Coordination is key in caring for complex diabetes
By Deborah Gesensway
Nicholaos Bellos, FACP, a Dallas-based infectious disease physician, recently surprised a roomful of infectious disease subspecialists attending an Infectious Diseases Society of America conference session by revealing that he routinely manages all of his diabetic patients, including starting them on insulin, without consulting an endocrinologist.
"We have ended up doing it ourselves," said Dr. Bellos, whose specialty is treating HIV and AIDS, not diabetes. "It may take six months to get somebody in to see the endocrinologist and start them on insulin therapy."
Dr. Bellos' concerns are backed by statistics indicating a shortage of endocrinologists nationwide, except the large urban centers of Washington, D.C., New York City and San Francisco. In 2003, the Endocrine Society, the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) jointly predicted that the current supply of endocrinologists, about 3,000 nationwide, was 12% less than demanded and, with the epidemic-like growth of diabetes, they said the situation was only likely to get worse.
General practitioner instructs his patient to use a self-assessment blood glucose test. With the shortage of endocrinologists, internists have taken on a larger role in the care of patients with complex diabetes.
However, some endocrinologists believe that a bigger problem is the lack of coordination between primary care doctors and specialists. They attribute that situation at least in part to the reluctance of many general internists to refer their diabetic patients.
According to John Buse, MD, in Chapel Hill, N.C., associate professor of medicine at the University of North Carolina and president-elect of the American Diabetes Association (ADA), about half of the patients he sees come to him on their own, without any referral, request or direction from a primary care physician. And in his experience, half of these individuals turn out to have serious complications or significant trouble controlling their diabetes that an easy endocrinology consult could have rectified.
While most experts agree that 90% of diabetic patients can be effectively treated by primary care physicians, the more complex patients could benefit from consults by specialists.
"I think we can both do better," said Richard Hellman, FACP, an endocrinologist in private practice in North Kansas City, Mo., and president-elect of the AACE. "The scientific data suggest that primary care doctors in the U.S. are not doing a good job with diabetes" while many endocrinologists tend to be poor at accommodating internists' referrals.
Patients with complex diabetes, meanwhile, stand to benefit significantly from a closer collaboration between endocrinologists and primary care physicians. Just as primary care physicians respect the added skills, knowledge and time specialists bring to complex patients, endocrinologists need to appreciate the primary care relationship.
"Doctors don't often value the interaction with each other enough and don't see how important that is for the patient."
—Richard Hellman, FACP
"An endocrinologist who doesn't respect the relationship a primary care doctor has to a patient who now has diabetes is making a serious mistake because there is a repository of information and influence there that can best be tapped by working in a collaborative way," Dr. Hellman said. "Doctors often don't value the interaction with each other enough and don't see how important that is for the patient, and I think it shows up strikingly in diabetes care."
Internist as diabetes expert
Some say that the solution to improving care may not be producing more endocrinologists but encouraging more general internists and family practitioners to become diabetes experts.
Three years ago, Robert J. Tanenberg, FACP, professor of medicine and director of the Diabetes and Obesity Center at East Carolina University in Greenville, N.C., started the nation's first one-year diabetes fellowship open to any primary care physician committed to improving care of diabetic patients in underserved areas. The program, funded by a private foundation, the Duke Endowment, is now a two-year endocrine fellowship.
"A primary care doctor wouldn't think about treating a patient with cancer or with HIV alone; it's so complicated," said Dr. Tanenberg, "but for most primary care doctors, diabetes is 30%-40% of their practice" and health care for [patients with diabetes] is becoming more complicated.
While physicians today have better medications and technology to work with, he explained, it is also more difficult to use them, and primary care physicians working alone in rural areas, such as is the case in Dr. Tanenberg's part of North Carolina, all too often have no one to turn to for help. "What I envision is that every town of 50,000 people ultimately has one physician who is a resource person for diabetes." Endocrinologists, largely based in academic centers, could then be their back-ups.
Amy L. Muzaffar, MD, a general internist at the Palo Alto Medical Foundation's center in Los Altos, Calif., said that finding ways of extending diabetes expertise has become vital to her effort to improve diabetes care. This is true even though she works in an area that abounds with subspecialists and is part of an integrated healthcare system with open access to primary care and specialty appointments.
Although the foundation's endocrinologists will see any of her patients quickly if she asks them to, they don't practice in the same building or even nearby, and many patients can't or won't commit to making or keeping an extra appointment.
In addition, she said, many of the problems patients encounter can't necessarily be solved merely by the primary care physician throwing up her hands and turning the case over to an endocrinologist. Instead, she said, complications and difficulties often have to do with the nuts-and-bolts logistics of controlling diabetes, from how to lose weight and adopt healthy eating habits to how to fit an exercise program into an already busy lifestyle.
Testing new models
One potential solution being tried by Dr. Muzaffar and other primary care centers with the necessary resources is providing support services on site, including diabetes educators, nutritionists and support groups.
