While the nature of practicing medicine has evolved to become a more results-oriented industry, Sybil Kramer, MD, believes providers need to focus more on getting back to the cornerstone foundations of clinical practice including listening and understanding their patients and playing a more humanistic role which may include being a coach and a teacher.

By: John Parkinson, Clinical Content Coordinator, Diabetescare.net

Nearly five years ago, when endocrinologist Sybil Kramer, MD, was in private practice, she was starting to feel the effects of the changing tide of medicine. At that time, she had been practicing medicine for 25 years and was seeing the emphasis of medicine was shifting away from the human elements of empathy and understanding, as well as addressing patients’ concerns to focusing more on the metrics of medicine in initiatives like pay for performance.

And between pay for performance responsibilities, dealing with changing government laws, haggling with insurance companies, and a prevailing mountain of paperwork, Kramer felt like a lot of medical providers—exhausted in running her own practice and being a primary care physician as well as an endocrinologist. She decided to transition to a position in a hospital setting where she could focus solely on endocrinology spend more time treating specific patient problems.

After all her years in medicine, Kramer (pictured, lower right) knew that the nature of appointments had become a lot more complicated and that diabetes patients needed more information they could use on their own.  So Kramer created first a website, Diabetic Survival Kit, for patients and then more recently wrote a book, Creating Success in the Face of Diabetes. Kramer explains that they are both ways to supplement and help patients implement information provided by medical professionals.

DiabetesCare.net spoke to Kramer about her approach to clinical care, the ails of practicing modern medicine, features of her website, and the intended audience for her new book.

DiabetesCare.net: Can you provide a breakdown of the types of diabetes patients you are seeing?

Kramer: I see mostly adults, and 10-15 percent of them are type 1s and the rest are type 2s. I do have some LADA patients, approximately 5 percent.

DiabetesCare.net: What is your clinical treatment approach to patients?
Kramer: When I first started practicing, I thought patients who were difficult were difficult because of their disease.  As I started to become more experienced, I realized you don’t treat a disease, you treat patients who have a disease. I started to take into account what is really more important than labeling someone with diabetes is to say to the patient, ‘you have diabetes but you can still have a great life. Let’s work together to give you a great life.’

In that role, I have almost become a coach, as well as a physician. Patients need to know that their providers actually understand and care about them.  

I like to know what is going on in their lives, and how having diabetes is affecting them and their life challenges. For example, we now just finished up the holidays. Some friends and relatives may say to people with diabetes (PWD), ‘hey why don’t you have a little of this.’ And then other people may say to PWD, ‘why are you eating that?’ The patients are finding themselves caught between people that want them to act like everyone else and others who are the diabetes police. And the PWD just wants to be left alone to make his or her own decisions. It takes a lot of strength in learning how to deal with those situations.

DiabetesCare.net: You had mentioned through one of the social media outlets about seeing LADA patients and picking up clinical points and overall awareness of these patients. Why so?

Kramer: A lot of people will be diagnosed with type 2 and yet these patients might say, ‘ I don’t have type 2; I’m not overweight, I don’t eat too much.’ They feel different from other type 2s and don’t feel as if they belong in this group. The second thing is that their diabetes is different. They are all at risk for going into diabetic ketoacidosis. Their providers might be trying to manage them with diet, exercise, and oral agents when they really need insulin. Other times I will see people who are under good control, and the provider will try to taper them off insulin. And if they have LADA, they should not stop an insulin regimen. This group of people really needs a diagnosis and their health care providers have to really know how to treat them.

DiabetesCare.net: Turning to your website, diabeticsurvivalkit.com, can you tell us what the site is all about?

Kramer: I try to recognize special challenges that people with diabetes have and how it impacts their disease. I know when people are diagnosed for the first time, they leave their health care provider’s office feeling very overwhelmed. They hear the word diabetes and they become very upset. And no matter what I say, they may not be able to hear what I’m saying because they are still processing the news. They have so much to learn and need to be able to implement that information. So, one resource I provide from my website is a diabetes overview to enable the patient and their family members to learn more at their own pace. I try to be very upbeat about diabetes, so when people read that they might say, ‘I have to make some changes but my life isn’t over.’

Along with providing information about diabetes, another point of the website is to enhance the quality of life for people with diabetes.

We try to give them a sense of community so that don’t feel like they are alone; and I try to give them a sense of the research relating to diabetes in layman’s terms.

The website has about 80 cooking videos, and they enable patients to prepare diabetic friendly meals suitable for them and their families. Learning how to prepare these types of meals helps some of my patients cope better with their disease because they can eat healthier, feel better, and sleep better.

Just improving the quality of life and psychological wellbeing will improve their control.

DiabetesCare.net: Can you explain what people see with your cooking videos?

One of the big challenges I noticed was that a lot of people were eating fast foods and junk. I tried to figure out why they were doing this when they know it’s not good for them. I found out a large number of them don’t know how to cook and assume appropriate meals are expensive, difficult to prepare and cannot be enjoyed by the whole family. That is where I got the idea to put together cooking videos. My daughter, Tova, does all the cooking demonstration in the videos.  

