Are residents receiving the training needed within their residency programs to optimally manage patients with diabetes?

ABSTRACT

Objective: Diabetes is a prevalent and growing problem in the United States (U.S.); primary care physicians need to be prepared to initiate and progressively advance treatment. The objective of this study was to understand how diabetes management is taught in U.S. Family Medicine (FM) and Internal Medicine (IM) residency programs.

Methods: Invitations to complete an online survey were sent via postal mail to U.S. FM and IM residency programs in 2019.

Results: Directors/associate directors from 68 FM residencies and 66 IM residencies completed the online survey out of 645 (10.5%) and 505 (13.1%) programs, respectively. Most respondents rated cardiovascular disease and risk management in diabetes as ‘very important’ (90%), but only about half (47%) did so for newer generation insulin analogs and 27% for digital health technologies. About two-thirds of programs cover non-insulin options for type 2 diabetes (66%) and types of insulin (63%) to a great extent, but only about one-third of programs cover social determinants of health (36%) and pre-diabetes (35%) to this degree. Many programs report plans to expand training on cardiovascular disease and diabetes (59%), but only 32% plan to expand training on digital technology for diabetes care. Lack of faculty time and competing priorities are cited as being the biggest barriers to expanding diabetes training.

Conclusions: Our study found that the current U.S. FM and IM residency program diabetes curricula are dominantly oriented toward cardiovascular disease and ‘traditional’ insulins. A variety of training materials and resources could help overcome some of the current barriers to curriculum expansion of other important components of diabetes care that may help future physicians successfully manage diabetes with newer generation insulin and glucose monitoring technologies.

Abbreviations: U.S: United States; PCP: Primary Care Physician; FM: Family Medicine; IM: Internal Medicine; CGM: Continuous Glucose Monitor; AAFP: American Academy of Family Physicians; ACGME: Accreditation Council for Graduate Medical Education; U/mL: units per milliliter; CME: Continuing Medical Education.

KEYWORDS:

• Diabetes
• diabetes management education
• family medicine residency curricula
• internal medicine residency curricula
• graduate medical education
• primary care training
• resident

Introduction

Diabetes is a prevalent and growing problem in the United States (U.S.); 34.2 million people have diabetes (10.5% of the population) and an additional 88 million individuals aged 18 years or older have prediabetes (34.5% of the adult population) [1]. Furthermore, researchers estimate about 7.5% of pregnancies have gestational diabetes complications [2], with these individuals having an increased chance of developing type 2 diabetes later in life [3]. In fact, diabetes is one of the most common diagnoses physicians-in-training will encounter in their residency training programs and in clinical settings [4]. Taken together, these data demonstrate the importance of understanding diabetes care and management.

The American Diabetes Association (ADA) Standards of Care discuss the importance of good diabetes control to prevent or delay both microvascular complications (i.e. diabetic retinopathy, neuropathy, and nephropathy) and macrovascular complications (i.e. stroke and myocardial infarction). The training residents gain in Family Medicine (FM) and Internal Medicine (IM) residency programs provide a critical foundation for their knowledge on diabetes management; however, previous studies show room for improvement in FM and IM residents’ knowledge of core competencies of diabetes care [5,6].

The relative paucity of U.S. practicing endocrinologists (7,495) compared to family medicine/general practice (113,514) and internal medicine doctors (115,557) [7] necessitates greater self-reliance on the part of primary care physicians to initiate and progressively advance treatment, including complex insulin-inclusive regimens and newer technologies as part of meeting their patients’ diabetes care and management needs [8]. Digital technologies for diabetes care include everything from continuous glucose monitoring (CGM) to digital dosing support and involves collecting data from various sources to improve outcomes [9,10]. CGM can be used to monitor for hypoglycemia, which has been associated with the risk of cardiovascular complications and mortality [11]. The American Diabetes Association Standards of Medical Care in Diabetes recommends the use of technology based on individual patients’ needs and describes the benefits of CGM use in both patients with type 1 and type 2 diabetes [12], thus training should be provided to ensure PCPs are more aware of and are comfortable using these additional care tools as well as the potential limitations of CGM use on hypoglycemic events in type 2 diabetes [13]. Additionally, recent research has shown the importance of considering measures other than hemoglobin A1C, including time-in-range [14] and glycemic variability [15]. Previous research has also shown that the use of an online patient portal for web-based disease management can improve patient outcomes for diabetes [16–21] and prediabetes [22]. However, few PCPs utilize these portals [23].

