A Multidisciplinary Approach to Diabetes Management

Peter Salgo, MD: We’re talking about physician awareness, and we’ve been talking for the past few minutes about the various new therapies out there. Of course, for patients, I don’t think there’s any disease in which patients are as involved as a copartner in the disease management as diabetes. What do patients need to know about the risk of hypoglycemia with the various diabetic therapies, Jay?

Jay Shubrook, DO, FACOFP, FAAFP, BC-ADM: You’re absolutely right: 95% of diabetes treatment is self-management, so the patient drives the ship. We give them tools and information. Part of that is raising awareness that hypoglycemia is unfortunately something that can occur, but it’s not universal and it’s not always severe. It’s important to know that you have to check to know when your glucose is low, so we can properly treat you, and that we have different types of treatment for different types of hypoglycemia. Knowing the 15/15 rule would be very important. Now, we have good choices for outpatient treatment of severe or level 3 hypoglycemia that we can individualize to the person. That’s part of the education.

So much goes into diabetes management that we really need a lot of touch points. If you’re in primary care, you don’t have to go alone. You don’t have to do all this. Involve any other specialists they’re seeing—whether it’s endocrine, diabetes education, a pharmacy team, or a nurse educator. Remember that every touch point is a chance for us to make sure we know what’s going on, and the more touch points, the better someone is going to be managed. By doing team-based care, we’re going to get more information, because if they only see me once every 3 months and the day after they see me they have a severe hypoglycemic episode, they’re not going to remember that 3 months later if they didn’t have an adverse outcome. Those other touch points are critically important.

Peter Salgo, MD: I remember giving a talk to the [American] Association of Diabetes Educators. There were 3000 or 4000 of them in a room, and I was struck by the fact that doctors sometimes don’t have a clue that this is a team—that the educators are there to help, the pharmacists are there to help, and the diabetic nurses are there to help. How do you get this team organized? Does every family care physician need to be integrated into this kind of a team, or is this for you guys, the specialists? Davida?

Davida Kruger, MSN, APN-BC, BC-ADM: Well, you must constantly be talking. If I see a patient, I make sure my chart goes to whomever else the patient is seeing, whether it’s cardiology, the pharmacy, or whomever. You do a cc, do an In-Basket message. I was talking today with cardiology because we were trying to persuade a patient to take a statin, and we wanted to be on the same page. I’m making sure that I tell the next person in line, just as Jay said, that this is what I prescribed, this is why I prescribed it, and I ask, “Can you help me with education of the patient to make sure they understand why we want to do it?” It’s really important that the right hand talks to the left hand and that we constantly work together and that we give the same message to that patient. I don’t have to know all this stuff. I don’t have to be the only 1 who does it, but I do need to pass off to my team members so we can help that patient. Make sure nephrology, ophthalmology, and all the other team members are involved. 

Peter Salgo, MD: It’s easy to say that from the perspective of you folks who are specialists and deal with diabetes every day, but on average—it seems to me—primary care physicians have everything coming through the front door: heart disease, diabetes, eczema, you name it.

Davida Kruger, MSN, APN-BC, BC-ADM: Correct.

Peter Salgo, MD: Is it reasonable to ask that PCP [primary care provider] to have this diabetes team available at his or her fingertips to integrate the patient into it from day 1?

Davida Kruger, MSN, APN-BC, BC-ADM: That’s why they use a specialist. That’s why they use an educator or nutritionist, so they can take the piece that’s appropriate to them and then pass it off. That’s why many primary care physicians, once the patient is on multiple daily injections, would prefer a specialist to manage that patient. I don’t want to take care of sore throats and ears. I want them to have a primary care provider that wants to manage those things and a cardiologist. It’s not that we want to live in our own little box. We want to share and make sure that everyone knows what’s going on with the patient. In primary care, as specialists, we should be helping them with these things and making sure they know that there are diabetes educators available, that there are clinical pharmacists available, and that there are dietitians available who want to support them in what they’re doing with diabetes.

Peter Salgo, MD: It sounds like you have to make 10 phone calls, right?

