Navigating your diabetes clinic can be so confusing. This is a guide to the who’s who in your diabetes healthcare team which is extremely useful because it can save so much time and frustration during your appointments, when you direct your questions to the appropriate person.
As a newly diagnosed adult with type 1 diabetes, you will be introduced to a number of health professionals and, in addition to all the staying alive information, it can be so confusing as to who is who? Or maybe you’ve been in the diabetes world for a while and you find yourself leaving your diabetes clinic appointment having met about four healthcare professionals and later wondering who they were beyond doctor and nurse and what exactly their role is in your care?
I did for the longest time this for the longest time and I have to say that knowing what role each professional plays in my care has saved so much time for me and for them, and frustration when I direct my question to the appropriate person.
There are some members of your diabetes healthcare team who are tasked with teaching you the basics of managing life with type 1 and, unless you decide differently, they will be your medical support for life. So it’s important that you get on with them and that they respect you.
New To Irish Healthcare
The Irish healthcare system is two tiered: public (free) and private (not free) and in my 25 years of living with type 1 diabetes I’ve used both tiers but not simultaneously. This post will talk mostly about Irish public healthcare system but I will reference the private system also.
** If you are new to Ireland you should note that “Your entitlement to health services is mainly based on residency and means, rather than on your payment of tax or Pay Related Social Insurance (PRSI). There are, however, some exceptions. Please review the information from the Citizens Information Website here for more specific information.
* Disclosure: This post is an update on the “Doctors and Nurses” chapter of the 2012 Irish Edition of the Type 1 Diabetes Starter Kit. I also realise that each clinic has their own way of operating and this post is based on what the standard is supposedly. It has been updated.
People with type 2 diabetes may be managed by their GP or a diabetes clinic: it depends on their individual situation. However, all people diagnosed with type 1 diabetes are referred to a diabetes clinic in a hospital. Your may be referred to a type 1 diabetes clinic or a general diabetes clinic or a specialist clinic such as a Young Adult, Intensive Insulin, etc. The National Survey of Diabetes Care Delivery in Acute Hospitals 2018, reported that 28 of 31 hospital services deliver speciality diabetes care clinics (see photo below). If you are curious about what diabetes service your clinic provides read the full review here.
** Note: Not all diabetes clinics have all of these health professionals. However, most of the health disciplines are part of our standard of care set out in the National Clinical Guidelines for Adults with type 1 diabetes.
The first person you will meet when you arrive at your clinic is the secretary where you check in. This is the person who pulls your physical file out and places it in the queue. Then you go to the waiting room.
Next you may see between two and four or more healthcare professionals.
Healthcare Assistant / Nurse
The healthcare assistant will take your blood pressure, weight and some details about any external health checks you have had since your last appointment such as your annual Retina Screening or a Podiatry screening. It’s always good to look these dates up in advance.
Diabetes Nurse Specialist or DNS
In my personal opinion, your DNS is the most valuable member of your diabetes team. A DNS is a nurse who has gained quite a bit of experience and has also done a 1-year post graduate course specializing in diabetes.
When you are diagnosed, it will most likely be a diabetes nurse specialist who will work with you to give you intensive education on the basics of diabetes care such as: how to do an injection, how to use your blood glucose monitor. They will then be your font of knowledge for all those niggling questions which come up.
The Intern or Non-consultant hospital doctor (NCHD)
Also known as “Doctor in Training”. Usually this is the health professional you will see only one time and on your next visit there will be a new intern. The Intern or Non-consultant hospital doctor (NCHD) is a term used in Ireland to describe qualified medical practitioners who work under the (direct or nominal) supervision of a consultant in a particular speciality. In Ireland, doctors typically spend one year as an intern,
In order to register fully with the Irish Medical Council, graduates are required to complete a minimum of two months and a maximum of three months in a speciality, which is why you will probably never see them again.
The intern will often leave to room to confer with their supervisor: probably your consultant endocrinologist. If your clinic visit is uneventful your visit may be completed at this point. However, if you have asked to see your consultant or if you have highlighted an issue or concern, you may have to go back to the waiting room and wait for your consultant.