Our Internal Medicine and Family Medicine Residency Curriculum Benchmark Study sought to understand how diabetes is currently being taught in internal medicine and family medicine residency programs in the U.S. The study focused on understanding inconsistencies between the professional provider competencies and current IM and FM curricula, as well as understanding barriers to implement the competencies in IM and FM residency training. We considered diabetes education in the context of the 2020 American Diabetes Association Provider Competencies [8], and explored the coverage of emerging therapies and technologies in residency curricula.

Materials and methods

Program directors across the U.S. were identified for 645 FM residency programs through the American Academy of Family Physicians (AAFP) program directory [24], and for 505 IM residency programs through the Accreditation Council for Graduate Medical Education (ACGME) public directory [25]. Further web searches identified a total of 917 directors, associate directors, and assistant directors of family medicine residency programs and 1,105 for internal medicine programs. Potential respondents were invited to participate in this cross-sectional, anonymous study between November 2019 and January 2020 through a postal mailing with a letter identifying the study sponsor (Novo Nordisk), study objectives, participation requirements, and a modest prepaid incentive. Non-responders after the first mailing received a second mailed invitation with the prepaid incentive, along with follow-up faxes and e-mails to remind them to participate. All respondents consented to participate in the survey. Potential IM survey respondents were required to be affiliated with categorical or preliminary/categorical combination residencies programs. Responses were restricted to one representative per IM or FM program to ensure consistent data and representation across institutions. The study was reviewed by the Western Institutional Review Board and was found to qualify for exempt status.

The online survey included 28 questions addressing the structure, format, content, and setting of diabetes education and included multiple-choice, scalar, and numeric text questions. Using a 4-point Likert scale (‘great extent,’ ‘some extent,’ ‘very little extent,’ and ‘not at all’) respondents were asked to assess the degree to which their curricula addresses core diabetes care and management topics, as well as emerging topics in diabetes care. Respondents were also asked about the importance of a variety of diabetes care topics, their familiarity with different diabetes topics, their expectations regarding future expansions of diabetes topics in the curriculum, and barriers to these expansions. See Additional File 1 for the complete FM survey and Additional File 2 for the complete IM survey.

We performed descriptive statistical analyses (means, frequencies) using SPSS Statistics for Windows 23 (SPSS, Chicago, Illinois) and Stata/IC 14.1 (Stata Corp, College Station, Texas). Data are presented as number and percentage for categorical variables, and continuous data expressed as the mean ± standard deviation (SD) unless otherwise specified.

Results

Characteristics of respondents

A total of 68 out of a potential 645 FM residency programs (response rate of 10.5% of invited programs) and 66 out of a potential 505 IM residency programs (response rate of 13.1% of invited programs) responded and completed the survey. Median length of time to complete the survey was 12 minutes. These programs were representative of the full set of FM and IM programs both geographically and by type of program. Nearly all of the respondents were either program directors or associate/co-program directors and had been in their current roles for an average of about 8 years. Almost all (99%) contribute to the decisions made regarding the curriculum at their institution and all teach/train residents. See Table 1 for sample characteristics.

