Anne L. Peters, MD; Tami A. Ross, RD, LD, CDE, MLDE

Disclosures

June 27, 2014

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My Favorite People: Diabetes Educators

Anne L. Peters, MD: Hi. I'm Dr. Anne Peters, and I am at the American Diabetes Association (ADA) Scientific Sessions in San Francisco. I am with Tami Ross, who is the immediate Past President of the American Association of Diabetes Educators (AADE). We are here to talk about the role of the diabetes educator and the care of the patient with diabetes.

Let me just start out by telling you that some of my favorite people in life are diabetes educators. I can't take care of a patient without the help of my diabetes educators. Could you discuss your sense of the role of the diabetes educator?

Tami A. Ross, RD, LD, CDE, MLDE: It is really a partnership. You said that you couldn't live without your diabetes educators, and from the moment that our patients are diagnosed with diabetes, it is a partnership among the educator, the healthcare team, and the physician to provide care for the patient. We give them the education, management skills, and support that they need to help deal with a diagnosis that is very scary for many people.

In terms of being a diabetes educator, we look at what can we do to help make this new diagnosis less scary, to quell the panic that occurs. The AADE has done some research looking at patients who are newly diagnosed with type 2 diabetes, and 6 in 10 are shocked and surprised by that new diagnosis. They don't have a clue that they are going to receive this news, and about one fourth of those patients are in denial.

You probably hear that in practice, "This isn't real; this can't be happening." That is where the diabetes educator can come in and spend time with the patient. Providers and physicians are stretched and busy, so we can partner with them and bring that education, management, and support piece.

Dr. Peters: The shock of being diagnosed is huge. I see people with diabetes all day long, so I forget how overwhelming it is. Hopefully, I won't forget about the psychosocial element to diabetes. I have heard people say that the day they were diagnosed with diabetes was one of the worst days of their lives.

A Multidisciplinary Specialty

Dr. Peters: When you use the term "diabetes educators," who do you include in that group?

Ms. Ross: A diabetes educator is a healthcare professional who specializes in helping people with diabetes stay well. This might include nurses, dietitians, pharmacists, physician assistants, nurse practitioners -- a whole host of healthcare professionals. It is multidisciplinary. The key is that it is a healthcare professional with the training and background in diabetes.

Dr. Peters: I love the fact that we can all help our patients, and at every point that a patient can be helped -- whether it is a pharmacist, a nurse, or a dietitian -- there are many different touch points at which you can connect with a patient.

Ms. Ross: My patients often say, "You are my cheerleader. You give me encouragement and help me to figure it all out." Support can be provided through email, a phone call, or a mobile app used to help patients stay in touch. We help them navigate those day-to-day challenges, because people with diabetes manage their diabetes on their own most the time. We are with them for a few minutes in the office, so what matters is what happens after they leave the office.

Dr. Peters: If you could tell me how I could make your life easier, what things do I do as a physician that help you educate or that hurt the education process?

Ms. Ross: How can we partner together? Monitoring -- looking at those blood glucose numbers -- is a key factor for educators. What do these blood glucose numbers mean, and how do we take those data and share them with our patients to improve their outcomes? Often when patients come in, they don't know what those numbers mean. They say, "My doctor told me to check my blood sugar, but what's my target -- where am I trying to go?"

That is an important area: the pattern management, the problem-solving, and healthy eating. Being a registered dietitian and a certified diabetes educator, I am an advocate for healthy eating. Patients come in with many myths related to eating. How do we help bring truth to some of the myths that are out there?

Dr. Peters: I look at myself as having a certain set of skills. I sometimes joke that my diabetes educator is the best diabetes doctor I know. But it is really a compliment, in the sense that we think similarly. We know that there are certain things that I am good at, and other things that I don't have time for. I always talk about diet and exercise -- making sure that people aren't "on a diet," but are eating healthy. I don't know anything more advanced than basic carbohydrate counting. I always refer patients to my registered dietitian, who is a partner in all of this.

My dietitian and educator are both incredibly good at pattern management. They have more time than I do. I look at data and I talk with patients, but for me the hardest part is when people tell the patient different things. Sometimes that becomes a barrier.

