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. – ,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