Fitting the Diabetes Bill in Billings
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 firstname.lastname@example.org.
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.
We have three children, aged 20, 22, and 30. We love Billings. It has been a great community in which to raise our children.
What is it like in Billings?
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.)
After a few evenings of this, I was hooked. I took pre-med courses during my senior year and got a job at the Peter Bent Brigham Hospital in Boston for the year after my graduation while I took organic chemistry and a course in genetics and applied to medical school.
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?
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
We also have two full-time CDEs for hospital education. We are in the process of developing a system to utilize them in our other primary care clinics as well. The CDE who works with me will be changing to full-time status in September, when I add a nurse practitioner to work with me full time.
Do any of your patients go on insulin
We are considering getting one of the MiniMed continuous monitoring systems as well. As I mentioned, I will be adding a nurse practitioner this September, and I would love to find someone truly interested in diabetology to join us. Any interested readers, please give me a call!
How many hospitals are in Billings?
That is such a large geographic area. How
far do people have to drive to see you?
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?
At present, there is very little managed care penetration of our market (<10%), and there is little prospect of much change in this area.
About 4 years ago, Deaconess Medical Center (the other hospital) bought the Billings Clinic (the competing medical group). That has caused some reaction at our end of the street, which has changed my practice. In order to compete in primary care, St. Vincent Hospital felt it needed to buy up some of the private primary care groups, including ours. So about 2 1/2 years ago, I became a hospital employee.
Thus far, this seems to have worked well and has allowed us to recruit more physicians. No one, it seems, wants to come out of residency and join a small group. People feel more comfortable being employed by a larger organization.
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?
In addition, both hospitals in our region have tried to start their own managed care programs, which has probably protected our rather small market from outside intervention. Our vice president, who came from the Cleveland Clinic System last year and is absolutely great, tells me that our market is likely too small to ever have widespread managed care penetration. I hope he's right. We have had some downward pressure on fees, but so far there have been advantages to being outside of the mainstream of medical economics.
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.
I also run. Correction: in my 20s and 30s, I ran; in my 40s, I jogged; now in my 50s, I slog. I just keep getting slower. I can still get up those mountainsit just takes a little longer.
Claresa Levetan, MD, is director of diabetes education at MedStar Research Institute in Washington, D.C. She is an associate editor of Clinical Diabetes.
Copyright © 2000American Diabetes
For Technical Issues contact email@example.com