Ms. Ross: We need to have a consistent message among all of us on the team.

How to Find a Diabetes Educator

Dr. Peters: The notion of a partnership is very important. Do you have any sense of how a provider can find a diabetes educator for a patient?

Ms. Ross: The AADE Website can help providers find a diabetes educator. You can search by ZIP code and find out where there are diabetes education programs. To find a dietitian, go to eatright.org.

Dr. Peters: Does the patient need a referral from a physician? How does that work in terms of reimbursement?

Ms. Ross: Yes; you should refer patients to a diabetes educator, so we can give patients the individualized attention they need. It may be through a group class, or it may be one-to-one, depending on the patient's needs and situation. The diabetes educator can take some of the stress off the physician and others on the healthcare team and spend the time with patients that you may not be able to spend. We can educate and empower the patient, partner with you on management, and provide support along the way.

Dr. Peters: It is very important. You may have more experience in listening to a patient's concerns, not only because of time but also because of the difference in your training, which is more educational.

The hardest patients for me are those who are either in denial or are just not ready to make a change. They aren't ready to give themselves insulin, or check their blood glucose. What tips do you have for helping the patient who seems stuck, who seems in denial? How do you get someone to change?

Ms. Ross: I spend a lot of time listening to them. I joke with my husband that I am going back to college to get a degree in psychology or counseling, because I spend so much of the visit listening. You are listening for what is motivating that patient and what is of interest to them, and then figuring out how you build on that, what their goals are, and where they want to go.

I'll give you an example. A patient came in who was drinking 6 Mountain Dews a day, with an A1c higher than 12%. You and I can look at that and know what we would like to see happen. But with this individual, we did some bargaining. He agreed to go from 6 down to 2. He wouldn't consider diet drinks, but at least we are making those small changes that ultimately are going to help patients better achieve their goals.

A Lifestyle Prescription

Dr. Peters: Do you do formal goal-setting? Do you write it down for the patient?

Ms. Ross: I do. I tell them they are getting some homework, and I have a prescription pad with their lifestyle prescription, and so we fill in what their goals are. It might be to keep their carbohydrates at a consistent level, or to work toward achieving 150 minutes of activity a week, or maybe it's to begin checking their glucose twice a day. Yes, I send them home with a written lifestyle prescription.

Dr. Peters: That's wonderful. Do you send that to the healthcare providers who are treating them, or do you just give that to the patient?

Ms. Ross: I have worked in a practice where it goes into the medical record. That way, we are all on the same page. Everyone knows exactly what I'm working on, and I know what they are working on, and what goals we are trying to achieve. It helps us to improve the patient's outcomes in the end, which is our ultimate goal.

Dr. Peters: That's wonderful. I really believe in all of this. I try to do goal-setting with patients. But sometimes I'm too busy, and sometimes I write down my goals instead of their goals. That's real easy to do.

Ms. Ross: Yes, it is. That's where the challenge lies, because we have the goals that we would like to see patients achieve, but we have to think about what is of interest to them and what they are willing to do. Ultimately, we can tell the patient whatever we want, but it's the patient's life. I always tell my patients, "It's your life, and it's your decision. In the end, we can be honest with you and tell you what we would like for you to consider, and how we get there could be any number of routes. There are many healthy eating plan options, and many exercise options." In the end, we can help them get to goal.

Dr. Peters: You have been at this ADA meeting. What have you found exciting? What have you heard? What's the buzz with diabetes educators?

Ms. Ross: I enjoyed the President, Health Care & Education address.[1] I found it very inspiring. One of the tidbits I took away is that so often, people have blame and shame placed on them with the diagnosis of diabetes. It's our role to back up and take that away and to empower them, encourage them, and help them set reasonable goals.

I heard the ADA Educator of the Year[2] speak, and her message was 6 things that we tell people that are impossible to do. How do we take these self-management behaviors and make them reasonable and applicable to our patients? I like the behavioral track -- looking at behaviors and the educational components that will help our patients.

Dr. Peters: Thank you very much for taking the time to come and talk to me.

This has been Dr. Anne Peters, for Medscape.

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