Type 2 Diabetes Mellitus and Cardiovascular Disease - Episode 8
Communication Between HCPs in Treating Diabetes
Troy Trygstad, PharmD, MBA, PhD; Tripp Logan, PharmD; Dhiren Patel, PharmD; and Javier Morales, MD, FACP, FACE, offer perspective on ways to increase communication and strengthen relationships between health care professionals to maximize care for the diabetic patient.
Troy Trygstad, PharmD, MBA, PhD: I want to talk about literacy of another type. As we’re having the conversation, we’ve learned a lot over the last few decades. We’ve invested a lot into understanding more about the clinician and patient interaction and how to optimize it—motivational interviewing, how to listen, how to be culturally competent. We’re still no good at it, but at least we’re aware of it and we’re trying to get better at it. We’ve learned, now, more around group medical visits, and what you’re describing as getting to peers and family members. So, patient to caregiver—we continue to work on that. And, patient to clinician. But, are we literate at health-care professional to health care professional communication?
So, I want to have a little bit of a discussion about how competent we are, as terminally degreed individuals, at communicating with each other and working with each other. It seems that this requires a multidisciplinary team, not just with diabetes but with patients who have diabetes, cardiovascular disease, and a whole host of other comorbidities. This is the hard part. We don’t train, perhaps, as much as we should train, in this area. But, for these patients with cardiovascular disease and diabetes, Tripp, what are the most important elements of care-team member to care-team member processes and communication? If we don’t do that, one clinician with that patient may not get it done.
Tripp Logan, PharmD: To me, it’s all relationship-based. There’s no standard. You’re not going to put a cookie-cutter out there, of template form, on how you should engage with each other. That wouldn’t work in any other part of the world, so why would that work with health care practitioners? It’s all relationship-based. In community pharmacy, what we’re guilty of is not getting out, from behind the counter, and engaging with our partners who are caring for the same patients. We don’t do that, nearly enough.
Troy Trygstad, PharmD, MBA, PhD: Interesting. So, what I hear you saying is, “I spend X% of my day speaking with patients, or patients’ representatives, or folks around them, or care providers, or caretakers.” What percentage of my day, if I’m in community pharmacy, am I in front of another health care professional?
Tripp Logan, PharmD: Even not in front of, but on the phone discussing a specific request or a problem. That’s what it is. I’m thinking of some of the most successful relationships we have, where we can really work with the local prescriber, their staff, our staff, and all really work together. It’s all people whose numbers are saved in my cell phone, who I can text. It’s relationship-based.
Troy Trygstad, PharmD, MBA, PhD: That may be the number 1 indicator of a successful relationship.
Dhiren Patel, PharmD:That happens.
Troy Trygstad, PharmD, MBA, PhD: Successful trust and relationship is that you have each other’s cell phone number.
Dhiren Patel, PharmD:You see this in the hospitals and with your partners. You want a quick curbside. What do you do? You take out your phone. You’re going to talk to your colleague, who you know is an expert in so and so, because you know you’re going to get that answer when you need it—not in 3 months from now, when you can book that specialist appointment for whatever it is that you wanted to talk about. I think it’s getting better, but there’s a lot of room for improvement. When we look at diabetes and cardiovascular disease, you see what’s happening. We frequent diabetes meetings, but now we’re also frequenting cardiology meetings. You’re seeing these roads come together, because there’s overlap there.
I’ll give you an example. At our institution, we previously would rarely get a consult from cardiology on something. Now that these medications reveal positive heart failure data or positive cardiovascular data, they understand the importance of putting these patients on it but they may not be comfortable in prescribing a diabetes medication. There are also considerations in the background of an insulin or an SU, where you would require modification of that agent that’s being started. And so, that’s opening it up. But, something else forced it to be that way. Even with nephrology, they’re like, “Hey, we have a patient. We know there is some renal data with this drug. Can you consider or evaluate this patient for it? They haven’t used it in that capacity, and it’s new to them.” So, I think that it’s about starting these relationships. We’re hoping that we can continue to build on them. But, it shouldn’t be the science that drives it. We should be taking that holistic patient approach—again, having those lines of communications open. It’s easy for me to sit here and say that, but I think that’s going to have to be the next wave. Everyone is going to have to own that patient.
Troy Trygstad, PharmD, MBA, PhD: It’s interesting. I grew in primary care. I spent 15+ years with Community Care of North Carolina. It was really the exclusive focus before we decided to dive into community-based pharmacy. I would run across a lot of pharmacists who would say, “Well, from time to time, there’s a little bit of tension.” Or, “I’m trying to relationship-build between the pharmacist and the physician and it’s not always pretty.” And I would always tell them that if you think it’s bad between pharmacists and physicians, you should get 2 physicians in a room who don’t agree. So, I’m interested in Dr. Morales’ experience? You’re a generalist. You’re a primary care provider. There’s a cardiologist following this patient with diabetes. You’re on point for diabetes. They’re on point for cardiology.
