Dr. Tricia Santos Cavaiola discusses how to incorporate diabetes management in the Primary Care Physician’s practice.
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perfect. Thank you, Athena. I have the honor of introducing Dr Tricia Santos Saviola, who is an endocrinologist at U. C. San Diego with special interest in diabetes. Both type one and type two. She's involved in diabetes research as well as education of both health care professionals and patients. For those of you local to San Diego, you you may recognize her because she is also involved in TCO i d. You're taking control of your diabetes, Tricia. Thank you so much, Dr Harris. And I just wanna thank you for having me today. I'm really excited to talk about this topic in particular because I think it's one of the pillars of taking care of patients with diabetes. So I'm excited to get to talk to you about that today. So let's get started. No disclosures for me and my outline is here Very simple outline for today. But I'm gonna go over a little bit of background as to why the patient experience is so important when we're taking care of our patients with diabetes. And then, um you know, the topic is tips and tricks, and I thought I would kind of boil it down to what I think are the five most important tips and tricks, um, for improving that patient experience between you and your patients. So the first statistic I want to go over that, I think is really shocking to me is that we have all of these wonderful medications to treat Type two diabetes. All of this new technology that you've heard about today and almost half of our patients with diabetes are not at their goal a one C. If we say, you know, for most patients in a onesie being less than 7% almost half of the patients have an A one C above 7%. And it's fascinating because this is despite the fact that we have 12 classes of medication to treat Type two diabetes, which is really unheard of in other disease processes and within each of these classes, as you know, and as you've seen today, we have, you know, many, many medication choices, so we literally have hundreds of medications you've heard today about the benefits in the cardiovascular standpoint and from the renal effects eso we have all these wonderful medications, and yet why is the A one C still so high in many of our patients, and a big factor is medication adherence. So we certainly have the tools to do the job. But how to get those tools toe work, I think, is where we run into a lot of problems. So, you know, we could spend the whole conference day talking about medication adherence and going over all the data, which we don't have time to do today. But I do wanna give you a little bit of data about medication adherence and how the patient, physician relationship and the patient experience kind of factors into that s o. There is great data showing that there is a link between the patient physician relationship and patients, a onesies and adherence to insulin. There's also data showing that there's a direct link between the patient physician relationship and a one c levels in our patients. Um, and we do know that by improving that collaboration with our patients that many good things can happen. So, you know, this is one particular study Looking at improved physician um patient relationship had more favorable ratings on patient reported diabetes related distress, which is a huge issue, their general well being, their lifestyle UM, medication regimen and adherents, their perceived diabetes control and then they're hyperglycemia symptoms as well. And when they survey providers, providers agreed that there was a need for better resource is in order to improve this relationship. Andi, I think, you know, especially as primary care providers, one of the biggest issues that I hear and we feel this as endocrinologist. But it's much, much harder. His primary care providers is, um, time and having time to establish that relationship with your patients. Thio go over all the medications to take care of diabetes when they got back pain and hypertension and COPD and all these other things going on in the visit on DSO. Certainly I can't fix that time factor for you, but the tips and tricks I am going to give you today I really think do not hinge on you spending more time with your patients so hopefully that will be helpful. So what can we dio as physicians? Um, there's a lot of data showing that if we can improve our communication with our patients, especially a diagnosis, it can improve their understanding of their diabetes, how much they're engaged with their disease and This can really lead to better self management because there is no disease like diabetes. You know, doctor on talked about, you know, feeling like you're driving 24 7 for patients with type one diabetes. But even patients with Type two diabetes You know, it's not like dislike academia or hypertension, where you can take your pill in the morning and then kind of forget about it. It's really people thinking about their diabetes all day long. Every time they're putting food in their mouth, checking their blood sugar multiple times a day, it really requires much more patient engagement than most other disease chronic diseases that they would have. And I love this quote from this paper that says, If the physician provides a clear delivery of the diagnosis, coupled with a specific care plan and a sense of hope that the patients Type two diabetes can be managed successfully with ongoing support from the physician and clinical staff, the result may be long lasting, positive impact on the patient's behavior and