Your young primary care doctor may not know a lot about diabetes, according to a study led by Stephen Sisson, MD, of the Johns Hopkins School of Medicine. “When I graduated from residency here, I knew much more about how to ventilate a patient on a machine than how to control somebody’s blood sugar, and that’s a problem,” said Sisson in a press release. “The average resident doesn’t know what the goal for normal fasting blood sugar should be. If you don’t know what it has to be, how are you going to guide your diabetes management with patients?”
Despite the ballooning numbers of older patients with type 2 diabetes and other chronic conditions like hypertension and high cholesterol, the medical establishment is apparently failing to adequately train young physicians to treat such patients. Although ninety percent of all doctor-patient visits are outpatient, medical residencies tend to focus on hospital care instead. As it stands now, only a third of an internal medicine residency is spent on outpatient care, and some of that time goes to outpatient specialty care or emergency department rotations rather than primary care.
For the study, published recently in The American Journal of Medicine. Sisson administered a test to internal medicine residents at 67 US medical residency programs during the 2006/2007 academic year. The residents failed to score more than 55 percent overall on topics such as chronic disease management, preventive care, and acute care, the very types of cases they’re likely to run into in a primary care practice. Chronic disease management fared the worst, with scores below 50 percent.
According to a 2010 study by Dr. Sisson and Amanda Bertram that looked specifically at diabetes medical training, even third-year residents’ knowledge of basic diabetes management is pretty weak. Only 39.7% of them knew the correct goal fasting plasma glucose, and only 54.4% knew the correct goal post-prandial glucose in patients with diabetes. The residents were reluctant start insulin therapy in patients with poorly controlled diabetes who were already being treated with maximal doses of metformin.
Speaking to Diabetes Health by phone, Dr. Sisson said, “There are some core facts for outpatient management of diabetes that residents do not learn well. They are not learning very basic ambulatory outpatient management facts that guide care in diabetes. Those include what is the goal morning fasting glucose, what is the goal post-prandial glucose, what do you do with a patient who’s on meds X, Y, and Z and their hemoglobin A1C is 10–what do you do? And there’s the patient who comes in and says they’re eating a certain diet: What should they change, eat less of, eat more of–nutritional recommendations. So that’s what we tested, and we found that residents really don’t do great in that regard.”
“What we’re doing now isn’t working, The next step is to do more, and that means dedicate more time to ambulatory topics, make sure residents are required to pass certain competencies, certain levels of skill in taking care of a patient with diabetes. There’s a skill set that needs to be there for trainees to teach patients to self-manage something as complex as their blood sugar. Whereas hypertension and cholesterol are a lot easier–take your pill, keep your doctor visit, and stay away from salt–diabetes is a lot more complicated.”
“There’s a real mismatch in the needs of our population and what all of our residency training programs seem to be accomplishing. They aren’t leaving people who graduate well trained in ambulatory care, and that’s where the big needs are right now. The question is, does better training in diabetes leads to better healthcare outcomes for patients with diabetes? The hope is that it would, and so we need to do better. We need to do better.”
Johns Hopkins press release
Primary Care Diabetes
Stephen Sisson, MD