Today, we feature the most seasoned member of our 2011 DiabetesMine Design Challenge* judging team: Dr. Rich Jackson, a senior endocrinologist at Joslin Diabetes Center in Boston, and also Director of Medical Affairs, Healthcare Services, and Strategic Initiatives for that famous clinic.
But don't be fooled by the fancy titles. Rich is a really down-to-Earth guy. He's Amy's co-author and friend, with a very "grounded" view of how technology can help us PWDs live better.
(*Note: As of today, you have exactly two weeks left to submit your entry to this $25,000 contest!)
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DM) In your opinion, what makes diabetes management today challenging?
RJ) The disease varies more than we realize. There are things we don't know how to look for that we need to measure. I also think that in America, we think that if something bad happens to someone, it's their fault for not doing something they should have. So we feel more secure that it won't happen to us.
If patients are doing well when I see them, then I think they are obviously listening to everything I say. But if someone comes in and they're not doing well, it's like "No wonder, look at what they're not doing!"
When the results are good, we think they're listening. But really it's often the luck of the draw of their disease.
As a physician, what qualities in a medical device do you look for when recommending something to your patients?
It has to make their life easier. What I see are a lot of things making their lives more complicated. People think, "Wouldn't it be nice if you could record things you ate, where you walked, and exercise — wouldn't it be nice if there was a website that could do all these things?" But people with diabetes have too many things to do already, and a lot of times they're told to do even more than they should by nurses, CDEs, or their family. They need something that actually helps them do the jobs they really want done, which isn't always recording tons of data. It needs to make things easier. That's the biggest miss!
Prof. Clayton Christensen wrote The Innovator's Prescription, which I think is really worth reading. I think it's the best healthcare book I've ever read in my life. The main question is: What's the job to people need to accomplish? That's what you need to think about. It's not "this tool, app, or gadget is really neat, smaller, faster." That's only important if the person with diabetes thinks 1 second is better because 2 seconds is too long, or wishes that meters were more accurate. But most people think meters are accurate enough. What they are looking for are tools that allow them to do less.
What do you think is the main thing missing from today's diabetes technology?
CGMs that are really accurate would be great. People are turned off because they still have to stick their fingers, and the CGM is stuck on their body, and it can be really frustrating because 80% of the time the results aren't as close as we think they should be. People think, "This hasn't made my life easier." So that hasn't been a helpful thing.
But if a CGM worked super accurately and you never had to stick your finger, and it was always calibrated, and was easy to stick on, then everyone would have one. Because that means you would have less to do. You wouldn't have to do all the other stuff. What [technology] often does is just add burden.
There's a lot of focus on what would make patients' lives easier, like mobile apps, but what would help you do your job better as a doctor?
I think physicians face the same quandaries that people with diabetes do. Too many choices. People thought electronic medical records would really help. Sometimes they do, and sometimes they don't. I travel around a lot, and for some of doctors, electronic medical records make their life harder, because they have to spend more time typing things in and it doesn't present data well. It doesn't make their job easier.
Maybe if there were tools that make it easier to communicate to people what they're seeing... People need to think about what the goals are and different ways to get there.
Also, there are many companies providing automatic uploads of glucose data, with the idea that, "if you were taking care of me, wouldn't it be good if I just uploaded all my glucose every week?" But first, how do I look at that? It's a lot of data. How do I use that information? If I don't know what you ate or your activity, that's hard to interpret. If you had to download all that data, you would hate that. There might be instances when it's useful, such as for older patients with type 2. They may need to check glucose less often, and uploads could be done in a different way so the information is useful. Less information, but still very useful.
What would be your dream technology for people with diabetes?
It would be great if you could take little pieces of your food, put it into a device and it would measure how much insulin you need. An insulin to carb ratio is a very crude approximation. It's very clear that it's not very good at figuring out your insulin needs. People find that for some meals that are supposedly 60 carbs, they may need to bolus for 72 carbs because they realize they need that much insulin. In one study, patients were given mashed potatoes and then the same amount of mashed potatoes with chicken breast. There was a lot of fat with the chicken, so they needed less insulin, yet the carbs were the same. Some people say they do "fat corrections," but very few people do a "protein correction." People do not eat food isolated; it's how the food fits together.
Also, as you know, there really is not a closed loop system yet, only half the loop. If you had a CGM it was really accurate, that would be great, but that only closes half the loop. The other half is getting insulin into the blood. When my glucose goes up (I'm not diabetic), it secretes into the blood, works right away and then it's gone. If your blood sugar goes up, the pump or pen gives a bolus, but the insulin doesn't get into you right away. It stays in your fatty tissue for a while, and the peak takes a couple hours or longer. That makes diabetes harder to control. If insulin went into your blood, the control would be much faster. If I have type 1 and insulin is in my fatty tissue, the insulin doesn't go away directly either; it still tails off over time, even if I remove my pump.
Researchers have been working for a long time on an implanted insulin pump. It's about the size of a hockey puck. It's implanted in abdomen and secretes insulin at a fairly constant rate. People testing it did surprising well, because insulin delivered in that way is just so much more effective. But the body has so many different ways to defend itself against things opening the blood vessels.
What advice do you have for people brainstorming their ideas for the design contest?
What caregivers often worry about is someone going low. The current monitors don't work well enough to be really useful. I saw a demonstration of a device for someone who's worried about their elderly parent taking their medicine. If the elderly mother didn't lift the cap off the pill bottle, it sent a text message to the caregiver. The thing with that, it's not used by the person with diabetes. Sometimes the patient wants a reminder, but the person who really wants to know is the caregiver. If your dad had diabetes, you'd want to know. You wouldn't mind doing a little extra work to get that information. So think of something that might appeal more to someone close to the PWD. But then, you do have to be careful not to set them up as the "diabetes police."
Thanks for your insight, Rich. Another angle on this stuff is always welcome!