Expert Blog

Challenges in Diabetes Education: Why So Much Confusion?

Irl B. Hirsch, MD

While traveling to the American College of Physicians meeting last week in San Diego, I read an interesting article sent to me from the Corpus Christi Caller-Times by Dr. Stephen Ponder. The article examined the reasons why a recently published study concluded that doctors who recently completed their training knew so little about diabetes. Dr. Ponder’s article focused on our current education model for chronic disease in general and why they are ineffective in training physicians to care for patients with diabetes.

The following day, I was asked to lead two identical “workshops” titled “Insulin For Internists.” A total of 900 general internists participated in an interactive case-based session focusing on common situations in the management of type 2 diabetes. My conclusions from these sessions were as follows:

  1. The group as a whole was extremely enthusiastic to learn more about insulin therapy.
  2. In general, basic principles of insulin therapy were not well understood. This included everything from how to dose basal insulin, to how and when to initiate prandial insulin, to how to interpret a blood glucose log book. Practical issues such as how to pick the right size insulin pen needle or which size insulin syringe to use was also new information.
  3. Dozens of participants came up to me well after the session thanking me and wanting more information about this topic.

Although I don’t have accurate data on this point, it seemed to me that internists of all ages were there—from those that have recently graduated from their training to those who are about to retire. I continued to consider Dr. Ponder’s comments about the recently published study, which was of a more general topic than simply the best use of insulin. The study focused on young physicians while my audience seemed to include a much more diverse group. But the general observation is the same. 

For insulin therapy, why is there so much confusion? Many reasons have been mentioned by many people: poor training environment often with a difficult population for learning this therapy, lack of resources and infrastructure for insulin therapy after training, intimidation due to lack of experience, and too many choices in terms of insulin and all of the paraphernalia associated with its use. While many physicians can rely on their nurses to manage most of the insulin therapy, this resource is often not available in primary care, meaning that much of the teaching and management is dependent on the knowledge of the physician.

The good news (to me anyway) is that the physicians I interacted with were excited about learning more and, to a person, wanted to do a better job. Solutions for this problem will need to focus on physicians and physicians-in-training of all ages. How to best do this is not simple since our traditional medical education has not been as effective as they could be. Nevertheless, I am enthusiastic that we can develop teaching tools to improve insulin management for many primary care physicians. If you have thoughts or ideas about how we might solve this problem, please share them here.