I have a host of friends who are doctors. So when I was diagnosed with diabetes back in 2002, I was confident I would never be short of good advise on how to manage my condition. Alas, my hopes were misplaced. Except for a few, most of my friends confessed they did not know enough about diabetes to guide me.
Mind you, these guys are good cardiologists, nephrologists, urologists, gastroenterologists, neurologists, oncologists ‒ all “hip and happening” disciplines ‒ but diabetes wasn’t/isn’t their cup of tea. Reason? They claim diabetes management, especially Type 2, was never really an important part of the curriculum. Surely, you must be joking, I would remark in all seriousness; but they assured me in all seriousness that this was indeed the case. Anyway, I dismissed these claims as meaningless till I came across a study recently that really validates this anecdotal evidence.
It seems that even in the US, many recent graduates of medical school programs may have very little training in how to care for chronic disease, which could greatly impair their ability to treat a patient who has type 1 diabetes or type 2 diabetes, according to a new study from Johns Hopkins University.
The researchers said that their study, which was published in the American Journal of Medicine, shows that there is currently an imbalance in the training of primary care physicians. Despite the fact that 90 percent of doctor visits are outpatient, most medical schools focus on inpatient situations. This leaves future primary doctors unprepared to deal with chronic disease like diabetes.
“When I graduated from residency here, I knew much more about how to ventilate a patient on a machine than how to control somebody’s blood sugar and that’s a problem,” said Dr. Stephen Sisson, who led the study. “The average resident doesn’t know what the goal for normal fasting blood sugar should be. If you don’t know what it has to be, how are you going to guide your diabetes management with patients?”
For the study, Sisson and his team of researchers administered a test commonly used to gauge the knowledge of medical students to a group of first-, second- and third-year residents who were practicing at either an academic medical center or community hospital. All of the first-year residents were poorly prepared to treat chronic illness. However, knowledge improved somewhat among community hospital residents over time.
The study points out, “At the end of residency training, graduates from community hospitals have greater knowledge than graduates from university hospitals on chronic disease management (especially diabetes) and symptom-based/acute management, but not on preventive care. Training for all residents is particularly poor on outpatient diagnosis and management of diabetes, lipid disorders, dizziness, anemia, and alcoholism.
Our results also suggest that university hospitals do not do as good a job as community hospitals at teaching residents about ambulatory care. The culture of a training program has a significant impact on residents. Some have noted that the culture at university hospitals, where specialists often assume leadership roles in resident education, is not hospitable toward primary care, where specialized medicine is emphasized over a broad education in general internal medicine
Knowledge on topics in chronic disease management was poor among all trainees. Competent management of chronic diseases is a core skill of general internists, and as the prevalence of chronic diseases such as diabetes, hypertension, obesity, lipid disorders and others increase, more general internists will be needed. Symptom-based and acute care knowledge among PGY3 residents was only marginally better than knowledge of chronic disease management.
If the mission of internal medicine residency programs is to train physicians to meet society’s health care needs, then our results suggest that they are failing. We note with irony that all surveyed programs use our ambulatory curriculum, most for several years, yet performance among all trainees, including PGY3 residents, was poor.
More than just didactic modules on ambulatory care are needed to improve ambulatory training during internal medicine residency. The inpatient and specialty-based orientation of university hospital-based residency programs represents a large barrier to improving training on chronic disease management,” the study noted.
Given the current demands being placed on the healthcare system by the high number of patients with chronic diseases, such as type 2 diabetes, which requires intensive care, Sisson said that medical schools need to consider changing the way they do business and incorporate more general teaching.
Now that we have a worldwide diabetes epidemic on our hands, we can only hope that the shrinking number of general internists and the shortcomings of internal medicine residency training which may be contributing to suboptimal care of common chronic diseases such as diabetes and hypertension receive adequate training in chronic disease management, and that training is redesigned to improve teaching in ambulatory care.