As a family doctor based in Brooklyn, New York, who has served the needs of my community since completing residency in 1982, I find myself with a unique privilege and opportunity to observe disease and wellness, the effects of lifestyle, policy and the collective efforts of myself and others, as we attempt to keep our patients well and affect the statistical bottom line. I’m typing this as I also think about the more than 10% of diabetics who are listed in my practice. A prime example of a need for population management if there ever was one.
Given my large population of diabetes patients and years, upon years of experience diagnosing and treating this disease, I wanted to share my story and approach to managing this population.
While there has been some improvement due to total team effort between my staff, insurance company reminders, patient education and incentives to patients, still greater than 50% remained uncontrolled with A1c levels greater than 7.0% and 20% with A1c levels greater than 10.0%. Tragically, we have had patients that have lost sight, limbs and kidneys in the last year to uncontrolled diabetes, Every cardiovascular complication has been manifest in one way or the other.
But in my opinion, the greatest tragedy is when it arrives in the form of new onset type 2 diabetes in the 18 -25 year old age group. This, if left unchecked, are the amputations and blindness of the future. This group is the most vulnerable, and the most fixable. This is the group on which lifestyle and education. This is the group which is, as I tell many of my young and pre-diabetic patients “the fixable group.”
Engaging and understanding your patients
To quote a famous statesman, “By any means necessary.” We utilize a patient portal for some, handouts and flow charts for others and for all we provide feedback after every visit. Also, we engage our patients at the place where they are. We ask questions and try and understand them and their lifestyle. It can’t happen in 15 minutes, which is why at my practice we believe strongly in working as a team.
Many of our patients are Afro American, Hispanic, or Caribbean. I try to establish rapport, and use the understanding of who they are to get my point across. Many are overworked, busy mothers who don’t have time for anything but the quick bagel and coffee, who inhale their dinners while checking homework or multitasking. Or there are those that are in complete denial, feeling fine, pre-diabetic, knocking on the door of diabetes, and do not see the dotted line between their current eating habits and the diagnosis.
How I manage my diabetic population
My approach to the care of my diabetic population has come the full 360° since I started. I have made the following observations which I believe will resonate amongst my peers.
1. This is no longer the disease of the endocrinologists. We diagnose 2-3 new diabetics and at least one new existing diabetic enters the practice per month. The wait time to see a specialist in this world of HMO and managed care is sometimes three months! Primary care has to educate ourselves and arm ourselves with new tools and reevaluate and eliminate the use of some of the old tools.
2. Teamwork is everything. Each diabetic needs the input of cardiology, ophthalmology, and when necessary, vascular and nephrology. It is near impossible to manage a disease based on eating without a plan for eating. Handing someone a 1800 ADA diet sheet is not enough. The most valuable resource for managing my patients is our registered dietician/diabetic nurse educator.
3. Persistence to the point of overkill. I am sure that the amount of paper generated can take down entire forests, but we believe in the visual. We have plate demonstrations for portion control, vials of lipid laden cholesterol. Pictures of clogged up arteries, and for the not so timid, other graphic reminders to the hard headed. We are gentle when we need to be and brutally honest when it is required.
4. Learning and relearning how to balance concern with detachment. Wellness is a choice, a journey and a lifestyle adjustment for patients. We can be the coach, but the ultimate choice is theirs. I care for them, but I have learned not to take them home.
I believe it all starts with a thought. It has always been my somewhat biased opinion that the wealth of a nation starts at the level of the family, and that the strength of the family was directly related to its health. I remain firmly committed to do whatever I can, as many of my colleagues within the sphere of their influence, to invest in this wealth by giving the present generation the tools needed to work with the things they cannot change (i.e. the genetic legacy of their parents), and to change the things within their power (lifestyle, exercise and food choices).
I firmly believe that when you combine advancing technology with the simplicity of common sense, things that change on a small scale can be compounded to the bigger picture. It is my fervent desire that diabetes not become the comfortable epidemic of the 21st century. We owe it to ourselves, to our children and their children to continue to try.
Bernadette Sheridan is a family physician and contributor to the athenahealth Blog.
