Melissa Young, MD

Diabetes mellitus is an increasingly common disease in the United States and is one of the leading causes of death. It is more than just elevated glucose levels. 

 mellitus, as part of the metabolic syndrome, is often accompanied by obesity, hyperlipidemia and hypertension. It is a complex metabolic disease and is considered a heart disease equivalent.

Diabetes has such a huge impact on cardiovascular health that over a decade ago, the FDA started requiring cardiovascular outcomes data for any new antihyperglycemic drugs. While we have known for many years that improved glycemic control decreased cardiovascular risk, we did not have specific data that any particular drug decreased the incidence of cardiac morbidity or mortality. Now, several newer diabetes drugs have been shown to decrease the risk of either hospitalization due to cardiac events or cardiac death. This has changed the way pharmaceutical companies have been marketing their drugs and it has changed the way people look at diabetes.

People other than endocrinologists, that is. Endocrinologists have always treated diabetes as a cardiometabolic disease. As a matter of fact, the American Diabetes Association’s (ADA) 

includes a whole section on managing cardiac risk. For years, endocrinologists have been treating hyperlipidemia and hypertension as part and parcel of their diabetes management.

Ask an endocrinologist how many times they have started a patient on a statin after that patient had been told by other physicians that his cholesterol is “normal”. Or worse, how often another physician stops the patient’s statin because his “level is good”. Too many. I’ve even had patients refuse statin therapy because their 

Patients with diabetes comprise a large portion of the population that endocrinologists see. There is now a push to create a new specialty, a new fellowship in cardiometabolic medicine. Most endocrinologists I’ve communicated with are asking “why?” Why do we need this new separate fellowship? Isn’t this what we’ve been doing all along?

If the argument is that there aren’t enough endocrinologists to go around (see my earlier post), then the answer isn’t training more people in a different specialty, the answer is creating more endocrinologists. The answer is making endocrinology more attractive to medical students and residents.

Why go into endocrinology when our healthcare system rewards people for procedures and not cognitive work? It is my hope that the new CMS physician fee schedule and the new visit codes will correct some of this. In addition, we need more funding for endocrinology fellowship programs.

Only about 300 new endocrinologists complete training each year, meanwhile 1.5 million new cases of diabetes are diagnosed in the same time frame. Wouldn’t it save the healthcare system millions of dollars to better compensate endocrinologists for managing diabetes and its comorbidities in order to decrease the need for cardiac testing and procedures and to prevent hospitalizations for cardiac events?

Diabetes is definitely a cardiometabolic disease. But we don’t need a whole other specialty to start managing it. Endocrinologists have been at the front line of this all along.

Articles

Melissa Young, MD, offers perspective on the push to create cardiometabolic fellowships versus making endocrinology a more desirable field. 

Cardiometabolic Health Fellowships: The Answer or Part of the Problem?

While we are all still dealing with the COVID-19 pandemic, we must not forget that patients with diabetes are also at risk of other preventable infections. Flu season will be upon us soon and our patients should be getting their vaccines.

It is recommended that those with diabetes receive a flu vaccine annually. The Centers for Disease Control also recommends that people with diabetes receive the pneumococcal vaccines PCV13 and PPSV23, the vaccines against hepatitis B and Herpes Zoster (shingles) and the Tdap vaccine (against tetanus, diphtheria and whooping cough).

Unfortunately, according to the National Center for Health Statistics, people with diabetes are not receiving the vaccines that the CDC recommends. In 2015, only 61.6% of adults with diabetes had received a flu vaccine. Only about half had received a pneumococcal vaccine and less than a fifth (17.1%) had had the 3 doses of the hepatitis B vaccine. And of those over the age of 60, just over a quarter (27.2%) had received a shingles vaccine.

People with diabetes, even when well-managed, are more likely to have complications of infections than those without diabetes. Furthermore, when patients with diabetes get an infection, it can lead to diabetic ketoacidosis. It is, therefore, imperative that we, as physicians, educate our patients on the importance of vaccines.

We need to dispel their doubts and suspicions about the dangers or inefficacy of vaccines.

There is a lot of misinformation on social media and other internet sites. We need to direct patients to other educational resources. The CDC has patient information regarding vaccines. The Cleveland Clinic Journal of Medicine had a nice commentary last year on how to respond to flu vaccine doubters.

Every year, thousands of people are hospitalized with influenza and pneumonia. In addition to the detriment that causes the individuals, it also poses a challenge to the health care system and utilizes significant health care resources. In a year when those resources are already being stretched thin, it is of utmost importance this year to help our patients prevent illness and prevent hospitalizations and emergency room visits.

An endocrinologist from New Jersey discusses the importance of flu shots in high-risk diabetic patients.

Melissa Young, MD: The Importance of Flu Shots in High Risk Diabetics

We all want our patients to receive the best care possible.

Patients with diabetes, due to potential complications and the number of organs that can be affected, really need a team of doctors and other health care providers helping them manage their disease. But should every patient with diabetes have an endocrinologist?

I suppose in an ideal world where there is no shortage of endocrinologists and where there are fewer people with diabetes, it would be beneficial for everyone to have a fellowship-trained specialist as part of that health care team. In reality, we live in a country with approximately 34 million diabetes and about 6500 endocrinologists, according to CDC statistics, and because of this, that just can’t happen.

Assuming all 6500 endocrinologists are actively practicing and seeing patients 365 days a year, we would all need to see 14-15 patients with diabetes a day just to see them once a year. And many patients, if not most, need to be seen every 3 months or so.

