Supply and Demand

Improved patient education and access to care are clearly the way to go as diabetes reaches epidemic proportions.

| Jan 21, 2009

The treatment of diabetes has come a long way since Dr. Elliot Joslin wrote The Treatment of Diabetes Mellitus in 1916. But Dr. Joslin's idea that diet, exercise, and insulin (when it became available as therapy in 1922) are the keys to managing diabetes remains true today. This doesn't mean that diabetes is not a complex illness requiring ongoing education and individualized care. People with diabetes benefit greatly from the services of a team of health care professionals including a certified diabetes educator and an endocrinologist--a doctor who specializes in treating disorders of the endocrine system.

Unfortunately, there is a shortage of endocrinologists and certified diabetes educators in the United States. According to the ABIM (American Board of Internal Medicine), there are a total of 6085 board certified endocrinologists in the US, and the AADE (American Association of Diabetes Educators) places the current workforce of CDE's at approximately 20,000. Diabetes is a great wall of water and the current health care system is a cork in the dam, struggling to hold back the surging water.  

The shortage of diabetes experts is partly due to the history of the specialty, says Dr. Colwell, MD, PhD, a specialist in the field of diabetes who retired this year at age 80. When Dr. Colwell became a doctor in the 1950's, endocrinologists focused on treating thyroid and adrenal issues. It wasn't until the 1960's and 70's that diabetes was placed under the umbrella of endocrinology. Dr. Colwell explained that the shortage is also due to the nature of the business: "`endocrinology is a time-consuming specialty (the average visit is 45 minutes compared to 15 minutes for a principal care provider visit), it's tricky because hypoglycemia increases the risk of malpractice suits; and there is not enough funding. "

"Restrictions began in the 1990's," Kim Higgins, RN, CDE says. "The recommendation was to promote PCP (Primary Care Physicians are capable of handling a variety of health related problems.) care for all. At that time there was talk of an 8% per year reduction of funding to endocrinology specialties." The total number of fellows enrolled in endocrine training programs declined from 459 in 1995 to 393 in 1999. This 14.4% decline was similar to the overall decline in all internal medicine subspecialty training programs (1). The good news is that there is a current increase of endocrinologists entering the workforce. Bryan Campbell, Director of Public and Media Relations for the American Association of Clinical Endocrinologists says, "There are waiting lists for residency programs, meaning more people want to take them than slots are available." However, the demand will continue to rise as many endocrinologists over 50-years-old retire in the next decade.

The increase in demand stems from a variety of root causes. The NAMCS (National Ambulatory Medical Care Survey) indicates that there were twice as many visits to endocrinologists in 1996-1998 as in 1993-1995 (2). This could be attributed to the increase in diabetes diagnoses, as well as overall patient awareness. In 1993, results of the groundbreaking DCCT study were released that showed a drastic reduction in complications with tight blood glucose management. Based on the DCCT findings, education programs were created that focused on tight glucose control. In Charleston, SC Dr. Colwell designed a diabetes program called IDEAL (Intensive, Diabetes, Education, Awareness, Lifestyle) at The Medical University of South Carolina where he was the Diabetes Center's Medical Director. Patients were managed by a team of physician specialists, nurse clinicians, counselors and dietitians. In-depth assessment, teaching and day-to-day management were stressed. This team approach provided patients a well rounded support system.

Programs such as these that emphasize patient education are ideal. Recent clinical trials have shown that it is possible to prevent or delay the onset of type 2 diabetes with education. When type 2's work with an endocrinologist; studies have shown that they are more likely to get a diabetes educator referral. According to an online survey commissioned by the American Association of Diabetes Educators, patients with type 2 who have seen a diabetes educator are more positive about their knowledge of diabetes management and feel more confident about a healthy, balanced diet than patients who have not worked with one (3). However, the average wait time to get an appointment with an endocrinologist is 3 to 9 months, longer than it is for other physicians (4). Currently, 80-90% of diabetics are handled by primary care doctors, many who don't have the time or the resources to educate their patients about diabetes care. So, the question for the future of diabetes care is how to encourage tight blood glucose control in settings outside endocrinology offices.

Certified diabetes educators would seem to be the answer to this problem. The mission of CDE's is to act as the link between the doctor and patient, to teach skills to improve a patient's health, and work to get the patient motivated. Numerous studies show that diabetes educators have a very positive effect on patient's A1c's. However, the approximately 20,000 registered diabetes educators are too small to meet the demand.

Reasons for the shortage of educators are varied. Lyndsay Riffe, CDE says, "To become a CDE, you need two years, and over 1000 hours of experience specifically with diabetes management. Getting the experience can be difficult since a lot of employers require the candidate to already be credentialed. Therefore, it can be difficult for the aspiring CDE to get the necessary hours when they can't get their foot in the door. Second, poor reimbursement for diabetes education equals smaller budget for diabetes educators, and finally, it is a notoriously tough exam to pass."

