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Diabetes: A Story of Understanding, Teamwork and Population Management

by Bernadette Sheridan, MD, family medicine

As a family doctor 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 think about the patients with diabetes who make up more than 10% of my Brooklyn, New York-based practice. A prime example of a need for population management if there ever was one.

Considering that November is American Diabetes Awareness Month, and given my large population of diabetes patients – and years of experience diagnosing and treating this disease – I wanted to share my story and approach to managing this population.

Diabetes: More Than a Word, Much More than a Diagnosis
At my practice, we’ve seen some improvements in the health of patients with diabetes, thanks to a total team effort that includes my staff, insurance company reminders, patient education and incentives to patients. Still, greater than conditions of more than half our patients remained uncontrolled, with A1C levels (an average blood glucose index) greater than 7%, with 20% of our patients having A1C levels greater than 10%.

Tragically, we’ve had patients lose their sight, limbs and kidneys in the last year to uncontrolled diabetes, and every cardiovascular complication has been manifest in one way or another. But in my opinion, the greatest tragedy comes in the form of new onset Type 2 diabetes for 18-25 year-olds. If left unchecked, these are the amputations and blindness of the future. This group is the most vulnerable, a population for which lifestyle and education is essential. But, as I tell many of my young and pre-diabetic patients, this is also “the fixable group.”

Engaging and Understanding Your Patients
Our approach to patient engagement is, to quote a famous statesman, “by any means necessary.” For some, we utilize a patient portal. For others, handouts and flow charts. For all, we provide feedback after every visit.

We engage our patients wherever they happen to be. We ask questions and try to understand them and their lifestyle. This can’t happen in a 15-minute chat, which is why we believe strongly in working as a team.

Many of our patients are Afro-American, Hispanic or Caribbean. I try to establish rapport with each person, and use my understanding of who they are to get my point across. Many are overworked, busy mothers who don’t have time for anything but a quick bagel and coffee, who inhale their dinners while checking their kids’ homework or multitasking. Some are in complete denial: they’re feeling fine, pre-diabetic and knocking on the door of diabetes, without seeing the dotted line between their current eating habits and the diagnosis to come.

How I Manage My Diabetic Population
My approach to the care of my population of patients with diabetes has come full circle since I started practicing. I have made the following observations which I believe will resonate amongst my peers.

  1. Diabetes is no longer the disease of the endocrinologists. Each month, we diagnose 2-3 new diabetics, while at least one existing diabetic enters our practice for the first time. The wait to see a specialist can be three months(!), so primary care physicians have to educate ourselves, arm ourselves with new tools and re-evaluate and eliminate the use of some of the old tools.
  2. TEAMWORK is everything. Each diabetic patient needs the input of Cardiology, Ophthalmology and, when necessary, Vascular and Nephrology. It is nearly impossible to manage a disease based on eating without a plan for eating— handing someone a 1800-calorie American Diabetes Association (ADA) diet sheet is not enough! The most valuable resource for managing my patients is our Registered Dietitian, aka The Diabetic Nurse Educator.
  3. Be persistence to the point of overkill.We believe in visuals making in impact. We have plate demonstrations for portion control, vials of lipid-laden cholesterol. pictures of clogged-up arteries (for the not-so-timid), and other graphic reminders for the especially hard-headed. We are gentle when we need to be and brutally honest when it is required.
  4. Learn and re-learn how to balance concern with detachment. Wellness is a choice, a journey and a lifestyle adjustment for patients. We physicians can be coaches, but the ultimate choices are made by the patients. I care for them, but I have also learned not to take them home.

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 is directly related to its health. I remain firmly committed to do whatever I can, as are many of my colleagues, to invest in this wealth by giving the present generation the tools needed to manage those things they cannot change – the genetic legacy of their parents – and to change those things within their power, such as lifestyle, exercise and food choices. I firmly believe that when you combine our advancing technology with the simplicity of common sense, things that change on a small scale can be compounded within the bigger picture.

It is my fervent desire that diabetes not become the comfortable epidemic of the 21st century. We owe it to ourselves, our children and their children, to continue trying.

Dr. Sheridan runs Grace Family Medical Practice in Brooklyn. She’s a native New Yorker and an athenahealth client.

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