By: Zachary T. Bloomgarden, MD
As an endocrinologist for more than 40 years, treating people with diabetes every day, following the best current treatments, everything in my office was nicely organized. My patients could schedule appointments, usually not needing to wait too long, and we could download their glucose meters to go over their patterns of control. If we needed more information, we could put on a sensor to measure glucose levels about every 15 minutes for two weeks. We could look at a summary of more than a thousand datapoints to see patterns overnight, and before and after each meal, and over a sufficiently long period to get a real sense of what the levels were overnight. We could see how much time is spent “in range,” how much time more mildly or more severely high or low, and whether there is a pattern to be discerned of highs or lows at certain times. For people taking insulin, particularly with multiple injected doses, or using insulin delivered by a “pump,” this allowed for even finer adjustments, as the glucose sensors could be worn all the time and read with a digital reader or using a cellphone.
COVID-19 DISRUPTIONS
Now COVID-19 has upended everything. With travel restrictions and to protect my patients, I have had to switch to teleconferencing. Of course, diabetes treatment also involves attention to the heart, the kidneys, the eyes, the feet, and the blood pressure, and blood cholesterol. I have to treat the whole patient, as all of this can be affected in different ways by diabetes. People with diabetes can have gastrointestinal upset, can have difficulty breathing, and certainly can have infections. In the COVID-19 era, they may even be more susceptible to infections when blood glucose levels are higher. It is particularly important for a person with diabetes to treat an infection promptly, since infections in turn can cause the blood glucose levels to rise.
I know many of my patients well, and my practice has always involved seeing patients who called because they were sick. Judgments had to be made. Was the dizziness from a minor inner ear disturbance, or from diabetic neuropathy, or from age-related cognitive impairment, or a stroke? Was the stomach ache just a stomach ache – or was it an infected area of diverticulitis, or a gallbladder infection? Were the urinary symptoms from prostate or dropped bladder – or a potentially serious urinary or kidney infection? Was the breathing problem an allergy? Asthma? A heart condition? Or sinus infection or pneumonia? I took great care to ask people to come in and determine the root of the problem with a face-to-face exam.
But now, suddenly, COVID-19 has exploded in New York! Travel has become more and more difficult, and dangerous because of risk of infection. We all need to practice “social distancing,” we all are wearing facemasks, washing hands, and worrying. But a lesson from China is that, during the height of the coronavirus epidemic in Wuhan, people there and in all major cities with chronic illnesses – not only diabetes but heart and breathing conditions, and gastrointestinal and urinary conditions, and arthritis and even injuries, had trouble getting care.
TELEPHONE FACE-TO-FACE
I needed to continue to be available, but keeping the office open and having people with infections, potentially (and not in a few cases actually) with COVID-19, would not work. Luckily, the movement to telemedicine, which has been growing over the past few years, simply exploded over the past few weeks – and Medicare and most insurance companies seem to understand this. They all require “face-to-face” encounters, so telephone calls by themselves do not work, but fortunately we have a host of ways to combine video and voice. We can use FaceTime, WhatsApp, Duo, or WeChat–apps that are available with Androids and iPhones – and Skype and Zoom work on a computer as well as on smart phones. The disappearance of the paper medical record of old and its replacement with the electronic medical record, and the availability of programs which receive faxes as “pdf” files, and the <ping> that I hear when a voicemail comes in, all combine to make the e-visit a real medical visit.
An important part of diabetes treatment is understanding glucose monitoring patterns, and the development of telemedicine for diabetes e-visits must allow people with diabetes to provide data on their glucose trends. There are some good approaches. Simply charting home glucose monitoring records has always been useful. Capturing the image of a glucose logbook and then looking at the pattern of glucose levels in the morning, and then before meals and at bedtime, provides a great deal of information. The continuous glucose monitoring devices all will “sync” (synchronize data) with a website, which allows me to go over blood sugars during an e-visit in detail. Unfortunately, most of the fingerstick glucose test meters do not directly support transfer of information about blood glucose levels at different times, and instead require cables, often different for each different type of meter, and either a computer or a device to attach the cable to a tablet. I hope that the meters will soon allow direct data transfer, to avoid this complexity, and I look forward to going over full glucose patterns with my patients in e-visits as I do in the office.
E-VISITS AND REAL HUMAN CONTACT
Over the past week, I’ve closed my office to visits. My medical assistant and I do need to go in at intervals, but I can sit at my desk with my computer, tablet, and iPhone, and see everyone who needs my help! And face-to-face smartphone and computer connection, rather than being an uncomfortable bureaucratic necessity, makes a huge difference in letting the e-visit include real human contact. A smile is worth a thousand words! Even for my patients who do have COVID infections (either with positive nasal swab tests or with symptoms that make me virtually certain of the diagnosis), seeing them, checking their temperature, going over their blood glucose levels, all allows me to get a real sense of their progress – and, happily, many are improving!
Certainly, I’m eager to get back to having office visits. The physical examination is important and helps me to get a better understanding of each person’s condition. We do need laboratory tests for most of the details of liver, kidney, and heart function, and to understand aspects of diabetes control. But I’ve seen an important new dimension as an “e-doctor” in how I can reach out to people, go over their condition, review their medications, and get a real sense of their problems. I think this will be an important advance going forwards.
