Chief Scientific and Medical Officer for the American Diabetes Association, Dr. Bob Gabbay, joined The Huddle live at ADCES' 2023 annual meeting in August. He touched on the challenges of addressing diabetes in primary care and the value of a DCES in this area, as well as the importance of active listening, perceived value, and engaging teaching styles when working with people with diabetes.
Chief Scientific and Medical Officer for the American Diabetes Association, Dr. Bob Gabbay, joined The Huddle live at ADCES' 2023 annual meeting in August. He touched on the challenges of addressing diabetes in primary care and the value of a DCES in this area, as well as the importance of active listening, perceived value, and engaging teaching styles when working with people with diabetes.
Kirsten Yehl
Hello and welcome to ADCES's podcast, “The Huddle, Conversations with the Diabetes Care Team". In each episode, we speak with guests from across the diabetes care space to bring you perspectives, issues, and updates that elevate your role and inform your practice. I'm Kirsten Yehl, Director for Research and Development at the Association of Diabetes Care and Education Specialists.
During the ADCES23 annual meeting in August, I was joined on the floor by Dr. Bob Gabbay, Chief Scientific and Medical Officer for the American Diabetes Association. As you'll hear, Bob and I jumped right into touching on some timely and challenging topics for diabetes care in the healthcare system. We sparked our conversation talking about the challenges of addressing diabetes in primary care and the value of a diabetes care and education specialist in primary care. Later on, we discussed how more diabetes care and education specialists can start to fill those gaps. Keep in mind, this episode was recorded live at the ADCES booth, so you may hear some background noise throughout.
Kirsten
Is the model of care different in primary care, though, than it is in…
Bob Gabbay
I think it is, yeah. Uh, because diabetes is only this much of the picture. And they're not going to have an asthma teacher and a heart failure teacher. You know, they're not going to have like the staff of you know, 20 different individual subject people. So you bring up a good point, and there are models where this has worked, right? You know, a while back, a good friend and colleague that I really learned a lot from, Linda Seminario, because I used to be at Penn State, and so we were in Pennsylvania.
Kirsten
Oh, I didn’t know you were at Penn State. Okay. Is that where you started?
Bob
Yeah, yeah, yeah. And so through watching what she did. I mean, she set up this network and it was hugely successful. Outcomes were good, you know, improvement, you know, all of the evidence base that you need. So it's not a new idea. That's probably 15, 20 years ago. So like, we don't need to prove that this works. We just need to do it.
Kirsten
Two questions, sort of like on the front end and the back end. So one is, could you just pick up diabetes care and education, or is it a shared service? Or…
Bob
Yeah, I think the models that work the best. So it depends how big of a practice it is, right? If it's one or two docs, as an example, there's not going to be enough business for one educator to be there, you know, the whole time. If it's a larger practice, yes.
Kirsten
Right.
Bob
Um, so if you say that, you know, panel size of primary care provider, they might have two to 300 people with diabetes. So you can almost start doing the math from there. Like, okay, how many empty slots would DCS have? So you could figure out what the right scale is. So, for the smaller ones, it's sort of the traveling person. So, this reminds me, I used to be the chief medical officer at Joslin Diabetes Center. And so, the history, uh, which, you know, I'm sure your listeners are aware of, is Eliot Joslin really started the profession of what was called diabetes educators at the time. And it was actually, they were called wandering nurses. And what they did is they wandered from, at the time they went to patients homes, uh, because, you know, medicine back in those days was about house calls and, you know, all that kind of stuff. And so they wandered and they went from place to place. And so maybe we're coming back to that idea where, where instead of visiting homes, we're visiting medical homes that are private care sites. And some will need more time and some will need less time.
Kirsten
I love that. Um, so if the diabetes care and education specialist in the endocrine clinic, right, they embedded so they get a significant amount of education, especially thinking about diabetes technology. How does that work with primary care with that shared model be they're sitting in an endocrine clinic and sharing or do they sit outside?
Bob
Oh, I see.
Kirsten
Yeah, the education piece is what I'm thinking about.
Bob
I think there could be different ones, um, different models. What I've seen is there are examples where the DCES is hired, in essence, and part of the endocrinology clinic. But their job is to go out to various sites and see patients. I think the advantage of that model is that their learning and connection to what's new in diabetes is always there because they're part of the endocrine practice where everyone is, you know, going to all these meetings and staying on top of everything and all that. But they spend their time in primary care.
Kirsten
You know, we talk a lot about, especially with this new funding that came through, bridging to these communities, right? And like, who is the right group to understand those communities? Try to make change in those communities. I mean, it's not one group. It's not just the DCES.
Bob
Oh, making a change in the community around healthy lifestyle.
Kirsten
Exactly. At one visit, are they going to change it? Well, it's not because there's these social structures that are in place, and how do we make that happen?
Bob
I think they're a piece to the puzzle, but that's a huge problem, right? I think positioning themselves as part of that solution, like the real solutions to social determinants of health are public policy things, right? Now we can help people figure out the resources that are there and make a huge difference right then and there, and that's some of the work that both of our organizations are doing through CDC support and elsewhere. There's a huge opportunity there.
