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Physicians Barrier to Initiate Insulin: An Indian Perspective

8 Jul, 14 | by BMJ


  • 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.



(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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