Teaching Health Professionals How to Treat Type 2 Diabetes

1. Teaching Health Professionals How to Treat Type 2 Diabetes Jennifer Larsen, MD Professor and Chief, DEM, University of Nebraska Medical Center

2. 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

3. 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

4. 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 latedisease, with complications • Outpatient <=> inpatient

5. 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

6. 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

7. 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

8. 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

9. 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)

10. 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

11. 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

12. 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