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Dr. Richard M. Bergenstal: ADA 2007 Clinician of the Year Shares Insights on Insulin Use and Blood Glucose Monitoring

At its recent annual meeting, the American Diabetes Association (ADA) awarded its prestigious Outstanding Physician Clinician Award in Diabetes to Dr. Richard M. Bergenstal. He is the is the executive director of the International Diabetes Center at Park Nicollet in Minneapolis, which cares for 15,000 patients. He also serves as the IDC’s principal investigator on NIH-funded trials studying the importance of glucose control in type 1 and type 2 diabetes. In a conversation with diaTribe, Dr. Bergenstal said he was honored by the award – "that's what happens when you're around long enough and you work with a great team" – and went on to share his views on insulin initiation and blood glucose monitoring.

Kelly Close: Congratulations on being named the ADA Physician of the Year and thank you so much for taking the time out of your busy schedule to speak with us. Could you share with us a little about your practice?

Dr. Bergenstal: I practice at a large diabetes center, which supports adult and pediatric endocrinology practices. Park Nicollet is the parent organization. It has about 700 multi-specialty physicians, including 300-350 primary care providers (PCPs), and what’s particularly interesting is that patients don’t need to go through endocrinologists to see certified diabetes educators (CDEs).

Kelly: That’s ingenious. I’m sure the patients must appreciate the help from CDEs!

Jim Hirsch: What sort of guidance do you give your patients on monitoring?

Dr. Bergenstal: Monitoring alone isn’t enough. Patients have to get the data and use the data. Meaning, they should write down the numbers and then take specific actions. If the blood glucose number is above a certain threshold, they should go for a walk and next time, eat fewer carbs. Monitoring reinforces specific actions that need to be linked to the numbers. That is true for type 1s and type 2s on insulin as well; the numbers are only beneficial if you know what to do with them.

Jim: What do you think is the best way for doctors to help dose patients on insulin?

Dr. Bergenstal: I could talk all day about improving our approach to starting and adjusting insulin. Let’s stop quibbling about the absolute best insulin to start and be willing to ask our patients a few simple questions and they will guide us to a good starting insulin regimen. We need to get more people on insulin, be it basal (or as we call it at the IDC, background) insulin or premixed analog insulin or background with mealtime (also known as basal-bolus, with the bolus being injected or inhaled). There are patients who are right for each regimen and in our experience most patients end up on basal-bolus insulin. The IDC has developed some nice educational materials for clinicians (Guide to Starting and Adjusting Insulin) and for patients (Let’s Talk About Insulin) – see them on our web site.

Kelly: Where do the incretins like Byetta fit into your practice?

Dr. Bergenstal: Ours is a little bit of a different approach - while most guidelines list every drug and then pick one, we don’t think that helps primary care providers. Instead, we show two paths – a preferred path and a lower-cost path. We use metformin and SFUs for the lower-cost path and some of the newer drugs for the preferred path, drugs that we think have been significant advances.

Jim: That sounds very sensible.

Kelly: Switching gears a little, what were your top takeaways at the ADA meeting in terms of new research and learnings?

Dr. Bergenstal: I really enjoyed the two main lectures - Bob Sherwin's Banting Lecture as well as the Young Investigator lecture. Just when you think you understand something, you realize that there’s a lot more to the brain and the pancreas than you thought! The young investigator talked about inflammation and insulin resistance and the interaction between the different systems; it’s all much more complicated than we thought. To learn that there’s plenty of room for new discoveries and innovations was inspiring.

Jim Hirsch: What about more clinically – how to improve patient care?

Dr. Bergenstal: I guess it is still my contention that a lot of the improvement we need in diabetes is still at the systems level and not necessarily just about the next better drug. We have a lot of room for better implementation, especially for the bulk of patients in primary care. We know diet and exercise can really work and yet no one has an effective way to implement it at the primary care level. Nobody downloads meter results because no one has enough time. We know we need to get the data, summarize it, have goals, and act on them, but do primary care physicians really have algorithms they like and that they could build into practice? No, they don’t. The communication part is sadly lacking. I was pleased to see the Predictive 303 study, which showed that you can give a patient a home protocol for insulin adjustment and they can do as well as the doctor. This reinforces that there is something to patient self-management, but you need to give them tools, tools that actually help them at home. If the patient understands the disease, they can take over.   

Kelly: So… it sounds like the problem isn’t so much about a lack of good therapies as a lack of good ways to put those therapies into action. 

Dr. Bergenstal: Yes, putting it all together is what is needed. I was very impressed with the incretins (like Byetta and Januvia) - that class is building some momentum.

Jim: Speaking of new drugs, are you concerned that the FDA has become too cautious in approving treatments in light of recent drug controversies?

Dr. Bergenstal: No, I support the balance of risk and benefit. We already have some reasonable drugs that work if applied judiciously with good systems, so we are only looking for drugs that represent great advances and are safe. I do agree the FDA is a little spooked, but I would just as soon that drug approval take longer and not have to tell patients, “Well, we thought this was good but...”

Kelly: Okay on to our last question - what part of your work do you most appreciate and what is the most difficult?

Dr. Bergenstal: I most appreciate my patient interactions. That’s why we all do this: so we can play just a small role in helping someone understand and live well with diabetes. Right behind that is the great privilege I have in working at an institution like the International Diabetes Center that so values patient-centered team care. Any accolades that may come my direction are certainly in great part due to the amazing team I work with. The most difficult part of my work and for that matter the work of the IDC is staying focused – we all love to multitask and there are so many burning questions out there that need be answered. I just hope we can slowly chip away at them to help ensure everyone with diabetes receives the best possible care.

Kelly: Dr. Bergenstal, thank you so much for your time and congratulations again on the best physician award – clearly a greatly merited award. We’re very happy for you and even more so for your patients! Thank you so much for all the work you do.