Dr. Girbés: "It would be good to create the culture that if you have DM you have to do diabetological education, it should be part of culture in health centers and coordinated from diabetes units"
The expectations are sometimes met.Psychologists say that 30 seconds are enough to train an idea of a person and use it to judge that person.In the case of Dr. Juan Girbés, it was like that.
The tranquility and safety that he transmits when speaking made possible a pleasant interview with the heat of a hospital cafeteria, more accustomed to the daily trajín of professionals and relatives of patients than to the calm that distils any Saturday.
Therefore, there is no less than thanking his courage to "face" the awkward questions of a restless patient - of which a priori knew very little of my intentions - and for the cordiality of the encounter.
When you prepare the interview, the first thing that catches your attention, for obvious, is the challenge of positions that you currentSeveral thirst working groups and permanent member of the continuing training commission of the thirst, among others.
It also compatibilizes this with its endocrinologist work at the Arnau hospital in Vilanova in Valencia.
The first question is obvious ... how so many charges arise.
Well, I think it all started when Dr. Picó, from the General Hospital of Alicante, who presented himself for president of the Sveydn asked me to introduce me to be secretary of this society.I was then working in Elda and had asked for transfer to Valencia.That the president was in Alicante and the Secretary in Valencia made it easier to perform many stems of the Svedyn.
After Dr. Picó, the president was Dr. Carlos Sánchez, a promotional partner and friend, who proposed to me at the end of his mandate, to introduce me to President considering that by my previous position as secretary I knew the dynamics of society.That is why I introduced myself to president in 2010, and was the only candidate for this position.
The vocal being of the Board of Directors of the Spanish Society of Diabetes is somewhat related to all this, since Dr. Gaztambide, president of SED, asked me to introduce me because I wanted it to have a representation of the different communities.It is also something that entails work, but my friendship with Dr. Gaztambide made her know she was not going to tell her no, and I think it is good that the Valencian Community has an institutional presence nationwide in an organism like thirst.
The tasks of the members of the Board of SED are distributed, and among them are dealing with some things, such as being part of the Continuous Training Commission in my case.
And then comes the director of the CV Diabetes Plan.I have always collaborated, for personal friendship, in virtually all projects, with the previous Plan director, Dr. Miguel Catalá.Last year he told me that he wanted to propose as a new director of the Diabetes Plan, so he would leave him before the time came to retire and could collaborate with the new director for a season, being still active.The Department of Sanitat accepted the proposal of Dr. Catalá.I thought about it quite a lot ... It is quite work, there is no extra remuneration, but I still have the same hospital salary, with which I have to make the activity compatible ...
because the sticks are going to rain ...
Exactly ... could be seen as being president of the SVEDYN could see the decision -making capacity mediated by thebelonging to the administration and vice versa.
After thinking about all that, I considered that our specialty is the most historically involved in the DM and it is important that we are there.If it was not me, it could be some member of the Svedyn involved in diabetes, but maybe not ... with which I thought it was an occasion that we should not miss, and it was not going to be bad for the Svedyn.I commented to the Board of Directors and in the Assembly of the Svedyn so that if there was any problem they told me and supported me in both cases.
We must look for a benefit for society to the extent that the last beneficiary is the patient, we must not lose that horizon.If the ultimate beneficiary is not the patient we are not doing things well.And if we don't do it, you will tell me ...
Do not hesitate, we will tell you ...
I think that as a doctor and as a person in this position I have to think that in the first place is the patient, secondThere must be conflict.
In the end the facts will give or remove reasons.
Exactly.
You have a position of great importance within the thirst, a member of the Continuous Training Commission.How you see the new endocrinologists, the latest generations of residents ... for example there is a big difference, you and I study without the Internet, that is a large advance ...
I see that they are getting better formed.The problem is that they have a little less placement facilities, the bad thing is that if they are not placed soon or if they go away it is difficult for them to come back ... they are much better trained because there is also a effort of the scientific societies in which they form well inNew technologies, in the techniques, for example, I did not train in thyroid ultrasound or in Ecodopler technique, which now are prepared.I had to do it next, on the march, they do it during the residence ... The current endocrinology services are very interested in forming well, in insulin bombs for example.Although you always have to have continuous formation, the resident has to be prepared with the most current.
There is a course that organizes thirst, intended for R4 that I like very much, a diabetological education workshop, I have to say that it surprises me and pleases me
In thirst on the one hand there is a specific course for R4, which is not always of diabetological education and then apart there is a diabetological education course every year.This last year there were 2 diabetological education, one aimed at R4, and apart from the diabetological education that is done annually.
Does the endocrine have to educate the patient more and devote less time to the clinic?