For people that don’t know how to cook they can click on any video from a list on the website, and learn from start to finish how to prepare their meal. We have certain criteria we use before we put any recipes on the site. First the recipe has to look good and has to have a reasonable amount of carbohydrates. The ingredients also have to be easy to get. We film Tova preparing the recipe for the first time and if it appears to be too difficult then it doesn’t make its way onto the site.

Once we make the meal, we go through a taste test with our family to make sure it tastes good. We also include a table of contents so people can see all the videos on the site.     

DiabetesCare.net: Do you think food and nutrition are overlooked by providers?

Kramer: I think medical providers should do more than they possibly can in the course of an office visit  and are getting a bad name for all of the things we cannot do without getting any credit for the things they actually accomplish. There is only so much that can be done during each appointment. We are under more pressure. We have more paperwork and prior authorizations, and talking with insurance companies and fighting to get medications and procedures authorized. Physicians are highly stressed and exhausted. I am seeing physicians with burn out.

Picture having a patient  with a new diagnosis of diabetes who doesn’t know how to cook and has limited funds. The physician has to first stabilize the patient medically, answering all the patient’s medical questions, and then focus on the person’s nutrition situation.

It’s incredibly difficult. Most of the providers I know are incredibly dedicated people who are really working as hard as they can. They have limited time and resources.

DiabetesCare.net: You spoke of some of the practice management issues facing medical providers, what are the biggest clinical challenges facing diabetes medical providers today?

Kramer: We have to spend a lot of time analyzing numbers and meeting goals. And frankly, half the numbers that we look at are meaningless. There is so much pressure on providers that they don’t even know where to go anymore.

There was a time where providers in my area would be penalized for patients having an A1c of more than 7 percent. So, if you had a patient whose A1c was 11 and you worked them down to 8 percent, you would still get penalized.

So the physicians are penalized for helping these patients and keeping them in their practice. So in these cases, it encourages providers to take on patients with lower A1cs to start and patients who have minor health challenges. That isn’t how the medical profession is supposed to work; we are supposed to help everybody. Pay-for-performance metrics where doctors are getting report cards aren’t reflecting all the good doctors are doing.

DiabetesCare.net: So a pay-for-performance scenario is not really giving a true outlook of what a provider is doing for his or her patients?

Kramer: Right. It’s pay for reaching the goal. I would like to use a football analogy. If you move the football from your goal line down to your opponents’ one yard line and you are stuck there and you don’t get a touchdown, you don’t get any points. You don’t get credit for moving the ball all the way down the field.

This has physicians focusing on numbers and metrics. This is taking time out from the human side of practicing medicine.

The reality is if you can move somebody from an A1c of 11 percent down to 8, you are significantly reducing their cardiovascular risk. You are also significantly reducing their chances of becoming blind or developing kidney disease but you are penalized for not reaching the goal of 7.0.or less. On the other hand, if you start with patients who have their A1C less than 7 or move them say from 7.5 to below 7, you are rewarded. This provides incentives for attracting patients who are close to or at goal into your practice.

We need a system that encourages doctors to get back to being human beings and showing compassion and empathy. This is the heart of medicine, not numbers.

DiabetesCare.net: How do you show the compassionate side of medicine?

Kramer: You really have to get to know your patients as human beings. You need to understand all the pressure that is on them. For example, if someone is not following their diet. You can’t just say to that patient, ‘you need to be better about your diet.’  

A lot of people get frustrated in these situations and they don’t want go to the doctors. Now these patients may feel like they are doing the very best that they can.

I had one patient who came in and she was crying because her primary care physician was very upset with her. She wasn’t following her diet. However, she had lost four family members in five months.  

By truly understanding the person, you can help them improve. You may only be able to improve peoples’ health in little increments at a time, but they need you to understand that diabetes is an awful burden for them. When they know that you care, they are more open with you, and you can work together as a team.  

You have also written a book, Creating Success in the Face of Diabetes. Can you explain what the book is about and who its target audience is?

Kramer: The purpose of the book is to enable people to see the psychological and environmental influences that enable some people to have successful lives as well as to control their diabetes. After reading Think and Grow Rich by Napoleon Hill and seeing how he studied people who became rich and analyzed their common characteristics, I wanted to do the same thing for diabetes management.

I went through the lives of 12 people who had diabetes including how they handled their diagnosis and what characteristics in their lives made them successful in managing their diabetes. For example, patients need to learn to set goals and follow the guidelines provided by their health care provider. When they are not on target, they can use their results as feedback to keep making adjustments.They also need to be very disciplined and good at time management. These skills can help them take care of their diabetes and succeed in other areas of life.

The book also gets people thinking about what is important in their lives, whether it be managing their diabetes, or their jobs, or families. The book also helps people who don’t have diabetes to understand it better. For example, there was a woman who didn’t have diabetes that called me. Her sister had type 1 and she said to me, ‘for the first time, I know what my sister went through.’

For anyone interested in obtaining a copy of Dr. Kramer’s book, you can buy it here.