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Steve: This is Steve Freed. We’re here at the American Diabetes Association 77th Scientific Studies and we are here to present to you some really exciting interviews with some of the top endocrinologists around the world. And we have a very special guest, Linda Siminerio. Maybe you can start off and tell us a little bit about what you do.
Dr. Siminerio: I am a professor of medicine and nursing at the University of Pittsburgh. I’m here at this ADA meeting in my position as chair of the national diabetes education program. And I’ve been actively involved clinically and in research in looking at self-management and healthcare delivery models for diabetes care.
Steve: the first question I want to ask you about diabetes management is how long have you been doing this?
Dr. Siminerio: 45 years
Steve: Let’s go back to your first year.
Dr. Siminerio: Oh, my goodness. Well, it’s so different. And that’s kind of what we were talking about.
Steve: What’s changed?
Dr. Siminerio: Everything, When I think about 1972, we didn’t have blood glucose monitoring. I remember going to camp and we would stay up all night with the children just feel their foreheads to see if they were perspiring from hyperglycemia. We had rows of test tubes for testing urine because we didn’t have blood glucose monitoring. We always had a station wagon there so if somebody came and was going into DKA and we had to get them to the hospital for severe hyperglycemia hat we could rush them to the hospital, that was 1972 and 1973. What’s changed? We didn’t have the evidence. We kind of thought that good glucose control prevented complications, but we didn’t have the science. We didn’t know then that diabetes could be prevented or delayed. We didn’t have a diabetes prevention program and our approach to how we work with patients, I guess wasn’t as effective as we thought it was going to be. So, I’m here at this meeting to just talk about how we need to learn strategies to have a more patient-centered approach.
Steve: Your presentations, “Shared decision making, why does this matter and what do we know?” and “Shared decision making: then and now,” which is what we were basically talking about. You know, 20 years of diabetes translation. So if you’re sitting with a patient back in 1972, we know that your conversation would be, very basic and probably having to teach the patient a lot more, because with technology now it makes it a lot easier. What would you say are the major changes?
Dr. Siminerio: You’re absolutely right. We had a lot of skills teaching to do. I think it’s still burdensome, but it was certainly more invasive and harder to do back then. But the way we did it, and I’m speaking of physicians that I worked with, nurses, dieticians, whomever was working with the patient, we had this notion that if we told them to do it, that’s what they were going to do. So, if you saw a patient and said, “you know you can’t eat donuts anymore” we just thought our advice meant everything and that everyone went home and did exactly what we asked them to do or told them to do. And over the years we realized, especially through these big studies, we learned a lot in the studies. One is that we needed a team. It takes a village to help people with diabetes, it can’t just be one healthcare provider. And that we needed to understand what the person’s personal goals were and what their challenges were.
Steve: So, it’s more patient-centered? Is that the major difference?
Dr. Siminerio: Absolutely. That’s the big thing now, patient-centered, quality, patient at the center of the team and that’s the way it should be. I don’t go home with the patients, they live with it. And to be honest 98% of diabetes care is managed by the patient. They see us 4, maybe 6 times a year, which is unusual to think about all the hours they are doing it on their own. It’s got to be their decision.
Steve: If you had to pick one piece of technology that has made the most difference in the care of a person with diabetes what would you say that technology would be?
Dr. Siminerio: Continuous blood glucose monitoring
Steve: More so than the blood glucose monitor?
Dr. Siminerio: Oh gosh, that’s a tough question, because at the time that was groundbreaking.
Steve: If you had the two together right now your decision would be CGM?
Dr. Siminerio: Yeah. Well, actually I will give an answer that might be broader than that. Probably whenever we began using and understanding HbA1c levels. Because before we knew about HbA1c levels, we had no idea. And that’s what led us to have the ability to do the studies that we did. Without A1c, we had no parameters at all.
Steve: It’s interesting because if go back to the DCCT trials and when you add the A1c and the expression “comprehensive tight control” it made a huge difference in how we treat patients, would you agree with that?
Dr. Siminerio: Yes, and without the A1c it would have been really hard to do the DCCT. I guess that to me, was one of the sentinel moments is when A1c was made available.
