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Earlier this summer when the American Diabetes Association named its diabetes educator of the year, the honor fell to Davida Kruger in Detroit, who’s been helping to shape diabetes care since the early 1980s.
Kruger has spent her career as a nurse practitioner (NP) at Detroit’s Henry Ford Hospital working with Dr. Fred Whitehouse — a “Historic Endo for the Ages” who once worked with the famous Dr. Elliot Joslin himself (!) — and she’s divided her time between the clinical practice and research. She was influential in the landmark DCCT study, has authored countless articles and books including the Diabetes Travel Guide in 2000, and overall has helped her profession keep pace with new diabetes technology and treatments as they hit the market.
As it happens, Kruger represents a small and under-represented portion of the 20,000 credentialed CDEs in this country, as only about 4% of them are NPs, who also have prescribing power like physicians. With the 2017 American Association of Diabetes Educators (AADE) annual meeting kicking off today in Indianapolis, we thought it was a perfect time to share her story here at the ‘Mine.
DM) First off, congrats on the ADA recognition for your work. How did it feel getting that honor?
It was very humbling. I’ve been in this position for 35 years and you do it for all the right reasons, for people with diabetes. You stay because you’re just enjoying yourself too much to leave. Every time you turn around, there’s new diabetes knowledge and new things to incorporate into your practice to help people. It’s been a nice, fun long run that I’m so happy has had an impact to help those with diabetes. So yes, it was very humbling in that I’ve also seen who has gotten the award before me and know that this many people believe in me.
Accepting the award, you talked about not living with diabetes yourself, but watching your mother and grandmother dealing with T2 diabetes…
Yes, my mom was diagnosed at age 30 with type 2 and was on insulin, but she died at age 47. My grandmother also had diabetes and was on insulin, and her three brothers had diabetes – so we really did have a huge cohort in the family with diabetes. I all but expected my generation would have type 2, but interestingly we don’t. I think that goes to everything we’ve learned about how to eat and manage blood sugars and so many things that people didn’t talk about in generations behind us.
Things were pretty different with diabetes care back then…
Yes, it was a different kind of time for diabetes, when you didn’t have the various classifications (like type 1, LADA and type 2) that we have now, and people weren’t talking about A1Cs, as we didn’t even have blood glucose monitoring back then. So, it wasn’t a disease that you really talked about and people were ashamed. We didn’t really have anything to offer people like we do today – no diabetes education or medical nutrition therapy, or BG monitors because they didn’t exist. You have to remember back then, we thought a blood sugar of 200 for someone with type 2 was OK. We didn’t think of it as a serious disease. Of course, now we know about all the complications and how serious this is.
Did that family history help shape your career decision for medicine?
Oh yes, without a doubt. My mother died several months before I finished graduate school, so I knew I wanted to look for a position in the area of diabetes. But I wasn’t trying very hard to find a job because during my first six weeks of grad school in 1980, I had my first child. I said to my friend at the time that I didn’t have a job, and it was because I hadn’t applied for one… She saw a classified ad in the Sunday newspaper in 1982 and circled it, and then I applied on Monday and by the end of the week I had it. That was here, at Henry Ford Hospital in Detroit. So I was just in the right place at the right time. And now I’ve been here for 35 years.
You came on with Dr. Whitehouse in the early 80s. What was that experience like working with him?
I would not have the career I’ve had without Dr. Whitehouse. We’re talking 1982, and people didn’t know what to do with a nurse practitioner back then. If someone called me into an appointment, they were uncomfortable… now in 2017, people don’t want to go to a diabetes practice unless there’s a nurse practitioner. Dr. Whitehouse just pushed me out there, and said ‘Go, Go, Go’ to me. He was really just so humble about his own career, and pushed me, so that I could feel good on the local and national scenes. He’d already been past president of the American Diabetes Association (in 1978) so he introduced me there, and to other organizations.