Kirsten
Okay, when you start thinking about access to medication, homelessness, even violence, all these things that are really public policy stuff.
Bob
Exactly. All these things, yeah.
Kirsten
So when you start thinking about on the other side, we talked about economics, you know, value based care, quality of life. That does become the problem of medicine.
Bob
It is, right? I mean, that's why we got into healthcare. We want to help our patients. I hope to the sick that I do that. I still see patients, and that's what I, you know, every patient has, you know, a new set of problems to solve.
Kirsten
I mean, I think the thing that every healthcare, right…
Bob
You guide them.
Kirsten
Well and you listen to them, right? And I think that's what every healthcare professional is trained to do.
Bob
So there are interesting studies, and this is another rabbit hole for another sort of thing. So I did a lot of training and motivational interviewing back in the day and taught clinicians, motivational interviewing, had NIH grants, all this stuff. Anyhow, so there have been studies that look at how long is it from the time a patient walks into the room that the clinician starts to interrupt them? And they even ask clinicians, like, what do you think? Like, do you listen? Do you think you're a listener? And they’re like, o, yeah, I listen to my patients, you know? Alright, tape your visit and check it out. And so, patients get interrupted like within 30 seconds or a minute of them talking.
Kirsten
Are you kidding me?
Bob
Yes, yes, many times. I think the average is maybe like a minute and a half or, you know, something like that. And the most instructive thing, if one wants to, like, this is a great tip for people. So I've done this. If you want to see how patient centered and shared decision making you are, humble yourself, ask the patient, of course, for consent, and tape your visit, and then listen to it. You will cringe. Most people will cringe. In the moment, you don't, you know, you want to do it, but you've got 16 things you're thinking about, and you've got to ask about, and check on, and this and that. So you're, you're listening, but you're also not listening as much as you might think you are. So taping and listening to yourself is a great way to get better.
And then the other that I would say is forcing yourself to listen, like training yourself to be a better listener. This idea of reflective listening, you give back what you heard. “So what I'm hearing is that you're struggling with this, this, and this. And you find this to be a problem and you might consider that”. If I know I have to say that back to the patient, I've got to listen to the patient a lot more carefully. And if you can do exercises where you put people in these situations where, with a mock patient, they have to do that, and it's hard. You immediately realize, wow, I really have to pay attention. Because I'm also trying to think of where I want to take the conversation. It's a learned skill. It's not easy. But it’s worthwhile.
Kirsten
How do you do that in 10 minutes?
Bob
You can. What you do is first you give them a little bit of time, and when you see that you're going too deep into that, you make a summary statement that shifts gears. “Yeah. So my daughter, she's…” Sounds like you're having a lot of problems with your daughter. Let's see what we can do about talking about your diabetes. So you sort of shift it. You acknowledge and then you make that shift. The important part of it is that you acknowledge the person, right? Like just changing the subject, which if you watch tapes of providers, they do a lot. They're not listening. They go: “Okay, so back to when was your last eye exam? I got to fill that out”. I'd be like, “well, I was just talking, you know, like, like I can't afford my medicines. I don't, yeah. Well, you know, can you take off your sock shoes? I need to examine your feet. And everyone's doing the best they can. There's no malintent. It's just the way the system is set up, which is why thinking about the system and how to change it is so important.
Of the different problems we've discussed solving having more people see DCES, that seems like a solvable problem. We can do that.
Kirsten
I think so. I think this is, this is something we can make happen, right?
Bob
We can make that happen.
Kirsten
In primary care.
Bob
Right. So step one is embedding more of them in primary care.
Kirsten
So orthopedics, when you have like shoulder surgery, they refer you to physical therapy. Nobody questions, right? When they go to physical therapy. They're like, well, of course, I've got the surgery. I need to go to the physical therapist. I'm not going back to the orthopedist to keep doing that. Isn't the DCS like the physical therapist?
Bob
Should be. So, we've spent a lot of time thinking about this and I've talked to a lot of people here and others. So there are three issues in terms of like why does this not happen? Right. So one is friction. It's just not easy to like get the person to see the DCES. They might not be in my practice, I don't know where they are, you know. From the patient's side, I have to come back on a different day, you know, like all of this stuff, right? So they're friction reasons and they're many of them are solvable.
There is perceived value. Both from the provider, I don't really know what they do. And then from the patient They’re like, well, I don't want to be educated. Right, they are still thinking of it as that they haven't reframed it as what they do and interestingly on the perceived value when the patient understands the perceived values They're no show. So the no show rate, I think nationally is about 15 percent or something like that, right?
So lots of reasons for that, but here's what's interesting. If you look at the no show rate for women during pregnancy, or when people want to start on a pump, it's a lot less. Because the perceived value is clear. I know why I'm going there and I'm going to go. So there's the perceived value.