There is probably less time to educate and for the clinic because we have to spend more time to the computer.Every time we look less at patients because we are looking at the screen ... still the patient's education is still essential but we cannot ignore the work of the educator, who has to be complementary, the educator nurse has probably spent more time thanWe, but the doctor's vision complements it and is essential because it guides where the shots will go.
Any person who treats a patient with DM- endocrinologist, nurses, podiatrists, ophthalmologists, psychologists ...- has to be an educator in DM ...
Yes, of course
You can't give you a diet taken from the drawer and give it to it without more ...
That is of no use, it has to be something complementary and everyone has to participate in DM education.
One of the policies that we are promoting from the diabetes plan is also a group education for patients.
The vision is: If you to drive a car you need the card, for the DMIt is also necessary to acquire necessary minimum knowledge, although then you have to expand them, it would be good to create that culture of whether you have DM you have to do education, essential, as part of the treatment ... I have been diagnosed with DM, DM1 or DM2, they have given me somePills ... You will have to do the training, it is part of the treatment ... it is the same as when one is driving it is assumed that you have the card, because the same in DM, it has a beginning and an end, although later you can recycle, but it is somethingThat is consubstantial part of the treatment.
It should be something that will be part of the culture of the health centers and that is something that is done systematically coordinated from the diabetes units, so that an advanced level is taught in the diabetes units, for the DM1 and someDM2, even if most of these were at the level of health centers.
Returning to thirst, lately there has been a historical fact such as the Union of Scientific Societies (SED, SEE, SEEP) with patients for the issue of reactive strips, it is a historical fact, it has never passed ...
A long time ago was the Fed - Endocrinologists, educators and patients - but it was extinguished.There is also the Diabetes house, recently created and that is still a little in diapers.
In the Valencian Community, also the SVEDYN, the Association of Educators and Fedicova we made an accession document with respect to the strips asking the Ministry not to join the specifications of centralized purchases ... The issue is paralyzed by a legal sentence, it isIt is possible that the Valencian Community does not adhere.We would have more offers of reactive strips and glucometers for patients in the Valencian Community and that each use the glucometer that best suits.
What bothers me the most is € 2.26 per recipe, because it only happens in the Valencian Community, in the rest of Spain they do not pay anything, except Galicia and the Canary Islands that pay € 0.45 and Andalusia € 1.50.>
Since July of last year the costs of my DM1 have increased by 176%- it is a sample of inequality of the national health system very evident….And it is that the problem is inequality, if they give me 8 strips/day in the Valencian Community if I go to Madrid I want them to give me the same 8 strips and that is not so ... the same is being triggered to a subject when theBase problem is another
I also don't understand why a patient does not have the same benefits in one place and another, or that in the same community or in a different one can have different benefits or medical care.
As for the type of cast in health centers or pharmacies, each one has its advantages: if it is dispensed in pharmacies you can go any time of the day to any pharmacy ... if they occur in the health center you have to go only to yoursAnd at established schedules, which are not always the most comfortable, especially the people who work.
For ending the theme of the strips, the self -analysis recommendations of thirst are quite unfortunate, from my point of view ... not because they do not have their logical basis but because they are poorly expressed ... the greatest they put is that theStrips can only be given to whoever has a diabetological education, a trained professional and a plan accepted by the 2 ... if we put ourselves in a strict plan that has almost no one in Spain
is like that ...
Yes, yes
By putting that on paper in practice you are opening the doors to any politician to undertake the cuts, any could say that if experts say you don't have these 3 things you have no strips ... is that you are a reference organ ...
Here in the Valencian Community, before those recommendations were others that, having done before, are a bit different, more basic, that indicate the recommendation in each case, and on those recommendations theProfessional can prescribe something different but it must justify it by marking a cross somewhere, so that it can prescribe what you want ... you cannot mark 20, of course, but for example a DM1 with multiple doses of insulin can prescribe 6 a day without markingNo cross, if you want to prescribe 8 then justify it and can continue ... in DM2 with normal it is not to prescribe any strip, but if you recipe any reactive strip, you put the reason- change treatment, for example- and the system allows you.
I believe that sometimes it was badly understood, the system did allow more strips of those recommended only that it had to be justified in certain cases that were not recommended and the system let you follow.
The DM1 are self -sufficient to modify and manage insulin doses, with the vital danger that has manipulate dose of a substance causing serious potential problems, and yet we are not considered self -sufficient to manage the number of strips necessary to control our DM.It is a really big paradox
In the Valencian Community, today, that is the responsibility of the doctor, being a prescription.For example, the nurse cannot prescribe strips.It is something that is decided on a normal visit.If the patient tells you: Look, I need more strips, if the patient uses them properly, we prescribe them and that's it, but if the patient comes with 6 daily controls for 1 month and has not adjusted his insulin, the doctor will have to tell himThat one is done less and make the strips better.In any case, it should not be difficult to negotiate with the doctor and if it is, that is, if it is difficult to negotiate it with a specific doctor of the health center, it must be sent to the Diabetes Unit and the coordinator will have enough criteria to solve that problem.
