Primary Care

Internal medicine residents need training to enhance their diabetes care

According to a recent study, improvements are needed in the way internal medicine residents care for patients with adult-onset (type 2) diabetes. Residents at one large, urban hospital outpatient clinic in Atlanta, GA, did not consistently follow recommended guidelines in five areas of diabetes care: referral for dilated eye examinations, measurement of lipids, screening of urine for proteinuria, performance of foot examinations to detect nonhealing injuries, and inquiries about patient self-monitoring of blood glucose. Recent clinical trials have shown that complications of diabetes can be prevented or limited by tight control of blood glucose and appropriate and timely interventions, thus increasing hope that outcomes can be significantly improved for patients with type 2 diabetes.

In a study that was supported in part by the Agency for Health Care Policy and Research (HS09722), the researchers surveyed internal medicine residents about how often they performed six diabetes care services advocated by the American Diabetes Association. They documented actual performance of these services by using the hospital laboratory database and reviewing the charts of 140 patients with type 2 diabetes who were seen by residents at the hospital clinic an average of five times during 1996. All patients in the study were black, had no psychiatric or central nervous system disease, and had received a minimum of 12 months of continuing care.

Both self-described and reported performance of all services fell short of recommended standards. For example, 60 percent of residents reported that they referred patients for an annual eye exam, 50 percent said they performed annual lipid testing, and 65 percent said they screened patients yearly for urine proteins. Only 52 percent of residents claimed to perform foot exams at each visit, but 80 percent said they asked their patients how often they monitored their blood glucose. Ideally, responses should have been 100 percent for each service. Sixty-one percent of patients had two or fewer HbA_1c measurements (blood sugar indicator) in 12 months, which is less than recommended. Nearly 50 percent of patients on either oral medications or insulin had an HbA_1c value of more than 8 percent. Three-quarters of the residents selected a target HbA_1c of 7.5 or less.

The researchers conclude that appropriate modifications in graduate medical training are critical for achieving the long-term goal of reducing the costs and complications of diabetes.

See "What do internal medicine residents need to enhance their diabetes care?" by Annette M. Bernard, M.D., M.S., Lynda Anderson, Ph.D., Curtiss B. Cook, M.D., and Lawrence S. Phillips, M.D., in the May 1999 Diabetes Care 22(5), p. 661-666.

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