attitude. And my favorite thing about this quote is hope, and I really think that you know, in when we take care of patients with diabetes, It's so easy and we've all done this before. I've certainly done it to kind of slip into that, um, those feelings of despair and to kind of tell the patients, you know, you're gonna end up on dialysis if you don't get this under control or, you know the complications of uncontrolled diabetes or severe and you could lose your limbs and all these big, scary things. And it turns out that patients know this. They know how scary diabetes is. They know that they can have an increased risk of heart disease, um, with uncontrolled diabetes. And so I really feel that coming from a position of hope with our patients and encouragement can help them take take care of their diabetes. More thing, just kind of really beating down on them about all of the hard things with diabetes. So this was a study looking at which types of statements that providers said that correlated with better outcomes for the patients. And I'm going to go over just two categories and there's a lot of statements here, but these are actual statements that patients have heard that have helped them do better with their diabetes, and I want to bring out these statements because I think they're great examples of things that we can all say to our patients that will give them hope, that hope that I was talking about. So with good care and effort, odds are that I can live a long and healthy life with diabetes. How many times have you really expressed that to your patient? This isn't the end of the road with good care and with a lot of effort, you can live a long and healthy life. I think that's so hopeful Compared to many years ago, managing diabetes thes days is much easier because we have many more tools that can help. More and more people are living long and healthy lives with diabetes, the provider told me, or explain to me what diabetes is. If I managed to control my condition, diabetes would not stop me from doing the things I would love to do in the future. I mean, that's a huge thing for patients, right? This isn't going toe limit you. If we take control, what I do on my own can determine whether my diabetes gets better or worse. This is another thing that's really new for patients that they have to do things in between those doctors visits in between seeing their providers every every three months or so and lastly, Ah, lot can be done to control my diabetes. So really hopeful statements thes air, some collaborative statements that patients said My provider asked how diabetes might affect my life. They thought about my values and traditions when recommending treatments to me. They gave me choices about my treatment to think about. So that collaborative thing that you've heard so much about today they've helped me generate a plan with how to be more active. They asked how my work, family or social situation related to taking care of my diabetes. They asked for ideas when we made a treatment plan. They helped make a treatment plan that I could do in my daily life that was personalized and worked. They helped to plan ahead so I could take care of my diabetes even in hard times. So I'm really, you know, the idea with looking at all these statements is really putting out the positive and the hope which I think can go such a long way. So that's kind of a little bit of background on adherence and the patient physician relationship. But I want to spend the rest of the time really focusing on what I call the top five tips and tricks for improving this patient experience. And we're going to go through each of these. So the first one is. Don't be the principal's office. Bring on the stress partner about new medications. Do be a ray of sunshine and stay up to date. So let's look at each of these one by one. Tip Number one is Don't be the principal's office, and I think you know, even though that none of us are trying to be the principal's office, I think with diabetes, it's very easy to be that person where the patient comes into the office and you're just hammering them and making them feel bad about the choices that they made and really coming down on them about that a one C or whatever it may be. So you want to set up a relationship with your patient, where they feel comfortable telling you about what they're doing because and the way I explain this to my patients is if I don't know about what you're doing. I can't help you. So bye bye. Letting them feel like they can tell you what they're eating that they can tell you. Hey, I'm really not checking my blood sugar or I'm really not taking my medication then that allows us to delve in and say why? But coming in and just hammering them about their A one c being too high doesn't help them. And it doesn't help you as a provider because then you can't dive in and help. You're just kind of restating the problem. So don't be the principal's office and I'll show you a couple of examples here. So these air to old school glucose logs that two of my patients had from back in 2013, which seems like a while ago. Now, Andi, I want you to take a look at these two logs and, you know, just spend a second and see which one of thes you wish was from your patients. And I think a lot of people you know, the log on the right looks a lot prettier to be honest than the log on the left. But I'll tell you that I really consider the log on the left to be a great glucose log and the one on the right to be, you know, made me as a provider feel like a failure s o The log on the left has bloodstains on it. So you can see, you know, the