You may come across a Specialist Endocrinologist Registrar in your clinic which is a fully trained doctor who is just finalising his/her specialist training in endocrinology. It might sound like they’re not your best choice - but think about it - they just finished med school this century so should be right up to speed with the latest and greatest!
Consultant Endocrinologist or Diabetologist
Generally 2 - 3 visits per year to an Endo are recommended and you’ll soon be calling them your ‘Endo’. This is a doctor who specializes in the endocrine system and the many hormones it produces, of which insulin is one. You may be referred to an endocrinologist by the hospital you were diagnosed in or if you weren’t hospitalized at diagnosis you will be referred by your GP.
Ideally, you need to find an endocrinologist who at least specializes in diabetes, and preferably one that sees mainly people with Type 1 diabetes. You may be lucky and find one who you get on well with when you’re diagnosed, but if you are not happy with the care you receive at this clinic or do not agree with your consultant you don’t have to stay at this clinic. One of the best ways to find out where the good endocrinologists are is to ask other people with diabetes for their opinions about where they go. If you do want to change where you are receiving your diabetes care, a GP can write a referral once you find someone you want to try.
You may choose to see your consultant endocrinologist privately and pay a fee. If you choose to do this make sure that they provide you with access to a diabetes nurse specialist and a diabetes dietitian.
Your dietitian is the food expert and as food is a big part of diabetes so make sure you ask lots of questions and get the answers to questions like “how much insulin do I need to eat pizza and chips?” You may get a funny look but this is not an unreasonable question so make sure you ask it or whatever you need to.
Be honest about what your favourite foods are and try to find a way to work your diabetes around them, even if it’s not as regularly as before. Gone are the days where you will be instructed to give up all sweet treats or desserts. There is a lot information about how foods affect our glucose levels and we have much better insulins to help us. You and your dietitian will figure out what way to eat works best for you and what eating pattern/plan you will find the most sustainable.
Only some of the public hospitals have dietitians in their diabetes clinics, if not your GP may be able to refer you to the community dietitian. Alternatively, you may find a dietitian who specializes in diabetes and practices privately. the Irish Nutrition and Dietetic Institute website <www. indi.ie> has a list of all the registered dietitians in Ireland. If you do take this route and you have private health insurance you may qualify for a rebate.
ADDITIONAL HEALTHCARE PROFESSIONALS
You will become really good friends with your local chemist, especially when you’ve forgotten to order extras for your holiers and find yourself in a bit of a pinch. Your chemist usually has your back!! You will have a Long Term Illness Scheme number or card, which will entitle you to all your diabetes medications and supplies for free and your local pharmacist will dispense these to you regularly.
As a person with diabetes you are entitled to an annual retina screen with the Diabetic Retina Screen Service. This screening looks for any diabetes related eye issues, this screening is really important as the early stages of Diabetes Retinopathy do not have any symptoms, so early detection can save vision.
For all other eye health issues you will need to see an optician privately.
Podiatrist or Chiropodist
As a person with diabetes you should have an annual foot check to detect early signs of neuropathy: the loss of sensation in your foot. The HSE National Model of foot care is adapted from the NICE guidelines. Your foot screening can be performed by any of your health care professionals, including practice nurses, primary care physicians, podiatrists, diabetes nurse specialists, tissue viability and public health nurses, orthotists, registrars and consultants.
It is important for you to pay attention to your feet in between foot checks as sometimes damage to the nerves in our feet can prevent us from spotting minor cuts which can become a serious infection very quickly. So getting in the habit of having a quick look at your feet every day is a good one.
Unfortunately, counsellors and psychologists who specialise in diabetes are thin on the ground. The National Survey identified that Ireland only has 5% of the recommended psychologists in diabetes care even though the National Clinical Guidelines for Adults with type 1 diabetes states “There should also be access to a diabetes psychologist.” and psychological wellbeing is mentioned 25 times.
But it is important for you to know that if you are struggling with your diabetes for any reason that there is help out there in peer support groups, do mention it to your diabetes team, do use google to find information on what you are dealing with because you are not the first, you won’t be the last BUT you are not alone!!!
Get yourself a great team of health professionals; people that you feel comfortable to ask questions. It might take some time, and even a few tries to find a team that works for you, but persist. It is definitely worth it.