Dr. Whitehouse just opened so many doors and believed in me. He pushed me forward and never got in my way, and that’s a positive too. He was always by my side when I needed him.
What was it like being involved in those early years of 1980s diabetes research?
I started right at the time of the landmark
We got really involved with the DCCT and over the years we’ve helped bring every new insulin, new agent and injectable to market, in the pharmaceutical world. We also have had a host of NIH grants for studies for technology and treatments, and Dr. Whitehouse was always comfortable allowing me be Principle Investigator in stuff like this. As you can imagine, people might have been like, ‘Whoa, she’s a nurse practitioner,’ but because he didn’t have a problem with it, it was easier for me to push that envelope. Now as he’s retired, I’ve taken up so much of the PI work in running all of the clinical research for the division, as well as managing all the NPs and my own clinical practice.
Your three daughters have been involved in your medical career, too?
Yes. You could say my first daughter went to graduate school with me (being born just before my graduation), and then I went into labor with my middle one while doing a clinical study, and then slept in a file cabinet drawer. And then I was an officer with the ADA when my third daughter was born, and when she was 10 days old I took her to a meeting. Of course, no one would do that in 2017… in part, just because you don’t know who is and isn’t immunized and I just didn’t feel too good 10 days postpartum.
And the birth of your middle daughter almost put the brakes on your DCCT research?
Yes, I was doing autonomic nervous system testing which is a lot of breathing, and I realized while my patients were breathing, that I was having contractions. That’s not unusual a few weeks before a baby’s born, but I realized I was breathing as hard as they were and I was probably in labor. They kept getting closer, and people there at Henry Ford Hospital kept insisting that I get ready for labor. Dr. Whitehouse kept saying, “I don’t remember how to deliver a baby,” and he assigned one of the fellows to try and convince me to go have the baby. Before I knew it, my OB was standing in the door telling me to come with them all now. But I was like, “No, I’m just going to finish doing this research first.” And there was no else certified for what I was doing and we couldn’t move the DCCT forward without this component. Literally, as soon as I was done with the two or three people in the study, my water broke. It was a mess. I went to have the baby and she was delivered within 45 minutes. That was Dec. 7, 1984.
So I had a 4-year old and this new baby, and she’s the one who slept in a file cabinet drawer for three months because I needed to get back to recruiting patients. Dr. Whitehouse would say, “You don’t need maternity leave, just bring her to work.” You could do things like that in 1984. The nursing administration actually had a cow over the fact that I did that, and they were probably right, but I worked for the Department of Medicine and was able to keep going.
As to your DCCT research, did you have any idea at the time that A1C would become the gold standard in diabetes care that it is today?
We had to wait for that in doing the DCCT, and up to that point we barely had fingersticks and fasting blood sugars from people coming into the clinic. To be honest, I’m not even sure that in 1982 the hospitals were doing A1Cs for patients because we sent them all out. Remember, we didn’t have computers then and hand-wrote everything, and Xeroxed, and didn’t have fax machines or cell phones. The only computer we had was this big chunky box that the DCCT research folks put into my office, and I was afraid of it. On Thursday morning we’d turn that sucker on, and Friday morning the A1Cs would come through.
Of course, at the time I was overwhelmed with learning about insulin pumps, what an A1C and blood glucose monitor was, and so were my patients because the meters were just coming out around then. A lot happened in the early 80s!
Now in 2017, we recognize that A1C may not be the same big deal anymore and there’s more beyond that measure, in that we have CGMs and can look at different components like time-in-range that A1C doesn’t tell us.
With all this, what are the very biggest changes you’ve seen in diabetes care?
There is of course a huge gain in knowledge, with A1C, glucose management and intensive insulin therapy. But if you read any of the recent trials, it’s about continuous glucose monitors. You can get just as amazing results on injections with a CGM as you can with a pump. It’s all about giving control to the patient, and all of the new tools – better pumps and CGMs, better insulins, the DCCT findings, and being able to better help patients.
