Old-Fashioned Care in the Big City

Editor’s note: In the “Practice Profiles” department of Clinical Diabetes, we spotlight clinicians who have chosen to dedicate a significant portion of their time to the care of patients with diabetes. Suggestions for clinicians to interview in the future are welcome and can be e-mailed to [email protected].

Where are you originally from?

Brooklyn, N.Y.

When did you first get interested in medicine?

I don’t remember, but my parents told me that I always wanted to be a physician.

Were there any doctors in your family?

My great-uncle Louie became a physician at the age of 42 after a long career of operating a pushcart on the Lower East Side of New York.

You started off in obstetrics and gynecology and switched to internal medicine. How would your life and practice be different today if you had stayed in obstetrics?

I would still being doing patient care if I had stayed in obstetrics, but I’d be doing more surgery. I enjoyed surgery the least and loved caring for all types of medical problems, so internal medicine was a better fit.

You have a unique practice in Manhattan, giving very personalized care, spending a lot of time with patients. How do you do that given the constraints of medicine today?

I have a large office staff that takes care of the business so that I can devote more time to my patients. My patients are also understanding, so if a patient who is in need of extra time backs things up, it usually isn’t a problem. Obviously, there are a few who complain. I also have an understanding and supportive partner and family. Working from 6:30 a.m. to 9:00 p.m. also helps.

So many patients with diabetes just give up. What do you believe is the secret to living successfully with diabetes?

Patients must understand that they are in control of their long-term health by tightly controlling their blood glucose, lipids, and blood pressure. A healthy lifestyle and love of someone or something, as well as faith, provide a real sense of well-being and anticipation of the future.

You recently told me an inspirational story about a young woman in your practice who is now blind from diabetes. What have you learned from patients like her?

It is important to feel positive about life even when there are obstacles (often many) to overcome and to accept those obstacles as a part of life—hopefully even a part that you can learn from. I believe that the ability to experience joy allows people to overcome incredible obstacles.

How do you try to get through to patients who are discouraged or depressed about their diabetes?

If patients feel that they are in control of their diabetes rather than the other way around, they do not get discouraged.

You decided to take very few insurance plans. How did you have the courage to do that?

I will accept insurance and even see patients for free or at a discount if money is a problem. However, most patients understand cash-flow problems that some insurance plans have caused and are sympathetic and willing to deal with their insurance companies themselves.

Were you afraid of losing some patients?

Yes, but thankfully there was little attrition.

As a patient of yours myself who has waited a long time in the waiting room to see you, I’m interested to know if your other patients mind the wait?

A few do, but most realize that when their turn comes, I will spend as much time with them as they need. What did you think about your wait, Dr. Levetan?

Well, I’m glad you warned me about it. I bring plenty of work to go through when I come, and the wait is always well worth it.

Manhattan is an affluent area. Do you think other doctors in smaller communities could get by without accepting insurance?

Yes, as long as they are willing to spend the necessary time with each patient. It is not about saving time; it is about spending more time with each patient. This will work anywhere. Patients will embrace this type of care, even in limited “accept insurance” offices, if they understand that they will get the proper amount of attention. That attention means everything to most people.

If you could change one thing about health care now, what would it be?

I would change the way health care is paid for. If everyone who could afford to would pay a co-pay of 20% regardless of how much the year’s outlay was (except in the case of hospitalization or other catastrophic illness), then all insurance would become affordable. Just think of it like the deductible you pay on car insurance.

You are also a clinical associate professor of medicine at Mount Sinai School of Medicine and serve on the Admissions Committee. What are the biggest differences you have noted in medical school applicants and medical students over the past few decades?

Today, they are more eager, brighter, more talented, and nicer than ever before.

With all of the new diabetes therapies and new insulins, do you think endocrinologists can help patients achieve normal HbA_1c levels without developing serious hypoglycemia?

This can only be done if wide swings in blood glucose levels can be identified and narrowed. This can be done through the use of diet, exercise, and medications that target fasting blood glucose as well as postprandial rises in blood glucose.

I typically have new patients begin checking their blood glucose levels before and 2 hours after all meals to get a sense of the trends. Decreasing wide excursions allows for achievement of the HbA_1c goals and minimizes hypoglycemia. Pre- and postprandial blood glucose levels must continue to be monitored.

As a member of the Executive Committee of the American Association of Clinical Endocrinologists, what role do you believe endocrinologists play in the care of diabetes?

Because endocrinologists have expertise and training in the prevention of diabetes complications and in designing more intensive medication regimens, I hope that endocrinologists will continue to be a resource not only to care for diabetic patients who already have complications, but also to aid in the planning of a treatment regimen for those at the onset of diabetes, before complications have developed.

Where do you predict diabetes care will be in another decade?

There will be more islet cell transplants earlier in the course of type 1 diabetes. For type 2 diabetes, there will be more drugs that target insulin resistance and obesity.

You have a particular interest in osteoporosis and metabolic bone disease. Do you have any thoughts on why patients with diabetes seem to be at increased risk for osteoporosis?

I’m not certain, but it probably has something to do with the release of cytokines that modulate inflammation and also can cause bone to be reabsorbed. Poor release or action of hormones and growth factors that stimulate bone formation probably also plays a role.

If you could say one thing to students entering medical school, what would that be?

Don’t spend so much time talking to your patients. Spend lots of time listening to them.

Any words of wisdom for new physicians just leaving medical school?

Don’t use your practice of medicine as an excuse for not spending time with your family or having some joy in your personal life. Also, believe in something.

You still practice general internal medicine. Given the complexity and subspecialization of medicine today, is that harder or easier to do than 10 years ago?

It is both harder and easier. It’s harder because there is so much to know and keep track of. It’s easier because I have learned how to really listen to patients and better understand why they are really coming in to see me.

What is your hope for health care in the future?

I hope that doctors will spend more time with their patients. I hope that someone will find a way to allow physicians to feel like they have the time to spend with patients rather than having medicine be an assembly line and doctors see too many patients with less time per patient.

When and if you ever retire from medicine, what would you do?

I can’t even imagine.