patient has, um, checking their finger frequently and often times, you know their fingers. Six they're still bleeding. And so they get blood stains all over food stains all over their log. And then you can see there's a lot of variability in the blood sugars here, you know, 61 to 36 lots of variability in this log on the right, it looks quite perfect and clean. Andi, you'll notice that almost every single number ends in a zero or a five, which is probably statistically impossible. And it turns out that this patient here was actually making up on the right, making up their blood sugars because they were afraid to show me what their blood sugars actually were. And I consider that a failure on my part. So I want to set up a situation where my patients feel comfortable coming to me with their riel data and they're really issues with diabetes. Here's another example. Um, this is a patient who was eating very high carb. And we talk to the patient about, um limiting carbohydrates to 45 to 60 g per meal so that they could have, um, you know, a steady amount of carbs per meal that was limited, um, for their diabetes care. And this I consider a success. So this patient really took it to heart, and she came back and she brought me this logbook of her diet that she was eating. And she was so proud that she kept her carbs for every meal under 60 g. So this one was my favorite meal. I just took a picture of it. Onda. She had a total of about 50 g of carbs. And you can see that for breakfast she had a slim Jim. She had to York peppermint Patties to resist peanut butter cups to and easements and the Diet Pepsi. And obviously this is not the diet that I want her eating. But I felt so happy that she felt comfortable sharing with me What she was really eating. Because then I have this data I can really intervene on it and do something about it on. Guy also congratulated her for saying under 60 g of carbs along these lines with Don't Be the principal's office is I actually encourage my patients Thio share with me what they're eating, share with what they're doing and then use that as a way for them to learn. So if a patient says to me, You know, sometimes I indulge and I eat an entire pizza or I go through the drive through and I get an extra large French fry or I, you know, eat a whole piece of cake, you know, whole half a cake at night. Then I use that as a tool. So instead of coming down on the patient saying, you know, you really shouldn't eat an entire pizza, I say, Okay, great. So when you have those moments where you indulge, I want you to check your blood sugar after you eat that meal, and I want you to check your blood sugar after you eat. Ah, healthy, well balanced meal that has maybe some lean protein and vegetables and see the difference, or I want you to check your blood sugar after you go for a walk around the block Onda way that that it's a way to kind of change behavior and educate your patient without coming down on them. They know that it's not good to eat a full pizza, but if you can teach them what that does to their blood sugar, then they can learn from that behavior and then maybe start to modify that behavior. Eso That's another way that we could be more encouraging instead of punitive. All right, so that was tip number one. Tip number two is bring on the stress eso just like all of us as providers. All of our patients are juggling a ton of stress in their daily lives. And I think it's really underscored how much stress effects diabetes. I'm going to show you this picture here. This is a picture of a snapshot of a continuous glucose monitor. This is a freestyle Lee Brae Doctor on talked about this monitor in his talk today. Andi, this is I don't have diabetes, but I wear these glucose monitors every once in a while. Thio, you know, experiment with them and see how they work. And I was wearing one I was actually giving a grand rounds talk Thio primary care providers in February of this year on continuous glucose monitors and I decided toe wear one during the talk to show how it worked. And then I checked my blood sugar in the middle of the talk and I don't have diabetes. And most of the time, my blood sugar, you know, is in the eighties or nineties. And if I would eat a really high carb meal, then sometimes it could creep up to about 120 or so. And in the middle of this talk, I had had to eggs for breakfast, no carbs whatsoever. And in the middle of this talk, my blood sugar got up. Thio 175. Andi, I think this is such and I don't have diabetes. I mean, totally freaked me out. I don't have diabetes. I couldn't believe my blood sugar was this high. And it's such a nice example of what stress does to your blood sugars. And I even, you know, I didn't consider myself to be somebody who was particularly nervous with public speaking either. But obviously I was very stressed during this talk Um and this happens because the hormones that are released during stress, cortisol and cattle cola means thes stress. Hormones are the same hormones that air counter regulatory hormones to bring up a glucose when it's too low. So any time a patient has either acute stress or chronic stress, it's gonna have a huge impact on their blood sugars. And what I mean by bring on the stress is we have toe ask our patients about stress. We need to know about it so we can't just say, Well, what happened with your A one C? Here's ah, patient of mind who is 46 years old. We worked for a few years to get his A one c down to the seven range, and he was doing really, really well. And then in late 2017 and early 2018, he came back to see me and his eight. Once he was up