Geographic proximity to diabetes educators is another challenge to diabetes management. According to U.S. News & World Report, the top hospitals for endocrinology are clustered in the North while the majority of people living with diabetes are in the South. (Nine out of sixteen states in the south region have the highest percentile of diabetes including Alabama, Florida, Georgia, Kentucky, Louisiana, South Carolina, Tennessee, Texas and West Virginia.) The following are the U.S. News & World Report's top five endocrinology hospitals:

  • Mayo Clinic in Rochester, MN
  • Massachusetts General, Boston, MA
  • Johns Hopkins, Baltimore, MD
  • University of California, San Francisco, CA
  • New York Presbyterian University Hospital of Columbia and Cornell, New York, NY  

Sometimes it takes a hurricane to build a stronger levee. For people with diabetes, education, diet, medication and exercise are the tools that keep complications from flooding our bodies. Because of the disparity in supply and demand, endocrinologists can no longer treat their patients with the traditional office model. According to Dr. Colwell, "It has to be a volume solution."

Solutions for the future will require a variety of changes to both patient education and access to care. As the link between the doctor and patient, Certified Diabetes Educators are an imperative component in successful management. Resources such as:

Solutions for the Future:

Patient Education:

  •  Better Diabetes Care is a website that was created by the NDEP (National Diabetes Education Program) with a long-term goal of comprehensive systems change for diabetes management.
  •  Web-based patient monitoring/education: patients can upload data onto secure websites that can be accessed and evaluated by endocrinology practices. Some endocrinologists such as Dr. J. Joseph Pendergast, an endocrinologist in Palo Alto, CA says, "There are only two options. Either massively increase the number of endocrinologists in the world, which isn't going to happen, or use technology to expand what we can do." (4) His education videos can be seen at:
  •  Primary Care: cluster diabetes appointments into one day develop and train staff to work with type 2 patients.
  •  Encourage group education; management centers such as Weight Watchers are often more effective at helping people lose weight.

Access to Care:

  • There is increasing interest in the field of diabetes education. There is a "Grass-roots initiative to train" Kim Higgins says about a push in California to promote diabetes educator programs across the state. The San Francisco Bay Area Association of Diabetes Educators was formed in 1985 with the goal of advancing diabetes education. The membership offers classes for healthcare professionals, lecture and interactive training for nurses, dietitians, pharmacists, PA's, NP's and anyone else who would like to learn more about diabetes. The website for the SFBAADE is
  •  Increased training and recruitment for diabetes educators.
  •  Team approach-collaborative, multidisciplinary teams to empower patients' self-management. Team care and diabetes self-management training have been proven to yield positive results. Clustering doctor visits to a single day.
  •  CDE's in primary care and non-traditional offices- Lyndsay Riffe says, "Recently I have seen job postings targeting diabetes education in the primary care setting which I think is a great approach and well needed." Non-traditional settings for educators could include community based wellness centers and retail clinics.
  •  Reform the process of CDE certification and compensation- The AADE is working to pass legislation that would allow Medicare to recognize CDE's as providers.
  •  Marketing efforts-Increase awareness of diabetes education benefits.
  •  Increase educator referrals from PCP offices.

As a pioneer in diabetes management, Dr. Joslin understood the importance of patient education. He dedicated his entire life to improving the health of his patients. Diet, insulin and exercise are still the foundations for good blood sugar control. As diabetes diagnoses continue to increase, the pressure for change will mount, and the demand for improved care will inspire change. We may be in crisis mode today, but improved patient education and access to care are clearly the way to go.  



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Categories: A1c Test, Blood Glucose, Blood Sugar, Diabetes, Diabetes, Endocrinology, Hospital Care, Insulin, Losing weight, Low Blood Sugar, Type 2 Issues

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Posted by krosetank on 30 January 2009

