Michele D. Huie
TCOYD Newsletter, Vol. 21, 2007

John B. Buse, MD, PhD, CDE President-Elect, Medicine & Science of the American Diabetes Association Director, Diabetes Care Center and Chief of the Division of Endocrinology, University of North Carolina at Chapel Hill, School of Medicine.

Adear friend of TCOYD, John B. Buse, MD, PhD, will take over as President for Medicine and Science of the American Diabetes Association in September 2007. John got an early start with the ADA, having attended his first meeting in San Francisco when he was twelve years old. At the time, his parents, both endocrinologists, had left John in charge of his younger siblings. Bored at the meeting, he walked off and was found hours later standing on tip-toe, peering through a paintstripped patch on the window of a strip club.

Today, John Buse is Director of the Diabetes Care Center, and Chief of the Division of Endocrinology, and Professor at the University of North Carolina at Chapel Hill School of Medicine.

Why Did You Choose to Go into Diabetes Care?
John is the son of 2 diabetologists. But that in itself didn’t lead him straight to diabetes care. When he eventually began his MD/PhD program at Duke University, he started in cancer research. “I knew that if I went into endocrinology, my parents would figure out what an idiot I was.”

John’s parents were the first endocrinologists in South Carolina, although no one in his family has diabetes. His father, “the real Dr. John Buse in the family,” was the chief resident at what is now called the Medical University of South Carolina (MUSC) in the 1950s when he decided to focus on diabetes. He was drawn to diabetes because of his exposure to patients with the disease through medical school and his residency. He was struck with how pitiful living with diabetes was in the 1950s. There was no glucose monitoring; syringes needed to be boiled and sharpened; half the people in the clinic were blind or missing legs, and many were dying of kidney disease. His parents met during fellowship while caring for the cats that were being studied to determine optimal treatments for diabetes. They moved to Charleston, South Carolina after they married a year later and founded diabetes specialty care and research at MUSC. Among their accomplishments were the first NIH grant at MUSC and pioneering dialysis in the state. Today, Dr. Maria Buse continues her work in diabetes research on the same NIH grant, arguably the longest running grant in diabetes in the United States. Her husband passed away six years ago, after a 50-year career treating people with diabetes and its complications.

John feels lucky to have done research with Dr. George Eisenbarth at Duke and the Joslin Diabetes Center. Dr. Eisenbarth was a pioneer in modern concepts of type 1 diabetes, and the first to do immunotherapy for type 1 patients. While John mostly worked on genetics of type 1 diabetes, Dr. Eisenbarth and the rest of the group also examined islet cell antibodies as a way to predict type 1 diabetes; islet cell transplantation; and the biology of how islet cells work and are destroyed. “I loved his flurry of ideas. He had more ideas before lunch than most people do in their lives,” says John.

In his research, John spent hundreds of hours taking care of “guant rats with matted fur” that had type 1 diabetes. After giving the sickly rats injections of insulin, he witnessed a miracle. Describing what finally made him do a fellowship in endocrinology, John says, “Just like my father was drawn by pitiful state of patients in 1950s, so I was drawn by pitiful rats, and what a difference I could make in them.” John completed his PhD dissertation at Joslin in 1985. He “vaguely remembers a guy there with modestly unusual hair,” Steve Edelman. After finishing medical school at Duke, John went to the University of Chicago for internship, residency, chief residency and fellowship before joining the faculty there in 1991.

Tell Us About Your Practice
“In my practice, my role is to look for complications, and to think about novel approaches to help patients overcome particular issues,” says John. Half of his patients have type 1 and half have type 2 diabetes. “It used to be that every week I’d see someone as pitiful as those whom my father was drawn to in the 1950s. Rarely do we see that now. In fact, I haven’t had a patient go blind or lose a leg in a number of years.” His patients still battle kidney disease and dialysis, but even those numbers are decreasing because of dramatic improvements in diabetes care, particularly in the last five years.

For type 1 patients, health is like a “precision drill,” he explains. “A zillion little details go into care and make it impossible to use cookie cutter approaches.” In Buse’s practice, writing prescriptions, and most details of how a patient manages diabetes day-to-day are negotiated with the diabetes educators. This is less the case in management of type 2. “Type 2 is a more conceptual, big picture, life-modification type of thing. People could read a book on type 2 and generally get the idea. An educator would help a lot for every patient with type 2 diabetes, but not having access to an experienced, creative educator is a serious limitation for patients with type 1.” Diabetes is a complicated disease, especially when it requires taking insulin. As patients strive for lower and lower A1c results, they put themselves at greater risk for serious hypoglycemia and hypoglycemia unawareness. “These days, I have more chewing out sessions with patients who need to loosen up their control more than with those who need to lower their A1c,” he adds.

John Buse and TCOYD
“Education immunizes patients from less than excellent medical care,” says John. “If patients know what they need, they can find a doctor who can help.” Early in his residency, a woman with a complicated medical history came in for a half hour appointment. When the allotted time flew by, John suggested she make another appointment to return in two months. She replied, “You seem like a nice boy. My last doctor told me that if you don’t check my feet I should fire you, but I’ll give you another chance.” John remembers the profound impact of having a patient call him on the carpet for a standard of care he wasn’t following. It struck him that the idea of an educated patient really can drive medical education.

John has been a seven-time TCOYD conference co-director in Raleigh, North Carolina. “I have a deep friendship and admiration for Steve [Edelman]. He has made a huge difference in the lives of many people,” he says. In April of 2009 John will co-direct yet again as TCOYD returns to Raleigh to hold a conference in the city’s refurbished convention center.

The ADA: What is Something You Feel the ADA Does Particularly Well?
“The ADA is good at being a consistent voice for people with diabetes. There are all kinds of people who advocate for particular things—the ADA tries to look at all these things carefully and cautiously. Sometimes it is criticized for being unduly conservative in its opinions. The ADA is a non-partisan organization that does an extraordinary job in advocacy efforts—making sure people with diabetes are not discriminated against, and have access to good services. We need to do more to advocate reversal of recent doldrums of diabetes research funding at the national level.”

Goals
In his six years as Division Chief of General Medicine at UNC, John Buse ran the primary care doctor group within Department of Medicine. Here he learned that “fragmentation isn’t good.” While it is necessary at times to draw on the expertise of specialists, not everyone can see an endocrinologist, and 80 percent of people with diabetes are cared for by primary care physicians. “We need to elevate the skills and extend the capabilities of primary care doctors so that they can do most of what a patient with diabetes needs. A good primary care physician is one who recognizes when a specialist needs to be called in.” John hopes to work toward enabling primary care doctors to take care of more patient issues through establishing guidelines and developing materials for patient care.

TCOYD wishes Dr. John Buse a successful and rewarding year as president of the ADA, and thanks him for his kindness and commitment to TCOYD over the years. We look forward to a successful TCOYD Raleigh conference in 2009!

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