How prepared will future doctors be to treat diabetic patients?
How prepared will future doctors be to treat diabetic patients?
From training to continuing education, diabetes should be a priority
Are medical students getting enough training to be able to treat their future diabetic patients successfully? Today’s doctors have mixed opinions.
"As a group, we have dramatically lagged behind the research providing the tools to assist us in improving our patients’ lives. Why?" asked Irl B. Hirsch, MD, editor of Clinical Diabetes, in an editorial in the April issue.
Hirsch, an endocrinologist, associate professor of medicine at the University of Washington, and medical director of the Diabetes Care Center at the University of Washington Medical Center in Seattle, answers his own question by placing the blame on what he calls woefully inadequate physician education in medical schools and in residency programs.
"It’s a giant mess," he says. "Everybody has different thoughts on the issue. Nobody knows how to fix it, and some even say there’s no problem."
He notes that medical students at the University of Washington, which is the state medical school for five northwest states, receive one afternoon of didactic diabetes education, which includes a two-hour lecture and small discussion groups that review various treatment issues relating to diabetes drugs, hypoglycemia, and complications. The university’s six-session elective endocrine course attracted less than a quarter of the students last year, Hirsch says.
During residency, he says, primary care doctors tend to focus largely on inpatient treatment and have little exposure to formulating treatment plans and working with diabetics as outpatients.
The problem of not getting enough training in diabetes care proliferates in practice, says Hirsch. "The reality is that once they get out of training, they tend to stay on the same track with medications and treatment programs."
While he recognizes how difficult it is for primary care physicians to stay current in the rapidly changing world of diabetes management, Hirsch says doctors are doing their patients a disservice.
He also takes aim at managed care for exerting time pressure on doctors. "Real diabetes management has almost become academic since they just don’t have time," Hirsch says. "They barely have time to write scrips, much less look at feet, eyes and take blood pressure.
"I think I have it easy compared to the primary care people," he adds. "I only have to be on the cutting edge of one disease. I don’t think I could do it if I had to do that with ten diseases."
However, Hirsch compliments some managed care organizations for "doing a better job than most of us in keeping current."
While many doctors agree the training can be improved, the problems may not be as severe as Hirsch says.
"I don’t doubt we could do a better job training doctors," says Stephen Spann, MD, medical director for diabetes and professor and chairman of family and community medicine at Baylor University in Houston. But he defends curricula like Baylor’s that focus on teaching basic science in medical school, holding off on specific diabetes care until residency programs. "A lot learning takes place in their medical rotation in the hospital," he says.
Spann notes residency programs are designed to train doctors in the day-to-day reality of managing chronic diseases like diabetes. "Our primary care residents follow diabetic patients for three years," he says.
As chairman of the American Academy of Family Physicians’ annual clinical focus training, Spann promoted a diabetes training program for family practitioners, designed to help them make their skills "state of the art" and to provide them with the latest patient education materials.
Physicians need to be teachers
"We also need to do a better job of teaching our patients," he says. "Family doctors can provide excellent care for the vast majority of diabetics," says Spann. "But we must be up-to-date and be aware of new drugs, the advantages of tight control, and the risks for minorities."
Medical schools are taking action, says Eric Bass, MD, associate professor of medicine at Johns Hopkins University School of Medicine. Bass participated in formulating a core medical clerkship curriculum guide for the Washington, DC-based Society of General Internal Medicine (SGIM) and Clerkship Directors in Internal Medicine (CDIM). (See information on curriculum components, inserted in this issue.)
"Diabetes is a high-priority area, and it needs to be a core part of the curriculum," Bass says. "It’s important that students and house staff see diabetic patients in inpatient and outpatient settings." Several medical schools are using the guide to help them further develop their curricula, he adds.
But Hirsch contends much needs to be done to change the way people think about treating diabetic patients.
In his editorial, he concluded, "We currently tolerate poor diabetes care by our colleagues . . . As a group, we need to catch up with all of the new diabetes-related research. Diabetes also needs to be a greater priority in our training programs. Otherwise we lose the opportunity to translate research into clinical practice and progress cannot continue."
[Contact Irl Hirsch at (206) 548-4882, Stephen Spann at (713) 798-7788, and Eric Bass at (410) 955-9871.]
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