How the Olympic spirit can transform diabetes care [PODCAST]

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Join us as we sit down with Gary Marc Rothenberg, a podiatrist, to explore the unique connections between Olympic-level perseverance and the day-to-day challenges of chronic disease management, specifically diabetes. We discuss how celebrating small victories, integrating mental health care, and addressing social determinants of health can inspire better patient outcomes.

Gary Marc Rothenberg is a podiatrist.

He discusses the KevinMD article, “Celebrating silver: 3 best practices for meeting people where they are with diabetes adherence.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Gary Rothenberg. He’s a podiatrist, and today’s KevinMD article is “Celebrating silver: 3 best practices for meeting people where they are with diabetes adherence.” Gary, welcome back to the show.

Gary Marc Rothenberg: I appreciate the opportunity. Thanks for having me, Kevin.

Kevin Pho: So Gary’s been on in the past, so let’s jump right into your most recent article, “3 best practices for meeting people where they are with diabetes adherence.” Tell us what this article is about for those who get a chance to read it.

Gary Marc Rothenberg: Yeah, I appreciate that. So it came out in the summertime, when we were all kind of enjoying the Olympics and watching that international competition and the great athletes from the Olympics and the Paralympics, and it kind of got me thinking around, you know, my patients that I treat with diabetes. We’ve been talking a lot about adherence and engagement with our technology at Plom Metrics, and I wonder sometimes, is the gold medal always the ultimate goal? Sure, it might be, but also just being on the podium, or those athletes that made it to Paris for the Olympics, like, how cool is that?

And so I tried to think about how does that relate to my patients. Is the goal for adherence and engagement and doing the right thing all the time, you know, 100 percent for my patients, or can we also celebrate the silver, or just doing your best every single day? So that was kind of the thought process behind the article.

Kevin Pho: All right. So from a podiatry diabetes standpoint, what would the gold, silver, and bronze medal be when it comes to your patients?

Gary Marc Rothenberg: Yeah. So I think we throw around this term, like adherence, compliance. In my world, what I’m trying to do with my patients with diabetes is prevent lower-extremity complications, right? Having patients check their feet every day, wear appropriate shoes, protect their feet, maintain good blood glucose control. Of course, that’s going to influence complication development, but ultimately we’re trying to prevent diabetic foot ulcers, infections, hospitalizations, and amputations.

So again, is it that my patients wear their shoes 100 percent of the time? I’m not sure that’s realistic. Many of us, culturally or within our own homes, like, that’s just not part of our practice. Or if a patient unfortunately is battling a diabetic foot ulcer, are they doing appropriate wound care every day? Are they meeting all of their milestones in terms of healing progress and so forth? So I think there are levels, and there are certainly influences to that gold, silver, and bronze, but understanding that it’s a challenge every day living with complex diabetes, especially when you’re trying to battle a complication like a diabetic foot ulcer.

Kevin Pho: So tell us your approach in action. If you see a patient with diabetes come to your office, give us that kind of gold and silver approach in terms of what would be some example case studies. What would that look like?

Gary Marc Rothenberg: Yeah. So I always encourage my patients, every patient with diabetes at every visit with the foot doctor. I reinforce three things. One is going to be good glucose management, right? So again, through lots of evidence-based medicine, we know that maintaining blood glucose levels in target range really will help avoid retinopathy, nephropathy, neuropathy.

So a kind of case example, though, is, you know, patients come into my clinic all the time with a hemoglobin A1c at 11 percent, and we know that’s not ideal, right? But I try and explore and ask the question, “Well, what’s complicated?” And I’m the podiatrist; I’m not their endocrinologist or primary doc, but, “What’s getting in the way, or what’s going on in your life that may be a barrier to better glucose management?”

