HJAR Sep/Oct 2023

CHANGING THE CARE: DIABETES MELLITUS 20 SEP / OCT 2023 I  HEALTHCARE JOURNAL OF ARKANSAS   who suffer from type 2 diabetes mellitus typi- cally make plenty of insulin, it’s just that their insulin doesn’t work as well as it should. High levels of circulating insulin in turn can precipi- tate weight gain, and increased weight causes even more insulin resistance, thus precipitat- ing a vicious cycle that is difficult to reverse. Under existing transactional models of healthcare reimbursement, type 2 diabetes care typically involves multiple players pur- portedly working together. The provider has a 15-minute visit where they will generally ask questions about diet, exercise, and medica- tions followed by dispensing advice on eating better, exercising more, or which medications to take. During that same 15 minutes, the pro- vider also must find time to address all ques- tions and concerns, perform a physical exam, manage other cardiovascular risk factors, and attend to any acute complaints the patient might have. Medications are prescribed based on a host of factors, including the provider’s individual knowledge and comfort, as well as the patient’s insurance coverage, which entails understanding which drugs are covered, which ones are favored, which ones are the least ex- pensive based on unit price, and so on. Other insurance factors include how many visits with a diabetes educator or dietitian might be cov- ered. A certified diabetes educator then has a finite amount of time based on the number of covered visits to explain the underlying disease process, teach how to monitor blood sugar, how to perform subcutaneous medica- tion administration, and so on. Health literacy is not routinely measured or even addressed. A patient may be educated about what diet they should follow, how much exercise they should get, what medications they should take, and how often and when they should be checking their sugars. Dietitians, who also typically only have a few visits to try and down- load as much information as possible, also feel rushed to try and tell the patient what they should eat, what they shouldn’t, and which foods are high in sugar and which ones aren’t. Each patient also needs to be regularly monitored for microvascular complications of diabetes, meaning they should get a foot exam annually to check for diabetic nerve damage (a risk factor for amputation), they should receive a yearly eye exam looking for diabetic eye damage (diabetes is the leading cause of blindness), and they should submit a yearly urine specimen looking for evidence of diabetic kidney damage (a risk factor for kidney failure). Systems and processes may or may not be in place to ensure that these assessments are reliably completed on an annual basis. Personal accountability may become a mantra where the expectation is that the patient com- plies with provider recommendations. Failure to change their diet, embrace regular exercise, check their blood sugars regularly, stop smok- ing, or take their medications as prescribed, are all deemed noncompliance. Accountability for “Burnout is not due to weakness or lack of emotional resilience. Burnout occurs when we find ourselves severed from the deep sense of purpose as to why we chose to go into healthcare. When we fail to deliver the type of care and the quality of outcomes that we believe we could, we experience moral injury, and the result is burnout.”