Diabetes Fellowship in Primary Care: A Survey of Graduates

Methods

This study was approved by the institutional review boards at OU, ECU, and Touro University California. A 26-item survey was developed by the research team and beta tested among faculty diabetologists. No external validation was completed. The survey was then distributed by a Qualtrics survey link via email to all graduates of the 2 programs. Results were collected electronically from July 8, 2016, to August 9, 2016. A reminder email was sent 2 weeks after the initial distribution to increase the number of respondents. Graduates who had completed their fellowships from 2004 to through June 2016 were invited to participate in the survey.

Demographic items were included to define whom was being surveyed. A Likert-type scale was used to quantify comfort level with clinical skills acquired during the fellowship and to gauge perceived patient and colleague acceptance of their diabetology specialization. Response choices were “very comfortable,” “comfortable,” “neither comfortable nor uncomfortable,” “uncomfortable,” “not comfortable,” or “credentialed.” Item responses regarding patient receptiveness and colleague receptiveness were on a scale from strongly agree to strongly disagree. Text responses were used to describe the most and least helpful aspects of the diabetes fellowship and to elicit barriers encountered by graduates. Descriptive analysis was completed on the survey results and reported as percentages. Further analysis was limited by the maximum denominator of 39 for this project.

Results

Thirty-six of the 39 graduates completed the survey (92% response rate). Thirteen respondents were osteopathic physicians from the OU diabetology fellowship, and 23 were allopathic physicians from the ECU diabetology fellowship. The respondents included 22 women and 14 men (Table 1).

All respondents were comfortable or very comfortable managing type 1 diabetes, type 2 diabetes, prediabetes, and metabolic syndrome. Almost all respondents (35 [97%]) were comfortable or very comfortable managing insulin pump therapy, and 2 respondents achieved certification as an insulin pump trainer. Continuous glucose monitor management comfort levels were comparably high (33 [92%]), and 1 respondent reported being credentialed. The great majority of respondents (31 [86%]) were also comfortable or very comfortable in managing gestational diabetes. Thirty-one respondents (86%) were comfortable with the management of atypical forms of diabetes. Almost all respondents (35 [97%]) were comfortable with the management of microvascular complications and macrovascular complications associated with diabetes and with inpatient diabetes management (35 [97%]). Thirty-four respondents reporting being comfortable or very comfortable with outpatient diabetes management. More variability was reported with the comfort levels in treating patients with pediatric diabetes or patients with pancreatic transplantation. Comfort level with adolescent diabetes was reported as higher (33 [92%]) than with pediatric diabetes (24 [67%]). Management of diabetes in patients with pancreatic transplants was reported as being comfortable or very comfortable by 20 respondents (56%), neither comfortable nor uncomfortable by 8 (22%), and not being comfortable by 8 (22%).

The most helpful skills reported included insulin pump management (13), insulin management (10), and diabetes pharmacology (6). The least helpful skills were reported by 5 (14%) respondents and included faculty development, homeostatic model assessment, management of diabetes through addressing social determinants of health, and documentation of long notes. Of these 5 respondents, 1 also felt that he or she needed more exposure to pediatrics. The remaining respondents either did not respond to the item (25) or stated that no skill was the least helpful (6).

Open-ended items addressed barriers to practice after fellowship training. The most common barriers included issues related to specialty recognition, board certification, defining the specialty, insurance reimbursement, time needed to manage a chronic disease, and the lack of financial incentives to pursue diabetes management/diabetology. One respondent stated that the lack of recognition as a specialty affected health insurance reimbursement. Another respondent stated that it is hard to find a job as a diabetologist because related job offers are either for primary care providers or endocrinologists, but little to no opportunities exist specifically for diabetologists. Without accreditation, the respondents thought that the fellowship did not allow for graduates to be considered specialists. Of the 27 text responses, recognition as a specialty was the most reported barrier.

Defining what a diabetologist does was a recurring theme in the text responses. Being used beyond the expertise of the diabetology training was reported, specifically to practice endocrinology. Text responses also revealed that respondents still felt that they had difficulty with the lack of time and resources to treat a patient with a chronic disease. Time and resource constraints made it difficult to adequately address diabetes in the way that they had been trained, especially in patients with several comorbidities. In primary care practice, they are responsible for all of their patients’ comorbid conditions in addition to diabetes. Getting more time than 10 to 15 minutes per appointment was another reported barrier. One respondent also stated that support from diabetes educators and nurses was important, and another stated that recruiting these support personnel had been a challenge with diabetology not being recognized as a specialty. All of the respondents reported satisfaction with having completed their respective fellowship program despite these barriers.

