Michele D. Huie
TCOYD Newsletter, Vol. 22, 2007

An Interview with TCOYD Medical Advisory Board Member Irl B. Hirsch, MD

“My mom was told in 1980 that we’d be curing diabetes in 5 years. But putting cells from one organism into another organism is very challenging,” says Dr. Irl B. Hirsch, Professor of Medicine, in the Division of Metabolism, Endocrinology and Nutrition at the University of Washington. An internationally recognized diabetes specialist, and researcher, Dr. Hirsch is a frequent author and editor of diabetes articles and publications, and a four-time codirector for TCOYD’s Seattle conferences. He recently gave us the opportunity to ask him some questions about his practice, new developments, and generally how he thinks things are going in diabetes care. I found, after asking a single question, “Why did you go into diabetes care?”, that Dr. Hirsch didn’t need much prompting. The “interview” that follows serves as this issue’s look at one of TCOYD’s medical advisory board members.

Dr. Irl Hirsch: “I have had type 1 diabetes since I was six years old; and my brother James Hirsch*, was diagnosed at 15.”

Dr. Hirsch shared the perspective of someone living with diabetes while being in medical training at a time when there was little known about diabetes, except for complications the disease causes.

“In the summer of 1980, I was one of the first people to wear an insulin pump [thanks to one of Hirsch’s mentors, Julio Santiago, MD] and to use a home glucose meter—which is something no one was doing yet. What I realized in medical school is that I had to put up a defense shield to the depressing reality of the destructive impact of diabetes, and to so-called experts who didn’t know what they were talking about. To study diabetes was to study pathology. So I went along and tried to trust that things would turn out ok for me.”

Dr. Hirsch went on to describe…

1. Where he studied: University of Missouri, MD; Residency in Internal Medicine from University of Miami; Endocrinology Fellowship at Washington University, St. Louis

2. Who the real experts were, his mentors: renowned specialists Jay Skyler, MD; David Goldstein, MD; Philip Cryer, MD; and Julio Santiago, MD

3. Who he married: then Dr. Skyler’s nurse, Ruth Farkas

“In the early 80s, they came up with the idea of doing the DCCT [Diabetes Control & Complications Trial]. We didn’t know at the time what the results would be—but before then, we didn’t even have the tools or motivation to get close to control, so it was a start. Up to that point, we were supposed to do urine tests…it was useless.

The reason people did so poorly is that the experts weren’t the experts. Well-intentioned patients were getting bad advice. To a large extent, that is still true. That is why what Steve [Edelman] does is so important.

Sadly, as much as the system is dysfunctional here in the United States—it’s far worse in other parts of the world. In many parts of Africa, a child won’t live a year with type 1 diabetes. Granted, 20-40 years ago we couldn’t have fathomed what we are seeing today in terms of advancements in treatment. Yet while we have made huge progress, the system is still failing patients.

[Hirsch—Exasperated] Michele, in Europe a study is currently taking place to evaluate whether blood glucose testing is really more effective than urine testing. That’s going on TODAY! Let me just tell you about some things I saw today.

I have a bright 3rd year [medical] resident who is going into private practice this summer. She doesn’t know that NPH is cloudy and Lantus is clear.

My first patient of the day has had diabetes for 47 years. For the last seven years he has worn an implantable pump and he recently went on CGM (Continuous Glucose Monitoring). He brought his A1c from 7.5 to 6.1%. u

The third patient I saw today has had diabetes for 25 years and wears a pump. He moved far out of town and went to a primary care physician who had never seen an insulin pump. His doctor told him he didn’t need to take insulin and he should stop using the pump.

I see this stuff day after day. I’m fortunate; I’m watching the evolution happening in front of my eyes. The bad part is that the tools and medications people need are not readily available, and also, not everybody wants them. A lot of people just don’t understand the importance of good care.”

At this point, Dr. Hirsch moved on to what he considers a real problem in diabetes care—our system of medical training. This he sees as a fixable problem.

“There are so many primary care physicians that don’t have the best attitude about diabetes—but then they don’t see the type of patients I see. We point a lot of fingers at primary care physicians, and many times it’s justified. But for a moment, I’ll defend them. We [at Dr. Hirsch’s clinic] see the cream of the crop in terms of people who want to be aggressive about their diabetes control. Eighty percent of my patients have type 1, and the average A1c for patients in my practice is 7.1%. People who don’t care about working on their diabetes go back to their primary care physicians.

The truth is, we don’t give primary care physicians what they need to know. One afternoon on diabetes in medical school and one afternoon in their third year of residency doesn’t cut it. We put the blame on the primary care doctors, but we don’t train them.

Once these new physicians get outside, the world is different. For many physicians, the only information they get is from pharmaceutical reps. And it is such a competitive market that the information is conflicting, complicated and even the most well intentioned doctors who may be informed of some new oral agent, still are not knowledgeable on adjusting them, or starting or adjusting insulin.

Unfortunately, there is a lot of evidence to suggest that the primary care goal is to not get the A1c under 7, but to not put the patient on insulin. That is the goal of therapy.

Just look at the marketing argument for oral medications: ‘Avoid insulin.’ We are procrastinating, and starting patients on insulin much too late. We are seeing more and more physicians throwing oral medications at type 1’s. And there is still widespread misunderstanding on the difference between type 1 and type 2 diabetes.

We need to put more emphasis on chronic diseases in medical school and in residency programs. We need more requirements for hands-on management. Two years ago I spoke at a conference with 100 endocrine fellows in the audience, all of whom were very book smart about the new insulin analogs. But in a non-scientific poll, one quarter of them had no practical experience using the stuff.

I used to send a fellow in to talk to the patient before I went in. [An endocrine fellow is a physician training to be a diabetes specialist.] But many patients are becoming too sophisticated for the fellows. As for the residents [a general doctor in training] the patients know more than they will ever know. There has been an evolution. Therapy has become so complex and sophisticated that we have cherry-picked the patients and the physicians. This is really the part that is most depressing. Some things are understood, [by most health care professionals] like diet and exercise. The bottom line is that the therapy is complicated, and things are changing very quickly. We aren’t just prescribing or taking 30 units of NPH anymore. In the early 1980s, few people with type 1 had an A1c under 10%. The goal then was 9%. [Now the goal is to “normalize” the A1c, at least less than 7%.]

The world has gotten better for people living with this disease, but it hasn’t gotten better for everyone. That’s why what TCOYD provides is such a special thing.

The technologies have improved; insulins are better and faster; CGM is great. It’s not just about biology— it’s about the technology added to the biology that can improve the lives of people with diabetes. Diabetes is about attitude; it’s about learning to use the tools we have and continuing to use them.”

At the conclusion of our chat, Dr. Hirsch shared some of the exciting research he is currently involved in including studies on glycemic variability and the impact of oxidative stress. Don’t miss the 13th annual San Diego TCOYD Conference & Health Fair, December 8, 2007 , where Dr. Hirsch will be speaking on these cutting edge topics. TCOYD is grateful for Dr. Hirsch’s continued support of diabetes education.

# # #