Javier Morales, MD, FACP, FACE: Where is the overlap? Where does the overlap occur?
Troy Trygstad, PharmD, MBA, PhD: Yes, where is the overlap? Can you describe that? What does that look like? How do we solve this problem of who’s on point for what, and where does it overlap? Is it relationships? It’s just a matter of a working relationship.
Javier Morales, MD, FACP, FACE: Yes. At the end of the day, it’s always going to end up being based on the relationship. And, it’s always going to be communication and emphasizing the need. In my practice, in particular, we never really make any changes to any cardiac medications unless we talk to the specialist who is talking to the patient. Likewise, if the cardiologist reads the data and feels compelled that this patient may benefit from a GLP-1 receptor agonist to reduce cardiovascular risk, or an SGLT2 inhibitor, they’re not going to or they may feel uncomfortable initiating it. They don’t know what the effect on glycemic control may be. It’s out of the realm of their expertise. But, they’ll call us and they’ll emphasize or speak to us. Likewise, sometimes we make a medication recommendation to our patients that may be to their benefit. But, the patient may not feel the need to move forward with that change. The cardiologist then becomes instrumental in further emphasizing why it’s important to do it.
Troy Trygstad, PharmD, MBA, PhD: Reinforcement.
Dhiren Patel, PharmD: It’s the second time that they’ve heard it. And, anecdotally, I always joke with the folks who I’m teaching. If you ask a patient, from their perception, whose weight matters more, or whose recommendation matters more, it’s always their heart doctor. They associate it to the organ. “They’re keeping my heart healthy.” Whereas, if you’re seeing the diabetes specialist, they say, “Oh, they just keep increasing this dose.” Or, “They keep adding another medication.” And so, I’ll take that. If they even put in their note or acknowledge that I agree that this patient needs a GLP-1 or an SGLT2 inhibitor, we’re happy to do the second part of it and initiate that. But, now it’s like, “Yes, my cardiologist also told me.” And so, that just shaved off 15 minutes of you having to tell them why it’s also important for you to go on it. I’ll take that collaborative action any day.
Javier Morales, MD, FACP, FACE: You know, we’re all forced to use electronic medical records, nowadays. The problem is, you have hundreds of EMRs that are out there, and not one communicates with another. So, you could make your recommendations in a note, and you could send your letter off, but, in the perfect world, all of these EMRs would integrate and you could see what the point of view was, from specialist to specialist. It further makes life easier. We’re at the crux of technology, but we’re in the need to further refine that technology to make it more user friendly for us, the practitioners, and patients, because they also have access to those records. They could review the information.
Troy Trygstad, PharmD, MBA, PhD: One of the things that’s interesting about what you just mentioned with combination therapies is you wonder if combination therapies have brought about an increased discussion, an inter-professional discussion, between health care providers. I go back to the early days of health information exchange. It was remarkable when everybody had to think about health information exchange. You’d get a meeting together, with the relevant parties included. You’d get together and you’d start talking about health information exchange. Lo and behold, you’d find out that none of the folks in the room had ever talked with each other. My observation was that they started having conversations about things that weren’t about health information technology. They needed to work together, but they had never been in a room together. They’d been forced there because of health information technology, putting it together, some regulation, and so on, and so forth. I wonder if it’s the same with combination therapies—you have this circumstance where you do need more than 1 prescriber, or health care professional, looking at it? It almost forces, on some level, relationship building. Has that been your experience at all?
Dhiren Patel, PharmD: I think it definitely helps. It’s a start in the right direction. But, again, it goes back to that ownership. I think what we’re really afraid of is, “Well, I don’t want to step on that person’s toes, right?” Everyone is trying to stay within their lane, without pissing the next person off. But, I think there’s going to have to be some back and forth. If this becomes the gold standard, and this is what’s now in the guidelines, saying that you’re considering these agents in those patients who have established cardiovascular disease—in 3 to 5 years, those cardiologists are probably going to get comfortable. They see enough, do enough. They’re smart individuals. They might not need us. We’re going to have to be alright with that—that someone just started a diabetes medication that has cardiovascular properties, and vice versa, and that we might add something that’s also going to have cardiovascular implications. I think that’s going to have to be alright, because more of that cross-training that will be happening will force the silos to kind of go away.
Troy Trygstad, PharmD, MBA, PhD: Yes. Well, for my money, if you’re telling me that dad can go on a therapy that positively affects both diabetes and cardiovascular risk reduction, and there’s a benefit of a forced conversation between 2 of his prescribers, it’s a win-win, from my perspective, as his son.