Teaching Health Professionals

How to Treat Type 2 Diabetes

Jennifer Larsen, MD
Professor and Chief,
DEM, University of Nebraska
Medical Center
 Implementing a diabetes
treatment paradigm or guideline
• Define or refine the science
• “Hone” a clear message or guideline
• Disseminate the message
– Specialty physicians: endocrinologists,
ophthalmologists, cardiologist, nephrologists
– Primary care providers: internists, family
physicians, mid-levels
– Diabetes educators and other health care
providers: pharmacists, dieticians, nurses
– Patients
 Diabetes care and education
assumptions
• More than 20 million with diabetes in the U.S.
– 170-180,000 Family medicine or internal medicine
physicians (2005 Bureau of Labor and Statistics)
– 4000 Endocrinologists (2008 recent workstudy
estimate)
• Most diabetes care is administered by
primary care physicians, independent of
endocrinologists
• Training of diabetes care begins in training
programs
 Learning to manage diabetes
• “Facts”:
– Diagnostic criteria: diabetes, pre-diabetes,
metabolic syndrome
– Standards of care
– Medicines: efficacy, side effects, contraindications
– Trial outcomes
• Achieving the goals requires management
strategies:
– Early and late disease, with complications
– Outpatient <=> inpatient
 Education venues open to all
physicians
• Publications, news: academic and lay press
(articles, editorials, reviews, interviews)
• Continuing education (live or prepared: audio,
video, web-based, journals, other periodicals)
• Mandated management/education activities: group
practice, hospital, board for certification (self study
modules)
• Member broadcasts (e.g., web or mail): hospitals,
professional societies, insurance co
• Pharma reps
 Strategies within primary care
training programs
• Training program specific venues (variable teachers):
– Lectures
– +Endocrine Rotation
– Morning report, journal clubs, case conferences
– Education through consultation (or not)
– Learning by doing: observing and taking care of patients, with or
without input from attendings
– In-service exam- what boards think important
• Diabetes facts learned easily--usually with lectures or other
didactic opportunities
• Diabetes management is a process and not so clearly
taught
 UNMC Training Model
• Didactic lectures provided through specific training
program-diabetes physicians involved in both
– 1/2 day teaching day/year in Family Medicine (FM)
– 2-3 hours lectures by DEM physicians in IM
• All FM and IM residents required1 month DEM
rotation/3 years
• DEM has didactic lectures: 3 for diabetes care
• Residents involved in both inpatient and outpatient
care: 50% or more is diabetes care
• Diabetes center: work alongside educators
 Learning challenges
• A lot of guidelines, a lot of drugs involved in diabetes
care
• Guidelines appear to compete with one another
– AACE vs ADA on A1C goal
– ADA vs NCEP on LDL goal
• Strategies to achieve those goals taught by example
– Primary care setting: patients early in disease but less
likely to use new drugs
– Endocrinology practice: patients late in disease so ideal
for teaching insulin initiation but not for early oral
medication management
 How is management taught?
• Case-based: who is the patient you see today
• Necessarily will be colored by the biases of the ‘teacher’,
and ‘concerns’ of the patient
• Focused on ‘today’ rather than the longterm
• Also limited by practice issues:
– Time: can pit the patient against the trainee
– Cost to the patient (drug) and/or the practice (time to teach)
– Limitations of the insurer, co-morbidities, motivation
– Available data (e.g., trends, current labs)
– Resources available (e.g., A1C already done, a nurse who can
teach insulin or the device)
 Diabetes management
paradigms can be reinforced
with other education methods
• Inservice exams or Board review self-study
modules: useful but occur too infrequently; focus
on testable “facts” more than management
• Continuing education programs: Cost and time
a greater barrier to trainees
• Member broadcasts: trainees often not
members
• Pharma reps: still valued in many primary care
offices, although role is diminishing
 Education opportunities

• To develop training program specific educational

materials that consolidate diabetes “facts” including
published guidelines
• To develop cases or other strategies that better
translate guidelines or provide “management
approaches” for both inpatient and outpatient settings
• To develop expert systems needed to monitor or
achieve ideal diabetes care
• To develop strategies that effectively disseminate
new information
 Summary
• The ‘facts’ of diabetes care will continue to increase
with more medicines and more trials
• Primary care physicians need to stay engaged in
diabetes care--some already “opt out”
• Even with the best training models, primary care
residents don’t learn all they need to know about
diabetes to be effective in their own practice, now or
into the future
• Translating new “facts” into changing practice
paradigms will require educational interventions
beyond what we have in place today