Table 1. Characteristics of 2019 family medicine and internal medicine residency online survey respondents and their institutions (n = 134)

Title/Role	n (%)^a
Program Director	79 (59)
Associate Director or Co-Director	49 (37)
Assistant Director	4 (3)
Other	2 (1)
Academic Experience	Mean (mean ± sd)
Mean years in current role	7.9 ± 6.7
Structure of Residency Program	n (%)^b
Categorical	33 (50)
Combination of Preliminary and Categorical	33 (50)
Residency Programs
Family Medicine	Survey Sample n (%) (n = 68)	US Family Medicine Programs^d (%) (n = 645)
Type^c
Community-based, medical school administered	8 (12)	14
Community-based, medical school affiliated	39 (57)	61
Community-based, nonaffiliated	9 (13)	11
Medical school based	10 (15)	11
Military	0 (0)	1
Unlisted	2 (3)	2
Region
Midwest	22 (32)	28
Northeast	12 (18)	18
South	19 (28)	32
West	15 (22)	22
Internal Medicine	Survey Sample n (%) (n = 66)	US Internal Medicine Programs^e (%) (n = 505)
Type^c
Community based	14 (21)	23
Community based, university affiliated	39 (59)	48
Medical school based	11 (17)	27
Military	2 (3)	2
Region
New England	6 (9)	7
Mid Atlantic	20 (30)	23
East North Central	12 (18)	20
West North Central	0 (0)	5
South Atlantic	11 (17)	18
East South Central	3 (5)	4
West South Central	4 (6)	8
Mountain	3 (5)	5
Pacific	7 (11)	11

SD; Standard Deviation. ^aPercentages may not sum to 100% due to rounding. ^bOnly asked for Internal Medicine programs. ^cTypes are not mutually exclusive for the sample or the population. ^dReference characteristics of family medicine regional and affiliation AAFP programs, AAFP database [24]. ^eReference characteristics of internal medicine regional and affiliation ACGME programs, American Medical Association’s FREIDA database [26].

When asked about their own preparedness in managing diabetes, three-quarters (75%) of respondents felt ‘very prepared’ to diagnose and treat cardiovascular disorders among patients with diabetes. However, only about one-quarter (28%) felt ‘very prepared’ to use newer generation insulin analogs (e.g. insulin glargine 300 U/mL and insulin degludec 100 U/mL or 200 U/mL – as defined in the survey) and very few (6%) felt ‘very prepared’ to use digital health technology for diabetes care (such as insulin pen connectivity, insulin pumps, automated insulin delivery, CGM, patient diabetes management tools). In contrast, about one-tenth (9%) of respondents felt ‘not all prepared’ to use newer generation insulin analogs and four in ten (39%) felt ‘not at all prepared’ to use digital health technology for diabetes care.

Perceived need for education

Residency program directors consider cardiovascular disease and management of comorbidities to be highly important educational topics, followed closely by lifestyle management and glycemic targets. Education focusing on cardiovascular disease and risk management (90%) and comprehensive medical evaluation and assessment of comorbidities (88%) are the diabetes topics most likely to be rated as ‘very important’ by program directors (Figure 1). Other topics are not seen as being as important, with only about half (47%) of respondents rating newer generation insulin analogs as being ‘very important’ and only about one-quarter (27%) considering digital technology for diabetes care to be ‘very important.’

Figure 1. (a) Panel 1. Stated importance of education on diabetes care and management in residency programs.s

Figure 1. (b) Panel 2. Stated importance of education on diabetes care in management and residency program

The actual coverage of diabetes care and management topics in residency programs reflect the importance placed on them by residency program directors. Overall, core topics are well covered (Figure 2). This includes coverage to a ‘great extent’ by about two-thirds of programs for topics such as non-insulin options for type 2 diabetes (66%) and types of insulin (63%). Other topics, including titration of insulin dose (46%), social determinants of health (36%), and management of pre-diabetes (35%) are covered to a ‘great extent’ by a much smaller percentage of residency programs. The application of digital technologies in diabetes management and care is barely covered at all in many programs, with respondents choosing ‘not at all’ or ‘very little extent’ for this topic about half of the time (51%). When considering possible glycemic targets, A1C (100%) and self-monitoring of blood glucose (85%) are taught in the vast majority of residency programs. In contrast, very few programs teach continuous glucose monitoring (21%) or time-in-range (9%).

