Evaluation of Patients with Type 2 Diabetes Mellitus


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Evaluation of Patients with Type 2 Diabetes Mellitus

  1. 1. PODCAST TRANSCRIPT EVALUATION OF PATIENTS WITH T2DMJoel Zonszein, MD, CDE, FACE, FACP: So the question is how can we evaluate a patient withdiabetes. Well let me tell you that primary care physicians who take care of probably 90% to95% of patients with diabetes, hate to see a patient with type 2 diabetes. The reason is that ittakes too long. A good physician is going to get a good history and a physical examination, andthey will make an assessment from the laboratory tests. Only after having all that is when theyare going to start treating the patient. This takes too long and is not properly reimbursed in ourhealth care systemSo, as I mentioned before, a patient coming to the office with viral upper respiratory tractinfection or a sore throat or urinary tract infectionisrelatively easy to evaluate and treat. To startdealing with the patient who has type 2 diabetes, it is not dealing with the sugar only, it is not thedealing only with the weight, or the cholesterol, or the blood pressure, or the abnormal kidneyfunction; It is dealing with all of it together. We need a very careful evaluation and need to knowthe laboratory values in order to provide the best therapy. We are now seeing patients whohave a much more aggressive disease and it impacts younger people so we see patients whoare very, very young and even children with type 2 diabetes. I do not treat children, but I seeadolescents and young adults who come with obesity, severe dyslipidemia, acanthosisnigricans, fatty liver, and already complications from the disease at a very young age.In fact, I have seen type 2 diabetes in three generations. Thereis the grandmother, everybodywill expect somebody to get diabetes at the age of 75 or 80-85; the daughter of that person alsodeveloped diabetes and often they have more severe and more aggressive cardiovasculardisease than the mothers, and then the granddaughter who is now the teenager or the child whomay also have diabetes, so we see now diabetes in three generations. This is very worrisome,and this brings me back to the importance of providing education not only to the patient but tothe entire family. But going back to the history and physical examination, to obtain a detailedhistory and physical examination takes a long time. The reimbursement by the insurancecompanies often will be less than the office overhead. I will have to pay (the overhead ofexpense is more than the reimbursement for the visit) to spend one hour or sometimes an hourand a half or even more on a good adequate comprehensive history and physical examinationfor a patient with diabetes. And I am not talking about providing education that is also notreimbursed adequately in our current healthcare system. So as I mention at the beginning, theprimary care physicians do not like to see patients with diabetes because it will take them alongtime.Developed in collaboration with the Center for Continuing Medical Education at Albert Einstein College of Medicine and Montefiore, and the American Academy of Nurse Practitioners, through a strategic educational facilitation by Medikly, LLC. Supported by an unrestricted educational grant from Lilly USA, LLC.
  2. 2. The diabetes prevention program includesa population of patients thatdid not have diabetes, butwhat we used to call pre-diabetes or impaired glucose tolerance or high risk for diabetes. Whenwe lookcarefully at that group of individuals, they already had complications of diabetes, evenbefore they developed diabetes. They already exhibited a bit of neuropathy and retinopathyeven in the prediabetes stage. Obviously when we look at these individuals with prediabetes,when they have other cardiovascular risk factors such as hypertension and dyslipidemia, andwe examined carefully their arteries, for instance by doing intravascular coronaryultrasonography (IVUS) studies,we find out that at the time of diagnosis of diabetes, 100% ofthose patients already have advanced atherosclerotic or arteriosclerotic cardiovasculardisease.I convey that to the patient. When making the diagnosis of diabetes it means that the patientalready had a heart attackbecause there are studies showing that the chances of getting asecond heart attack in somebody with diabetes is exactly the same forsomebody who alreadyhad a heart attack.What we need to do in that patient, is to prevent a second heart attack.So, in summary, when we see a patient with diabetes, we have to get a good family history,good personal history, we have to do a careful physical examination, we have to assess if thereis neuropathy or retinopathy or to be sure that the ophthalmologist will see the patientimmediately. We will have to make an analysis to see if there is any organ disease such askidney disease, heart disease, etc. We obviously have to measure albuminuria and ormicroalbuminuria which aremarkers of both small and large vessel disease. Something weoften forget is dental care. Many of these patients have gingivitis or have tooth decay. Theyhave to see the dentist and very often dentists are aware and they can tell by the way justlooking at somebody’s mouth if they do or do not have diabetes. There is now evidence of howchronic gingivitis, chronic infection of the mouth can add insult to the inflammatory process thatwe see in patients with type 2 diabetes. So it is important to make a good history and physicalexamination and evaluation, and then treat these patients.The physician has to spend a lot oftime in providing education, guidelines and review of blood glucose monitoring.Ifthe patientneeds to be on insulin we need to teachthe patient how to inject the insulin and how to adjustthe insulin doses.The difficulty is in adjusting the dose of insulin, so it would be effective andthat will require different telephone conversations with the patient, different questions that thepatient may have.So in an ideal situation, in order to do these well, the physician needs to get paid, and what wesee in reality is that the reimbursement is very low, so this is a major problem. I want to point itout because we often talk about barriers, and I thinkthe reimbursement system is a veryimportant barrier.Developed in collaboration with the Center for Continuing Medical Education at Albert Einstein College of Medicine and Montefiore, and the American Academy of Nurse Practitioners, through a strategic educational facilitation by Medikly, LLC. Supported by an unrestricted educational grant from Lilly USA, LLC.