Doctors who care for people with diabetes   (October 12, 2007)

Ever since I can remember, most people with diabetes (PWD) have had their medical care done by physicians who are generalists (a categorization which includes general practitioners, family practice docs, and internal medicine or pediatrics doctors). It's been said that over 80% of PWD are cared for by generalists.

And ever since I can remember, most diabetes docs and diabetes teams (teams that include diabetes docs, diabetes nurses, diabetes dietitians, and others) have had concerns that the generalists don't have the time nor the resources to care for people with this amazingly complex disorder. Some diabetes docs have chosen to work together with generalists; others, to take over the complete care of the PWD. But it has always been a battle of egos and a battle for resources: with limited reimbursement, many generalists defer referral to diabetes specialists and/or diabetes teams, and it is the PWD that suffers from the generalist's lack of knowledge of the fine points of diabetes care.

It's a puzzle: if the patient had leukemia, a referral to a cancer specialist (oncologist) would be inevitable. Or if the patient needed brain surgery, no generalist would undertake it (I think). But diabetes can be an annuity for the generalist: do marginally efficacious care, and the patient will keep coming back for year after year, until someday they go blind, or need an amputation, or they are on three diabetes pills and refusing insulin injections, or go into end-stage renal disease. All these, of course, are preventable outcomes if the doc pays attention to the entire disease process, and consults early with specialists. The simplest intervention that doesn't get done nearly often enough? Referral to a dietitian for meal planning.

When should a patient be referred to a diabetes team? I've listed my thoughts about When to refer to an endocrinologist in an earlier discussion.

May I suggest a simple idea to the generalists? If your patient has diabetes, don't assume that you can handle their entire care by yourself. Get a diabetes nurse educator and a dietitian onto the case. Have an eye doc check for retinopathy annually. A podiatrist should care for the yuckky nails and bunions. Etc.

And ask for help from a physician who specializes in diabetes when you know you're in over your head.