There's the friction. I think those are the two big ones, and then the third one is, um, so this is probably true for some. The engagement style. This might be a little bit controversial, but there are, maybe we'll call them the old fashioned DCES that tend to be fairly directive. “I've got what I'm gonna cover, and I gotta get through this. I might have a bunch of slides and a classroom, and we're gonna go through this curriculum. I'm going to make sure you learn everything you need to learn”. And it's a laudable sort of thing, but what we know from adult learning theory is no, that doesn't work. Right? I have to teach you what you want to know, and then I'm going to tease you with things that you don't know and go, “oh yeah, no, maybe I want to know that too”. Right? That works like a hundred times better. And so that's the third piece because, you know, I hear this from my patients, you know, I just went there and I got a lecture and like, let me tell you, I'm done with school. Like I'm not going to do that anymore. So I think it's those three things. And if we can systematically attack each of those three things then you can unpack them into lots of other things. I think that's part of the solution. I could be wrong, but it's resonating with a lot of different stakeholders that we've spoken to.
Kirsten
Yeah, no, I love that. And maybe it's the friction and perceived value. Those are attainable. I mean, yes,
Bob
And I think engagement style, it's, it's, you know, these people who teach in that way, I get why I guess it's so much easier. It's so hard to pivot, you know, like I used to always do my talks with slides. Right. And I've learned, you know, this skill, which has been hard and, you know, today's program with Leslie, uh, we don't really have slides. We're just going to have a conversation. And, you know, years past, I would be petrified to walk in front of a large group of people and do that.
Kirsten
Really?
Bob
Well, because it's hard. You, you want to make sure you cover everything. You want to say all the right, you know, and it's sort of like, no, but engagement is really more important. If people walk out with three new things, that's going to last. Whereas if I went through 50 slides and showed you all the evidence for, you know, A, B, C, D, yeah, you're not going to remember that in a week. And in a month, even less in a year, you've not changed your practice at all. This is true for all sorts of clinicians. You know, the evidence of how people learn is pretty clear. And it's, it's not the 50 slide, you know, hour long webinar.
Kirsten
Well, then I would go, this is again another conversation, but just like what you just said, it took you time to get there.
Bob
Yes. So I had to learn. I had to learn. Right. So we need to help people learn that. And I would love to do that.
Kirsten
I think we should do it.
Bob
I would love to do, I man not I, me. You know, the American Diabetes Association and ADCES working together. We are the people to do that. To make that happen.
Kirsten
Yeah. Totally. Who better?
Bob
Who better? And I would say that is a..
Bob
It'll make a difference. Yes. And it's hard.
Kisten
It's hard. It takes a high-level professional, honestly, to be able to do that. Okay. Well, one last thing, because really early on you talked about your work with writing NIH grants and really focusing on these like small variables and how that's unfair to like look at...
Bob
Yeah, single variables, single interventions.
Kirsten
If you could design right now a study that would look at the friction, the communication style and the value, the perceived value of a DCES, I mean, would those be the three variables that you would design the study around?
Bob
Right. We would design a program aimed at addressing all three of those things and we do it across health systems. And, you know, to be honest, like. I'm an old guy, so like I don't have time to do like a million of randomized control trials. I spent a large part of my career. Let's just do it.
Kisten
Let's just do it.
Bob
Let's just do it.
Kirsten
I would say we can just do a program. I would love to get funding.
Bob
Yeah, it is a fundable idea because everyone knows that there's a need for this.
Kirsten
Absolutely. I am. I'm 100 percent on board. We made it happen on this podcast, by the way.
Bob
There you go. There you go. Right, right, right. So that this is one step. And you know, getting your listeners to think about this in this way, I think is, is a step in that. It's, you know, what I'm going to try to do on stage, you know, in an hour or two. Yeah, we all need to start this dialogue and think about this. And I think it can be done. It's, it's, it's definitely doable.
Kirsten
I do too. It's collaborative work. It's too big of a problem to not be collaborative.
Bob
If any one organization could have done this, they would.
Kirsten
They would have. Thank you. I totally agree.
Bob
And that's like five to 10 percent of people seeing a DCES. That number has not changed over, you know, over I don't know, 20 years. I remember quoting that number 20 years ago. So we're not doing it.
Kirsten
We're not doing it, but we're going to do it. And we have to do it.
Bob
Yes, we will.
Kirsten
Hey, Dr. Bob, thank you for stopping by. I know I dragged you off the floor here, but I truly appreciate it.
Bob
Thank you so much. I enjoyed the conversation immensely.
Outro
Thank you for listening to this episode of The Huddle. Make sure to download the resources discussed on today's episode. You can find them linked in the show notes at adces.org/perspectives/the-huddle-podcast. And remember. Being an ADCES member gets you access to many resources, education, and networking opportunities. Learn about the many benefits of ADCES membership at adces.org/join. The information in this podcast is for informational purposes only and may not be appropriate or applicable for your individual circumstances. This podcast does not provide medical or professional advice. and is not a substitute for consultation with a healthcare professional. Please consult your healthcare professional for any medical questions.