want to grow their profit margin. So our doctors are continually squeezed in the pocketbooks and wallets.

As a result, I will continue to advocate for state medical boards to loosen their strangle hold on nurse practitioners and physician assistants and allow them to operate with more independence. This blog has a map showing the states that are allowing NPs the freedom to practice medicine without supervision. Only 18 states are presently allowing this. It is a shame that the same information is not available for PAs. My endocrinologist has at least two NPs on his staff and I see one of them. I also see a NP at my Veterans Affairs (VA) appointments and I am very happy with both.

The American Association of Diabetes Educators (AADE) could really help with education, but at present, they are reluctant to do so. I have been on their case for some time now and all it has gotten me is derogatory emails. Even my CDE cousin will not talk to me anymore because she knows I am serious.

The AADE is not adding CDEs at a rate needed to serve patients adequately. Therefore, the AADE should be required to open up a classification or group for peer-to-peer workers and peer mentors, give them some training and classes, and let them move out into the diabetes community and help people with all types of diabetes. Then they should provide continuing education for them. This is supported by several studies where peer-to-peer workers have helped other type 2 patients lower their A1c's. This would work for type 2 helping type 2's and type 1 helping type 1's.

Even the ADA and AADE Task Force that developed the Diabetes Self Management Educations (DSME) and the Diabetes Self Management Support (DSMS) National Standards included lay people and peer workers in the area requiring more research, yet the AADE has chosen to ignore this. Oh, yes, they will take credit for the CDC programs that they participate in for training peer workers, but will they open a designation for them and continue to assist them with more education – no. They can't wait to be separate from them and let them go their way. This is not the correct attitude to my way of thinking, especially with the shortage of certified diabetes educators.

Fortunately, some doctors in rural areas and some not so rural areas are seeing the need for peer-to-peer workers and peer mentors and having them educated. Then they are returning to help their doctor and other doctors in their areas. One doctor that I started to work with in Montana, now has three peer mentors in three chronic diseases doing what needed to be done for education of his patients.

Another area that needs to be opened up is telemedicine where doctors could practice across state borders and others could assist people in doctor sparse regions of the country.