Editor's note: In the "Practice Profiles" department of Clinical Diabetes, we spotlight clinicians who have chosen to dedicate a significant portion of their time to the care of patients with diabetes. Suggestions for clinicians to interview in the future are welcome and can be e-mailed to levetan@juno.com.

Where are you from and where did you go to school?
I grew up in Great Falls, Montana, about 225 miles northwest of Billings, went to prep school in New England for the last 2 years of high school, and got a bachelor's degree in English from Harvard. I attended the University of Colorado School of Medicine, graduating in 1974, and did a medical residency at Presbyterian Medical Center in Denver, Colorado, finishing in 1978, when my wife and I moved to Billings.

What is it like in Billings?
I have practiced in Billings since completing my residency in internal medicine in 1978. Billings is a community of about 120,000 and is the largest city in Montana, which is the third-largest state in the nation. Billings is a trade and transportation center for the Northern Rockies area.

When did you get interested in medicine?
I became interested in medicine at the end of my junior year at Harvard, when it finally dawned on me that I would have to do something useful after college. A friend of mine was going to Stanford Medical School the following year and took me down to Boston City Hospital, where he was volunteering as a scrub nurse on weekend evenings. (It seems incredible that they would let college students do this, doesn't it? But this was in the 1960s.)

When did you get interested in diabetes?
I became interested in diabetes while in my residency, where there was a four-man group that specialized in diabetes. With the advent of intensive therapy, the care of diabetic patients became much more interesting to me. My practice currently provides general medical care for diabetic patients, and I can't think of another area in which more disease can be prevented through good management of chronic medical problems. I love the fact that everyone I see has a significant illness to follow and care for, regardless of whatever complaint may have brought them to the office.

When did you begin practice in Billings?
I began an internal medicine practice here in 1978, and after several years of doing critical care medicine, I looked at other niches as board-certified pulmonary care physicians came to Billings. I recognized the need for physicians interested in caring for patients with diabetes.

You successfully started caring for patients with a challenging disease without having served a diabetes fellowship. How did you do it?
I joined the American Diabetes Association (ADA), read a lot, and gradually built a diabetes practice. In 1982, I started doing intensive diabetes management, with four shots per day and measurements with the old Ames Glucometer that had to be calibrated before each test (a 20-minute procedure). In 1983, one of the hospital diabetes educators began to work as my office nurse, and I was able to add certified diabetes educator (CDE) services. By 1985, about 50% of my patients had diabetes. Currently, about 95% of my patients have diabetes, and I am booked out 3 months in advance.

Do you have diabetes educators in your practice now?
I couldn't possibly do what I do without my diabetes nurse educators, and what a debt I owe to them! I have a half-time diabetes educator in my office who literally spends 4 hours per day on the phone with patients from all over, helping them adjust their medications using our protocols and answering innumerable questions. I simply would not be able to do what I do without her. The rest of our office staff is wonderful as well. But the key to what I do is a good CDE.

Do any of your patients go on insulin pumps?
My patients have access to a CDE who is also a certified pump trainer for both MiniMed and Disetronic. I currently have approximately 100 patients on pumps. With my other partners taken together, we have about 130 pump patients.

How many hospitals are in Billings?
Two hospitals serve as a tertiary referral center for a population of 350,000 distributed over an area that is significantly larger than New England.

That is such a large geographic area. How far do people have to drive to see you?
People drive up to 5­6 hours—300 miles or so—to visit us.

You are very involved with ADA. What other professional activities have you made time for over the years?
In the mid-1980s, I was also very active in medical staff affairs, serving as chair of the department of medicine and as president of the medical staff at St. Vincent Hospital. In 1989, I actually left practice for 3 years to serve as the hospital's first vice president for medical affairs. I learned in the process that patient care is what keeps me going, and I returned to full-time medical practice in 1992.

What are the medical politics in Billings?
The political climate in Billings is interesting in that we have two hospitals that are two blocks apart with two relatively separate medical staffs who have been competing for years. This has resulted in very nice facilities and medical staff capabilities beyond what one might expect for this region. Both facilities provide full cardiac services with angioplasty and open heart procedures, dialysis, high-quality neurosurgery, orthopedics, and full retinal services.

If you could change one thing about health care delivery for patients with diabetes, what would that be?
I would vote for consistent payment for educational services and telephone management of medications, which we do largely for free at present.

What has changed the most about diabetes care since you began practice?
It is somewhat amazing to me that not one of the drugs I currently use for diabetes management was available when I began practice in 1978. The sulfonylureas are all new; metformin and the glitazones have been added; the insulins were purified and then made with recombinant DNA technology; then lispro and insulin pumps were added, and now glargine and aspart have been added. We've also had the Diabetes Control and Complications Trial and the United Kingdom Prospective Diabetes Study. There have been lots of fun changes, which have made many patients' lives infinitely better.

What do you look forward to in diabetes for the future?
Better, simpler glucose monitoring for everyone, closed-loop pumps, and islet cell transplants.

What do you do for fun?
For fun, I spend time with my wife and kids, backpack, do some nontechnical mountain climbing, fish, and learn to play the guitar (a life-long process). My wife (who plays bass and sings) and I play in a group with four other physicians about once a week. We have a blast.

Claresa Levetan, MD, is director of diabetes education at MedStar Research Institute in Washington, D.C. She is an associate editor of Clinical Diabetes.