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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