Continuing Professional Development and Diabetes Management: The Case of Mr. Thando By Charles Adesokan

The constant feeling of fatigue and lack of energy wasn’t something that Mr. Thando or anyone close to him could relate to. He has always been vibrant and energetic. Now in his early 50s, many of his friends dismissed his lack of vibrancy as ‘old age catching up with him.'

However, it wasn't long before they started noticing the sudden weight loss. Mr. Thando kept reassuring everyone that he felt fine. Thankfully, his wife, concerned about her husband's deteriorating health, confided in a close friend, a medical doctor at the local hospital. That was the beginning of Mr. Thando's diagnosis of Type 2 Diabetes Mellitus (T2DM), a diagnosis that was complicated by underlying comorbidity.

Like Mr. Thando, many African adults are quick to overlook the early signs of chronic diseases with the false assurance that they are well and healthy. Mr. Thando's story is not unique. It is a story that is told across Africa. More than nineteen million adults in the International Diabetes Federation (IDF) Africa region were estimated to be living with T2DM in 2019.1 Cases of T2DM in the IDF Africa region are projected to increase to 47 million by 2045, a 143% increase from 2019 and the highest predicted increase of all the IDF regions.1 Approximately 366,200 deaths in 2019 were due to T2DM. Effectively managing T2DM is complicated by the almost 12 million cases of T2DM that are not diagnosed and the various underlying and often untreated comorbidities.1

Challenges of managing Mr. Thando's T2DM

Mr. Thando was eventually referred to Dr. OC, the go-to doctor for everything diabetes. Dr. OC started Mr. Thando on a treatment plan, as he did for his other patients with diabetes. 

Several months into his treatment, Mr. Thando's blood work showed high blood glucose. He was experiencing spiraling complications. Dr. OC was puzzled. 

Why wasn’t Mr. Thando responding to treatment? 

Like Dr. OC’s other patients, Mr. Thando had T2DM; he was also HIV positive with a confirmed AIDS diagnosis, unlike other patients. Dr. OC was not aware that HIV/AIDS and its treatment with antiretroviral drugs could lead to impaired glucose metabolism requiring dose adjustment to the antidiabetic medications.2?? The lack of awareness resulted in a potentially life-threatening but avoidable mistake. Dr. OC was consistently undertreating Mr. Thando. The consequences of this mistake -- Mr. Thando's progressive poor health -- were evident.

The optimal management of T2DM is made more difficult by limited health care resources and complications of other diseases such as obesity, hypertension, cardiovascular disease, malaria, tuberculosis, and HIV/AIDS.1 According to Dr. Joshua Egbedimame, a general practitioner at the Royal Hospital and Maternity Centre, Igbo-Ora, in Oyo State, Nigeria. "The healthcare giver understands the patients' dynamics as it relates to comorbid conditions. The type of comorbid conditions that a T2DM patient has will determine how they are managed. This includes lifestyle changes, things they can do and not do, and the medications to use".

Dr. OC and Mr. Thando's story is familiar across Africa.

Healthcare professionals should deliver evidence-based patient-centered care.? [Evidence-based guidelines] allows medical practitioners to have a standard for managing diabetes patients and their comorbid conditions," said Dr. Pius Almalugsi, a general practitioner at Tamale Teaching Hospital in Ghana. "Failure to adhere to such guidelines leads to malpractice."

Patient health outcomes correlate directly to the treating physician's knowledge and clinical skill, which should be continuously updated through professional development.?,? Indeed, the practice of medicine is, at its best, a journey of continuous professional development (CPD). Access to quality and relevant CPD opportunities is essential on this journey, made urgent by the year-on-year shortage of healthcare professionals across Africa. A 2013 report commissioned by the World Health Organization showed that sub-Saharan Africa had a deficit of an estimated 1.8 million qualified healthcare workers, a statistic that is projected to increase to 4.3 million by 2035.? This is a frightening trajectory for a continent whose population is projected to almost double by 2050.? 

Opportunities for CPD programs can, however, be challenging in some but not all countries in Africa. For example, in Nigeria, more than 200 institutions are recognized as CPD providers. They potentially can meet the need of healthcare professionals seeking CPD opportunities. However, the ease of access varies. In general, established and specialized practitioners and those in a residency program appear to have greater access than junior healthcare practitioners and private practice practitioners. Barriers to CPD opportunities may contribute to wrongful diagnoses and treatment errors.1?,11 Therefore, access to CPD programs is critical. Irrespective of the ease of access, a significant barrier to CPD in Nigeria is the out-of-pocket cost and lack of time, especially for junior healthcare professionals and those in private practice. 

