Thank you for taking the time to go over this with me. I wouldn’t have been able to figure it out on my own.
This was the core of a conversation with a patient that still echoes in my mind with the work I do today. A person with diabetes had felt transformed after a simple interaction I had with him years ago.
My passion for chronic disease management started during my fourth year of pharmacy school as I completed my advanced practice rotations. I was on my infectious disease rotation at the University of Michigan Hospital, and a patient on our service had a diabetes-related foot infection and osteomyelitis. The person’s A1C was severely elevated, and they were in excruciating pain. It was hard to look at the wound because it was bandaged and the person was prepared for an amputation. While I reviewed antibiotic regimens and monitoring with my preceptor, I couldn’t help but wonder how this patient even got to this point. What could we have done better as a health care system in the outpatient setting to prevent this from happening?
After pharmacy school, I decided I would complete residency training and selected one with opportunities to train in endocrinology and cardiology. I loved both disease states and would have been happy working in either. As residency neared completion, I was offered a position to start heart failure services in a clinic on the south side of Chicago. I was tasked with developing the role of the pharmacist in heart failure and creating a protocol to initiate, titrate, discontinue, and monitor medication use. I was beyond excited at the opportunity and couldn’t wait to get started.
I will never forget the day I was interviewing one of my first patients. His heart failure was doing well, he had no issues with congestion or symptoms of worsening heart failure, and he was taking his medications. I planned to increase his carvedilol from 12.5 mg twice daily to 25 mg twice daily and help him get to the target doses of his heart failure medications.
While reviewing the patient’s chart, I noticed that his A1C was 16%. He was taking the maximum dose of metformin and had been recently hospitalized for hyperglycemia. The patient stated that he was taking the metformin twice daily as directed, but he had not started the insulin aspart initiated in the hospital because he didn’t know how to use the insulin pen and he didn’t have pen needles.
I started asking symptom questions related to diabetes management and learned that the patient was experiencing frequent thirst and urination. He told me that his blood glucose levels at home were frequently 500 mg/dL, especially after drinking soda or juice. We reviewed the effect of soda, juice, and other foods and beverages on blood glucose management. I talked to him about initiating basal insulin (this was in 2010 before the glucagon-like peptide receptor-1 agonist recommendations).
My collaborative practice at the time only allowed for the management of heart failure, so I contacted the patient’s primary care physician about starting basal insulin to improve his diabetes management. We were able to start insulin at the visit, and I showed him how to use the insulin pen, ensuring he had a prescription for pen needles, alcohol pads, and blood glucose testing supplies.
The patient was scheduled to come in every 2 weeks for heart failure management, and we continued to discuss diabetes management as well. I provided recommendations to his primary care physician to adjust his diabetes medications accordingly.
Over the next few months, the patient’s A1C came down to 6.5%, and he reported feeling remarkably better. He was so thankful for the time I spent teaching him about diabetes, and I will never forget the impact I made by spending a little extra time addressing diabetes management at each heart failure follow-up visit.
Over the next year, I started to have conversations about diabetes management in people with concomitant heart failure and diabetes during their heart failure follow-up visits. Everyone appreciated that I was taking the time to help them with diabetes management. Based on the improved diabetes outcomes in the heart failure population, our primary care team asked if I could start managing people with diabetes even if they didn’t have heart failure. Of course, I said yes, and the rest is history.
In December 2010 I became a DCES and ever since have spent as much time as possible trying to learn how to take better care of people with diabetes and to integrate diabetes care and education into my pharmacy practice. It has been great to see the shift from the glucocentric model of care to a more comprehensive focus. I look forward to continuing to learn and grow as a clinician as the field of diabetes and cardiometabolic kidney care continues to evolve.
Christie Schumacher, PharmD, BCPS, BCACP, BCCP, BCADM, CDCES, FCCP, is with Midwestern University and Advocate Health in Chicago, IL.
Christie Schumacher https://orcid.org/0000-0002-6501-1590
