2016 Allan Drash Clinical Fellowhip Report

Allan Drash Clinical Fellowship

28th Aug 2016 – 1st October 2016

 

I, Dr. Dhruvi J Hasnani, have been a part of ISPAD (International Society for Pediatric and Adolescent Diabetes) for the last 4years. As an ISPAD member, I have been fortunate to have been in contact with innumerable Diabetologists, physicians and health care professionals from all around the world. This has had a tremendous learning influence in shaping me as the Diabetologist that I am today. The most beneficial & educative experiences were my first ISPAD conference in Brisbane in 2015 and the Allan Drash clinical fellowship award.

I announce this with a great sense of satisfaction and achievement, that I have successfully completed my Allan Drash Fellowship at the Barbara Davis Center, Aurora, Colorado, USA with the support of ISPAD. The complete duration of my visit was 5 weeks from 28th August to 1st October 2016, under the able mentorship of Dr. Marian Rewers & Dr. Guy Todd Alonso.

As per several of my discussions with Dr. Alonso about my areas of interest and the activities available at the BDC for my exposure, we scheduled the whole duration of visit in various parts:

  1. Shadowing the clinicians in the pediatric and adult departments according to their availability and convenience

  2. Shadowing of nurses, dietitians, social workers

  3. Attending the team clinics, pump prep classes, CGM classes, psychological evaluations

  4. Shadowing at the eye clinic

  5. Attending endocrine grand rounds

  6. Being a part of the quality improvement sessions

  7. Attending a telemedicine session

  8. Data analysis and quality improvement

  9. Newer research/ongoing research activities

After the initial orientation process and getting myself acquainted with the centre and the university and the staff, the process was very friendly and the people were very accepting.

The duration of my visit was educative, eventful, and clinically life changing. I was involved actively in shadowing all different clinicians both at the pediatric and the adult department of Barbara Davis Center.

 

 

During the process of shadowing I learned what should be the leading questions to be asked to the kids, parents and/or guardians to find out about the present condition glycemic status and the medical history. The process of data entry into their EHR system was also done during the visit, which was very different from our way of working at my institution. Shadowing the clinicians gave me ample amount of opportunity to get exposed to various different kinds of patients from different backgrounds. This gave me an insight into “how different but still the same” are patients on basic concepts and troubles regarding their diabetes!

Dr. Klingensmith, Dr. Alonso, Dr. Steck, Dr. Zietler, were the clinicians who specifically taught me about type 2 diabetes in adolescents, non-type 1 diabetes in the paediatric population,and the evaluation of autoantibodies in paediatric population through various existing studies such as the TEDDY and DAISY studies.

Dr. Garg, Dr. Polsky, and Dr. Shah in the adult clinic department enhanced my knowledge on the management on type 1 diabetes in adults and pregnant patients, on pregestational diabetes, and geriatric type1 patients.

I also assisted the technical team at the BDC and came to know about the ways to download and upload data from various glucometers, CGMs, and insulin pumps onto the computer for saving and analysis purpose.

The shadowing of the dietitians helped me learn more about carbohydrate counting and its importance, food replacements, food around time of exercise, and other nutritional facts important to educate the patients on.

The nurses were more particular in teaching about the basics of diabetes such as what is diabetes, what needs to be done, insulin- what is it, its storage, insulin injection techniques. The nurses also thoroughly educated patients about self monitoring of blood glucose, management of hypoglycemia and hyperglycemia, ketones, sick day management and follow up, which I found was of utmost importance.

I also had the opportunity to attend the “pump prep” class and classes on continuous glucose monitoring systems by Dexcom and Medtronic. I was able to wear a Dexcom CGM myself and really came to know how it felt to have a sensor on all the time, a real experience to understand its implications.

Social workers were another experience new to my concept of diabetes education wherein they took to looking after the psycho-social wellbeing of the patients and solved the issues pertaining to the behaviour, alcohol, and substance abuse. The phenomenon of substance abuse and having specially trained social workers to deal with it is very rare to be seen in Indian population.

A major exhilarating experience was telemedicine with Dr. Slover and Dr. Wadwa. The recent exponential rise in the use of technology, applications and mobile health for diabetes and its management had raised me interest in telemedicine.

The use of electronic health records and mobile applications is spreading rapidly. The understanding of these from Dr. Alonso helped me analyse the numerous platforms which are available back home and how use them to the best of our capacity.

My mentor Dr. Alonso was the Quality Improvement director at the BDC. He involved me in all his QI sessions and their value and implementation process. This has encouraged me to start my own Quality improvement drive in Diacare.

During the fellowship, I also got the chance to be able to attend lectures along with the pediatric endocrinology fellows at the Children’s Hospital, Aurora.

Another new concept which appealed to me was the concept of “team clinics” for the adolescents. This consisted of 6 or 7 middle school or high school aged students, playing games like Jeopardy and sharing their knowledge and doubts regarding Diabetes mellitus in practical life.

A part of my fellowship at BDC consisted of experience with the research team along with Laurel Messer. This included the ongoing trials on algorithms of hybrid closed loop pump systems. The experience was one of its kind, and provided me with a firsthand experience on how these systems worked.

I also attended the eye clinic and shadowed Dr Bucca to learn to evaluate the eye disorders – retinopathy in type 1 patients.Along with Dr Naedau, I was allowed to shadow a patient through the procedure of hypoglycaemic clampat the children’s hospital.

To summarise, I achieved my objectives of learning the different aspects of diabetes management along with learning the process of digitisation of data and analysing. I also learned more about the psychosocial and behavioural issues in paediatric population. The icing on the cake was the additional Q-I program learning.

Implementation at Diacare- Diabetes Care & Hormone Clinic:

  • The first implementation after going back home was analysing our own system of procedures and making a team of people responsible to find out areas that needed improvements.

  • We have planned to start doing a depression screening of our T1D adolescents.

  • We have also started to strengthen our digital records and customise it according to our requirements.

The fellowship has imbibed in me characteristics which can act as a catalyst for change in diabetes management and care at Diacare- Diabetes Care & Hormone Clinic.

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