Diabetes management by residents in training in a municipal hospital primary care site (IPCAAD 2)

Purpose: Since diabetes is largely a primary care problem but we know little about management by residents in training - the primary care practitioners of the future - we examined surrogate outcomes reflective of their performance. Methods: A seven-week observational study was conducted in a typical training site - a municipal hospital internal medicine resident "continuity" (primary care) clinic in a large, academic, university-affiliated training program. We evaluated control of glucose, blood pressure, and lipids; screening for proteinuria; and use of aspirin relative to national standards. Results: Five hundred fifty-six (556) patients were 72% female and 97% African-American, with mean age 63 years, duration of diabetes 12 years, and BMI 34 kg/m². Patients were managed largely with diet alone (22%) or oral agents alone (40%); 7% used oral agents and insulin in combination, and 30% insulin alone. Hemoglobin A_1c (mean 8.2%) was above goal (<7.0%) in 61% of patients. Low density lipoprotein cholesterol (mean 128 mg/dL) was above goal (<100) in 76% of patients, but high density lipoprotein (mean 53 mg/dL) was at goal in 46%, and triglycerides (mean 138 mg/dL) were at goal in 85%. Diastolic pressure (mean 75 mm Hg) was at goal (<85) in 77% of patients, but systolic pressure (mean 143) was at goal (<130) in only 25% of patients. An average of only 53% of the patients had urine protein screening per 12 months, and use of aspirin was documented for only 39% of patients. Conclusions: Patients with type 2 diabetes in a typical internal medicine resident primary care clinic frequently do not achieve national standard of care goals. Since skills and attitudes developed in residency are likely to carry over into later practice, local diabetes educators may need to work with medical faculty to develop new interventions to improve post-graduate medical education in diabetes management.