We really are on the true verge of closed loop technology now. Some patients are doing it on their own, which makes me a little nervous, but the devices that are in place right now open up the possibilities. We couldn’t have done this without any of the components. It’s amazing what has happened in just the past five years for both type 1 and type 2 diabetes with technology, oral agents and everything. It’s too exciting to retire, even though I should be thinking about it.
Is retirement on the horizon for you anytime soon?
Well, I’m 63 and am certainly not going to do what Dr. Whitehouse did (working until his late 80s and continuing with his research work). I would certainly like to work until between 67 and 70, somewhere in that vicinity. As long as you wake up every single day excited about going to work, that’s what you should be doing. But I certainly don’t always want to work as hard as I am… especially since my oldest daughter is pregnant and we’re expecting my first grandchild in September. I’m so excited, I’m dancing on my desk! So, I’ll need to figure out how to do deal with all this excitement and not work as many hours.
How would you describe the fundamental need for diabetes education?
Quality diabetes education and medical nutritional therapy are cornerstones that every patient deserves. Without that, it’s tough to own your own diabetes. It’s not enough that I just give you a new medication, but you as a patient need to understand where it came from, what it’s actions are, what it may mean and all the potential benefits and risks. Diabetes education is not just a one-time thing. You get it at baseline, and then periodically throughout your career with diabetes. Anytime there are any changes, you should have diabetes education and those educators are in the prime role in really making a difference.
Yes, but what about the lack of coverage and access to diabetes education?
I think we’ve made a lot of headway, and need to continue to push in understanding diabetes education overall, to make sure it’s reimbursed and that people can get it not only at diagnosis but throughout their lives with diabetes. In particular, everyone should be seeing a dietician, because there’s no place in our lives where we learn nutrition the way we need to. It’s more important in 2017 than it’s ever been for people to have a full understanding. I don’t go home with patients at night — which is good for both of us — so we need to teach PWDs to incorporate this education into their lives to manage. As a CDE, I’m just your little cheering section and Q&A person. And what we need to push is that it’s ongoing.
So true, especially with all the new tools coming out now for patients to use…
I switched a patient today to a new medication and knew that was going to be an extra amount of time with that patient. But there’s no way I should be prescribing a new medication to someone without taking the time to help them learn what it does and doesn’t do, the benefits and red flags, and why I think they’d be better on it and how to use it. That’s just not fair to the patient. Without that, a patient won’t be successful. And that falls to me. If you’re not successful because I haven’t given you the education you need, then I have failed.
Are you involved in lobbying on access and insurance issues for patients?
I used to be able to give input and feedback as to why we needed newer medications. I can tell you, as a clinical researcher who’s written papers and given talks, there is not a medication I couldn’t give the Pros and Cons on from an objective perspective and how it would work in clinical practice. But now, the process is beyond us. An insurance company may ask us to evaluate a request on a new medication… but I’m not wasting my good time on that anymore (because) they’ll get around to approving it when they get around to approving it, and will make their own decisions regardless. So at that level, I’ve given up.
As to Prior Authorizations, absolutely I’ll write those if the drug is on formulary. If not, I know the drug companies want us to write PAs to show the need, but I don’t think that matters and it just puts us over the edge because it’s going to get denied anyway. I’ve become very realistic as to how this works, and while I’d like to get every medication for every patient, I realize that’s not feasible.
What else would you like to say to the Diabetes Community?
It’s never a good time to have diabetes, but in 2017 it’s about the best time to have diabetes in terms of all the therapies, devices and education we have. There is just so much knowledge about diabetes, and what to do long-term. I wish I had a cure in my back pocket, but I don’t, so the best I can do is to take the best care of my patients as possible until we do, and make sure they’re equipped to do well!
Thank you for sharing your story and being such a force for good in the D-Community, Davida! We appreciate everything you’ve done over the years.
Dear Readers: You can follow the annual educators’ conference live on social media at #AADE17, and watch for our event coverage next week.