I read with great interest the recent commentary by Dr Gregory Rutecki, "Predicting the Risk of Type 2 Diabetes: When Does the Clock Start Ticking?" Dr Rutecki makes some excellent points about the costs of diabetes care and how the reduction of complications such as myocardial infarction, heart failure, and renal disease will decrease costs and suffering. But I have difficulty with the tone of his comments that seem to shift blame for the cause of these costs. It is similar to the dysfunctional term compliance that arises out of the need to blame someone.
I suggest that we not use the word blame but barriers to reaching diabetes goals. Physicians and health care systems create significant barriers to achieving goals.1 We are the adults in this equation and cannot state that patient barriers are a bigger issue.
The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial2 and Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial3 inform us that many procedures used to evaluate patients with diabetes are no more effective than addressing lifestyle changes, but physicians continue to use all of this technology. This drives up cost and with no difference in outcome. How often does a chest x-ray substitute for a thorough chest examination? Why do we not want to admit that we as physicians are responsible for the increase in health care costs and a change in our behavior will decrease these costs with no change in outcomes except a decrease in income for us?
How well do we as physicians motivate patients to change? Lack of training in motivational techniques rests with our educational institutions. Lack of time to motivate patients is a reflection of our reimbursement system that favors volume rather than quality of care.
Of course, patients are responsible for changing their lifestyle, but we need to understand our responsibility to help patients achieve lifestyle changes. Many patients lack the fiscal resources and literacy to achieve lifestyle changes. Healthy, affordable food choices are more costly and hard to find. Restaurants, grocery stores, and supermarkets do not help patients with these choices. How many of our patients are aware of affordable, appropriate, safe choices for physical activity? Have we given them options that are within their ability?
Dr Rutecki has made some excellent points, and I hope I am adding an additional perspective.
| Edward J. Shahady, MD Clinical Professor of Family Medicine University of Florida, Jacksonville President for Medicine North Florida/South Georgia Chapter of the American Diabetes Association Medical Director Diabetes Master Clinician Program Florida Academy of Family Physicians Foundation Jacksonville |
REFERENCES:
1. Shahady EJ. Barriers to effective diabetes care: how to recognize and overcome. Consultant. 2009;49:493-496.
2. BARI 2D Study Group, Frye RL, August P, et al. A randomized trial of therapies for type 2 diabetes and coronary artery disease. N Engl J Med. 2009;360:2503-2515.
3. Boden WE, O'Rourke RA, Teo KK, et al; COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356:1503-1516.
I don't disagree with Dr Shahady's valid concern about medical costs consequent to the prevalent overutilization of technology. There is no doubt that reimbursement in our present model comes from doing expensive things rather than spending quality time or thinking. That is a wrong-headed approach, we agree, and I suspect we both practice what we preach. But, the procedure surfeit chronicled by the BARI 2D and COURAGE trials is at best a "straw man" and a non sequitur to discussions regarding lifestyle and health.
I admit that I as a physician bear responsibility for reducing health care costs. At the same time, when Dr Shahady posits that by broadly "sharing" lifestyle responsibilities (weight, eating habits, and exercise), I am inappropriately "blaming"—he misses my point. The issue in the editorial is bigger than medicine, reimbursement efforts, and our motivational skills as health care workers.
As a society, we permit advertisements of inexpensive (often $1.00) "super-sized" portions of fast food that target children and members of minority groups and encourage them to economize through unhealthy eating habits. I would love to believe that health care reform alone will fix that. However, call me cynical, I think that health care itself is only one piece in a much bigger puzzle. Yes, we are adults and therefore all bear responsibility for diabetes, not only medicine. Our entire culture needs to fundamentally change and share the burdens of lifestyle, diabetes, and obesity. Dr Shahady and I agree on the goal, but I think medicine needs more help from our many constituencies to get there successfully.
| Gregory W. Rutecki, MD Professor of Medicine University of South Alabama College of Medicine Mobile |