Figure 2. Coverage of diabetes care and management topics

Some competencies have been shortened for presentation. Responses of  'some extent' not shown.

The residency program directors were asked about their own familiarity with a variety of digital health technologies for diabetes care. Four in ten (40%) are at least ‘very familiar’ with CGM (Figure 3). However, of the respondents that are at least ‘somewhat familiar’ with CGM, only about half (52%) of their institutions actually use the technology to at least ‘some extent’. Across all of the digital technologies discussed in the survey, of those respondents that were at least ‘somewhat familiar’ with these technologies, there were varying levels of actual use of the technology by their institutions, with the vast majority of institutions using self-monitoring of blood glucose (89%) to only about one-third (29%) using telehealth.

Figure 3. Familiarity with digital health technologies for diabetes care

Priority to expand diabetes education in the curriculum

Many of the residency programs have plans to expand the diabetes curriculum. The expansion plans mainly focus on topics that are already the focus of the diabetes curriculum, with six in ten (59%) planning to expand training on prevention and treatment of cardiovascular disease among patients with diabetes (Figure 4). However, only four in ten (41%) of programs have plans to expand training on newer generation insulin analogs and only about one-third (32%) plan to expand teachings on the use of digital technology for diabetes care. The timeline of these planned curriculum expansions also varies depending on the topic. Two-thirds (65%) of those planning on expanding teachings on cardiovascular disease among patients with diabetes are currently expanding these teachings and about half (51%) are currently expanding teaching on newer generation insulin analogs. Expansion plans for the use of digital technology for diabetes care are further out for many of the programs planning to expand these teachings, with only about one-quarter (28%) currently expanding this topic.

Figure 4. Plans to expand curriculum

Training time is a barrier to expanding diabetes education in the residency curricula (Figure 5). Almost half (44%) of programs consider inadequate faculty time allocated to train residents in diabetes care and management to be a large or moderate barrier and over half (54%) say competing priorities with other disease care areas is a large or moderate barrier. In contrast, inadequate access to emerging research is only a small barrier or not a barrier at all for most programs (78%).

Figure 5. Barriers to expanding diabetes education/training in curriculum

Discussion

IM and FM residency programs currently focus on core diabetes care and management topics, which provide a solid educational foundation; however, less attention is given to newer generation basal insulin analogs (e.g. insulin glargine 300 U/mL and insulin degludec 100 U/mL or 200 U/mL) or digital health technologies (such as insulin pen connectivity, insulin pumps, automated insulin delivery, CGM, and patient diabetes management tools). Although the current ADA Standards of Care and the American Association [27] of Clinical Endocrinologists and American College of Endocrinology (AACE/ACE) [28] guidelines provide little guidance on the use of newer generation insulin analogs despite a recognition of their potential benefits, both ADA [12] and AACE/ACE encourage use of various digital technologies including CGM which is positioned as a tool to help lower A1C levels and/or reduce hypoglycemia.

Residency programs are adequately covering glycemic treatment goals (particularly A1C and self-monitoring of blood glucose) and comorbidities and complications of diabetes, and some of these residency programs are aware of concepts such as time-in-range and its potential implications. However, very few programs are covering diabetes-related digital technologies. The current curricula reflect the familiarity of the residency program directors with various digital health technologies for diabetes, as well as the use of these technologies at institutions where the program director is familiar with the technology, which could potentially be due to the socio-economic status of their patient population or other external factors.

Most of the focus on expanding the diabetes curriculum is on topics that are already being covered, with less focus on expanding topics currently not well covered, such as digital health technologies. The focus of curriculum expansions on areas that are already well-covered may result in a continued slow adoption of new technologies and treatments/treatment paradigms [29,30]. As patients continue to have positive experiences with and recognize advantages of CGM [31–33] and other digital tools that can have a significant benefit to patients [16–22], it will be incumbent upon residents to gain sufficient comfort with these methods to effectively apply them and guide patients on their use. Program directors cite lack of faculty time and competing priorities as the greatest barriers to curriculum expansion. However, these barriers do not reflect the choice being made to focus on diabetes topics already being covered when they do expand the curriculum. Lack of familiarity with the topics are likely what is limiting the expansion of the curriculum for digital health technologies, despite the cited high level of access to emerging research.