I totally agree with all the items mentioned in this article and would like to highlight two of the Solutions for the Future that I have been involved in... 1- encouraging group education/ support groups and 2- diabetes self-management training programs. As a type-1 diabetic for 13 years I have lived much of the diabetes care systems and agree that they are lacking. For the past 2 years I have been involved with a healthy cooking and eating support group called THE SUPPERS PROGRAM at or This past fall we started a group for type-2 diabetics and next week will add a group for type-1s. We meet once a week to cook delicious vegetables, lean proteins, healthy fats as we explore new recipes. We then eat at the table together and share our struggles, brainstorm solutions, problem solve, discuss blood sugar chemistry and the effects of carbs on our brains, cravings, moods and bodies. We have seen amazing results and progress with our participants as most have extremely little understanding of their disease and are hungry for real life experience and knowledge in how to cook, exercise and progress towards a more healthy life style. SUPPERS is a non-profit organization and this program is free to users except for the cost of groceries, about $5 per meal. What a deal! Right now we are located in Princeton, NJ but will soon be expanding to other locations in NJ. For the past 2 weeks I have been training as a Peer Leader in the Stanford Chronic Disease Self-Management Program with the goal of teaching 6-week support groups to others living with chronic diseases. This is a hands-on participatory program where participants learn how to effectively set out Action Plans to accomplish goals for healthy eating, exercising, and managing their healthcare. the program is being taught by the Dept. of Health- Office of Aging and Community Education in Trenton, NJ. I am not paid for any of these support group activities... they are all volunteer as helping others struggling with their disease, helps me cope and learn to live with mine! I looked into training as a CDE but am neither a dietician nor a nurse... I am trained as a BS biologist and MS economist before getting diabetes, and at the age of 51 am not looking to go back to school to get those degrees. However, I am passionate about diabetes education and have been looking for ways to get involved and help others. My solution thus far has been to go outside of the existing medical community with programs. It is my hope that more and more doctors will refer their diabetes patients to both the SUPPERS and Stanford programs. Karen Tank

Posted by chanson on 2 February 2009

Great article. Well presented and clear, with plenty of detail to support the major themes. Thank you. Carl Hanson

Posted by jimmysdevoted on 23 February 2009

It is time for reorm and to get a standard of care enforced. Being a diabetic, Allied health worker and allopathic doctor who underwent training as a Diabetes Educator but was NOT allowed to take the exam. It is time to recognize that you neednt be a nurse to be a Diabetes Educator. Montana recognizes Lay educators. If they can do it and have agreate compliance group why not take that as an example.

Posted by pamkram on 23 February 2009

As a long time type 1 diabetic who has learned many of the necessary changes in management by trial and error on my own, I have long wished to be a CDE. At a mature age I went back to nursing school, went to the preparation classes to become a CDE taught by Kim Higgins who commented in this article, have done 2 years of hospital nursing with the hope to be fully prepared to begin to enter the field of diabetes education, only to find the CDE requirements are beyond strict they apparently intend to keep the numbers of CDE's down. Having worked in a law school for nearly two decades and then having gone back to nursing school, you don't get to practice your profession until you get your license after studying and doing internships. The requirements for being eligible to take the CDE exam are such that you must do two years and 1000 hours at prevailing wages for a CDE. That essentially means you have to be one before you can apply to be one???? I know numerous other qualified people wanting to get into the field who are as frustrated as I am. We know the need is there and we want to be out in the field helping those with "borderline" or prediabetes delay onset with life style changes. Although having diabetes certainly should not be a requirement, but those of us who do have it and have lived with it are among the best to share information to help others make the necessary life style changes and prevent the peripheral problems that could lie ahead without intervention. If there are others who share in what I have said we need to work together to address the need for change in the NBCDE approach and work toward creating training centers so interested and appropriately trained persons can get into the field and get out there to help make improvements in education for the many undiagnosed, as well as struggling, diabetics regardless of type 1 or 2.

Posted by Anonymous on 24 February 2009

pamkram is right. I am an adult nurse practitioner who also has experience in adult education. I teach diabetes self-management education classes on a monthly basis as well as survival and refresher skills for inpatients newly diagnosed and those admitted for complications. I cannot get enough practice hours to qualify for the exam even though teaching (and teaching how to live with diabetes) is a passion.

Posted by cardiomomof4 on 24 February 2009

I thought I was alone in thinking the qualifications to take the CDE test were ridiculous. I have been a nurse for 33 years and an exercise physiologist for 4 years. I have worked with diabetics for many years in hospital nursing and Cardiac Rehab as well as a hospital-based fitness and wellness center. My position now is as a diabetes educator but I can't take the test to say I am "certified" until I work in it for 2 years and log 1000 patient hours. I don't know of any other certification in nursing that requires you to work in it for that long before you can take the test. We all know diabetes is increasing every day. It's time to look at these requirements and at least allow people to certify who are working in the field.

Posted by Mistymax on 28 February 2009

I have been a CDE for over five years, having completed the arduous process described in the article. Since earning the credential, I have lost two jobs because of the closing of two hospitals. I currently work in an outpatient diabetes center in a large urban hospital, but there are a large number of no call/no show patients. They do get reminder phone calls. Our services are greatly needed, and yet many patients do not avail themselves of this opportunity.

Furthermore my hours were just cut at my per diem job at another hospital. Here too there are plenty of patients in need, but perhaps they do not realize it. Last week there were three pregnant type 2 patients on my schedule, all were no shows. How do we get patients to keep their appointments--any suggestions?

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