Meeting the challenges of optimal T2DM management.

A fundamental component of optimal T2DM management includes consistent patient lifestyle management, diabetes self-management support, and education.12

The good news is that several public and private sector organizations across Africa are rising to the challenge of providing CPD and patient education opportunities. The Missing Link to Improved Health Outcomes (MiLHO) Initiative online courses will add to the effort to expand opportunities for CPD.

Are you looking for online diabetes courses?

The International Diabetes Federation has developed customized online courses for primary care physicians/general practitioners, specialists, and diabetes educators. Courses are accredited by the European Accreditation Council for Continuing Medical Education (EACCME). Some courses are free to access. Visit the IDF School of diabetes https://www.idfdiabeteschool.org/ to learn more.

 The Missing Link to Improved Health Outcomes (MiLHO) Initiative provides online CPD courses that recognize and consider the unique medical practice environment in Africa, by developing evidence-based and relevant content. The initiative's goal is to expand opportunities for CPD to assist healthcare practitioners in staying current with evidence supporting patient care in their local setting. Courses are certified by the CPD Certification Service. Visit the MiLHO Initiative to learn more.

References

1, International Diabetes Federation. IDF Diabetes Atlas 9th edition 2019. Accessed April 21, 2021. Click here to access the article.

2. Burgess PI, Harding SP, Kayange PC, et al. High mortality in subjects with both diabetes and HIV in sub-Saharan Africa. AIDS. 2018;32(14):2083-2084. doi:10.1097/QAD.0000000000001929.

3. Maganga E, Smart LR, Kalluvya S, et al. Glucose metabolism disorders, HIV and antiretroviral therapy among Tanzanian adults. PLoS One. 2015;10(8):e0134410. doi:10.1371/journal.pone.0134410.

4. Abebe M, Kinde S, Belay G, et al. Antiretroviral treatment associated hyperglycemia and dyslipidemia among HIV infected patients at Burayu Health Center, Addis Ababa, Ethiopia: a cross-sectional comparative study. BMC Res Notes. 2014;7:380. doi:10.1186/1756-0500-7-380.

5. Institute of Medicine (US) Committee on the Health Professions Education Summit; Greiner AC, Knebel E, editors. Health Professions Education: A Bridge to Quality. National Academies Press (US); 2003. Chapter 3, The Core Competencies Needed for Health Care Professionals. Accessed April 21, 2021. Click here to access the article. 

6. Dorman T, Miller BM. Continuing medical education: the link between physician learning and health care outcomes. Acad Med. 2011;86(11):1339. doi:10.1097/ACM.0b013e3182308d49.  

7. Anshu, Singh T. Continuing professional development of doctors. Natl Med J India. 2017;30(2):89-92.

8. A universal truth: No health without a workforce. Forum Report, Third Global Forum on Human Resources for Health, Recife, Brazil. Geneva, Switzerland. Global Health Workforce Alliance and World Health Organization; 2013. Accessed April 21, 2021. Click here to access the article.

9. Unicef. Generation 2030 Africa 2.0. Published November 2017. Accessed February 13, 2021. Click here to access the article. 

10. Rodziewicz TL, Houseman B, Hipskind JE. Medical Error Prevention. 2020 October 17. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan–. PMID: 29763131. Accessed April 21, 2021. Click here to access the article.

11. Iloh GU, Emeka EA, Ikwudinma AO, Amadi AN. Patient safety in a Resource-constrained Context: A cross-sectional study of experience, drivers, barriers and preventive measures for safety incidents and accidents amongst medical doctors in South-east Nigeria. Niger Postgrad Med J. 2020 Jul-Sep;27(3):202-208. doi: 10.4103/npmj.npmj_45_20.

12. Dube L, Van den Broucke S, Housiaux M, Dhoore W, Rendall-Mkosi K. Type 2 diabetes self-management education programs in high and low mortality developing countries: a systematic review. Diabetes Educ. 2015;41(1):69-85. doi: 10.1177/0145721714558305.