CLINICAL DIABETES These pages are best viewed with Netscape version 3.0 or higher or Internet Explorer version 3.0 or higher. When viewed with other browsers, some characters or attributes may not be rendered correctly. EDITORIAL Diabetes Education (for Doctors) Irl B. Hirsch, MD, Editor The statistics are alarming: in the United States, there are nearly 16 million people with diabetes, yet almost 6 million of them are unaware that they have the disease. Each day, 1,600 people develop diabetes, a disease that results in the deaths of 160,000 Americans annually. The morbidity and early mortality of diabetes are particularly concerning as we approach the end of the decade, because treatments—some old and some new—have clearly been shown to reduce the impact of this disease. For example, we know that:
Still, we have a major problem. Two patients seen in my clinic on one recent rainy day exemplify the frustrations. One is a 44-year-old man diagnosed with diabetes 10 months ago. It is not clear whether his condition is due to chronic pancreatitis or to type 1 diabetes. He is receiving twice-daily 70/30 insulin, is not supplementing any insulin for premeal hyperglycemia, has poor knowledge about diet, and is having frequent hypoglycemia both before lunch and in the middle of the night. His wife has no knowledge about glucagon treatment, and the paramedics can now find his bedroom without asking directions. He does not know his HbA1c level. He measures his blood glucose levels but does not know what to do with the numbers or even why he is measuring. He is intelligent and "compliant." The other patient is a 27-year-old woman with an 18-year history of type 1 diabetes, self-referred due to frequent nocturnal hypoglycemia. She is receiving twice-daily NPH and regular insulin and has little knowledge about self-management skills. She has no complications from her diabetes. Due to a previous physician's suggestion, she has had a bilateral tubal ligation. Unfortunately, these are not exceptional stories. As a group, we have dramatically lagged behind the research providing the tools to assist us in improving our patients' lives. Why? In my opinion, the greatest reason relates to physician education. At my institution, which is a state medical school for five states, we provide a total of one afternoon of didactic diabetes education for our medical students. This half-day, which occurs in the fall of the second year, includes a 2-hour lecture (with a break) and then small discussion groups that review various treatment issues relating to diabetes drugs, hypoglycemia, and complications. There is also a six-session endocrine elective course. In each session, the students interview a patient with a specific endocrine disease and then discuss the disease in detail. In the diabetes session last year, 36 of 160 students attended. After that, students learn much about diabetes on the wards, where their residents describe the ever-present "sliding scale" for insulin. There is little opportunity to learn outpatient diabetes management skills. But that shouldn't be a problem, since after graduation there should be plenty of opportunity to learn about diabetes as a resident. Right? Unfortunately, although it appears to me that diabetes is receiving more attention in the primary care residency programs around the country, there are still wide gaps. Some of this is inevitable. For example, many residency programs are competing with diabetes clinics for patients. The more difficult cases, particularly those requiring insulin, will usually be found in these specialty clinics. The residents do not get the experience of managing insulin in their "continuity clinics." It is also difficult for residents in some programs to follow complicated patients as closely as required. Residents have many responsibilities, sometimes requiring them to participate in rotations that may not even be in the same city as their clinic. If the resident is on a hospital rotation and a patient who is started on insulin needs to contact the resident before the next clinic visit, it is often difficult to arrange a telephone meeting. There can also be issues with the patients themselves. Learning how to use more complex insulin regimens and to interpret blood glucose results can be difficult in county hospitals that often cater to patient populations that are largely illiterate. Certainly, this is also a wonderful opportunity and challenge to try to improve diabetes control as much as possible. Still, if these residents eventually enter practice with a different patient population, the training will be inadequate. Postgraduate training has its problems. Much of this medical education is sponsored by the pharmaceutical industry. Although rules attempt to provide fair balance, there is always an obvious potential for bias. Furthermore, formal traditional continuing medical education generally has not been found to be effective.1 I also wonder how the capitated managed care environment affects the quality of diabetes care. I am not aware of any studies examining how capitation alters physicians' behaviors as they pertain to diabetes, but my anecdotal experience suggests that care is withheld. It seems to me that we dramatically underemphasize diabetes education for physicians and physicians-in-training. How is it that we can produce doctors with so little understanding about a disease that is responsible for one in every seven health care dollars spent in the United States? According to a national survey of clerkship directors in internal medicine, diabetes should be one of the top priorities during the medicine core clerkship.2 Understanding the frequency, complexity, and expense of diabetes, I would suggest training in diabetes should be a priority throughout medical school and primary care residency training. Curriculum committees should provide greater time commitments to diabetes and its complications. Of course, something else will need to be sacrificed. For our students and residents, we tend to emphasize rare diseases that are often only referred to tertiary care centers. While often fascinating, this information does not prepare young physicians for the real world they will encounter after they leave the academic environment. We currently tolerate poor diabetes care by our colleagues. The two patients presented above are not exceptions. As a group, we need to catch up with all of the new diabetes-related research. Diabetes also needs to be a greater priority in our training programs. Otherwise, we lose the opportunity to translate research into clinical practice, and progress cannot continue. REFERENCES 1Davis DA, Taylor-Vaisey A: Translating guidelines into practice: a systematic review of theoretic concepts, practical experience, and research evidence in adoption of clinical practice guidelines. Can Med Assoc J 157:408-16, 1997. 2Bass EB, Fortin AH, Morrison G, Wills S, Mumford LM, Allan GH: National survey of clerkship directors in internal medicine on the competencies that should be addressed in the medicine core clerkship. Am J Med 102:564-71, 1997. Copyright © 1999 American Diabetes
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