Regarding practice type and location after graduating from the fellowship, 15 (41%) returned to practice primary care. Of those 15 respondents, 7 practiced family medicine; 6, internal medicine; 1, pediatrics; and 1, internal medicine/pediatrics. Of all respondents, 5 (14%) reported that they were full-time diabetologists; 7 (20%) reported practicing as hospitalists, and 8 (22%) went on to complete endocrine fellowships and practice endocrinology. One-third (12/36) of the respondents worked in hospital-owned practices, 11 (31%) were in private practice, 7 (20%) worked at academic centers, and 6 (17%) worked at community health centers (Table 2).

The majority of the respondents (27 [77%]) reported spending more than 75% of their time providing direct patient care for diabetes, and 13 of those 27 were spending more than 91% of their time providing direct patient care for diabetes. The great majority of the respondents (31 [86%]) agreed or strongly agreed that their patients were receptive to their having diabetes-specific training. The responses were much more mixed regarding endocrinology colleagues’ receptiveness to their specialty status. Ten respondents (28%) reported that they agreed or strongly agreed that colleagues were receptive to their diabetes training. Seven (19%) responded “neutral” for this item, and 7 (19%) disagreed or strongly disagreed that their colleagues were receptive to their training. Twelve respondents (33%) left this item blank.

Discussion

Elliot P. Joslin, MD (1869-1962), was the first diabetologist in the United States.¹⁰ He dedicated his career to diabetes and created a diabetology program to train others in his methods. His programs evolved into today's endocrinology fellowships. The diabetes programs in the current study seem to successfully increase physicians’ confidence in managing all types of diabetes and working with patients and families with many of the modern technological advances that help manage diabetes.

In the current study, comfort levels were high across the skillsets surveyed. However, graduates still felt frustrated by the lack of health system and payer recognition. The lack of recognition as a specialty is also a significant factor in the lack of standardization between the programs. An encouraging finding was that most of the graduates reported working in primary care or as hospitalists. In these specialties, they can better collaborate with colleagues in diabetes management and can also serve as diabetology mentors to other clinicians. It was surprising to see that the next largest number of respondents reported working as endocrinologists. After graduating from the diabetology program, they completed an endocrinology fellowship. Although both programs support the graduates and their career paths, the diabetes fellowships were not designed to serve as a prerequisite to an endocrinology fellowship.

This survey study has several limitations and flaws. First, the sample was small. The items gauged comfort levels in skills that were acquired in the 2 fellowships, but there was no measure that could show whether comfort level equated to better patient outcomes. Two of the comfort-level options were the same—uncomfortable and not comfortable; thus, both answers were rated the same.

With respect to items that asked for respondents’ perceptions of their patients’ and colleagues’ receptiveness of their training, it is possible that respondents may have had access to physician satisfaction survey results and were able to be more objective in their answers. Our research team has surveyed colleagues of diabetologists in other studies to gauge the reception of diabetology as a subspecialty.¹² Reasons for a lack of peer support included endocrinologists’ concern that they would lose income, the increased risk of burnout due to the complex population served, and the fear of how the quality of care would be affected.¹¹

Based on the comfort levels reported in the current study, one would think that the quality of care would be higher than before the fellowship; however, more concrete data looking at the quality measures of primary care providers who have trained in these programs vs those who have not would provide more objective evidence. Quality measures include hemoglobin A_1c levels; dilated eye examinations; foot examinations that assess neuropathy and ulcer prevention; laboratory tests for cholesterol levels; and urinalysis of albumin levels to detect nephropathy. These measures are all involved in the comprehensive care of a person with diabetes and are now being tracked by the Centers for Medicare and Medicaid Services through the Merit-Based Incentive Payments System.¹²

Conclusion

Diabetes fellowship programs address the growing need for health care providers who are skilled in diabetes management. The current study found that physicians who graduated from these programs were confident in the skillset they received. They also reported a number of barriers to practicing as a diabetologist, such as its lack of recognition as a specialty and thus lack of health insurance reimbursement. As more diabetes fellowship programs are created and successfully graduate specialists in diabetes management, and as recognition that primary care providers are increasingly burdened with the growing number of patients with diabetes and prediabetes becomes more widespread, perhaps diabetology may be more widely recognized and accepted as a specialty.

Author Contributions

All authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; all authors drafted the article or revised it critically for important intellectual content; all authors gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.