The Los Altos clinic recently began experimenting with "shared medical appointments," where groups of four to 12 diabetic patients at various stages of their disease, attend 90-minute evening group meetings led by a general internist and a specialist, currently a behaviorist. In the future, Dr. Muzaffar plans to invite a nutritionist, an exercise specialist and perhaps an endocrinologist.
"In the past, I found that a lot of my diabetes patients weren't coming in for a yearly physical or a diabetes checkup," she said. "They would come in for their sore throat in February. And in April, they might have back pain. And in June, they might have a sprained ankle. If you spend 10-15 minutes on that issue, and then they also mention two other things, you have a very small window to focus on their diabetes."
Moreover, added Nathaniel Clark, FACP, an endocrinologist in Alexandria, Va., and until recently the ADA's vice president for clinical affairs, patients don't generally go to their doctor specifically for their diabetes.
"Most patients who are seeing primary care doctors go there because they have a concern or a complaint. Their diabetes can be out of control and they think they feel fine," he said.
Creating a computerized, population-based system to track diabetes care is becoming essential, he said. Unless physicians know that a patient's diabetes isn't under control, they won't know which of their patients truly could benefit from a consultation with an endocrinologist.
"When you look at who is really doing well in diabetes care," said Dr. Clark, "it tends to be those that have computerized records, generally larger health plans, where they can constantly look at their patients and identify who needs help."
Dr. Muzaffar said that having an electronic health record system in place is what both prompted and then enabled her to experiment with shared medical appointments as a way to give patients more of what they get from an endocrinology consult—time focused on their disease and concrete ideas and support in making lifestyle changes—but delivered in a primary care office.
First, she used her computerized patient records to learn that 60% of the clinic's diabetic patients lacked good blood pressure control. Then, she used it to target invitations to the shared medical appointments. Now she can use the computerized record system to track patients' progress after they began participating. She doesn't have hard results yet, but Dr. Muzaffar said she is in a much better position to respond to insurers' requests for quality data as the industry moves towards performance-based reimbursement systems.
But sophisticated computer systems and extensive support services alone are not the only way to improve care, noted Dr. Clark. Part of the problem lies in physicians' often-mistaken assumptions about how diabetes should be treated.
A variety of studies have observed that primary care physicians in general share a reluctance to be as aggressive in treating diabetes as experts now believe is necessary. Results of the "Diabetes Attitudes, Wishes and Needs" (DAWN) study, for example, published in the October 2006 issue of Clinical Diabetes, found that more than 40% of providers preferred to delay initiation of medications until absolutely necessary, with specialists and opinion leaders less likely than general practitioners and nurses to delay initiation of insulin.
The DAWN study found that both patients and physicians shared many misconceptions about efficacy and side effects about medication. That study also found that primary care providers commonly used insulin as a "threat" to encourage diet and exercise behaviors among their patients.
"Diabetes treatment in 2006 is completely different from that in 1995," Dr. Buse said. Any primary care physician older than 45, unless he has made diabetes a priority in his continuing medical education, has misconceptions about the best way to care for his diabetic patients and generally is not aggressive enough about recommending pharmacological treatment, he said. And it's not just that the drugs are different or the target measurements of glycosylated hemoglobin, blood pressure and cholesterol have been lowered in recent years.
"There are a lot of doctors who say, 'The numbers might not be good, but they aren't so bad either, so we'll wait,'" said Dr. Muzaffar. She was among those physicians, she admitted, until she began researching all aspects of diabetes care while searching for an intervention that might lead to improvements.
Another roadblock to physician collaboration is that most internists are taught throughout their residencies that diabetes is their bailiwick.
"It is drilled into you (during residency) that you should be able to handle patients with the following problems, and diabetes is definitely one of those problems," explained Dr. Clark.
As a result, added Dr. Hellman, by the time an uncontrolled or difficult patient sees an endocrinologist, the specialist often either blames the primary care doctor for inadequate management of the condition or for "dumping" difficult patients instead of trying to work collaboratively.
A related misconception, he said, is that patients should be referred to endocrinologists only when primary care physicians can do no more themselves.
"It should be done the other way," said Dr. Hellman. "It would be better if [primary care physicians] referred their patients early because the care at the start of the diabetes seems to be proportionally more important in influencing the outcome than at the end. Instead, we see people coming in who say that after their first eye hemorrhage they started looking on the Internet and realized that what their doctor was saying wasn't right. Very often, we have people coming to us who are very frightened and very upset."
Referring more diabetes patients early in their disease for a one-time consult to establish a treatment path would be a step in the right direction, he said. However, endocrinologists also have to do a much better job in accommodating primary care requests by opening up lines of communication with patients and physicians and adjusting their schedules to allow non-urgent patients to be seen in a timely manner.
"We should be liberally using each other," said Dr. Hellman, "We need to accommodate each other more."
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