By Laura Hieronymus, M.S.Ed., A.P.R.N., B.C.-A.D.M., C.D.E., and Kristina Humphries, M.D. | April 2, 2007 12:00 am
Coming together is a beginning.
Keeping together is progress.
Working together is success.
Diabetes is a chronic condition, which means it lasts for a lifetime and requires ongoing care. Diabetes can also affect many parts of the body, sometimes in obvious ways but sometimes in ways that can only be detected by sensitive laboratory tests in the early stages. Although many people successfully manage their diabetes year after year, doing so is challenging and requires acquiring knowledge, learning certain skills, and being able to adapt to change.
Given the lifelong and complex nature of treating diabetes, it’s no surprise that people with diabetes often see many health-care providers on a routine basis. In fact, it’s often said that diabetes is best managed with a team approach. That is, the person with diabetes should have a team of health-care providers to help him manage the condition on a daily basis and to treat any complications that may develop.
Many diabetes centers and clinics already use a team approach to treat diabetes. People who do not get their care at such a center, however, may need to do some of their own legwork in establishing a diabetes team that works together and communicates among the members.
No matter who else is on the team, the person with diabetes is the key player. He is the one who knows himself and his diabetes best. He also knows the most about his ability to manage his diabetes. The rest of the team can help the person with diabetes acquire knowledge, learn skills, and set goals, but because the person with diabetes provides most of his own care, ultimately he is the one in charge.
Besides the person with diabetes, typical team members in diabetes management include a physician, a registered nurse, and a registered dietitian. A pharmacist and in many cases a mental health professional round out the team for optimal diabetes care.
Physician. Most people with diabetes see either a family practice physician or a physician specializing in internal medicine for most of their diabetes care. This is the team member who will prescribe medicines for you, recommend target blood glucose goals, order laboratory tests, examine you, encourage you to exercise, and look out for your overall health. Your physician may also refer you to other team members for specialty care, nutrition education, and diabetes education and training.
Family physicians are specially trained in preventive medicine, while doctors of internal medicine (also called internists) have special training in the prevention and treatment of diseases of adults. Endocrinologists are internists with advanced, specialized training in the care of endocrine diseases, which include diabetes, thyroid disorders, growth hormone deficiency, osteoporosis, cholesterol disorders, hypertension, and obesity. About 20% of people with diabetes get their primary diabetes care from an endocrinologist.
When selecting a physician to treat and manage your diabetes, it is imperative that that person have expertise as well as experience with the current standards of diabetes care. One way to find such a physician is to use the National Committee for Quality Assurance Recognized Physician Directory. (See “Rounding Up Your Team” for contact information.)
Registered nurse. Nurses that specialize in diabetes care and education are very active in helping people with diabetes learn to control their condition. In addition to instructing people individually, many nurse-educators lead group diabetes classes, and some also lead diabetes support groups.
Registered dietitian. The registered dietitian is the nutrition expert on your team, and because nutrition is such an important part of diabetes management, it’s a good idea to seek out a dietitian who is knowledgeable about diabetes. Your dietitian should be able to explain how various foods affect your blood glucose level and help you work out a meal plan that meets both your nutrition needs and your diabetes goals. In addition to offering one-on-one sessions for individualized planning, many dietitians also lead diabetes education classes. These can be helpful for learning about nutrition and for sharing recipes and ideas with others.
Registered pharmacist. Most people are familiar with pharmacists as the professionals who dispense medicines in pharmacies. Pharmacists also practice in other settings such as hospitals, long-term care facilities, and clinics. Some pharmacists are also involved with drug research, either in a laboratory or in a clinical setting.
In recent years, many pharmacists who interact with the public have gotten additional training in diabetes care and management. Many have even become certified diabetes educators, and some offer diabetes classes or one-on-one educational sessions in local pharmacies.
Pharmacists can help you manage your drug therapy, identify potentially harmful interactions among the drugs and over-the-counter products you use, and often answer questions about insurance reimbursement for your medicines and diabetes supplies. If possible, it’s a good idea to purchase all of your prescription drugs from the same pharmacy. That way, your records are all in one place, and it’s easier for a pharmacist to spot any potential problems.
