Demystifying Diabetes: Q&A with Mary Ettari
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Mary Ettari, MPH, PATo learn more about CME diabetes education, visit AAPA’s Diabetes Leadership Edge page.

Diabetes is a national health crisis: 25.8 million Americans have it—or 8.3 percent of the U.S. population. Of these, 7 million don’t know they have the disease.

Because of diabetes’ complications, physician assistants will encounter diabetic patients in almost all practice settings. But the good news is you’re in an excellent position to identify the disease and help patients manage the condition.

The American Academy of Physician Assistants recently launched a nationwide initiative, the Diabetes Leadership Edge, to support PAs in fulfilling a vital role as champions of diabetes care. The initiative gives PAs the resources to become expert care providers in diabetes and keep patients on track with their treatment.

As part of this initiative, AAPA is profiling PAs with diabetes expertise to share their experience and offer some advice to PAs interested in learning more.

Today, PAsConnect sits down with Mary Ettari, MPH, PA, a volunteer PA at the Volunteers in Medicine clinic for the uninsured in Stuart, Fla.

How long have you been a PA, and where do you practice?

I’ve been a PA for 32 years. I currently practice as a volunteer in a clinic for the uninsured in Stuart, Fl. That’s about 40 miles north of West Palm Beach.

How are you involved with diabetes?

My clinic is mainly primary care, and I’ve been volunteering there for about five years. Because we do so much general primary care, we have a substantial population with diabetes.

At the clinic, we have a lot of patients whose first language isn’t English. There are migrant farm workers and laborers, and we also have people who have lost jobs or health insurance. This is a diverse population, but we do have a slightly higher percentage of diabetes because of the socioeconomic groups that a lot of our patients fall into.

I see new patients with pre-diabetes or diabetes, and I do follow-ups on existing patients. Most of the providers in the clinic who do primary care—physicians, NPs and PAs—have their own panel of patients, with the caveat that since we are volunteers and are really only there one day a week, if one of the patients has an urgent need, they might end up seeing someone else.

Why is diabetes an important issue for PAs?

It’s a perfect space in which PAs can take the lead in providing care. We have a fast-growing population of patients with pre-diabetes and diabetes and a static or some might say shrinking pipeline of primary care physicians. And with this growing number of patients with diabetes, with potentially 37 – 40 million patients coming to providers in the next several years, family physicians cannot take care of all these patients—nor can anyone else in the primary care arena.

PAs can claim diabetes and be experts on it—manage, treat and do prevention.

Diabetes is also a condition conducive to being managed by a team. No individual provider can do a stellar job of treating diabetes because of its complexities—comorbidities, complications, follow up and the management required. PAs can lead this team, coordinating all the various providers, which can include PAs, NPs, medical assistants, nurses, physicians, certified diabetes educators, etc.

What are some of the resources you use to treat diabetes?

I got involved in diabetes when I was AAPA president in 2007 and got invited to go to the Johnson and Johnson Diabetes Institute’s opening in San Jose, Calif. Johnson and Johnson fully funds the program. They bring in PAs, NPs and certified diabetes educators (a.k.a. CDEs). They give them a day-and-a-half training on diabetes, looking at it from the “chronic care model.” That was the first place where I got some intense education.

After I participated as a student, I got invited to participate as a faculty member, which I still do on an occasional basis, and go out and teach.

More recently, in the past two years, I’ve been working with a group out of Georgia and Oklahoma called GO! Diabetes. Currently the faculty consists of three family physicians, one certified diabetes educator/dietician, and me, a PA. We’ve developed a train-the-trainer program for family physician residents and faculty, and we also have a master class that we teach.

I’ve been exposed to, and have had to delve into, the literature on diabetes—especially the American Diabetes Association (ADA) guidelines—to be able to put together these classes and teach them. I’ve had access to a wealth of information and taught with family physician faculty, who teach residents. Those are my primary resources.

I’ve immersed myself in diabetes for the past two years. I would point to the ADA, the International Diabetes Federation (IDF) and the American Association of Clinical Endocrinologists (AACA) guidelines. These are all applicable for PAs. They also reference all the studies they’ve used to develop the guidelines.

Any advice on how to work with diabetes patients and help them deal with the disease?

First, in terms of recognizing diabetes or pre-diabetes, look at weight, family history, waist circumference, ethnicity and other conditions they have that could be associated with or precursors to diabetes.

“PAs can claim diabetes and be experts on it—manage, treat and do prevention.”

Then, in taking care of these patients, consider a concept that’s gaining traction: “motivational interviewing.” Say patient X comes in for a follow-up, and you’ve asked them to lose five pounds over the last three months, decrease their calorie intake and get their A1c down, and they’ve done none of the above. Instead of saying, “Why didn’t you lose the weight, get the exercise, etc.” with motivational interviewing, you say, “So Mr. X., help me understand what kind of barriers you’re experiencing that you can’t get to these goals that you’ve set for yourself.”

In other words, it’s not being paternalistic. It’s getting them to identify the barriers, the stressors, the roadblocks to them being able to do it. When you do that, patients open up more. Then if they identify a roadblock, they identify a way to go around it and they’re likely to be more successful.

Another thing to add: Rather than looking at just treating diabetes, we need to think about how can we treat chronic disease and do more prevention. Most of what we do nowadays is chronic care. Go back 200 years, and the majority of illnesses were acute. They didn’t live long enough to have chronic illnesses.

To learn more about CME diabetes education, visit AAPA’s Diabetes Leadership Edge page.

Stay tuned for the next installment of “Demystifying Diabetes” on PAsConnect.

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