When to refer to an endocrinologist   (July 4, 2007)

Many people with diabetes receive their medical care from general physicians, including Family Physicians and Internists (specialists in Internal Medicine). And some people receive most of their care from a specialist (so some folks with diabetes might be receiving most of their care from a cardiologist, for example).

It is a frequently asked question: When is it appropriate for a general physician to refer a person with diabetes to an endocrinologist?

There probably will be differences of opinions about the answer, depending to a large extent on the "comfort level" of the general physician about caring for diabetes. Here are some thoughts on the subject of when referral is appropriate.

1. At the time of the initial diagnosis of diabetes. If the physician doesn't have the time or the resources to do the initial patient education, referral is critical to the development of a well-trained, well-motivated, independent patient.
2. When a patient with Type 2 diabetes is on two different diabetes pills, and still has high blood sugar levels or elevated glycohemoglobin levels. In this situation, the choice of using a third pill, or adding insulin, or reassessing exercise, meal planning, and stressors, requires someone who is very used to dealing with complicated situations.
3. When a patient with Type 1 diabetes is on routine therapy and frequently crashing into hypoglycemic reactions, or still has high sugar levels (or both!). The decision to initiate a complex basal-bolus program of injections, or using an insulin pump, requires a physician who has experience with these programs.
4. When a new complication appears (for example, retinopathy or nephropathy). The development of complications requires a reappraisal of the status of the diabetes program, as there is now evidence from the DCCT and UKPDS studies that aggressive therapy of the complication, and of the diabetes itself, will slow the progress of the disease.
5. When a person with diabetes is hospitalized for any reason, and their blood sugar is high. Although occasionally the blood sugars might stay okay, when there's high stress from an acute illness, combined with inactivity, it's likely the blood sugars will go way up. The risks of poor healing from high sugar levels, with consequent prolonged hospital stays, is reason enough to ask an endocrinologist to assist.
6. When the patient requests consultation.
7. Newly arrived, previously diagnosed patient who says they are "brittle." The term "brittle" is poorly defined; it implies both high and low blood sugars (see above). When a patient first comes into a practice already bearing this label (whether self-diagnosed or diagnosed by a previous physician), getting the help of an endocrinologist to assess the situation seems obvious.
8. If the patient's job or school schedule changes, and previous diabetes control disappears, and neither the doctor nor the patient can figure out what to do to reestablish control.
9. Any child with diabetes. The younger the child, the more important it is to find a pediatric endocrinologist.

Implicit in this discussion are some other issues: will the endocrinologist "take over" the complete care of the patient, or manage only the diabetes and leave the rest of the patient's care to the previous physician (which is termed co-management), or advise on a one-or-two visit basis then return the care of the patient completely to the first physician (consultation)? For many patients with diabetes, consultation or co-management seems a reasonable solution. It is rarely appropriate for any specialist to take over the total care of the person with diabetes.

There is another category of referrals that every physician dealing with people with diabetes should routinely use. All people with diabetes should have access to:

• a diabetes nurse educator (preferably one with the CDE credentials).
• a dietitian (preferably one with the CDE credentials).
• an eye doc (ophthalmologist or optometrist).
• a podiatrist (foot doctor).