At least in my apartment I think we have no problem and if we have it we solve it quickly.Perhaps I am lucky that in the Arnau department of Vilanova-Llíria we have a very good relationship from the diabetes unit with primary care doctors and that is used to the fact that there is any questions we have a quick way of communication, we have periodic meetings, we have contact by email and a coordinator-referent in each health center for the topic of the DM.When there is some therapeutic novelty or withdrawal of a drug or any problem, the coordinator of the unit that is now Dr. Sales, sends it to each of those references that in turn forward it to all the doctors and nurses of their center.And when something happens they consult us on the same way.I think we are quite well coordinated.
endocrinologists do not only live from DM.Obesity is the most frequent pathology you see.
It is the most frequent pathology in society, it is true.
In adulthood, 18 years and older, approximately 25% of the population - with Valencia Study Data - has an BMI greater than 30. To attend that, within the public system, the participation of the primary care doctor is necessaryAnd, like the diabetes plan, there should be a plan of obesity.There was a proposal from the Svedyn - with Dr. Carlos Sánchez of President and the participation of other colleagues - to the similarity of the Diabetes Plan, create a plan of obesity ... but the crisis came, changes in the Ccselleria, etc., and I suppose that thatYou'll have to wait.
attracts attention that there is a footing boom, races ... as opposed to the figures you give.There is a polarization of the company obesity vs. athletes
Yes it is true.Together, in society there are more sedentary people than those who exercise, there are those who do a lot of exercise and the sedentary who do nothing and these that are more and more.You have to address from school to promote healthy life.
Dr. Juan Carlos Ferrer, recently, published a communication on the double DM.Can DM1 and DM2 exist at the same time?This can be a bit complicated, a higher cardiovascular risk than we already have the DM1 and a huge insulin resistance ... it is a watchmaking pump.
It can exist, in effect.In type 2 you have hereditary genetic factor plus the load of obesity, if you also have an independent autoimmune cause, when the DM1 has everything else we would have that case.
Arnau Vilanova Valencia Hospital.
Let's go to your most clinical facet.How do you see, or how do you use new technologies?
We increasingly use new technologies, it is the future and we have to make it the present.It can be part of therapeutic education, can prevent the patient from moving to solve doubts and can help the patient modify their doses with bowling calculators, insulin pumps ... is what will improve the DM, much sooner than thebiological or genetic therapy or stem cells.The future goes there.
is increasing the prevalence of the DM1, is it known why?
It is not very clear, in recent years in the congresses of thirst there have been different communications about this.It seems that there is no clear increase.
Not even under 5 years?Long ago we read very clear news about it.
It seems that there are cycles, increases and descents, but it does not seem clear that it is increasing, it could be yes, even if we did not know the cause.
In recent years there have been discordant communications, and this year there was a communication that gathered a review of all the communications that had been in recent years and that concluded that there was no evidence that confirmed DM1 increase.
I also thought so, but it seems that in the end this cannot be concluded.
You mention the importance of technology, it does not seem that health professionals outside the world of DM directly know the new devices well, and even in some cases it is difficult to differentiate the types of DM.
The differentiation between DM1 and DM2 in general is done well, the bombs depends more on when they have formed, because they do not have so much time, they have heard of it but they do not just understand what it is.The concept that they understand of insulin bomb is of an artificial pancreas, the bomb does everything and you forget, this is what the profane, including many doctors, understand ... this is a problem but little by little as it popularizesThis will be changed.
Within the endocrinological world, this was not so well known, both thirst and SEEN have made much effort to describe and write the management of these appliances in magazines such as advances in diabetology, creating documents that have helped the specialists a lot and those who were notSo involved in this issue, so that it is no longer uncommon for endocrinologists to be prepared to solve a problem to any patient.
As for continuous glymia meters, we are also a bit in diapers, although in the last thirst there have been a few more communications than I expected.I believe that many more hospital studies are needed on this subject and not only to outpatients but also to ICU patients who are where more important and vital improvements can be achieved.
The first studies that were done in UCI showed spectacular results because strict glymia control, in the Estancia in ICU, increased survival a lot, but the following studies were not the same, so that having the very controlled blood glucose could be harmful, by theRisk that supposed not to be perfect, it was easier to make mistakes or have hypoglycemia problems, created more problems because the therapeutic margin was lower.
WithWhich recommendations in ICU are now keeping glycemia patients somewhat higher than the first jobs.
These meters would have more paper, especially if they were cheaper and non -invasive, it would be very good.