New Mexican–Style Care With a New York Accent

I am a native New Yorker, born and bred in New York. I grew up on Long Island and moved to Little Neck Queens in the early ’70s. I picked up and moved myself to Albuquerque, N.M., 7 years ago. Actually, most people ask me why I made that move. To quote a Lovelace Regional Diabetes Program brochure, “No one can beat us for our climate, our culture, our cuisine . . . and our shocking rate of diabetes!”

I went into nursing in my late 20s, later than most nurses I know. I had worked in a variety of places, owned a business, and then worked for an orthopedic surgeon as an office manager. His wife was a physician also, and for community service they would do physical exams for new people who were staying at the Salvation Army. As I assisted them with this, I became interested in learning more about medicine and decided to try nursing. I went back to college for an associate’s degree and then continued on eventually for a master’s degree in adult health from the State University of New York at Stony Brook, where I also got my nurse practitioner (NP) training. It took about 10 years because I was working full time and going to school.

I owned a luggage and leather repair shop in Great Neck, N.Y. I was sort of a “Ms. Fix It” for luggage and handbags. I learned all about fixing things and how luggage and handbags were made. (You would be amazed at the garbage used to put these expensive things together!) But ultimately, I sold it.

After a vacation cycling through New Mexico, I was so taken with the beautiful weather, the mountains, the desert, the people, the New Mexican and Native American cultures, and the incredible food (the only place to get green chile!). I thought, “Why not?” I knew I could get a job here because of the high incidence of diabetes.

I thought things would be a little bit slower here, but I have not found that to be the case. I keep very busy both in my office and out of it. My husband, whom I met in New Mexico but who is from Galveston, Tex., still thinks I have a lot of New York energy! I do miss some of the culture of New York, the concerts, shows, museums, Broadway, my football Giants, and all the different types of wonderful food.

Albuquerque is more like a small town when compared with the metropolitan New York area. I went from living in a tiny 3 1/2-room apartment in Queens to where I presently live, which is on a half-acre of land where I can plant fruit and vegetables and water them with the water from the irrigation ditch that runs through my backyard. I have an adobe house with brick floors, vigas, and kiva fireplaces. I don’t think I would have found that in New York.

To my surprise, I have met so many people who are now friends and medical colleagues who all come from somewhere other than New Mexico. This has made for interesting blending of people. There is a lot of history here, particularly in the Native American and Hispanic cultures. I have met people who tell me that they live on land that belonged to their families from as far back as the 1500s or 1600s. That is astounding to me!

The diabetes health professional community is a fairly close-knit group of people who are dedicated to trying to improve the quality of diabetes health care in all of New Mexico. The New Mexico Diabetes Advisory Council meets quarterly, and it is an opportunity for different health professionals from different medical groups and from different geographical areas to come together and share information and to work on projects. I have done some work with the state Department of Health as part of a mentorship program with rural health care centers to improve the delivery of diabetes care. There are areas of New Mexico that are very rural, and that is certainly a different experience for someone like me.

I had to learn a whole lot when I moved out here—I was a real gringo. The food was one of the biggest issues. I thought I had seen a wide range of different ethnic groups in New York, but the diet of many here in New Mexico is different from anything I had seen in New York.

There is truly a difference in terms of how to approach people of different cultures. I had to talk more slowly, explain things in different ways, understand something about beliefs regarding illness and health. I saw a fatalistic attitude in some people here that upset me, and I had to learn about it.

I still have so much more to learn, but I see such a variety of wonderful people every day who are willing to teach me about themselves and really don’t seem to mind that I am such a gringo. I definitely need to learn to speak Spanish, although the language I hear most often in New Mexico is “Spanglish.”

When I was completing my nursing degree, I worked for Health Insurance Plan of New York, the first health maintenance organization in New York. I had the opportunity to work with the NPs there who were doing a great deal of diabetes education and management. I found that I loved being able to incorporate nursing, counseling, patient education, and medical management and decided that I wanted to become an NP specializing in diabetes.

