Oct 1, 2015

Interviewer: When do you need to see a diabetes specialist? We'll talk about that next on The Scope.

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Interviewer: Dr. Tim Graham is a diabetes expert. He's also the medical director of the diabetes, obesity, and metabolism programs for University of Utah Health Care. When do you need to see a diabetes specialist? When is it beyond something that your primary care physician can help you with?

Dr. Graham: That's a great question, and it's actually somewhat debated even in the medical community.

Interviewer: A hot topic.

Dr. Graham: Yeah, it is. It is. It's important because every time you escalate care it costs more for the patient, and it may or may not benefit them in the long run. So we do take seriously when to escalate care and when we get the most out of that extra bang for the buck when we send someone to a specialist.

Basically, we tend to look at diabetes as a general medicine problem, and it really is. It's a chronic condition that can generally be managed with the knowledge of a good internist, or a good family physician or generalist.

However, sometimes some patients don't fit into the usual protocols that we use in general medicine. So when patients start to develop recurrent low blood sugars or if they've been hanging out at a high blood sugar for more than six months and working with their primary care physician they're not really achieving the target blood sugar that they would like to get to, or the one that they need to get to to be more healthy, then I would recommend that they consider seeing a diabetologist.

Diabetology is just a fancy name for something we do in endocrinology. So it's always been endocrinologists or hormone doctors who tend to oversee the specialty care of diabetic patients.

Interviewer: So the primary care physician in how many cases would you say is able to handle through exercise, maybe medications, helping them with nutrition?

Dr. Graham: I would say at least 80% to 90% could be easily handled by the primary care physician. However, there are these patients that their physiology just doesn't fit into the normal sort of mold, the normal care protocols that we use. So really there's no reason to hesitate to take it outside the primary care setting to see the specialist physician at some point to get some additional input into the care plan.

Interviewer: Are there some specific indicators that a patient would see that would indicate that maybe they would want to request to be elevated to the next level?

Dr. Graham: Well, a couple things. If your primary physician isn't helping you set goals and telling you where you should be in terms of your hemoglobin A1C, which is the number . . . It's a blood test that we often follow to tell us where a diabetic patient is on a three-month basis for their blood sugars. If that goal isn't being set, then you need to address that with your primary physician. Say, "Hey, let's set a goal and let's make sure I'm getting there, and I'd like to talk about how to get there."

Now, maybe you have a goal that's been set, and maybe it's been communicated to you. But it's been six months and you're still not there. I think that's time to bring up the discussion with your primary physician, "Do you think we should escalate care a little bit and see a diabetologist?"

Now we've, at the University of Utah, taken a new approach to this. We want diabetic patients to be seen in their medical home with their primary care provider. So what we're actually doing is bringing diabetes specialty services to each of the community clinics in the University of Utah healthcare system. That way we don't have to have patients making this uncomfortable discussion with their primary care physician about whether they need to be referred out for something that the primary care physician may not be able to achieve easily in the primary care setting.

So instead, the primary care physician can literally just, at the click of a button, have the patient seen by one of our diabetes care teams right there in their own clinic where we've integrated into their practice. So we think that's easier for both the primary physician to deal with and easier for the patient to deal with.

Interviewer: That's something that primary care physicians kind of like. It's a checklist meaning, "If it's to this point, I'm just going to go ahead and refer."

Dr. Graham: Yeah. In fact, we're working with our primary care colleagues to decide really where exactly to activate the referral. At what point do we identify a patient who's been, say, lingering with a high blood sugar for six months or has had multiple episodes of low blood sugar? At what point do we pull the trigger, if you will, to get them hooked into one of these community care teams?

Interviewer: Then at that point, what would that expert do?

Dr. Graham: So typically what happens is, when they see the community care team, they get a lot more face time. They'll either see a specialist nurse practitioner or an M.D. physician such as myself, who's a diabetologist endocrinologist, and we'll sit down and do some problem-solving. We'll look at their medication list and we'll try to figure out what they aren't getting or what they might be able to get, from a medical standpoint or pharmaceutical standpoint, that would improve their blood sugar better.

Or maybe sometimes it's the timing of the dosing. Or maybe it's the types of foods that are being eaten. So we also tend to have them see a dietician nutritionist no matter what at those visits, as well. We'll often bring in our colleagues in pharmacy who are very good at helping adjust complex insulin regimens.

Interviewer: So a lot of tools that you have if the standard treatments don't work.

Dr. Graham: That's exactly right. I would emphasize, I like the term, it takes a village to care for a diabetic.

Interviewer: Yeah. Okay.

Dr. Graham: There are a lot of aspects of diabetes care, including even things like exercise, physiology, physical therapy, and we try to bring all of those to bear on these care teams. So we have people who are experts in behavioral health that work with the care team. We have specialist physical therapists who can work with people who have neuromuscular problems that makes it hard for them to be active.

We have exercise physiologists who can work with just the average person to come up with a good exercise regimen. Then of course, the nutritionists and diabetes educators, and then the pharmacists. All of those, that village of care is what the primary care provider gets when they reach out to one of these teams.

Interviewer: I guess what you're learning is that the old adage of eat better and exercise, you can't just tell a patient to do that because it's a lot more complicated than maybe a lot of us get.

Dr. Graham: Oh, yeah. Absolutely right. We've been doing that for years, telling patients to eat better and exercise.

Interviewer: It can be overwhelming.

Dr. Graham: In fact, no one really complies well with that because we all kind of know anyway we should be doing that. Right? So hearing one more person say it doesn't really change anything. However, it's really about strategizing.

So if you have people telling you not just that this is what you ought to do, but exactly how to do it and how to make it work for your life so it's actually personalized to you, we know that the impact is much more substantial. The more times you have people telling you that the better. So the other thing these care teams do is they bring more face time to the patient, basically.

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