Beyond re-aligning curriculum expansion plans, there are additional resources that could be implemented to improve residents’ knowledge. For example, virtual case-based simulations of diabetes interventions improved core competencies in residents [34]. A similar strategy could be utilized with digital health technologies. Additionally, providing order sets, pocket cards, lectures, or rounds related to specific diabetes knowledge to first-year residents improved resident knowledge on diabetes core competencies [35]. Providing similar types of information, including currently available CME courses online, on topics currently not well covered would expand the knowledge of the residents. Finally, a group of family medicine residency programs developed a learning collaborative on diabetes care, resulting in improved care in these practices. The researchers attribute this to the focus on evaluating care and regularly reporting activities to peers at other institutions [36]. A similar technique could allow for the sharing of resources (including expertise between faculty) across programs to leverage knowledge and create a focus on improving skills and outcomes.

This research is limited to its cross-sectional nature, the relatively small sample size, a response rate ranging between approximately 11% and 13%, and how well our sample of 134 residency programs reflects the broad population of family medicine and categorical internal medicine residency programs in the United States. However, the sample includes a representative distribution with respect to program affiliation and geographic region of the larger universe of residency programs. The sample methodology was not random, thus potentially introducing responder bias. The respondents who participated (or their institutions) may look different due to time restraints, institutional policies, comprehensiveness of diabetes curriculum, perceived importance of diabetes education, or other qualities. We believe our results are generalizable as responder bias here would likely result in ‘better’ programs responding, or at least fewer poorly performing ones from responding. Some of the reported data, including diabetes care topics covered, personal and resident preparedness, and the prioritization of diabetes education, are subjective. However, we believe this bias is conservative; respondents are more likely to have overestimated what is being taught on diabetes care and management. Lastly, we were not able to directly survey graduating family medicine and internal medicine residents to assess their preparedness to utilize the variety of diabetes care and management tools available to treat patients with this disease. Our findings can shed a spotlight on potential additional education in other residency programs as well.

Conclusion

Currently, most FM and IM residency training programs focus on the core diabetes care and management topics. There is much less focus on emerging topics, such as newer insulin analogs and digital health technologies, particularly for outpatient care. These topics are also relevant for the future of diabetes care and as diabetes care and management guidelines continue to evolve, addressing these topics in residency programs will likely help prepare physicians to provide care and solutions that meet the needs and goals of individual patients in hospital and ambulatory care settings. We proposed some possible solutions to fill these gaps, and more work should be done to identify ways to better prepare residents to provide better diabetes patient care.

Declaration of financial/other relationships

JM is a consultant for Novo Nordisk Inc, Eli Lilly, Bayer, Janssen Pharmaceuticals, Boehringer Ingelheim, Abbot Pharmaceuticals, Intarcia. On the Speakers Bureau for Novo Nordisk, Eli Lilly, Boehringer Ingelheim, AstraZeneca, Janssen Pharmaceuticals; and on the advisory boards for Novo Nordisk, Eli Lilly, Bayer, Boehringer Ingelheim, Intarcia.

LK is a consultant for Sanofi, Eli Lilly, Novo Nordisk, Boehringer Ingelheim and Pfizer.

FL is on the Speakers Bureau for Janssen Pharmaceuticals.

MS is a Senior Medical Director employed at Novo Nordisk Inc.

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Declaration of interest

No potential conflict of interest was reported by the authors.

Acknowledgments

The authors would like to acknowledge Rebecca Hahn (KJT Group) for her medical writing assistance.

Additional information

Funding

The study was funded by Novo Nordisk