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Archive for July, 2014

Ban the Diabetologist

14 Jul, 14 | by sghosal

A recent news post from a reputed newspaper quoted a medical regulatory body and suggested that the physicians practicing as “Diabetologist” should be brought under the scanner. (1)

 What were the points in favour of such a move?

  • The Medical Council of a particular state in India feels that designating oneself as a “Diabetologist” is like “cheating the citizens.”(1)
  • Diabetes is a disease. How can we have a specialist for an individual disease? (1)
  • Only Endocrinologists (DM) & Internists (MD) should be eligible to treat diabetes (not those with MBBS). (1)
  • The diabetes diplomas acquired by the MBBS doctors are not MCI (Medical Council of India) recognized. (1)
  • They are not competent enough to deal with the complexities associated with this disease entity. The article goes on to nearly implicate them as a cause behind the increasing diabetes related deaths in India. (1)

A few questions

  • India has the second largest diabetes patient in the World after China. The State in the above-mentioned article experienced an alarming rate of increase in diabetes in the recent past.
  • Who is going to take care of them? There are approximately 600 MBBS, lesser MDs and 60 Endocrinologists in the State. (1) And how come a MBBS is not trained to tackle diabetes competently when he/she is licensed to undertake surgeries? Who is to blame if the MBBS is not qualified to tackle a disease of epidemic proportions? I think the same organizations raising the questions will have to take up the blame for not up-grading the teaching curriculum.
  • If the issue is all about complete ban on non-MCI approved degrees, why should it be so selective? Why there has been no questions raised about those specialists (non-diabetologist) practicing with degrees from the UK (MRCP, FRCS etc.) & US (AB)?

 Conclusion:

  • At a time when several countries like Japan are looking at supporting the “Diabetologist” with getting them board certified credentials and the ABCD (Association of British Clinical Diabetologists) expanding their membership & activities, the steps proposed by the State council seems out of place. (2,3)
  • A commentary in a reputed journal was looking into the issues related to poor interest of the physicians in pursuing a carrier in diabetes. (4) The ways and means of motivating, supporting and nurturing them were explored.
  • Yes, there is definitely a need to scrutinize and clamp down on courses with poor credentials. However those Universities and Organizations with credibility and Internationally certified courses should be allowed to train the physician.
  • The answer to the problems associated with a disease compared to the ‘Tsunami” in India lies in empowering the physicians and not discouraging them.
  • It would be interesting to note the views expressed by the prominent diabetes related organizations running the show (training and research) in India.

References:

 (1). Diabetologists’ under govt scanner. 2013. [Online] Available at: http://timesofindia.indiatimes.com/city/hyderabad/Diabetologists-under-govt-scanner/articleshow/20564812.cms

[Accessed on 14th July 2014]

(2). Credentialing of Board Certified Diabetologists. Japan Diabetes Society (JDS). [Online] Available at: http://www.jds.or.jp/modules/en/index.php?content_id=25

[Accessed on: 14th July 2014].

(3). Association of the British Clinical Diabetologist (ABCD). [Online] Available at: http://www.diabetologists-abcd.org.uk/welcome.htm

[Accessed on: 14th July 2014].

(4). Wilmot E. The future role of the diabetologist. Pract Diab Int 2008; 25(8): 306.

Physicians Barrier to Initiate Insulin: An Indian Perspective

8 Jul, 14 | by sghosal

Introduction:

  • India is home to the second largest diabetes population after China.
  • The problem is compounded by an increase in onset of Type 2 Diabetes at an early age predisposing them to diabetes-related complications at a very young age (1).
  • The DiabCare Asia study documented that 50% of Indian diabetics have poor glycaemic control (2).
  • A large quantum of data and effort is spent on the patient’s reluctance to accept insulin as a therapeutic strategy.
  • However physician’s barriers are rarely dealt with.

 

What are the physician-related barriers in India?

  • Education: Routine University teaching focuses on Diabetes as any other disease entity ignoring the magnitude of problem associated with it. Patient education does not feature in any of the training curriculum (3). Most of the physicians look upon diabetes as a disease entity where the only goal is to look for plasma glucose values and adjust the dose of oral hypoglycaemics. Lack of adequate physician education results in poor glycaemic control.
  • Time constraint: An average physician with a special interest in diabetes has to see nearly 30-50 patients in a day. Initiating a patient on insulin including demonstrating the injection technique as well as explaining the dose titration algorithm has to be done by them. It seems convenient to add or up-titrating the existing medications which saves a lot of time.
  • Lack of support staff: Except for a few premier institutes and corporate hospitals, most of the physicians do not have the luxury of assistance from a nurse practitioner or a diabetes educator. This adds on to the issue of time constraint resulting in avoidance of insulin initiation.
  • Lack of referral system: There is no existing tier system as far as referral is concerned. This results in patients reaching an endocrinologist or a tertiary care center with multiple co-morbidities.

 

How do we attempt overcoming physician’s barrier to insulin initiation?

 

  • Education: The existing teaching curriculum needs to be revamped with special focus on diabetes as a special subject incorporating patient care. Not only National University courses which will probably fall short of training such large number of physicians, but reputed organizations with diabetes-related curriculum needs to be invited to fill in the empty training space. The endocrine and diabetes related organizations could collaborate with reputed international courses to deliver online training, which would not hamper the physician’s busy practice.
  • Time constraint: This issue is intricately associated with the lack of support staff. Once again its courses directed at training diabetic educators with a uniform curriculum complementing the physicians training could make all the difference. When we have a huge team of diabetes educators assisting the physician the issue related to insulin initiation becomes easy.

 

Although the problem seems diverse, the solution is rooted to education and awareness.

 

References:

(1). Ghosal S and Batin M. The diabetes epidemic in India: where we stand and future projections. Journal of the Indian Medical Association 2013; 111 (11): 751-4.

(2). Raheja BS, Kapur A, Bhoraskar A, Sathe SR, Jorgensen LN, Moorthi SR, et al. DiabCare Asia – India study: Diabetes care in India – Current status. J Assoc Physicians India. 2001;49:717–22.

(3). Wangnoo S.K, Maji D, Das A.K, Rao P.V, Moses A, Sethi B, et al. Barriers and solutions to diabetes management: An Indian perspective. Indian J Endocrinol Metab. 2013;17(4): 594–601.

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