Mental health professional. Living with any chronic condition can be stressful, and diabetes is no exception. In fact, people with diabetes have a higher incidence of depression than the general population, and depression is often linked to stress. If you feel overwhelmed, lost, stuck, or depressed, it’s worth seeking the services of a mental health professional. Talking with a licensed practitioner can help you figure out why you feel that way and what you can do about it.
Several types of professionals, including psychiatrists, psychologists, and clinical social workers, offer psychotherapy (or “talk” therapy). The type of practitioner you see is less important than the relationship you have with that person and the sense that meeting with that person is having a positive effect on how you feel and behave.
Your primary health-care provider may refer you to a specialist because you’ve developed a condition that requires special care or simply for specialized screenings. How often you should see these and other specialists depends on your health status and your medical needs.
Podiatrist. If you have a foot problem such as a corn, a bunion, or even toenails that are difficult to trim, your primary-care provider may refer you to a podiatrist. Doctors of Podiatric Medicine (DPMs) are physicians and surgeons whose scope of practice is limited to the feet and usually the ankles. Even if you currently have no foot problems, you may be advised to see a podiatrist periodically to have your feet screened for early signs of diabetic neuropathy (nerve damage) or other foot problems common to people with diabetes. (Your primary-care provider should also conduct regular foot checkups.)
For people with neuropathy or reduced blood circulation to the feet, a podiatrist may be a very important team member. People with these problems are at high risk of developing foot ulcers. A podiatrist can advise you on choosing socks and shoes that will help prevent foot problems, prescribe special shoes to protect vulnerable feet from damage that could lead to a foot ulcer, and treat any wounds or other problems that do develop.
Ophthalmologist. An ophthalmologist is a medical doctor who specializes in eye and vision care and is specially trained to provide the full spectrum of eye care, from prescribing glasses and contact lenses to performing eye surgery. Some are also involved in scientific research into the causes of and cures for eye diseases and vision problems.
According to the American Diabetes Association, people with Type 2 diabetes should have an initial dilated and comprehensive eye exam shortly after diagnosis with diabetes. People with Type 1 diabetes should have an initial dilated and comprehensive eye exam within five years of diagnosis. Following the initial examination, everyone with diabetes should have eye examinations on an annual basis, unless advised otherwise by their eye-care professional.
Women with diabetes who are planning a pregnancy are advised to receive a baseline comprehensive eye examination as well as counseling on the possibility of development and/or progression of diabetic retinopathy associated with pregnancy. Women should also have a comprehensive eye examination in the first trimester of pregnancy and monitoring during and following pregnancy, as recommended by an ophthalmologist.
Optometrist. Like ophthalmologists, doctors of optometry (ODs) examine, diagnose, treat, and manage diseases, injuries, and disorders of the eye. Optometrists are also trained to detect the ocular manifestations of systemic conditions, such as high blood pressure and diabetes, and to refer people to other health-care specialists for eye surgery and/or further medical evaluation. Unlike ophthalmologists, optometrists do not perform surgery. Therefore, if a person requires laser or surgical treatment of the eye, the optometrist will refer him to the appropriate ophthalmologist (such as a retinal specialist).
No matter what sort of eye doctor you see, it’s important to find one who is knowledgeable about and experienced with the eye complications of diabetes.
Obstetrician-gynecologist. Women with diabetes visit the obstetrician-gynecologist for much the same reasons as women who don’t have diabetes: cancer screenings, other preventive health-care services, birth control, and treatment of any conditions or diseases affecting the reproductive system and sometimes the urinary tract.
Women with diabetes who plan to become pregnant are urged to discuss their plans with their obstetrician (and other members of the diabetes team) before becoming pregnant. This is because of the high risk of developing pregnancy complications if blood glucose is not in optimal control before and during the pregnancy. Planning ahead gives you time to bring your blood glucose into “tight” control before conception and to consider how you will deal with the need to maintain tight control over the course of the pregnancy.
In some cases, a woman with diabetes who is pregnant may be referred to a perinatologist, an obstetrician with specialized training in managing high-risk pregnancies.
