Diabetes Is Still Primary Unless We Give It Away

I can’t begin to tell you how much I have enjoyed being a primary care physician for the past 20 years. It has been a privilege to be a part of my patients’ medical family and to engage with their mind, body, and spirit. I do believe that we are a rare breed—maybe even a dying breed—of physicians who care for the whole person, often for decades of an individual’s life. It is an honor to be a patient’s primary caregiver. Personally, my practice centers around diabetes intervention, all wrapped in the wisdom primary care affords. My goal has been to turn patients into experts on their own disease, giving them guidance for health with each chapter of their lives.

However, throughout my career, I’ve noticed a disturbing trend. The amount of time allotted to patient care has been shrinking. More and more of our practice is spent checking electronic health record (EHR) boxes that have the stated goal of improving patient care but don’t allow time to care for patients when they are seated in front of me. Primary care is a marathon, not a sprint. Typical appointments are full of metric measurements to meet outcome goals—checking off all the “to do” items for comprehensive diabetes management—all shoved into a 10-minute appointment with no time left to hear patients’ concerns or to educate them. The practice of medicine (the time spent actually applying our skills) does not increase burnout; it is the nonmedical data entry work that does that. It’s as if there has been a slow chipping away of our profession, causing us to lose sight of our why: our reasons for pursuing this career to begin with.

I believe primary care is silently responding to this time barrier by deferring diabetes care to other health care providers. I’m not saying for a moment that I don’t support the team approach. Indeed, I helped to define who is on Team Diabetes, from certified diabetes care and education specialists to pharmacists and all of the other disciplines traditionally included in diabetes care, to not mention inviting additional professionals such as dentists to the table as needed for truly comprehensive diabetes care. What I am saying, rather, is that I’ve noticed a disturbing trend among my primary care colleagues. They seem to be giving it away, almost taking themselves out of the diabetes game altogether. We are still on the roster, signing orders and approving the interventions of other diabetes team members, but we’re just not really contributing our own skills and expertise as much as we could.

When I question my colleagues about this emerging hands-off approach, they say they don’t have time to manage diabetes and that others within their practice settings who have more time are now tasked with this responsibility. First, I would like to meet these individuals with more time and ask them where they found it. Second, I’d like to ask them if they desired to take the lead in diabetes and its management or if, instead, that role was foisted upon them.

Perhaps we should pause and determine how we arrived here. Diabetes is a complex, progressive condition that lasts for decades. Therapeutic inertia has permeated every point of intervention in this chronic disease. Patients are forced into time slots irrespective of their disease state or current health needs at each visit. It’s as if we are allegiant to the schedule and have forgotten the patients who allow us to have a schedule in the first place. No clinician would disagree with this, and yet we shrug our shoulders and carry on, seemingly voiceless, as we watch our profession erode. Additional time stealers include endless prior authorizations for insurance coverage, EHR documentation, and a lack of cohesiveness on Team Diabetes. The fact that we are drowning forces us to pass our patients with diabetes on to others. We still want them to be cared for, just not by us.

As noted in a 2021 consensus report (1) from the National Academies of Sciences, Engineering, and Medicine’s Committee on Implementing High-Quality Primary Care, “absent access to high-quality primary care, minor health problems can spiral into life-altering chronic disease, chronic disease management becomes difficult and uncoordinated, visits to emergency departments increase, and preventive care lags.” A September 2021 Harvard Business Review report (2) noted that the United States spend 50% less of every health care dollar on primary care than any other developed country. As a result, the declining primary care workforce capacity is associated with a loss of 85 lives per day (1).

Noticing this primary care trend, I decided to stand my ground for my patients and profession. I simply said “no” and established practice boundaries to protect my practice. For me, workflow and preparation have been my saving grace. We need time to prioritize patients over paperwork. My husband, who is also a physician, summarized it best, saying, “The paperwork in the U.S. health care system is exceedingly healthy; the patients, not so much.”

Awareness is half of the solution to this problem, and there are steps that can help you reclaim diabetes care in primary care.

Begin by deciding to continue caring for people with diabetes. Involve your system administrator or director in the steps necessary to accomplish this goal. I know some of you must be thinking, “That would never work in my practice setting!” Have you asked? If not, I encourage you to do so. There is much work to be done in terms of legislation, competitive compensation, and bureaucratic overhaul in primary care. In the meantime, primary care providers, as the primary engine of health care, can decide where our profession is heading, or we risk a future in which our profession is abandoned and being stripped for parts. If just 20% of us decide to reclaim our calling, we could radically disrupt the current primary care trajectory for the better.

As a second step, institute diabetes-only clinic appointments that will never be less than 30 minutes in length. Doing this will enable you to accommodate the space for effective diabetes management within your clinic workflow. My front office staff created an appointment template and reminders to patients to bring diabetes-related technology devices, medication lists, and any diabetes-related questions to these appointments. When I implemented this change, my patients welcomed the focus on their diabetes management. If I would bring up other conditions during these meetings, the patients themselves often would remind me that we were having a diabetes-only visit and would come back to the office at a later date to address those other concerns. I could not have predicted that my patients would respond so positively to prioritizing their disease at these special visits.

Finally, leverage your care team to improve clinic efficiency. Take a moment to really look at the time barriers you face every day and fix them. For example, create a diabetes visit EHR template for you and your medical assistant to follow. Include medication reconciliation, adherence, and side effects. Equip your staff to obtain point-of-care A1C levels, diabetes technology data, and vision screening records and even to complete foot exams. If a patient’s shoes are still off when I walk into the room, I know there is something on the feet that needs my attention. A final step to improve time efficiency for prior authorizations is to dictate your clinical decision-making and justification of decisions using the American Diabetes Association’s Standards of Care in Diabetes. Periodically reevaluate your clinic workflow to identify and address additional barriers that could lead to inertia.

With emerging and established cases of diabetes reaching pandemic levels, we should be involved in prevention and detection of and intervention for this disease at all stages. Diabetes, by its very nature, lends itself to the type of care we primary care clinicians already provide to our patients. After all, the clinician who knows the patient best should continue to treat the whole person even after, or especially after, diabetes develops. They say “diabetes is primary.” Let’s take action today to keep diabetes primary.