Noah Nesin, MD
Interview with MMA's Diabetes Prevention Project Physician Champion, Noah Nesin, MD
Name: Noah Nesin, MD
Title: Vice President of Medical Affairs at Penobscott Community Health Care
Specialty: Family Medicine
State Medical Society: Maine
What would you like members to understand about diabetes prevention?
I think the members of the medical association certainly understand the challenge that diabetes presents in our society, and in our communities and in our practices. And I think that primary care in general is overwhelmed and time-pressured and so just dealing with people who have chronic diseases requires a high level of work and energy. But if we can take a moment to look at prevention, especially around a disease like diabetes, and creating a level of education and awareness for our patients that would allow them to avoid the problem in the first place or at least mitigate its impact very significantly then it’s worth the effort on the other end of the process. So although we tend to be fatalistic about outcomes, I think it’s really critical that people understand that early intervention, early education for people at risk or people who just care about healthy life and healthy lifestyle, can have a profound impact on a population of patients.
What role do physicians and healthcare teams play in diabetes prevention?
I want to emphasize the team aspect of it, and that is, a physician who’s helping to lead a team, caring for a patient and a panel of patients. Also, especially in primary care, I would argue, there’s an additional responsibility to their community and to society at large to promote healthfulness and to promote choices that allow people to live healthy lives. That requires partnership within the practice and the team so that the burden doesn’t fall all just on the physician, or a nurse practitioner or a PA, depending on the circumstance, but that work is shared among all the members of that team. But also the partnering with all of the people and entities that can help advance that work in their community and creating an awareness and understanding of the importance of engaging, not only the patients themselves, but the context of their life, that is the entire community. And an awareness and an understanding of the impact of choices we make on our health outcomes and an interest in addressing those choices is key to our role. It isn’t just taking care of the patient or just caring for our own panel of patients but our responsibility to our community at large.
What type of impact do you feel physicians and care teams can have in helping stem the tide of type 2 diabetes?
So not withstanding what I just said about it being the responsibility of the entire community, there’s no question that physicians and primary care providers and their teams are fundamental to the efforts. Not only will our individual patients take cues from us about what’s most important, but our practice will and our community will. And if we can message consistently and in an accessible manner the importance of prevention, the importance of engagement in your own health outcomes and the importance of that engagement occurring early in your life and consistently throughout your life, if we’re able to message that consistently and powerfully enough, there’s a significant percentage of the population of people that we serve who will take that to heart and make changes in their life, especially if we apply strategies to those conversations that we know work like motivational interviewing. And so we aren’t the entire answer, but we have to be the start of the answer or they won’t catch on.
How can members become invested in helping address diabetes prevention in their patient population?
We’ve been talking about patient engagement a lot, but this question really gets at provider engagement, physician engagement, which is challenging because physicians and primary care providers, of all stripes, PAs and NPs, as well, are already invested in all kinds of really important work and invested in the care of their individual patients. Lots of them are doing lots of other good work as well. So each new initiative feels like one more straw on the camel’s back that’s really hard to tolerate, yet this is a really critically important big challenge with potential big impact. And any improvement that we can make on it is the sort of burden that diabetes creates on the health of our population in this country. So understanding that big picture and prioritizing are the things that can make the most difference in the health of our patients is one way of getting that. And I think the other key aspect to anybody’s ability to invest and engage in this important undertaking is to make sure they’re taking care of their own energy and their own needs so they have the capacity to do the work. And I think all of us in healthcare have an obligation to advocate for that for ourselves, and those of us who have roles of leadership in healthcare have an obligation to make sure that we are providing the resources and creating a work environment that enhances rather than deters a physician’s ability to maintain energy and build resiliency.
What steps has your medical society taken to spread awareness around diabetes prevention?
The Maine Medical Association has undertaken this diabetes initiative under the auspices of the American Medical Association. It’s really just getting rolling in Maine, although obviously any responsible medical society has been talking consistently about the major challenges to public health and individual patient health, and diabetes has long been on the front burner of things that we wish to address. The other thing that the Maine Medical Association had done is we’ve developed an academic detailing program, and I think it was the first academic detailing module that we were able to provide around the state at no charge that was on evidence-based treatment of diabetes. This obviously goes well beyond that and the idea of the prevention of diabetes, and we’re excited about the potential impact it could have.
How effective have those methods been? Please explain.
For the academic detailing initiative, we have process metrics, so we know how many practices we’ve been able to get that program into. We know how many providers have heard that information. We get feedback on the quality of the information and lots of feedback on intention to change the practice or to make a change in their approach to treatment of whatever the topic is, and that would certainly be true of diabetes. And we have a pretty high level of response rate of that kind of intention. I would say we don’t have data on actual outcomes, on how people actually may change as a result of those kinds of interventions.
What tools do you believe members will find most useful in helping patients prevent diabetes?
I think if we’re assuming that people have time to engage in this, and that’s going to be key, that this will have to be a priority for a physician, a provider and for the practice. That will mean that they will have time to consider the resources that are available and consider the impact that they might have. I think the most fundamental tool is the understanding that these kinds of interventions actually can make a difference. We know that from work that’s been done in other areas and this work as well, that there’s a very significant part of the population at risk that if we can provide them with education and information that they will react to it. They’ll respond to it and make a modification that will make a difference, in this case, in preventing diabetes. So I think the most critical tools are educational tools, skill sets and time that will allow us to take advantage of the most important aspect of primary care, which is our relationship with the patient. To take advantage of the power of that relationship to provide information and convey to them that we think this is important information in their life.
What aspect of diabetes prevention for your patients is the most daunting for you? (Any ideas for improving?)
I don’t see patients anymore. My job has been administrative for the last five years, but I can speak on behalf of our practices for this one, which is resources. In a rural state like Maine, and any community in Maine, we’re serving a full spectrum of our community and that includes people who have very limited resources. So something like housing is even a problem or even the ability to buy healthy food or access an exercise program, especially in the dead of winter or to make other lifestyle changes that for some of us are options and for others of us they’re very significant barriers to those changes. Dealing with the social determinants of health is probably the most daunting part of the work and also a critically important part of the work because if we really want to get outcomes, we do have to address those social determinants of health. And that really requires that we embrace our role as advocates for the best interests of our patients and our community, and as collaborators with the other entities in the community that can help impact those social determinants of health, as well as the advocates for policies at local, state and federal levels to help us advance this.
What would you like patients to understand about diabetes prevention?
It’s very similar to any other prevention of chronic disease that they have the most power, the most ability to affect their own health, and that they actually can, regardless of their family history, maybe especially due to their family history, determine whether or not they develop diabetes. If they’re willing to learn, and I’ve run into very few people who are unwilling to learn, if we can convey the information in a way that is meaningful to them, and that is real to them, and we can provide the resources they need to make changes to prevent diabetes, that they really are the most important factor in determining whether or not they’ll end up with diabetes. That’s a decision that has to be made actively and not passively, and that the earlier they make that decision, the better it is.