Jay Shubrook, DO, FACOFP, FAAFP, BC-ADM: I’d like add something to that. Every person with diabetes has a diabetes team. It is just a matter of who’s on that team. Most people with diabetes are managed in primary care, but that doesn’t mean they don’t have a team that’s helping them. It might be that there are family members, a community leader, or a friend. I ask, “Who’s on your diabetes team?” If they don’t know what that means, then I might actually say, “Do you also see an endocrinologist? Do you also see an ophthalmologist? Do you see a nephrologist? Do you see a podiatrist? Do you see a dietitian? Have you had other forms of education? Do you work with other people at work or at home on your diabetes?”

That raises awareness that this is a lot of work, and we utilize different resources, depending upon what the needs are. Everybody must have a team approach to this. Having done both primary care and specialty care, I put the onus on the primary care practitioner to send the first letter saying what I would like help with, because when I send that first letter, then I’m surely going to expect a letter back saying, “What did you find?” Too often, we don’t send the letter the first time, leaving it unclear what the consultation is supposed to be. My message would be start the process and the communication from the get-go.

Peter Salgo, MD: OK, but let me ask you, what is this letter? Who’s sending it and who’s it going to?

Jay Shubrook, DO, FACOFP, FAAFP, BC-ADM: If it’s to another health care provider, the primary care provider is sending it to whomever they refer the patient to. If it’s team members in the community, then of course you aren’t sending a letter. You might say, “Why don’t you invite them to your next appointment? Because if they’re able to help you, then I want to make sure you’re getting all the help you need.” Knowing key players in that person’s health care plan is really important.

Peter Salgo, MD: We’ve been talking about all these experts who are weighing in to take care of this patient. How important is the education of the patient themselves, to deal with this and to understand what’s being said and to make choices and selections, Jay?

Jay Shubrook, DO, FACOFP, FAAFP, BC-ADM: Diabetes is 95% self-managed, so we have to give people the tools so they know how to make decisions. Surely, there are several thousand minutes in a year, and most patients might only have 60 minutes with us, so that means they’re on their own more than 8000 minutes per year. We have to make sure we give them the tools to make decisions. This group knows very well that only a minority of people get proper diabetes education in the first year, which really prevents them from being able to make smart decisions. We have to go through a lived experience, which sometimes can be painful.

Davida Kruger, MSN, APN-BC, BC-ADM: I used to say to my patients, “I don’t go home with you at night, and that’s a good thing for both of us. So I need to equip you with the education you need to feel comfortable about managing your diabetes.” If the patient calls and says, “You’re going to be upset because I made changes in my medication,” I say, “No, if I’ve done my job right, you feel comfortable doing that and informing me of what you’ve done and knowing when you can call or you should call for assistance if you need it.” Diabetes is a disease that requires self-care. We must arm the patient with the right education, the right tools, and the right knowledge. Family members need to be as well educated. I love doing a video visit when all the family members come in to help, and it may be the first time I’ve ever met all family members, so you get that input. The patient is in the driver’s seat with diabetes, definitely.

Anne Peters, MD: Can I add 1 more thing about education?

Peter Salgo, MD: Sure.

Anne Peters, MD: There are 2 problems that are very specific. One is people who have recurrent episodes of severe hypoglycemia or significant hypoglycemia unawareness. Those are people who need to be referred to a diabetes team specifically because there are educational programs that exist to work with patients to help them get their blood glucose levels above 100 mg/dL and keep them above 100 mg/dL, so that it restores hypoglycemia awareness. There are very specific approaches to restoring awareness that are very important for those patients who have recurrent episodes of level 3 hypoglycemia or even level 2 hypoglycemia.

The other problem is perhaps something only we endocrinologists see. I see patients who cling to being low because they’re so afraid of being high and getting complications. It becomes a psychological disorder—they may deal with anxiety or even OCD [obsessive compulsive disorder]. Whatever it is, it’s not something I can fix just by telling the patient, “Take 1 unit less before lunch.” It’s a psychological problem that actually requires that patients get therapy, mental health help, and work through their issues, because I want people to feel comfortably safe and in a normal zone. If they want to be too low too often, that’s also a real problem we’ve discussed. We need to think about the psychosocial aspects for certain patients who may need psychological help, and then the notion that there are programs and approaches for people who have recurring, real lows.

Peter Salgo, MD: I want to thank all of you at home for watching this HCPLive® Peer Exchange. If you enjoyed the content, I want you to subscribe to our e-newsletter to receive upcoming Peer Exchanges and other great content right in your in-box.

Transcript Edited for Clarity