A trend that we are seeing is a movement away from using the primary care physician as a gatekeeper in managed care plans. Nonetheless, the majority of patients will not see an endocrinologist on a regular basis.
What I would suggest is that as soon as possible after the diagnosis is made, the primary care physician should think about the resources in the community. If an endocrinologist is available, he or she should develop an initial care plan and then discuss it with the primary care physician, who will often have invaluable insights about the patient and what is practical.
Ideally, this will lead to a modified plan that is a cooperative effort among the physicians, and, ultimately, also strengthened by input from a podiatrist and other specialists. We’ve actually done that in our community. We see a lot of people with diabetes who get much of their care from an internist or family practitioner, but when the patient has an acute illness, we can participate early in the course of the disease as well as later on when the patient’s condition gets worse.
It is not good for the patient if the endocrinologist is seen only as a last resort. In that situation, we lose the advantages that come from implementing a comprehensive and intensive care plan early in the course of the disease. As we look at CHD, neuropathy, retinopathy, and kidney failure, it is very clear that if we want to reduce the disease burden, it’s at the front end that we really need to do our work.