Steve: What do you suggest? You sit with a patent, you’ve got their blood results, you’ve got their triglycerides…cholesterol…LDL…A1C…fasting blood sugar…blood pressure. It’s five or six pages, you can’t explain everything on there.
Dr. Siminerio: No, but we try to.
Steve: What do you find are the most important couple of things?
Dr. Siminerio: Getting to know the patient. And that’s what shared decision making is all about. You know, I’ve got some colleagues who had this epiphany that, “Oh my gosh this is the way we should be approaching patients.” We feel like we’ve got do all of these things and I always cite a study that in follow-up visit the number of prescriptions and recommendations that the patient has to absorb that the provider is giving to that patient is phenomenal. Then you leave there and it’s overwhelming. I think we need to start a conversation with, “What’s the biggest concern for you? What about your diabetes has been challenging?” Just to have an open-ended question to really gain an insight of what the patient is there for, we just assume we know.
Steve: You have been dealing with diabetic patients for many years, type 1 and type 2, now let’s take a different look at it and that’s prediabetes…now you’re sitting with a prediabetic. Is it any different than sitting with a person with type 2 diabetes?
Dr. Siminerio: Yes. Because I think in many cases people have a hard time accepting that they are at risk. And we’re still not there, where they’re getting the message from all their providers, that, “Oh, don’t worry about this. You have a touch of sugar, we’ll just keep an eye on this” when we really should be aggressively preventing it, but sometimes the patient or the person who is at risk for diabetes doesn’t get that message. There again, is shared-decision making and explaining this is why this is important now, here’s the benefits and here’s the risks.
Steve: With 90 – 100 million people with prediabetes it’s important that we discover who those people are, what do you think is the best way to find these people so you can explain to them what their risk values are and how they can change that?
Dr. Siminerio: As a first step, again it’s about communication. It’s going to be very hard to get people out on the street and say, “let’s take you in for a test.” That doesn’t work. At least at the first layer, we need to make sure that when patients do go to the doctor and they get their routine lab work done that there is a communication. I think it’s about how we communicate it. This is a glucose result. You’re at risk of diabetes, and here again are the benefits of starting to attend to this, these are the risks. Helping people to think through that, not this is borderline diabetes or a “touch of sugar.”
Steve: So you think it’s important that they understand and that really comes from the education. Because right now they don’t have a clue.
Dr. Siminerio: They don’t have a clue. And I don’t mean education not just for people who are at risk or people with diabetes. But I think education is important at a community level, so those who are making policies or doing environmental things understand these risks and providers. When you’re a provider who says you have the borderline diabetes, it’s just not appropriate anymore. We have a condition and it’s called prediabetes.
Steve: What do you want people to take away from your presentations here at ADA?
Dr. Siminerio: To make sure that we are current on the evidence. The first step in shared-decision making is making sure that the patient has received information on their condition and that it’s evidence based and it’s not your own personal idea. The next step is deliberation. We need to start listening to the patient, “what are your goals?” We have to listen to their goals, what their priorities are. We ask people with diabetes to do a lot of things, we bombard them. They have to prioritize and that’s why it’s important for them to deliberate what they’re going to prioritize on, what they can do, not what we say they should do. what they’re able to do at that time and work from there so they can make that informed decision.
Steve: Have you ever put together a list of tips to give to providers to help them through that?
Dr. Siminerio: I have colleagues that have worked on this. One tip would be the use of decision aides. It’s an easy way for them to understand the information, I’ll use A1c as an example. “What does an A1c mean?” Some people know, “My doctor told me that my A1c should be this.” They don’t know what that is, we have to explain to them in a user-friendly way what an A1c is. Then what are the benefits and risks, a colorful or graphic way, show them this is what happens if you do this or if you don’t do this. Then letting patients deliberate on that and decide what they’re going to do to manage it.
Steve: If you could have any number that you wanted, what would you like your A1c to be?
Dr. Siminerio: 5.5%
Steve: That’s curious because I get all different numbers, you know what is normal? We have a hard time defining what is normal.
Dr. Siminerio: For patients though, it’s different and depends on who the person is and what they’re indications are.