to 9.9% and I said, and he said, I'm taking my medication. I'm checking my blood sugar. I'm doing everything right. And I said, Okay, well, what else is going on in your life? And it turns out that he had been in Thieve Las Vegas shootings that year and his PTSD from that from that incident, um, cause so much stress that literally his blood sugar's went through the roof. Now most of our patients are not going through a major traumatic stress like that. But truthfully, the stress that people have with their families with their Children, with their lives during this pandemic especially, um, this can really affect their blood sugar. So always checking in about stress is important. And sometimes I can't tell you how Maney patient visits I have, where I do nothing with the medication adjustment. I really don't. I spend time talking to them about their social stressors, their life, stressors or stress at work and figuring out ways to manage that stress. Because I know not only is that gonna lower those hormone levels to improve their diabetes, but you know patients when they're stressed, they eat more poorly. They're less likely to take their medication. So really understanding this from a provider standpoint and making sure that they're comfortable sharing that is another important tip. Okay, Tip number three is to partner about new meds, and you've heard a lot about this today But when we're thinking about prescribing new medications for our patients, it's really a team effort now. So, you know, in the old days it may have been, you know, the doctor telling the patient exactly what to do next. But the American Diabetes Association, you heard this today and doctors make his talk. And in Dr Vincent's talk, um, really tells us now that we need to partner with patients about new medications on do this, I cannot hone in on enough eso. These were some of the things again Doctor Vinson talked about. A lot of this is Well, um, to think about, we have to think about costs. You know, I still use so funny areas and and T. C. D. S and patients because I see a very underserved population. And so in those medications work. And if I prescribe a medication that costs, you know, $150 a month, then they're just simply not going to take it. We have to think about social situation. We have to think about the complexity of the regiment, adverse effects, positive effects, timing. Do they need someone at home to help administer that medication? May be a once weekly is better. In that case, um, stigma. There's a lot of stigma about, um, insulin. Especially. Many patients think that it is, um, really the end of the road. And a lot of times I think people think that patients don't want to take injectables because they're afraid of needles most of the time. If you drill down Thio why they're afraid of insulin, it has to do with the fact that they feel like they're a failure, that they have hit the end of the road with their diabetes, that their aunt went on dialysis when she went on insulin and somebody else had a heart attack after they were on insulin. And so, really drilling down about the stigma is important as well. This is an example of, ah, patient of mine who just an example of, you know, partnering with the patient s o. This patient had and stayed renal disease and was on basil bullets, insulin. And this was their scale of insulin with how to adjust their insulin by their blood sugar at each meal, Um, starting at five units going up to 10 units, and the patient came back and saw me. And, um, I said, you know, are you taking this scale? And, you know, how are you doing with your meal time? And the patient said, Well, I'm taking five units when my blood sugar is good and I take 12 units when my blood sugar is high and they couldn't really tell me what that meant, But they weren't using the scale at all. So I sent them home and I said, Okay, I really want you to use the scale and they gave them the same scale. And then the next time they came back, they said, While I'm taking five units when my when my blood sugar is good and 12 units when my blood sugar is high and sometimes I have low blood sugar. So they were doing the exact same thing, and that's because I didn't really listen to what they were saying. So even though they could repeat this scale back to me and do teach back, um, they weren't going to use it. And so me sending them home for a third time with this scale is not going to get anywhere. And so instead, I sent them home with the scale that looked like this. If your blood sugar is less than 250 take five units. If it's over 250 take eight units on. When the patient came back the next time they had been following the scale, they found that it was very simple. So really, you know, modifying things. Thio be patient centric to do things that are easy for them to dio. Um and you know, thinking about their what's most important to them when you're adding a new medication. If they're on, you know, to medications for type two diabetes, and you need to add another one saying, what is most important to you with adding this medication? Is it getting your A one c down? Is it not getting wait? Is it having a beneficial effect on your heart? Is it staying away from injectables? Whatever it is? And then you can start to Taylor, um, towards what their wants are, because if you're able to do that, what I usually do for patients is I give them two or three choices of the medication. And then I say, I am here to give you this information. I can tell you what I think is best, but it's your body and you get to choose. And by letting them choose, they're more likely to