February 25, 2006
Question from Suffolk, Virginia, USA:
My question is about my stepson who lives in North Carolina. My husband and I recently got a copy of his medical records from his general physician. It shows that his son has not been to his pediatric endocrinologist for over a year due to missed appointments. His A1c has increased from 8.8 to 9.1 and we are concerned. Should the care of a juvenile with type 1 diabetes be limited to a general pediatric doctor? Or, is it essential that he see an endocrinologist every three months?
I should begin by telling you I am a pediatric endocrinologist. The trick to managing any disease is knowledge and, then, dedication. Diabetes isn’t so complicated that a general pediatrician can’t manage it. Most just don’t have the time. The numbers of kids that need to be seen, the sick kids, the shots, etc. can just overwhelm them. Being told you have 10 sick kids with the flu just doesn’t allow justice to the well child consult who happens to have diabetes. A pediatric endocrinologist doesn’t have such a schedule. Knowledge, too, isn’t the issue either. Most general pediatricians did care for kids with diabetes in training. The problem is a lot has happened since training. I tell patients when referred that it isn’t that their doctor didn’t do a good job at keeping them alive. A 9.1 A1c is more than alive; it is just that their doctor doesn’t make it his/her life’s work to keep the latest and best for kids with diabetes. (The latest isn’t always necessarily the best.)
That said, diabetes is a day to day adventure. Missing appointments, when they are far away, may have good reasons…unplanned tests at school, a trip, other illness, or other reasons. I guess it is a race for priorities and what is the priority for diabetes in the family. It can be hard for many families so we should not be too judgmental.
I also have families where I really wonder why they get in the car and drive so far to see me. They do not seem to be involved on a day-to-day basis. There are big holes in the glucose data or even a “forgotten” meter. Can you imagine parents don’t even know the dose of insulin!
I should imagine a committed family is likely the best “doctor” of all. Who gives advice and consults? I think the committed doctor. Can it be a general pediatrician? Sure, just not as often the case as one who makes the long-term commitment via training to diabetes, that’s all.