But when I look at trends, and I really do, I have this nice feature. We work with Epic, as probably a lot of your listeners do, and I can pull in the last three hemoglobin A1cs into my note, and I always look at that trend. So in terms of gold versus silver, I really appreciate and acknowledge when a patient’s hemoglobin A1c is in target range. That’s a goal for me, but a silver might be that you’ve gone from an 11 to an 8.5. I still recognize that they’re not at target range, but that’s a success, and so you’re trending in the right direction. I really think that’s important to acknowledge.

Kevin Pho: So that’s important. I want to expound on that, celebrating a small win. So even if someone goes from, like, an 11 to 8.5, it’s not within the ideal range, but that’s trending in the right direction. So talk more about how celebrating those small wins is still important, the fact that patients are trending in the right direction even though it’s not in the target range.

Gary Marc Rothenberg: That’s right. I think it serves towards motivation, right? So when I acknowledge that success and that trend in the right direction, first of all, I’m excited for the patient. I acknowledge that, and I think that’s more motivating. I truly believe all patients, I call them provider pleasers, want to do the things that we ask them to do. It’s just, I think they need to understand why.

And kind of going back to the sports analogy from the article, I think we need to be more coaches than a provider. We probably heard that analogy before too, but the coach is part of the team, right? They’re just leading you, but they’re certainly invested in the outcome as well. And so I think when we have our patients understand that we’re part of that team, and the end result is shared responsibility, and I educate my patients and I give them all the tools and the opportunities, but also, on the flip side, kind of discuss some of the barriers. Sometimes those conversations are difficult because they might relate to mental health issues or they might relate to SDOH issues, but just opening that conversation, I think, is motivating for patients and for me as a provider, because I want to be invested in that too.

Kevin Pho: So let’s talk about some of those barriers and obstacles that prevent patients from achieving these ideal A1C goals. So when you ask them, like you said before, “What’s preventing you from achieving those goals?” what are some of the things that you hear from patients, that you see?

Gary Marc Rothenberg: Yeah. So, a couple of specific foot examples. Oftentimes, if a patient is battling a diabetic foot ulcer, we put them in these special boots. We tell them, “Stay off your foot.” People are trying to pay the bills and keep the lights on, so going to work with a boot that maybe is open-toe, or a surgical shoe, might not be an option for somebody who works in a factory, for example.

So I have to compromise with my patient oftentimes: “OK, Mr. Jones, I get it. You got to wear your steel-toe boot to work, but when you come home, I want you to take that boot off and treat that offloading shoe or boot that I’ve given you kind of like your house shoe.” So it’s those compromises, oftentimes, that again relate to SDOH issues that typically have nothing to do with the patient’s medical status but more to do with their financial status or their ability to function in daily life.

Kevin Pho: So with these social determinant of health factors that sometimes may impede optimal treatment, you’re only one person. So tell us the other members of the team that you engage to kind of help them overcome those issues.

Gary Marc Rothenberg: Yeah, crazy important, right? So I practice at the University of Michigan. We have a great network and a wonderful resource of social workers. Not enough; we don’t have enough social workers, but we utilize things like findhelp.net, people with local resources, those types of things.

Probably the unsung hero, in my opinion, in the diabetes space is certified diabetes care and education specialists. I was just recently reading an article. I saw 5 percent of people with diabetes are given the opportunity to interact with diabetes care and education specialists, and in private insurance, it goes up to only 6 percent of people. So people with diabetes should be seeing diabetes educators, I think, routinely, and it is a covered service by Medicare and many private insurances: anytime you’re newly diagnosed, annual refresher, not meeting those target goals of A1C, and other issues, when there are significant complications like, unfortunately, an amputation. Patients should be utilizing resources, and hopefully today those are even more available through technology and telemedicine.

So I think those are my typical partners. Social work, online resources, and diabetes educators, I think, are really, really important for this population.

Kevin Pho: I want to follow what you said earlier about the dynamic in the exam room, how sometimes our relationship with the patients has to be more like a coach rather than a provider. So talk more about what that looks like. For those who may not be familiar and have a traditional, perhaps paternalistic approach to health care, how does that dynamic change when we are more coaches to our patients?