take that medication on Be adherent. Next tip Number four is Do be a ray of sunshine, so this goes back to that hope and a lot of those collaborative statements. Um, but these air some things to think about when you're being a ray of sunshine. Patients with Type two diabetes, especially, have a lot of guilt and shame about having diabetes. They feel like it's their fault. Um, some of those pictures that Dr Harris showed you about Googling obesity. Some people feel that way about their Type two diabetes. People have told them it's a lifestyle disease and you know you ate your way to diabetes or those sorts of things, and it's just not true. Thio Type two Diabetes is a genetic disease, so I always tell patients it's not their fault. It's important Thio as the provider to remove the shame and the guilt that patients may carry about this disease because that shame and guilt just adds to stress, which we know again raises the blood sugar. Um, so taking, you know, the burden that you can take off of them by taking that off of their shoulders cannot be underscored enough. The other thing that's really important in terms of being a ray of sunshine is give your patients if you have goals for them, like checking their blood sugar or eating a certain way or exercising. They should be small, achievable goals that your patients cannot fail at because then they will come back to you with more hope they will feel more successful. They'll be more willing to take their medications. So things like if I have a patient who really likes to eat rice instead of saying you need to cut out rice, which is, you know, not possible for many people, either. You know, just in with their preferences are culturally then then I'm not going to tell them. Don't eat rice. I'm going to tell them, Um, is it possible for you to limit your rice to one cup per meal or a half a cup, or whatever is reasonable, or is it possible for you to go from eating three tortillas per meal to two tortillas per meal? It's a much more achievable goal than saying no more tortillas for you or, you know, no more lemonade. Can you change the lemonade to crystal light? Eso small, achievable goals. Don't say you need to start a huge exercise program. So can you walk around the block? Can you walk to the end of your driveway once every day or twice every day? Very, very small, achievable goals. So they're not feeling like a failure. This is a example of a patient who brought in their glue commenter to me. Um, this glue Kant. So this is a download of the glue commenter, and every little dot here that, you see is a time that they did a finger stick glucose check. So if you look up here in the right upper corner, you can see their average blood sugar was 341 and their highest was reading high on the glue comet er, and the lowest reading was 245. So many of us may get this data and say, Oh, no, this patient is in horrible shape. Their average blood sugar is 341. Well, it turns out this patient, um at the visit Prior had not been checking their blood sugar at all, not checking, didn't want to know, was not willing to take medications because didn't really believe their blood sugar was that high. And so we spent a long time building that safe relationship where the patient feels that they can, you know, tell me the truth about what's going on, And I tried to encourage them, and once they came back with that data, instead of coming down on the patient, I actually said Congratulations because now you're checking your blood sugar, and now we can see that it's high and because we can see it, we can do something about it. So instead of, you know, being kind of coming down on the patient, I want to be a ray of sunshine for them and accentuate the positive and encourage them to keep going farther. Okay. And the last, um, the last tip may be the hardest, and this is stay up to date. So there are as you you know, and I think the one nice thing is that just by being here today, you are getting so much cutting edge information on these new medications and how to use them and what the benefits are in the new technology. And, UM, and that will go a long way with your patients. But the reason that I say that this improves the patient experience is because by staying up to date, it gives us the opportunity to know what's out there toe offer to our patients, and not every patient wants all of this. Not every patient wants new technology or new medication or, you know, new things to help with their diabetes. But some do, and some feel very encouraged by it. And it's, ah, huge challenge to stay up to date with Type two diabetes, especially because just when you feel like you've learned everything, a new class of medications comes out or a new type of technology comes out. So it's very hard to dio Um, but I'll just hit on a couple of things that can that can make patients lives easier. So there are fixed ratio combination medications that actually combine a GLP one receptor agonist, which you've heard a lot about that medication today and basil and spline in tow, one injection. So in those patients that feel like it's a lot to take multiple injections a day. This is a very easy medication. There's two on the market, um, that where you can easily dial up the medication according to the insulin dose, and the patient ends up getting that GLP one receptor agonist as well. And it turns out that by using these in combination with each other, it mitigates some of the side effects of both. We also have newer, I say newer now because they have been around for a few years. Basil influence, um, thes basil insolence to J. O. And receive