How ready are we, as diabetes educators, to take on the job of educating uninformed providers who aren’t easy to work with?
I’m pretty sure every diabetes educator I’ve talked to, at some point in her career, has had to deal with this type of provider.
The question is: how are we responding as a whole? Are we holding ground and assuming the role of an educator to other healthcare professionals or are we shying away from those who are misinformed or under-informed and in a position of power? I think that if we maintain our focus as educators on the health and well- being of our patients, we have no other choice than to rub some AACE guidelines or ADA Standards of Care in the face of Dr. Diabetes Downer.
Recently I was talking to a colleague about this subject. She sees patients in a primary care setting and will often cover multiple offices. In this type of setting, the primary care physician or case manager will identify patients who can benefit from diabetes education and make the referral. Unfortunately, she had a difficult circumstance to deal with but I found it interesting and inspiring to learn how she approached the situation. Here is the story about a patient who was referred to her from a primary physician who had been managing this patient’s diabetes. I hope you will find it as empowering as I did.
I’ll begin explaining in a simple case study format:
- Diabetes meds: Metformin 2000 mg daily, Glimepiride 4 mg with breakfast and Lantus 70 units BID (that’s TWICE PER DAY!) No regular or rapid acting insulin prescribed. TDD of 140 units. She is getting 1.8 units per kg.
- Testing glucose twice daily; fasting blood sugars in the 130s and pre-meals later in the day in the 140-180 range.
- GFR 34 and Creatinine 1.5
- She eats two meals daily (breakfast and dinner). Breakfast is usually bacon (4 strips) and 2 eggs.
- She had diabetes education classes about 20 years ago
After seeing this patient, my colleague discussed with her ways to improve her insulin resistance with diet and exercise. She also started to instruct her on carbohydrate counting. Additionally, she made some recommendations to the primary to get this patient started with a basal bolus insulin regimen. Knowing that it would be a process to guide this patient to improved glycemic control, she came up with the following medication management plan for the physician to review:
The total daily dose was calculated at 0.8 units per kilogram (0.8 x 77 kg = 62 units). Because this patient is on a high dose of Lantus, she decided to go for 70% of the TDD as basal (42 units basal Lantus once daily). With the remainder amount of insulin, she recommended a fixed meal dose of 8 units rapid acting bolus insulin with breakfast and 12 units with dinner. It was also discussed to discontinue Glimepiride when starting mealtime insulin and discontinue the metformin with her renal function in mind.
She sent this plan off to the physician to sign off or adjust accordingly. His response, more or less,harshly mocked her reasoning and criticized her for cutting back on her insulin so drastically. As if 140 units of solely basal insulin was an appropriate alternative plan.
Her response to his feedback was something like this: “The protocol we follow can be further explained by the AACE guidelines which suggest calculating a TDD at 0.2-0.3 units/kg. If glycemic control is not at goal (A1c <8%), add prandial insulin with a TDD of 0.3-0.5 units/kg with 50% from basal and 50% from prandial. Considering she is obese and very insulin resistant, I calculated her at 0.8 units/kg. I made these recommendations as a starting point knowing she would be returning to see me for further evaluation. In diabetes education we will be working with her closely on ways to decrease her insulin resistance via lifestyle.” She then attached a link to the guidelines and the phone number to our medical director if he found the need to discuss it further.
He hurled back a comment about“those guidelines” being used for empiric therapy when you basically have no idea what someone’s insulin requirements are; requirements which in his opinion, he fully understood.
Judging by his backlash, I wonder if this physician felt insecure about his ability to manage diabetes better than the diabetes educator. And it probably wouldn’t shock many educators that she did know how to medically manage this patient’s diabetes better.
This is a physician who she will have to continue to work with and educate. By no means is this going to be easy, but in standing up for what’s going to be best for this patient, she will remain grounded when facing his criticism.
How would you have handled this? Would you have stood up for what’s right for the patient or agreed that this physician knows more than you about diabetes management and continue to work around a poor medication plan?
Check this out: Competencies for Diabetes Educators. Under competency: “Works with an interdisciplinary diabetes care team to tailor interventions to individual patient self-management education needs,” it implicitly states that Level 5 objectives include: “Instructs healthcare professionals in various levels of pattern management.” Whether you’re at this level or not, this will be one of the ultimate objectives we meet as diabetes educators.
Not all people living with diabetes are going to have access to a diabetes educator but hopefully, that will continually change for the better. Recently the American Association of Diabetes Educators, the American Diabetes Association and the Academy of Nutrition and Dietetics released a Joint Position Statement which will eventually circulate its way through the nation’s DSME programs and be used as a tool to show primary care offices how to gain access. So you can expect that diabetes educators will be working with more and more providers who are not used to having a truly collaborative team member.
It’s time we talk more about how to deal with uninformed providers and challenge them to see us as a highly effective resource. Let’s continue to learn from each other in how to manage instructing other healthcare professionals.
What advice do you have for educators who are working to help educate other members of the care team?
Disclaimer: This blog is a personal opinion and does not necessarily reflect the position of the American Association of Diabetes Educators. The intention of this blog is to do no harm. The writer is responsible for all content but the writer is not responsible for any blog comments.