A bad miss

A delightful 78-year-old woman with Late Autoimmune Diabetes of Adults (LADA) — a seeming increasingly common diagnosis in my practice — came for a clinic visit after she had followed my recommendation that she see the podiatrist. She was full of good cheer and excitedly told me that the podiatrist has used a vacuum cleaner to remove a small sliver of glass from the sole of her left foot. The referral to podiatry followed my examination of her legs and feet, which revealed a significant peripheral neuropathy without evidence of peripheral vascular disease. I had noticed something unusual on the sole but shamefacedly, I did not pursue it at the time and simply made the referral to podiatry.

I certainly learned an important lesson from that, but that is not the main point I want to get across. The majority of patients with diabetes referred to an endocrinologist are sent because glycemic control is sub-optimal. That first visit is devoted predominantly to patient education and making appropriate adjustments to their therapy for diabetes. Most patients have had regular follow-up of HbA1c (too many think that’s all that needs to be followed and it is the doctor’s responsibility, not theirs) but fewer have regular monitoring of microalbumin.

Most patients have an eye exam on an annual basis but, again, all too often it is an examination for their vision and not for monitoring their eyes to check for retinopathy. This is one area we can improve on quickly: the patients have health care insurance that covers an annual eye examination but do not realize that an examination for retinopathy is covered as a medical visit and may be needed more often than annually.

Too few patients do not have regular examinations for peripheral neuropathy or other aspects of foot care, and many report that they have never had such an examination. The extent to which we (endocrinologists and PCPs alike) neglect this is highlighted in a “must-read” brief article in Diabetes Care. The personal and financial costs of this oversight should serve as a wakeup call for all of us.

Disclosure: Dr. Kleerekoper reports no relevant financial disclosure.

For more information:

Campbell LV. Med J Aust. 2000;173:369-72.
Herman WH. Diabetes Care. 2005;28:1480-1481.
Kanji JN. JAMA. 2010;303:1526-32.