As I called out for help on what to do with a patient with diabetes, over to Susan, my fabulous CDE, whose office is about 10 feet away, I thought about how critical it has been for me to have a Certified Diabetes Educator in my office. Susan has helped my staff to be understanding of patients with diabetes, and hopefully I have imparted some wisdom on my patients and the staff on the complexities of diabetes and the simplicity that sometimes, we don’t have a good answer on how to treat this disease.
My thoughts flooded back to my first scientific publication, which was finally accepted after literally dozens of rejections in the American Journal of Medicine in 1995. The focus was the importance of the team approach to diabetes care in the hospital setting and how care by a team including an endocrinologist, diabetes educator and nutritionist made a difference. We also had every diabetes patients admitted primarily for diabetes get a dilated eye exam while in the hospital along with a visit by a podiatrist. Of course, length of stay was shorter when the specialty team got involved. We were also fortunate to identify patients who were found to need acute sight-saving interventions that may not have been found had the inpatient dilated eye exam not be performed.
After that study, our vision was to have an outpatient clinic in which patients could seamlessly see an ophthalmologist, nephrologist and endocrinologist and developed a turnaround time on labs and visits with a beautiful personalized poster before patients left the office with their diabetes status and goals. We demonstrated that simply knowing your A1C and cholesterol status and goals improved A1C and cholesterol dramatically.
The concept of a team is intuitive and makes so much sense, yet justifying the financial value of having a team has become more and more difficult for many reasons including insurance carriers sometimes discourage patients from seeing more than one provider a day. Often there is no reimbursement for services of a CDE or dietitian. So as I call for Susan’s help, I am so grateful to have her services in my office, along with my entire staff, who often know what to do better than me because they have learned to be diabetes detectives.
For example, my patient, who is thrilled to share her story, simply can’t afford insulin. Video of Patient discussing health insurance. As I shared at my recent talk at the American Association of Clinical Endocrinologists Annual Meeting, some health insurers have a cap on the amount of insulin patients can get per month as shown in this UnitedHealthcare Update.
Dr. Elliott Joslin was the first to recognize the importance of the diabetes team. He sent nurses to the homes of patients with diabetes in the early 1900s, prior to the discovery of insulin. Dr. Joslin pioneered diabetes self-management. One of my favorite quotes from Dr. Joslin is, “Everyone knows it requires brains to live long with diabetes, but to use insulin successfully require more than brains.” I too believe that to manage diabetes successfully, requires more than brains. It requires fully functional islets that make insulin, amylin, glucagon, somatostatin, pancreatic polypeptide and ghrelin that all work together as a team communicating harmoniously.
In those without diabetes, this harmonious hormone team so effectively communicate in order to keep 95% of daily life spent with glucose levels 60 to 120 mg/dL, and 80% of life is spent at 100 or less. It takes a team of hormones to manage glucoses. I thank the team at my practice (Susan, Pat, Ava and Gina) and the team at Perle for their dedication and belief that insulin independence will occur sooner than believed possible by the generation a new team of islet hormones generated from one’s own pancreatic ductal cells.