I have been extremely lucky in my career and have met some wonderful people who served as teachers but who also believed in me and gave me the opportunity to grow and develop. When I first became an NP, I wasn’t really sure how different my practice in diabetes would be. Most of the places I worked had not had much experience with any NPs, let alone one that specialized in diabetes. I was pretty much able to pave my own way and define my own role.

Being an NP in diabetes allows me to expand my role as a diabetes educator and truly treat the whole patient. In addition to the physical assessment and management of a patient’s diabetes, I manage many of the associated complications and some of the psychosocial issues.

In my position at Lovelace Health Systems, I work both in endocrinology and diabetes. Because all of our patients have primary care providers, I focus on diabetes-related medical management rather than primary care for my patients. In addition to my clinical role, I am the program coordinator for our ADA-recognized education program.

Sometimes the role of the diabetes NP feels a little schizophrenic between the pure “educator” role and the “NP” role. You do both roles, and sometimes you act more as a certified diabetes educator (CDE) and other times you are more of a medical manager. Whichever I’m doing, it is a fulfilling job in that it provides me with both opportunities and is always challenging.

I was one of the “founding members” of the Metropolitan New York Association of Diabetes Educators, which is a chapter of the American Association of Diabetes Educators (AADE). The CDE examination was first given in 1986, and those of us in the newly formed chapter all decided to take the exam that year because many of us had been practicing in diabetes education for several years already.

In addition to myself, we have seven nurses and dietitians who are also CDEs, and we have just hired another NP, CDE. We have a specialty clinic in our main site, but Lovelace has a number of satellite primary care clinics in Albuquerque and Santa Fe. Many of our diabetes educators travel to those clinics and provide diabetes education and care. It is a great way to incorporate diabetes education in the primary care setting and work closely with the primary care providers.

Although we are in a specialty clinic, our site is attached to a small hospital, and I also have the opportunity to manage patients’ diabetes in the in-patient setting, particularly when they have been admitted for bypass surgery, some other surgery, or some other acute problem affecting their diabetes.

I have been involved in diabetes care since 1984, and clearly the treatment of diabetes and the practice of medicine has changed dramatically since then. Just the availability of new antihyperglycemic agents has made the treatment of diabetes more complex but also much more exciting. In the past, it was sulfonylurea or insulin, period! Now we have many more choices.

Diabetes education has become a well-respected and essential part of diabetes care and a profession unto itself, and the CDE is really a very sought-after credential in diabetes—now that’s progress!

The concept of “team care’” has really evolved and in diabetes is definitely now a reality. Certainly the Diabetes Control and Complications Trial was a major impetus for that. I see much more emphasis on early detection and intervention to prevent diabetes complications now than in past years.

When a primary care provider refers a patient to me who is “at-risk” for diabetes instead of waiting until the situation becomes a crisis, I feel like we are making a difference and getting the word out. The focus on prevention, not only of the diabetes itself, but also of complications, has become more a part of treatment than ever before. I don’t hear the words “a touch of sugar” much anymore, and I now get to see patients when they have some glucose intolerance or mild elevation in their fasting blood glucose. I feel that we are able to intervene much earlier in the course of the disease because health care providers are more aware of prevention.

The recognition of the association between diabetes and cardiovascular disease has changed how aggressively we treat lipids and other cardiovascular risk factors. The fact that we are seeing many more clinical trials dealing with diabetes and associated complications is encouraging.

I am seeing more groups of diabetes experts getting together to “get the word out,” both to health care professionals and to patients. We are seeing an increased use of lay health advisors or community health advisors as diabetes educators in smaller, rural communities. Pharmacists are expanding their roles to become more involved, as are diabetes educators. Some pharmacists and advanced practice nurses now have prescriptive authority. What I have seen over the past number of years is a large movement of all health professionals to be involved in helping to improve the health of people with diabetes.

The sad thing we are seeing now in New Mexico and other states is the increasing prevalence of type 2 diabetes in children. I think that the NP, CDE can play an activist role in educating the public about the seriousness of this and in early intervention with diet and exercise. I don’t see this as an exclusive role of the NP, CDE; this is something the entire diabetes health care community needs to work on. We need to educate the legislators and schools about setting policy for food in schools and requiring physical education.

