Individualizing Treatment in Type 2 Diabetes Mellitus - Episode 4

Overcoming Clinical Inertia in Type 2 Diabetes

Peter Salgo, MD: Can I throw a grenade on the table? Persistence. Adherence. Should follow-up be our fault? It’s very tempting to blame patients, but if you’re not calling them, you’re not using physician extenders, you’re not getting people out in the community to help bring these patients back (yes, there are going to be some patients who don’t come back), is that really our fault?

Vivian Fonseca, MD: It’s the system’s change. Now, they may get paid for coordination of care, which requires those phone calls and other things like that—following up.

Carol Wysham, MD: Kind of getting back to that clinical inertia issue.

Peter Salgo, MD: That’s what I’m trying to get at.

Carol Wysham, MD: The issues are multiple, and I think Vivian really addressed something that hopefully is going to change things. If you were seeing a patient who is not bringing any glucose testing, and you don’t have their A1C from the last week or month, how are you going to make that decision on what to do with that patient?

You send them to the lab. They go get their A1C checked, and then you get it back. You don’t even have the opportunity to see the patient or talk to them about it. So, it’s typically going to happen. The letter goes out: “Your A1C is high. Try to be better with your diet and exercise, and we’ll talk about it next time.” And then next time is just a repeat of the same.

So, having the appropriate data at the time you see the patient so that you can have that conversation is something that a lot of doctors, or providers, in general, don’t do—to plan their visits and to use their staff to make sure that they have all the information they need for appropriate management for that patient at that moment.

Vivian Fonseca, MD: Coordination of care.

Peter Salgo, MD: Yes, coordination of care. That’s part of inertia.

Robert Henry, MD: The difficulty is that, as you know, the majority of patients with diabetes are taken care of by primary care providers who often don’t have the resources to share with a nurse, or an educator, or someone who can help them. And, often, they’re out there by themselves in a 10-minute interview. The primary care physician sees the patient, and then they spend 20 minutes writing the notes that they have to do.

Carol Wysham, MD: I will tell you that a medical assistant can take on a lot of responsibility of knowing the patient is coming in and in making sure that the tests are ordered. Order the tests if they’re not ordered, do the foot exam when they come in, counsel the patient on goals. You can do this in a primary care office, but you have to change the system. You have to change how you deliver care.

Vivian Fonseca, MD: It’s a pretty big change, because even just administration of insulin, to teach somebody how to administer insulin, takes about 20 minutes to go over. And then they need to go over it again, and again, and again.

Julio Rosenstock, MD: We need to give credit to the primary care physician. There’s no question that those guys are smarter than us because we only do diabetes. These guys do everything.

Peter Salgo, MD: They see everybody who walks in.

Julio Rosenstock, MD: Everybody who comes in, and there’s competing needs. People come, and they don’t come just for the diabetes. They come for asthma, they come for a skin rash, they come with all sorts of things. But things changed in 1995—major changes when metformin came. The other major change was when basal insulin glargine came in 2000. Actually, the primary care physicians are doing very well starting people on basal insulins because we kept it simple.

Peter Salgo, MD: I don’t want to hammer on primary care. I think that your point is well taken, which is that everything comes flooding through that door. But, by the same token, diabetes is bad. Diabetes is everywhere. It’s a pervasive disease. Is it your responsibility, as thought leaders in this profession, to give them an easier pathway? That’s the problem?

Julio Rosenstock, MD: Yes.

Robert Henry, MD: Carol is saying that. She’s saying that if you can, you should do everything you can to make it simpler and easier, and to train as many people as we can. This is not a 1 person show. Treating people with diabetes is not just for the physician, or the physician’s assistant, or the nurse practitioner. It really is a team, as much as possible, even if you have to get your assistant to help you.

Carol Wysham, MD: Absolutely. You can train them to do a lot of what you know the patient needs to do, and to make sure that they organize for you, so you have everything you need. And probably, one of the most important things that I think primary care doctors can do to take better care of their patients with diabetes is to plan a diabetes specific visit. “This is your diabetes visit.” If the patient says “Oh, doctor, I have back pain,” we say, “We can handle your back pain or your diabetes. If we do your back pain, you’re coming back for your diabetes.” We need to not let the patient’s other priorities take over what is supposed to be a visit focused on diabetes.

Peter Salgo, MD: Will third-party payers cover 2 visits?

Carol Wysham, MD: Yes, because you’re seeing diabetes and you’re seeing back pain. You just need a diagnosis.

Peter Salgo, MD: OK. So at least we’ve got some pathway here—some advice you can give these (I’m not being facetious), overworked, under-funded, primary care physicians who see the whole community.

Julio Rosenstock, MD: Absolutely.

Peter Salgo, MD: But I don’t want to lose sight of the fact that diabetes is big, pervasive, and potentially lethal. It’s a big problem.

Transcript edited for clarity.