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1. PODCAST TRANSCRIPT
EVALUATION OF PATIENTS WITH T2DM
Joel Zonszein, MD, CDE, FACE, FACP: So the question is how can we evaluate a patient with
diabetes. Well let me tell you that primary care physicians who take care of probably 90% to
95% of patients with diabetes, hate to see a patient with type 2 diabetes. The reason is that it
takes too long. A good physician is going to get a good history and a physical examination, and
they will make an assessment from the laboratory tests. Only after having all that is when they
are going to start treating the patient. This takes too long and is not properly reimbursed in our
health care system
So, as I mentioned before, a patient coming to the office with viral upper respiratory tract
infection or a sore throat or urinary tract infectionisrelatively easy to evaluate and treat. To start
dealing with the patient who has type 2 diabetes, it is not dealing with the sugar only, it is not the
dealing only with the weight, or the cholesterol, or the blood pressure, or the abnormal kidney
function; It is dealing with all of it together. We need a very careful evaluation and need to know
the laboratory values in order to provide the best therapy. We are now seeing patients who
have a much more aggressive disease and it impacts younger people so we see patients who
are very, very young and even children with type 2 diabetes. I do not treat children, but I see
adolescents and young adults who come with obesity, severe dyslipidemia, acanthosis
nigricans, fatty liver, and already complications from the disease at a very young age.
In fact, I have seen type 2 diabetes in three generations. Thereis the grandmother, everybody
will expect somebody to get diabetes at the age of 75 or 80-85; the daughter of that person also
developed diabetes and often they have more severe and more aggressive cardiovascular
disease than the mothers, and then the granddaughter who is now the teenager or the child who
may also have diabetes, so we see now diabetes in three generations. This is very worrisome,
and this brings me back to the importance of providing education not only to the patient but to
the entire family. But going back to the history and physical examination, to obtain a detailed
history and physical examination takes a long time. The reimbursement by the insurance
companies often will be less than the office overhead. I will have to pay (the overhead of
expense is more than the reimbursement for the visit) to spend one hour or sometimes an hour
and a half or even more on a good adequate comprehensive history and physical examination
for a patient with diabetes. And I am not talking about providing education that is also not
reimbursed adequately in our current healthcare system. So as I mention at the beginning, the
primary care physicians do not like to see patients with diabetes because it will take them a
longtime.
Developed in collaboration with the Center for Continuing Medical Education at Albert Einstein College
of Medicine and Montefiore, and the American Academy of Nurse Practitioners, through a strategic
educational facilitation by Medikly, LLC.
Supported by an unrestricted educational grant from Lilly USA, LLC.

2. The diabetes prevention program includesa population of patients thatdid not have diabetes, but
what we used to call pre-diabetes or impaired glucose tolerance or high risk for diabetes. When
we lookcarefully at that group of individuals, they already had complications of diabetes, even
before they developed diabetes. They already exhibited a bit of neuropathy and retinopathy
even in the prediabetes stage. Obviously when we look at these individuals with prediabetes,
when they have other cardiovascular risk factors such as hypertension and dyslipidemia, and
we examined carefully their arteries, for instance by doing intravascular coronary
ultrasonography (IVUS) studies,we find out that at the time of diagnosis of diabetes, 100% of
those patients already have advanced atherosclerotic or arteriosclerotic cardiovascular
disease.
I convey that to the patient. When making the diagnosis of diabetes it means that the patient
already had a heart attackbecause there are studies showing that the chances of getting a
second heart attack in somebody with diabetes is exactly the same forsomebody who already
had a heart attack.What we need to do in that patient, is to prevent a second heart attack.
So, in summary, when we see a patient with diabetes, we have to get a good family history,
good personal history, we have to do a careful physical examination, we have to assess if there
is neuropathy or retinopathy or to be sure that the ophthalmologist will see the patient
immediately. We will have to make an analysis to see if there is any organ disease such as
kidney disease, heart disease, etc. We obviously have to measure albuminuria and or
microalbuminuria which aremarkers of both small and large vessel disease. Something we
often forget is dental care. Many of these patients have gingivitis or have tooth decay. They
have to see the dentist and very often dentists are aware and they can tell by the way just
looking at somebody’s mouth if they do or do not have diabetes. There is now evidence of how
chronic gingivitis, chronic infection of the mouth can add insult to the inflammatory process that
we see in patients with type 2 diabetes. So it is important to make a good history and physical
examination and evaluation, and then treat these patients.The physician has to spend a lot of
time in providing education, guidelines and review of blood glucose monitoring.Ifthe patient
needs to be on insulin we need to teachthe patient how to inject the insulin and how to adjust
the insulin doses.The difficulty is in adjusting the dose of insulin, so it would be effective and
that will require different telephone conversations with the patient, different questions that the
patient may have.
So in an ideal situation, in order to do these well, the physician needs to get paid, and what we
see in reality is that the reimbursement is very low, so this is a major problem. I want to point it
out because we often talk about barriers, and I thinkthe reimbursement system is a very
important barrier.
Developed in collaboration with the Center for Continuing Medical Education at Albert Einstein College
of Medicine and Montefiore, and the American Academy of Nurse Practitioners, through a strategic
educational facilitation by Medikly, LLC.
Supported by an unrestricted educational grant from Lilly USA, LLC.