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Taking Care of a Population One Patient at a Time

By Kathy Whitney
January 2010

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Famed clinician William Osler, M.D., once said, “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”

This is a favorite quote of Tom Elasy, M.D., director of the Vanderbilt-Eskind Diabetes Clinic, and associate professor of Clinical Research and Medicine. In the United States diabetes affects 24 million people or 8 percent of the population. While all diabetics share a common problem, the inability to regulate glucose, the way the disease affects them is impacted by myriad outside influences.

Recognizing that personalized medicine is really about the person, the Vanderbilt-Eskind Diabetes Clinic has developed several initiatives directed at caring for the individual patient from the inside out.

Tom Elasy, M.D., director of the Vanderbilt-Eskind Diabetes Clinic. Photo by Anne Rayner.

Tom Elasy, M.D., director of the Vanderbilt-Eskind Diabetes Clinic. Photo by Anne Rayner.

“Diabetes is a common, complex condition that has so far eluded our ability to achieve goals that we know would make a significant difference in the lives of individuals. Despite some decent data about the importance of controlling glucose, much of which was developed here at Vanderbilt, we’ve not been able to do that,” Elasy said.

Diabetes is further complicated by being a chronic disease that requires a good amount of effort after the patient leaves the doctor’s office. Patients must check their blood up to five times a day, monitor carbohydrate and nutrient intake, dose insulin according to what they eat, log their numbers, and plan ahead for prevention. All the while, they may be dealing with depression, job loss, marital trouble and any number of stressors.

“Too often caregivers have shrugged their shoulders and said, ‘there’s not much we can do.’ Increasingly, we’re being more creative about tending to that other aspect of care. It requires a lot of work outside the office, and we don’t control that. I think we’re seeing more and more folks trying to take ownership for that. It’s a joint model of care with the patient,” Elasy said.

At the foundation of that model are several initiatives designed with various patient populations in mind.

Teaching Tools
Russell Rothman, M.D., assistant professor of Internal Medicine and Pediatrics, has studied low literacy as an important barrier for patients. Some Vanderbilt studies have found that about 25 percent of diabetes patients have less than ninth grade literacy skills, and about two-thirds have less than ninth grade math skills. “We have been performing numerous studies demonstrating the challenges that many of our diabetes patients face, and designing tools to improve how we communicate and educate our patients with diabetes,” Rothman said. This has included training providers with the Diabetes Literacy and Numeracy Education Toolkit (DLNET). This toolkit includes more than 24 chapters that can be used in educating patients with diabetes and poor literacy or numeracy skills. Providers can use different sections of the toolkit as they see fit.

Your Avatar Will See You Now
With 46,000 patient visits to the Vanderbilt-Eskind Diabetes Clinic each year, there is more demand than there are exam rooms. Oftentimes, a patient needs information from his physician or nurse but does not require a face-to-face interaction. Second Life is a three-dimensional virtual world where patients create a visual model of themselves (an avatar) and participate in a simulated appointment with a virtual nurse practitioner. The software is currently in development to create different scenarios using the 3D graphics and incorporate video of high-fidelity simulators. Second Life will provide what video streaming and e-mail exchange cannot: a richer, interactive experience. “Second Life will supplement, not replace, the individualized care we give our patients,” Elasy said.

Time 4 UR Meds
Children with type 2 diabetes are often diagnosed during adolescence — at the same time that they are transitioning into adulthood, testing boundaries and taking more risks. So they are diagnosed at a time when they may be less responsive to dealing with health problems, particularly those that they may not see as an immediate threat to their health.

While their diabetes may not always be on their minds, their phones are usually in their hands. Shelagh Mulvaney, Ph.D., assistant professor in the School of Nursing and Department of Pediatrics, and Kevin Johnson, M.D., professor and vice chair of Biomedical Informatics, are conducting a new study to look at using text messaging to prompt children and teens regarding self management and medication. Mulvaney is evaluating the timing and content of the messages, which could be a generic reminder or a motivational message created by the patient.

One-stop Shopping
Diabetes care at Vanderbilt entered a new era with the opening of the Vanderbilt-Eskind Diabetes Clinic in 2005. The clinic offers comprehensive outpatient care for both adults and children with diabetes, including subspecialty visits, social work, nutrition and allied health services all under one roof.

The clinic is named for the late Irwin B. Eskind, M.D., (MD ‘48, HS ‘51) a retired Nashville physician and philanthropist who died from complications of diabetes. Its establishment is due largely to the generosity of the Eskind family who envisioned a more patient-friendly model of diabetes care.

As a diabetic himself, Eskind knew how inconvenient it is to have to go to five to six clinics to get care.

At the Vanderbilt-Eskind Diabetes Clinic patients can see physicians from nine different subspecialties in the same place. The clinic also is designed to provide a “seamless transition” from pediatric to adult care for adolescent patients when they turn 18.

“If we are going to improve both individual and population care, it is incumbent upon us, I think, to know the patient that we serve as much as we understand the disease,” Elasy said.





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