a have some benefits for our patients. They last longer than 24 hours and every patient, so there's no and they have a very flat action profile even flatter than insulin enlarging you 100. So it's very, um, they do have some benefits. You know, those patients that have to take a split dose of their raisel insulin because it's not lasting 24 hours thes last the full 24 hours. They are associated with less hyperglycemia and even less weight gain in some cases. So that's some benefits for your patients. Dr. On talked extensively about continuous glucose monitors You know, we used to think of these as a type one, um, option. And really, these are becoming more and more mainstream for patients with type two diabetes. Andi patients love them, and I will tell you, um, I have had so many patients where you put them on a continuous glucose monitor and just that behavior that they're learning where they can see gosh, stress makes my blood sugar go up and eating that pizza or walking around the block. And what happens to the blood sugars? Many times the patients will actually have a reduction in their blood sugar or improving their time in range without any medication. Doses and Soto have a device that can improve your life, see my control without adding, you know, side effects from other medicines. I think is a really wonderful options. So please consider these for your patients with type two diabetes and then lastly, doctors make us, um, discuss this very briefly this morning. But we have new ways to treat hypoglycemia now with an inter nasal hypoglycemia with the inter nasal spray as well as the auto injector pen. It's kind of like an EpiPen where you just take the cap off and you can just inject glucose gone right away. So these air making it easier in that regard for family members? Yeah. Um um and I recognized it saying, You know, staying up to date is probably the hardest one of all these things, but I think in combination. If you're trying to do all of these things together, little by little as you can, um it will make a difference. So in summary, many many of our patients are not meeting their goals in terms of glycemic control. And our relationship with the patients can improve that experience and subsequently improve adherence. So thanks, everyone. I'm happy to take any questions. Thank you so much, Trish. That was really informative. And I think it goes really well. We have another lecture coming up this afternoon with Carl Espinosa, who is a psychologist who deals a lot with diabetes. Distressed. So I feel like these are very complimentary. Ah, lot of people in the audience work in the primary care fields, So we were wondering if you have any recommendations for those in primary care in terms of increasing their comfort and expertise with some of the newer medications. And similarly, at what point do you recommend referring beyond primary care to an endocrinologist? Yeah, you know, I do a lot of education with primary care here, atyou, CSC as well, and what I'll say is, and all of you know, this in primary care already. But what I'll say is there is a huge spectrum in terms of comfort level with medication. So we have some primary care providers who aren't comfortable using GOP ones as they are, and some who will, you know, prescribe continuous glucose monitors and kind of are on the other end of the spectrum. So what I would say is the time to refer is I believe when you are out of your comfort zone and or and or you feel like you have tried all of your tools in the toolbox and you're not making any progress, then certainly that's the time to refer, but there's not really a cut off as to kind of which met at which medication point or at which level to refer. It really has to do with your own comfort level because in primary care, there's so many things to keep track of that some people you know are a little more attuned with diabetes, and other people are a little better at COPD or whatever it is. So it's really, I would say where your comfort level is, Um, and then doing ongoing things like this where you're going to see me, I think, is the best way toe learn how to use thes new types of devices and new medications and really practicing. I think, um, you know, not trying to use things that are too complicated, but for example, Ah, Basil, insulin is a basil insulin and trying a new basil, insulin and somebody while it can be intimidating because you haven't used that one before, it's pretty similar to using another one. Um, trying these continuous glucose monitors talking thio the reps for these device company. They can come in and give you little tutorials on how to use them and and how to download them in your clinic and that sort of thing. Um, but I realized that time is of the essence, and I think that is the biggest barrier for primary care. Yes, thank you. That was really, really helpful. Hopefully, people are able to sort of put that into practice and really see good results. So thank you very much. Thank you. We are going to go toe lunch now, but before everybody leaves, I have a few reminders. Make sure that you visit the exhibit halls. Also, we have a scavenger hunt going on with the exhibit halls to pay attention to that and then starting at 12. So in about one minute or a couple minutes, we have Dr Dan Einhorn presenting, um, sponsored program, which is not CMI, but for your own enrichment. Talking about the library to device. So if you want, you can navigate over there. Otherwise, we will meet back at 12 45 to meet with a panel of so specialists to talk about some of the complications of diabetes, so we'll see you soon.
