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SpecialEndocrinologist Zachary Bloomgarden knows what it takes to treat patients with diabetesBy Allison Tsai

Treatment

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There’s never a

one-size-fits-all

solution.

Zachary Bloomgarden, MD, is on the verge of a breakthrough. It’s taken multiple appointments

and countless conversations, but Bloomgarden, an endocrinologist in private practice in New York City, is talking to a patient with type 2 diabetes about adding rapid-acting insulin to his current regimen of oral medications and basal insulin—something his patient has resisted for many months. But this time Bloomgarden has numbers to back him up.

After loaning the patient a continuous glucose monitor (CGM) for two weeks, Bloomgarden pored over the 4,000 blood glucose readings. His experience in treating people with type 1 diabetes comes in handy when working with those who have type 2 and insulin deficiency. It’s part of the reason he spotted this pattern: His patient’s blood glucose level was good in the morning but sky high the rest of the day.

Now, Bloomgarden shows the man his glucose data and explains how rapid-acting insulin before meals can bring down post-meal highs. And then comes the breakthrough: The patient agrees to try it. “It’s a process,” Bloomgarden says. “You can’t just hit somebody on the head and say, ‘OK, you need basal-bolus insulin.’ It doesn’t work that way.”

Bloomgarden is playing for the long game—exercising patience and compassion to guide his patients toward better treatments and, ultimately, better health. Often, that strategy works: A few days later, his patient calls to say, “I’ve been taking the rapid-acting insulin before meals, and I feel so much better!”

COMPLEX CASESEndocrinologists manage disorders of the endocrine glands (which produce hormones), including

diabetes and thyroid, pituitary, and adrenal diseases. They also treat conditions such as high cholesterol and osteoporosis, among others. Knowledge of the complicated medicines used for managing diseases like diabetes is essential. “Treating diabetes really involves all aspects of medicine,” says Bloomgarden. It’s one of the reasons he wanted to become an endocrinologist.

A DAY IN THE LIFEWhen you’ve been a practicing endocrinologist for 38 years, you develop a routine. After a quick 6 a.m. workout, Bloomgarden walks to the hospital to see his patients, if he has any there. They’ve been admitted for a variety of reasons, most unrelated to diabetes. His first patient of the day is a senior with type 2 who’s recovering from back surgery.

The hospital setting can be tricky for people with diabetes because staff doctors may be more concerned with treating patients’ other ailments—the aches, pains, and conditions that brought them to the hospital in the first place—than monitoring blood glucose. That’s where Bloomgarden comes in. Today, a finger stick reveals his patient’s blood glucose is 300 mg/dl. While the man isn’t experiencing symptoms of high blood glucose, Bloomgarden wants to make sure wound healing isn’t hindered. He administers extra insulin to bring levels into target range, checks the blood glucose again, and then leaves the hospital and heads to the office.

He typically sees between nine and 13 patients at the office, which makes for a long day. In a time when many primary care doctors are spending 10 to 15 minutes per patient in order to see as many as possible, Bloomgarden, like most endocrinologists, devotes 30 to

40 minutes to each appointment.

His next patient, a woman with type 1, is so concerned about overnight lows that she regularly goes to bed with high blood glucose. This is common, says Bloomgarden, and it’s also understandable, as hypoglycemia can be dangerous, especially at night. He helps her apply for a CGM, which will sound alerts to wake her if her glucose level dips too low. He’s seen the devices work wonders for other people with diabetes who fear overnight lows. “Type 1 patients using CGMs get remarkably stable blood sugars,” he says.

But, like the rest of diabetes management, there’s never a one-size-fits-all solution. Sometimes Bloomgarden treats the same issue by reducing the person’s insulin for a period of time to try to avoid lows as much as possible. “Sometimes you have to simply respect what a person is telling you about how they feel,” he says. “The person with diabetes has to be patient with the doctor, and the doctor has to be patient with the person, and we have to agree on where we’re going to compromise.”

THE NECESSITYEndocrinologists are an important part of a diabetes care team, particularly for people with type 1, whose care requires extra attention and, often, a familiarity with devices such as insulin

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WHAT IS AN ENDOCRINOLOGIST? A doctor who specializes in diseases of the endocrine glands (which produce hormones), including diabetes and thyroid, pituitary, and adrenal disorders. Endocrinologists also treat conditions such as high cholesterol and osteoporosis.

HOW DO I KNOW IF I NEED ONE? If you have type 1 diabetes, or you have type 2 diabetes and are not reaching your blood glucose goals, you may want to see an endocrinologist for specialized diabetes care.

pumps and CGMs. It’s important a doctor understands and has experience with more complex treatments for type 1 diabetes, such as intensive insulin therapy.

Seeing an endocrinologist isn’t always necessary for people with type 2, especially if they have a primary care doctor who has taken the time to learn a good deal about—and has experience treating—diabetes, says Bloomgarden. The same can be said for diabetes nurse practitioners and certified diabetes educators with up-to-date training. Those health care providers are also good alternatives for people in rural areas with a lack of endocrinologists.

Some people with type 2 may need more assistance than a primary care doctor can provide, particularly if they require basal-bolus insulin along with oral medications. That’s when an endocrinologist is helpful. “It’s a matter of doing all the fine-tuning,” Bloomgarden says. An endocrinologist’s job is about more than adjusting numbers, though. Bloomgarden understands the importance of a doctor’s empathy and ability to clearly show patients why behavior change is necessary. Just as important: an endocrinologist’s support of patients’ independence in their diabetes management.

HOW DO I FIND AN ENDOCRINOLOGIST? There are several places to look for endocrinologists in your area. Check with your insurance company to find one in network, ask your primary care doctor for a referral, or contact your local American Diabetes Association (find yours at diabetes.org/local) for a recommendation. You can also search for an endocrinologist in your area through the American Association of Clinical Endocrinologists at aace.com/find-an-endocrinologist.

WHAT CREDENTIALS DO ENDOCRINOLOGISTS HAVE? Endocrinologists are medical doctors with extra training. That means they attended medical school for four years, completed a three-year internal medicine residency program and internship, and finished a two-year endocrine fellowship. Make sure your provider is board certified in endocrinology and metabolism by checking his or her credentials on the American Board of Internal Medicine’s website, abim.org.

BLOOMGARDEN’S WALL OF PATIENTS, A REMINDER HE’S TREATING PEOPLE, NOT JUST THEIR DIABETES

AT A GLANCE: ENDOCRINOLOGIST