The Status of the Diabetes Team

Irl B. Hirsch, MD, Editor

Elliot Joslin is credited with developing the concept of the "diabetes team." Even in the pre-insulin era, he realized the importance of having nurses and other health care professionals assist in diabetes treatment. After the discovery of insulin, Dr. Joslin had nurses assist patients with insulin use after discharge from the hospital.¹ Added attention was required for children starting insulin.² Dr. Joslin appointed Dr. Priscilla White to initiate this monumental task, and in 1925, the first camps for children with diabetes were started. This concept was obviously well ahead of its time.

In the late 1970s and early ’80s, more physicians were learning about the usefulness of the diabetes team. Several physicians acknowledged that diabetes care was becoming so complex that other health care professionals would be required to help provide optimal care. Subsequently, many diabetes centers, mostly but not exclusively within academic settings, routinely began including the services of nurses, dietitians, pharmacists, psychologists, and podiatrists in the daily management of diabetes and related problems. This "team approach" seemed to be effective and efficient for many reasons, not the least of which was that every team member was aware of the other team members’ roles.

After the development of many new tools for managing type 1 diabetes in the 1980s, a large trial was commissioned to determine the relationship between glucose control and the microvascular complications of diabetes. While it is often accepted that the results of the Diabetes Control and Complications Trial (DCCT) were made possible only by the introduction of home blood glucose monitoring devices and insulin pumps, I maintain that this trial was successful due to the nurses, dietitians, and other health care professionals involved in the care of these research subjects.

After the trial was completed in 1993, many people asked a fundamental question: "Is the DCCT reproducible in a nonresearch setting?" Those who answered this question in the negative correctly pointed out that the majority of patients with diabetes in the United States receive their care from primary care physicians who have little interaction with other health care providers. Sending patients to a nurse to learn how to measure blood glucose levels or how to inject insulin or sending them for a one-time visit to a dietitian to be told to "avoid sugar" is not the same as including these health care professionals as part of a true team.

There is no reason why the type of treatment team used in the DCCT cannot be used for most patients with diabetes. Still, we all know this is usually not the case. An angry patient recently complained, "I am assigned one primary care physician. It takes almost an act of God to get a ‘team’ together, much less a referral to a specialist such as an endocrinologist."³ Another patient pointed out that team members "even argue points and disagree, with the patient acting as a messenger."³ These observations by our patients emphasize the fact that we do not work well together, at least not as a cohesive team.

One of the goals of our editorial team’s first year at Clinical Diabetes was to introduce our readers to the different components of the diabetes team, the various professionals assisting in the management of our patients with diabetes. In a department titled "Team Approach," we have attempted to bring to you some new ideas about different ways to create a true, multidisciplinary health care team for the management of diabetes patients in your office or clinic.

This issue includes the final installment of this department, in which Davida F. Kruger, MSN, RN, CS, CDE, and Belinda P. Childs, ARNP, MN, CDE, describe the role of advanced practice nurses in diabetes care (p. 183).

I am extremely fortunate to work with an advanced practice nurse, four clinical nurse specialists, and two dietitians. I also work closely with several podiatrists, psychologists, and psychiatrists on an almost-daily basis. The other physicians in my clinic and I could not possibly manage our patients at the same level without all of this support.

Why is this type of practice so unusual? Why is it that neither specialists nor primary care practitioners often replicate this "DCCT level of care" in their practices? As usual, it comes down to cost. Solo practitioners simply cannot afford this type of support. Even large group practices often do not see these services as necessities as they strive to meet their all-important bottom lines.

Another obstacle, perhaps even more serious than the last, is that many physicians are not comfortable having health care providers from other disciplines assist in diabetes management. I would argue that diabetes clinical nurse specialists can do a better job on insulin management than can physicians. Remember that clinical nurse specialists were responsible for most of the diabetes management in the DCCT.⁴ A clinic in which nurses follow physician-supervised protocols and are aided by a computerized tracking and recall system recently reported that glycated hemoglobin levels were lower during follow-up compared to the "average (suboptimal) quality of care provided to patients with diabetes in the U.S."⁵

It seems to me that there is no ideal formula for managing diabetes, given the fact that our practice environments are so different. Although I still struggle with the concept of "population-based medicine" for the treatment of diabetes, protocols such as Staged Diabetes Management (SDM) can be highly effective for large staff-model health maintenance organizations or in geographical areas with limited resources.⁶ Not surprisingly, SDM can be very beneficial when implemented by nurses.⁷

For family physicians or internists in large group practices, resources must be available to assist in diabetes management. All physicians, including endocrinologists, need to work with nurses and dietitians who can manage much of the diabetes care in their practices. One priority should be to explore which system works best in each environment and to provide the resources necessary for all team members to function most effectively.

Another, more fundamental, issue is that we physicians, as a group, need to better accept and rely on the expertise of our colleagues from other health care disciplines. It worked for Elliot Joslin. It can work for us.

REFERENCES

¹Joslin EP: The Nurse and the Diabetic. New England Deaconess Hospital Annual Report, Boston, Mass., 1924.

²Joslin EP: Annual Report for Diabetes Foundation. In: Joslin Archives, vol. 10, 1960.

³Mail Call. Diabetes Forecast, Jan. 1998, p. 16.

⁴Ahern J, Grove N, Strand T, the DCCT Research Group: The impact of the trial coordinator in the Diabetes Control and Complications Trial (DCCT). Diabetes Educ 19:509-12, 1993.

⁵Peters AL, Davidson MB: Application of a diabetes managed care program. Diabetes Care 21:1037-43, 1998.

⁶Mitchell P, Pipemeyer J, Glass M, Mazze R, Ghodes D, Bradley R: Long-term impact of Staged Diabetes Management (SDM) to im-prove metabolic control in an American Indian community [Abstract]. Diabetes 47 (Suppl. 1): A183, 1998.