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. We welcome suggestions for future interviews.

Where are you from originally? Who inspired you to go into medicine?
I am from India. My two older brothers are also doctors, and they and my parents inspired me. There was very much of a medical atmosphere at home.

Tell me a little about your background.
I came to the United States more than 5 years ago. Initially, I trained as an anesthesiologist in a formal residency program in India. I wasn't getting satisfaction in my work because there was no continuity of care in that specialty. There was no rapport with patients. Therefore, I decided to go into internal medicine.

Where did you go to medical school and serve your residency?
I received my medical education in India, at Gandhi Medical College in the city of Hyderabad. I completed an internal medicine residency at Maimonides Medical Center in Brooklyn, which is affiliated with the State University of New York. I joined the Marshfield Clinic in 1997, practicing at the Park Falls Center in Park Falls, Wisc., a rural community with a population of about 3,000.

When did you become interested in diabetes?
During my residency, I was clearly interested in providing continuity of care, especially to patients with chronic diseases. I always thought about how good it would be to have programs designed to provide more comprehensive care to diabetic patients with a real focus on preventing long-term complications.

Tell me about the Marshfield Clinic.
The Marshfield Clinic is the largest private group medical practice in Wisconsin and one of the largest in the United States, with 611 physicians and 38 regional centers in 31 Wisconsin communities. It is one of only a few large, independent nonprofit medical practices. The system is owned and run by physicians.

The clinic has its own residency programs and research foundation. Also it is the sole sponsor of a health maintenance organization called Security Health Plan of Wisconsin, which has more than 107,600 members. The clinic is affiliated with local hospitals.

Our diabetes program is provided by Flambeau Hospital, which has a self-management program with extensive support and assistance from the Ministry Health Care Systems/St. Joseph's Hospital in Marshfield, Wisc. Flambeau Hospital is located in Park Falls and is jointly operated by Marshfield Clinic and Ministry Health Care. The hospital is physically connected to the Marshfield Clinic's Park Falls Center.

How did you end up in Wisconsin?
I was looking for a job in a clinic system, and Marshfield Clinic attracted me. It is owned by physicians. I was lucky to join this system, and now I am one of the many physician directors.

How were you chosen to lead the diabetes program?
I had a strong interest in diabetes, and my colleagues at the Park Falls Center requested that I be selected to be the medical advisor to the diabetes program.

How do patients get referred to the diabetes program?
Patients are generally referred to the program by their physician. A hospitalized patient can also be referred to the program when the initial contact with a diabetes patient is in the hospital. There are also self-referrals. No one is excluded.

What diabetes services are provided?
Initially, an individual appointment is set up with the diabetes nurse and dietitian educators. Each consultation is approximately 2 hours in length, with the patient spending 1- to 1 1/2 hours with a nurse and about 1 hour with a dietitian. After being seen individually and having issues addressed such as home monitoring procedures, schedules, target blood glucose ranges, meal planning, and diabetes medications, the patient is enrolled in a small group series where ongoing self-management training is provided.

Small group sessions are provided by a physical therapist, occupational therapists, certified athletic trainers, registered nurses, and registered dietitians. Topics include foot care/individual foot exams, stress management, coping with chronic disease, diabetes basics, exercise and diabetes, fine tuning the meal plan, label reading, eating out, recipe adjustment, and so on. Most patients are involved for at least 6 weeks, followed by visits scheduled at 6 months after completion of the program

We really take pride in our program and, with the assistance of St. Joseph's Hospital Diabetes Program, we are taking steps to apply for recognition by the American Diabetes Association. Our target date for recognition is spring 2001.

Do all patients get nutrition visits or diabetes education visits?
All patients receive nutrition and diabetes education visits. All providers of these services are either certified diabetes educators (CDEs) or are working toward becoming CDEs.

How are the educational services paid for?
The system gets reimbursement for most services via Medicare or private insurance under a Wisconsin state law mandating insurance coverage for diabetes services. We are a hospital-based service, which also helps in reimbursement issues.

When a patient goes to the diabetes program, how does the nurse and educator communicate back to the referring doctor?
The diabetes educators communicate back to the primary physicians via the combined medical record. They also maintain a diabetes chart, which the physicians have access to.

How are referrals to endocrinologists made?
There are no endocrinologists in our town. We do have endocrinologists in the Marshfield Clinic system. We refer patients to endocrinologists who practice at the Marshfield Center, located about 95 miles south of Park Falls, or patients may also be seen via Marshfield Clinic's telemedicine program.

Telemedicine removes barriers to access of specialty services by using telecommunications and information technology to provide clinical care. Telemedicine uses interactive audio, video, and data communication networks for health care delivery, diagnosis and consultation, treatment, and transfer of medical information. For example, if an endocrinologist, nurse, or dietitian is not available on site in Park Falls, a telemedicine visit with a provider in Marshfield Center can be arranged.

How does the telemedicine program work?
We use the broadband video conferencing system that links all of the Marshfield Clinics in our system. Our link runs from Park Falls to Marshfield and then is rerouted to any further destination. For the Diabetes Center services, the call is routed to St. Joseph's Hospital in Marshfield. The diabetes education center in Marshfield receives the call on a desktop PC COREL Video system.

The services provided are in addition to and in support of the local services that the Park Falls Center and Flambeau Hospital provide to the patients of Park Falls and the surrounding service area. The services are based on three levels, ordered by the physician. Level one involves education only. The second involves education and monitoring of HbA_1c, glucose, and CBC levels, with contact with the primary care provider for orders to adjust medications. The third level is a management level, with the certified diabetes educators, including nurses and dietitians, working as a team with the physician to care for the patient.

You have consultations done via telemedicine, is that correct?
Yes, complicated patients can always see an endocrinologist, and we encourage consultations if there is great difficulty controlling patients' blood glucose or if patients have multiple other problems, such as obesity and hyperlipidemia, but endocrinologists communicate with the generalists through e-mail and our systemwide electronic combined medical record on Clinics Network System and our telemedicine program. All physicians, nurses, medical assistants, and physician's assistants have their own computer.

Endocrinologists are reimbursed through the usual insurance and Medicare procedures for telemedicine, but not for e-mail and phone contact.

How do you keep your physicians up to date with all of the changes and new medications in diabetes?
By e-mail and interdepartmental communication, which includes hard copies of lab reports. And sometimes by direct phone call, although phone calls are used rarely for real emergency calls.

What percentage of patients with diabetes go through the program?
Since this is a new program, the numbers are steadily increasing. We are at about 20% currently.

What would be the one thing that would make your diabetes program run more smoothly?
Now that's an easy one: we need administrative and secretarial support!

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