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Patients Educating Doctors: A First Draft CME Syllabus for Diabetes
Yesterday, I responded to the question about "things you wish your doctors knew about diabetes and the daily task of living [with it] by mentioning that many healthcare providers' knowledge of diabetes is incomplete and/or out of date. Rather than be a part of the problem, I've proposed a first-draft solution some things I would put into a Continuing Medical Education (CME) syllabus to fill in some of those gaps. I'm sure I'm missing rather a chunk of stuff, but then again, this is a first draft.
If I were to develop a syllabus to fill in the gaps in professional diabetes education, as I perceive they exist today, these are some of the things I would consider:
Initial diagnosis. While the American Diabetes Association's (ADA) 2010 Standards of Care make a case for initial diagnosis by any one of four methods (HbA1c > 6.0%, fasting blood glucose (FBG) > 126 mg/dl (7.0 mmol/ml), Oral Glucose Tolerance Test (OGTT) > 200 mg/dl (11.1 mmol/ml) after 2 hrs, random blood glucose > 200 mg/dl), if type 2 diabetes is suspected, then FBG is needed to determine initial medication load (is a background medication, such as extended-release metformin or one of the once-daily drugs, required?); OGTT and mixed-meal postprandial patterns are needed to determine which of several dietary approaches is most likely to be successful in managing food-related spikes, as well as whether or not a meal-based medication regime is needed.
- Type 1 versus Type 2. At its extremes, c-peptide test may be able to determine early-onset insulin-resistant type 2 diabetes, or diabetes with severe beta-cell depletion, but it may not be sufficient to distinguish late-stage type 2 (insulin-dependent nonautoimmune) diabetes from type 1 (autoimmune) diabetes. While a GAD antibody test should confirm autoimmune diabetes, a negative test does not rule out slow-onset type 1 diabetes (LADA). If a person with diabetes does not respond to oral drugs, or those drugs cease to work after a period of less than two years, a follow-up GAD antibody test should be run to confirm type 1 diabetes.
- Type 2 versus Type 2. "Type 2 diabetes" can mean insulin-resistant hyperglycemia due to either incorrectly-formed insulin or unresponsive insulin receptors; it can mean impaired glucose tolerance, in which glucose consumption does not trigger insulin release; it can mean inappropriately high glycogen-to-glucose conversion; it can mean lipokine interference with the insulin-leptin-ghrelin cycles... Each of the major classes of oral diabetes medication addresses a different potential root cause of persistent hyperglycemia. Assigning the wrong class of diabetes drug to a patient is likely to result in suboptimal glucose patterns, suboptimal glycemic management, and associated poor outcomes. In short, it won't work very well or for very long, and may have undesired and undocumented side effects
- Other Forms of Diabetes Hyperglycemia which does not seem to respond to standard treatment may be a symptom of one of several types of monogenic diabetes (MODY). Genetic testing may reveal if this is the case; existing literature will point to best known management techniques.
Home glucose tests and CGMs are both friend and foe. Taking the monetary costs of testing out of the equation, the testing-logging-analysis-correction loop takes time often more time than is easily managed with a heavy work schedule, household chores, and family obligations. In addition, the whole concept of glycemic control means that patients and their families regard in-range numbers as "good" and out-of-range numbers as "bad", regardless of how they are presented. While insulin users have, at least in theory, the option of taking correction boluses to bring down higher-than-desirable numbers, all people with diabetes need to understand that out-of-range numbers are not always due to the failure of the person with diabetes to correctly calculate insulin dose for food, activity, and known metabolic stressors, but medicine's incomplete knowledge of how every potential stressor affects an individual's body at any given time as well as the sheer impossibility of calculating corrections for all of those stressors at any given time. Without psychological support and when possible help learning to accommodate these variables, a person with diabetes may tend to test less frequently (so as to have fewer "bad" numbers), cease wearing a CGM, or cease eating (for fear of spiking blood glucose levels outside the desired range).
Not all "diabetes diets" are the same. For someone who is overweight or obese, sometimes calorie restriction and weight loss either alone or in conjunction with the appropriate pharmaceuticals may be sufficient to keep glycemic excursions within an acceptable range. The carbohydrate-centered (and particularly grain-centric) ADA diet will cause a number of people with impaired glucose tolerance and/or insulin resistance to routinely exceed established desired upper limits on glycemic range; they will need to adopt either a lower-carbohydrate diet (the Atkins approach), a glycemic-index diet, or a whole-foods diet (the Mediterranean Diet approach). Comorbidities such as hypertension suggest a whole-foods approach (lower sodium), while celiac (common among people with Type 1 diabetes) requires a gluten-free diet.
Income level and family circumstances directly affect "compliance". In lower income neighborhoods, fresh foods and whole grains may be difficult or impossible to find. Persons living in a family or other communal dining environment may be limited by other members' dietary tastes and food restrictions, and/or by the overall food budget. Sudden changes in living expenses such as car repairs, appliance replacements, medical emergencies, and school projects may limit a person's ability to purchase and use testing supplies and medications according to medical direction. In these cases it is less that a patient wishes to forego self-care, but that ongoing everyday survival (shelter, job, basic food and clothing) trumps medication purchases, and the needs of the entire family may financially overwhelm the needs of the individual patient.
Don't assume the needs, priorities, income level, or education level of a patient, or his willingness and ability to learn. Every person has different needs and priorities. Someone who appears well-dressed may be wearing hand-me-downs needed to maintain a low-paying job; someone else may choose to cut out movie night (or pizza night) if it means he'll be able to afford his medications. Some people who were not motivated to learn in grade school and high school may be reading jargon-laden medical literature before you can get to it when the incentive is their own (or their child's) health.
Diabetes is a twenty-four hour a day, seven day a week, job. While the job is arguably easier for those people with diabetes who don't require medical insulin, the thoughts and fears of highs, lows, numbers, and foods are never far from our minds.
I'm sure I missed something in this quick prcis things like whether or not to count fiber and sugar alcohols in carb counts, how to bolus for fats and proteins (which are largely ignored and may cause some PWDs to go high or low at weird times), and how to argue with insurance companies to get every PWD who wants one an insulin pump and/or CGM but these are things I believe every doctor who has a patient with diabetes (which means, every doctor) should know about diabetes.
How about you? What would you add to the curriculum?
Megan was diagnosed in 2009 with Type I. As an RN, she was familiar with the medical side of her diagnosis; learning to be a good patient on the other hand, was and continues to be the challenge of her day to day life. (Read More)