Gary Marc Rothenberg: Yeah. I think language matters. We’re learning more and more around that, right? To try and use language that’s nonjudgmental, that really is more explorative instead of truly inquisitive, right? The days of using yes-or-no questions: “Did you check your blood sugar, yes or no?” Or, “When you last checked your blood sugar, what was the number?” And maybe they’re ashamed to tell you the number. Maybe they shouldn’t be.

So opening a conversation around a coach, much like, “Hey, why aren’t you hitting all your three-pointers?” It’s, “What is getting in the way of meeting those markers that we’re looking for?” So I think it starts with, again, not calling people diabetic. We’re not labeling them. They’re people first; they’re people with diabetes. Asking them, “Did you test your blood sugar?” implies that there’s a right and a wrong answer, or a passing and a failing grade.

So it’s more about checking, being less judgmental around the numbers that we see. Again, I tell all my patients that that’s OK. Whatever the number is, it’s just, “Do we need to do something about that blood sugar of 350, or can we leave it alone?” So it’s about being in target range, not a good or a bad A1C. So I think that coach mentality, part of the team, again, invests me and invests my patient. They know that I care, and they want to do better for the next time.

Kevin Pho: So you obviously work for a health technology company as well. Tell us about the role technology has in achieving some of the things that we’re talking about today.

Gary Marc Rothenberg: Yeah. So I believe the most influential relationship or factor within health care today is trust between patients and providers, right? To me, in my experience, twenty-five years of practicing podiatry, that’s what I’ve learned kind of really promotes, or is a challenge to, my successes with and in outcomes with patients, specifically in diabetic foot ulcer complication prevention, like amputations. So I really believe that technology and data should serve as an extension of that trust relationship.

And so, yes, I work for Photometric, which is a remote temperature-monitoring company. We do, essentially, you can think of it as like a CGM of the foot. So we monitor foot temperatures, and we intervene on those. So we get data, but truly it’s not about the data. It’s about, what do we do with that data? What’s the intervention? Just like a CGM. So you can download somebody’s CGM report in their quarterly PCP or endocrinology appointment, and you make modifications on that.

We can monitor people’s foot temperatures, and when we see that there’s a potential pending problem, a nurse will call the patient. And what do we find out? Things are very significant. There is a complication going on, or it could be around the foot, or it could be around something else that we learn, which is important then to help provide resources or also connect them with their health plan provider so that they’re aware of that. So we kind of connect patients, providers, and data so that we can hopefully keep eyes on these patients in between their usual visits. It’s an extension of that trust relationship.

Kevin Pho: We’re talking to Gary Rothenberg. He’s a podiatrist, and today’s KevinMD article is “Celebrating silver: 3 best practices for meeting people where they are with diabetes adherence.” Gary, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Gary Marc Rothenberg: Yeah, I appreciate that. I think, again, celebrating the small successes, the trends instead of the static numbers, can really be influential. That’s what I’ve seen in my practice has been very significant and helpful in positive outcomes for my patients. Incorporating technology early and building on that trust relationship that you already have with a patient, so that we can ultimately see the right patient at the right time for the right reason, since we’re all so busy in health care and our time and resources are limited.

But I also want people to remember that there are some myths in health care that we really need to try and dispel, especially around the use of technology, underrepresented minority populations. We specifically have data around Native Americans, African Americans. They want to use technology. They want remote patient monitoring options for them, because they have hoped that it will be an advantage into the health care realm, and we see that it is being incorporated. So let’s try and bend some of the curves around health care equity and health care disparities and better outcomes, especially for people living with complex diabetes. That’s my goal.

Kevin Pho: Gary, thank you so much for sharing again your perspective and insight, and thanks again for coming back on the show.

Gary Marc Rothenberg: Pleasure. Appreciate you having me. Thanks to your listeners.

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