NPs who are also diabetes educators can definitely have an impact on diabetes care by following standards of medical care for people with diabetes and modeling appropriate treatment and preventive examinations. We are and should continue to be educators and mentors to new nurses and new NPs regarding diabetes care. We also are educators, and our role extends to educating not only health professionals but also the community. We need to educate and help more health professionals to become diabetes educators and CDEs. The more CDEs out there, the more impact we can all have. We also need to focus on the various ethnic groups and different cultures. What works in New York will not necessarily work in New Mexico!

We will never be able to make a real impact on diabetes care unless it is a full-force effort by everyone involved. That means the health care professionals, the patients, the general community, and policy makers. Education in nutrition and exercise need to be included in all health care delivery systems and in schools. We need to take a stand against the focus on fast food and “supersizing” in our society. It is killing us!

Patients have a role and responsibility in their own health care. We provide diabetes care cards to our patients not only to educate them on what the standards of care are and what they should expect, but also to encourage them to demand that they get appropriate care. I teach a class in which I coach patients on how to approach their providers when they want a screening test done.

The only way real change occurs, I think, is when the public starts to make demands. This can happen in diabetes if we all work together.

In addition to managing some of the associated complications of diabetes (e.g., hypertension, hyperlipidemia, neuropathic symptoms, and depression) as well as the treatment of blood glucose levels, I do a great deal of counseling. Sometimes patients feel more comfortable talking to a nurse about some of the more embarrassing complications of diabetes, and I am able to either help or steer them in the right direction.

When I think about changes in health care for diabetes, I think of access—access to the tools people need to self-manage and to help prevent complications. Those tools include testing supplies and medication, but at least as important or perhaps more so is access to quality diabetes education. This would mean more diabetes educators and a realistic process to ensure that people get the continuing diabetes care and education they need.

Third-party payers don’t seem to understand that one or two visits for diabetes education is inadequate, that having diabetes requires major behavior changes, and that these changes do not occur easily or quickly. Diabetes is a chronic and oftentimes progressive disease that requires ongoing and continuing care—care that includes diabetes education.

It is sometimes easier for my patients to see me, as an NP, regularly because I can provide more comprehensive care, and many third-party payers will cover evaluations and management visits to a specialty NP. But we do need legislation that extends access to diabetes education so that patients can get insurance reimbursement when they see a CDE. AADE is very active in trying to pass this legislation. If CDEs are recognized as certified providers by insurers, we will see more referrals to diabetes education and, I believe, ultimately, more healthy and positive outcomes.

Some of my spare time is spent in volunteer activities connected with diabetes and diabetes education. I have served on a number of committees, task forces, and boards to try to affect the quality of diabetes care and education. However, one of the reasons I love New Mexico is because I love the outdoors—gardening, jogging, skiing, hiking, and bicycling. Albuquerque has some great bicycle paths, and I have even commuted to work by bicycle a few times. My husband and I have also been host parents to a couple of foreign exchange students, which has been an enjoyable experience.

We enjoy going to shows and concerts, and although there is no Broadway here, Albuquerque does have a lot of touring shows and small theatre. And of course there is the Santa Fe opera. We also love the arts and crafts of the southwest and attend all the art shows here. We like to travel and recently spent some major rest and relaxation time in Baja, Mexico, and a week of touring and tasting in the wine country of Northern California.

The one of thing I have learned is to listen to patients and suspend judgment. Patients are often the experts in their diabetes, particularly if they have lived many years with it. I always tell people that I am good at what I do but that they have more experience with their own diabetes.

I will say, “If I tell you to do something that does not feel right to you or that frightens you, then don’t do it! Tell me what you are thinking. We are partners here, and we both need to agree on the plan.”

I may disagree with what my patients want to do, but I may tell them to try it, monitor the blood glucose values, and report back to me with the results. Once they see for themselves what works and what doesn’t, they are much more willing to try new regimens. We call it self-management education for a good reason!