Add that to the fact that not all endocrinologists are in clinical practice, some are in research or academia. And there are other patients that need endocrinologists—such as, those with pituitary, adrenal, and thyroid disease. Clearly, there have to be some patients with diabetes that need to be managed by someone else.

So, who is that someone else? For patients with type 2 diabetes, I believe the perfect place to start is the primary care physician.

Given the incidence of diabetes, every internal medicine and family medicine resident should have extensive training in diabetes management. In my opinion, too much residency time is spent in hospitals and not enough time is spent in outpatient clinics.

Everyone knows what to do about acute chest pain but few know what to prescribe after metformin and a sulfonylurea. Primary care physicians should be armed with the knowledge they need to educate their patients about the complications of diabetes (how to avoid them and how to monitor for them) and about the medications available or most appropriate for them.

Much of diabetes management is lifestyle intervention. Counseling on diet and physical activity. I realize that PCPs’ time is limited, and therefore referral to diabetes educators and nutritionists should be done early, ideally upon diagnosis. Patients should be encouraged to go back for “refreshers” from time to time. Medicare pays for 12 hours of initial education and 2 hours annually after that. Sadly, it remains an underutilized management tool.

Granted, not every physician has access to good educators, but even when they do, they often neglect to refer to them. A good diabetes educator can be of immense help to a primary care physician, as patients will sometimes divulge things to them that they would not normally share with their doctor.

Endocrinologists need to be available to patients with disorders that are beyond the scope of most other physicians—ie, Graves’ disease, adrenal insufficiency, type 1 diabetes, hypopituitarism. While type 2 diabetes may be our bread and butter simply due to patient volume, most patients with uncomplicated type 2 diabetes can and should be managed by their PCPs.

An endocrinologist from New Jersey reflects on whether or not the management of type 2 diabetes should fall under the umbrella of primary care specialists rather than endocrinologists as diabetes become more prevalent. 

Melissa Young, MD: Should Primary Care be More Involved in Diabetes Management?

These have been unprecedented times. The coronavirus disease 2019 (COVID-19) pandemic is something none of us have ever experienced. We learn more about the virus and the disease each day and, as new information comes in, recommendations change.

So, it becomes very difficult when patients ask us for advice, particularly about things that are as yet hypothetical. A frequent question that I get is “can I go back to work?”, and I am getting that question more and more as schools prepare to reopen and my patients who are teachers and other school employees are concerned about their safety.

I am not an infectious disease specialist. Nor am I an epidemiologist. I don’t consider myself a front-liner. I am an endocrinologist. And my first-hand experience with COVID-19 has been limited. But, I do know diabetes, and I know that people with diabetes are at high risk of more serious complications of infections, not just from SARS-CoV-2 but from all infections. So when my patients ask me about returning to work, I take that seriously.

Don’t misunderstand me. I have never considered diabetes to be a disability (although some complications thereof can be). However, given the statistics surrounding this current health emergency, I am much more inclined to tell patients’ employers that these people need special consideration. I have had people argue that we can’t excuse every person with diabetes from work.

What about nurses, physicians, EMTs, police officers? Agreed. There are some professions that require people to be physically present and there is no getting around that. Hopefully, those people are being provided with the proper protective gear (many of my teachers are told they have to provide their own) to lessen their chances of exposure. What if someone has a job that can be done remotely or can be otherwise modified to decrease one’s risk, then isn’t it in everyone’s best interest to protect their health and well-being?

My problem, however, with answering my teacher-patients’ question is that the schools don’t even have concrete plans in place yet. So, I can’t give my patients definitive answers. Here is what I tell them I would need to know in order to give them specific guidance:

How many students do you usually have in your room? How big is the classroom?How old are your students?

If masks are required, will they be able to keep them on and wear them correctly?

Will the students be changing classrooms, and where will you be when the student body descends upon the hallways?

Can you keep a physical distance from your students? Do you ever have to touch the students (I have preschool teachers who have to hold students' hands, clean them, etc.)?

What is the school doing about lunch period? Where are you during lunch?

Can you do part or all of your job remotely?

In addition to the questions above, I also wonder what the schools will do if a student or a staff member gets a COVID-19 infection? Will the school close? Do the class and the teacher need to quarantine for 14 days? What kind of disruption will ensue?

I believe that if the class size is small, if the teacher can maintain a safe distance from the students, and if personal protective equipment is provided, then teachers and other school employees may and should return to work. If, on the other hand, precautions cannot be maintained, then it is in the best interest of the teachers as well as their students, that education be provided remotely.

It is a truly difficult situation. I have two high schoolers myself, and I firmly believe that they did not obtain the education they were supposed to during their last marking period. They need a structured environment and interaction with their teachers and their classmates, but I also want them to be safe and healthy. I do not have all the answers, perhaps I don’t have any. I certainly have questions.



Melissa Young, MD, FACE, FACP, is a practicing endocrinologist with

Mid Atlantic Diabetes and Endocrinology Associates

based in New Jersey. This piece reflects the author’s views and

not necessarily those of the publication.

For more information on contributing to EndocrinologyNetwork.Com, 

Melissa Young, MD, discusses how she addresses questions from patients related to returning to work or back to school during the ongoing COVID-19 pandemic. 

Author | Melissa Young, MD

Articles

Cardiometabolic Health Fellowships: The Answer or Part of the Problem?

Melissa Young, MD: The Importance of Flu Shots in High Risk Diabetics

Melissa Young, MD: Should Primary Care be More Involved in Diabetes Management?

Discussing Returns to School, Work for Diabetics During COVID-19