Exercise physiologist. Exercise physiologists prescribe exercise regimens based on a person’s needs, strengths, and weaknesses. Depending on their training and place of employment, they may administer certain fitness tests before making their recommendations.
Exercise physiologists who work with people who have diabetes should be familiar with the effects of exercise on blood glucose control. They should also understand how exercise can interact with diabetic complications in both positive and negative ways.
Anyone can benefit from meeting with an exercise physiologist to work out a fitness plan. It can be especially beneficial for people with little exercise experience and for those with any kind of diabetes complication, including cardiovascular problems.
Physical therapist. If you are unable to be physically active or carry out activities of daily living because of an injury, disability, or complication of diabetes, your physician may refer you to a physical therapist for treatment. A physical therapist can help you maximize your physical function by assessing what is limiting your ability to move and working with you to strengthen, stretch, or otherwise rehabilitate your body as needed. In many cases, a physical therapist will show you exercises to do at home in addition to working with you in an office setting or rehabilitation facility. Physical therapists can also treat certain kinds of pain and teach people to use assistive devices such as walkers and canes.
A primary-care provider is not always a physician. Some people see a nurse practitioner or a physician assistant for their routine diabetes care.
Advanced Registered Nurse Practitioner. Nurse practitioners provide nursing and medical services to individuals, families, and groups. They may practice independently and/or in collaboration with other health-care professionals. They manage acute and chronic illnesses, as well as emphasize health promotion and disease prevention. Their services may include ordering, conducting, interpreting, and supervising diagnostic laboratory tests and prescribing nonpharmacologic and pharmacologic therapies. They can serve as counselors, educators, researchers, consultants, and patient advocates. Nurse practitioners are different from registered nurses in that they diagnose, treat, and manage health problems.
Physician assistant. Physician assistants are health-care professionals licensed to practice medicine with physician supervision. As part of their comprehensive responsibilities, physician assistants conduct physical exams, diagnose and treat illnesses, order and interpret tests, counsel on preventive health care, and assist in surgery. In most states they can write prescriptions. Although they are supervised by physicians, physician assistants exercise autonomy in medical decision making and provide a broad range of diagnostic and therapeutic services.
Health-care providers should have a basic knowledge base relative to their profession. Some important considerations in evaluating and choosing your diabetes team members include the following:
Degree from an accredited college or university. All of your health-care providers should hold a degree in their field of practice.
Registration or license. A health-care provider who is registered or licensed has successfully passed a national or state licensing examination for his professional discipline.
Board certification. Board certification assures the public that a health-care professional has completed an approved educational training program and an evaluation process that includes an examination designed to assess his knowledge, experience, and skills within his professional discipline.
Specialty certification. Health-care professionals can become certified in specific areas of expertise such as diabetes education and management. Currently, more than 10,000 health-care providers in the United States are Certified Diabetes Educators (CDEs). The CDE credential demonstrates that the health-care professional possesses distinct and specialized knowledge about diabetes and its treatment.
Some providers also have the Board Certified–Advanced Diabetes Management (BC-ADM) certification. This certification is available only for registered nurses, dietitians, and pharmacists who also have a master’s degree. Health-care providers with this certification have demonstrated that they meet nationally recognized standards in the specialty area of diabetes.
Some diabetes educators are also certified pump trainers (CPTs). This means they have completed a program designed by an insulin pump company to enhance their knowledge and expertise in the operation and training process for a specific brand of insulin pump.
A health-care provider may have more than one specialty certification that is diabetes-focused, as well as other certifications that are not specific to diabetes. In some places of employment, certifications are required; in others, they are voluntary.
Any working team needs a manager, or someone to coordinate it, and in a diabetes team, that job often falls to you, the person with diabetes. Although your team members should be willing to communicate among themselves, it will often be up to you to inform each member of any treatments prescribed by the others. You will also have to provide your medical history to each team member and keep them up to date. (For more about communicating with your team members, see “Maximize Your Team Meetings.”)
Based on the information you provide about yourself, your diabetes team members can support your diabetes management efforts with their advice, expertise, and experience. You should not have to go it alone in caring for your diabetes, and with the help of your team, you won’t have to.
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