By. Dr. Walter M. Bortz, II
Some of the happiest and saddest moments of my full life are the days when I volunteer in one of the nearby community free clinics. This commitment gives me pleasure, as I may be filling an otherwise unfilled need. My down days trouble me by the content of my experiences.
A typical patient is a rotund thirty-five-year-old Hispanic mother with four overweight kids. She has come in for one purpose, and that is to receive free drug samples for her Type 2 diabetes. She even brings in a shopping bag in anticipation of filling it with outdated pills that happen to be in the supply closet.
Predictably, her hemoglobin A1C levels are terrible despite or because of the pills. I say because of the pills because she, like millions exactly like her, defaults her care to a drug with no attention whatsoever to physical activity or diet. In my view, her future is full of dark omens; as is that of her kids—seeing her accumulated neglect.
As I do a brief inventory of her knowledge about her disease, ignorance abounds. And of course language barriers make such communication even more difficult. Effectively, her diabetes IQ is barely detectable. Sadly, in her view I and the clinic am in charge of her sugar levels. And she recognizes no personal responsibility.
I mention this fact of life to illustrate my major cause right now, which is health illiteracy. In my view health illiteracy is the ultimate cause of more deaths than all the traditional major villains of heart disease, cancer and stroke combined. Such a pervasive ignorance underlies the neglect or contempt for self-care. The chic term for this psychological condition is “abandonment of the locus of control.”
In general, there is a universal public assumption that the medical profession is in charge of the collective well-being, and thereby able to mobilize a magic bullet to shoot whenever difficulties present. This is a forlorn and fatal miscasting. Virtually all the big killers are incurable. You never cure a heart attack or stroke, or rarely diabetes; we palliate. After the fall, Humpty Dumpty is never whole again, despite 2.7 trillion dollars each year in the effort.
Probably the best use of my time at the clinic would be to spend an hour or more with each patient with the intent of establishing a curriculum to understand the disease adequately, gradually building up knowledge. I would guess that maybe a five or six hour crash course might be a start, but even that modest investment in my and my patient’s time is not to be. And that is sad.
Enter the CDE—Certified Diabetes Educator. My admiration, respect, and commitment to the CDE are deeply felt. Some of you may recall that I dedicated my book, Diabetes Danger, to Certified Diabetes Educators because I feel that within their job description, philosophy and practice lies our best hope for addressing the diabetes epidemic.
The American Association of Diabetes Educators list 15,000 CDEs across the country. Roughly one per hundred medical doctors and one per 20,000 population. The principal reason behind this small supply is, guess what? Money!
The CDE’s pay is perhaps one quarter that of a physician. A survey of physicians’ incomes by Modern Physician magazine records that the average internist makes about $180,000 per year. The AADE reports that the CDE’s average pay is $65,000 per year. On average, she is 51 years of age and has spent 25 years in the healthcare arena—11 in diabetes specifically. Most hold college degrees; one third hold advanced degrees.
Several reports indicate that the involvement of the CDE results in a marked improvement in diabetes care—hemoglobin A1C levels are better. The inescapable result is an improvement in health care expenses, so that the cost-benefit relationship is clear.
The general issues surrounding the CDE’s role in disease prevention and management is very much a miniaturized version of what we are facing in the healthcare system in general in America. Professor Clayton Christiansen of the Harvard Business School asserts that one of the critical problems confronting our troubled profession is what he terms “overshoot.” He principally illustrates this with the abundance or superabundance of specialists and who care for conditions for which a far less polished professional would serve adequately. He feels that such an overshoot is a major characteristic of our bloated system—using a sledgehammer when a fly swatter would suffice.
For me, this strikes close to home. My medical training in general, and in diabetes in particular, has been exquisite—college, residency, fellowship, research, etc. I am really very overqualified for what I encounter in the community clinic. One of my favorite sayings is that of Sydney Brenner. His words: “You can’t know everything. You don’t need to know everything. Just enough.” How much is enough when caring for the average of our tens of millions of diabetics overflowing the system?
What is needed in the clinic is not me, but three or four CDEs. They will spend more time, communicate better, relate better and have better outcomes.
All of this takes a stronger focus on the floor of the House of Representatives in Washington as House Bill HR-2425 is debated. This is intended to provide provider status to the CDE. In the big picture the cost savings will be immense. I have lobbied my local representative and Speaker of the House Nancy Pelosi in support of this bill. I encourage any and all of you to push any buttons that you might have to push for the support and approval of HR-2425.
As a sports enthusiast, I’m always caught up in the hoopla connected with the choice of the MVP. I have cheered Joe Montana for example. But when it comes down to the MVP of diabetes my choice would not go to the doctor or even the endocrinologist, to the ICU, nor the dietitian, the exercise trainer, or to the pharmacy… particularly not to the pharmacy. My vote enthusiastically goes to the CDE as the MVP. It even sounds right—CDE … MVP, CDE…MVP.
Let’s hear it!
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