“Life with Diabetes”: A Pilot Study on an Experiential Continuous Glucose Monitoring Curriculum for Resident Physicians

Abstract

Background

The use of technology in diabetes mellitus (DM) management has been growing. The indications and coverage for continuous glucose monitoring (CGM) have increased. Primary care (PC) clinics, including resident continuity clinics, are the frontline for DM management; however, they struggle to adopt CGM.

Aim

To implement a CGM curriculum to resident physicians to improve knowledge and confidence.

Setting

An internal medicine (IM) resident PC clinic in an urban academic medical institution.

Participants

Twenty-four IM residents.

Description

We designed a curriculum that included a lecture about CGM indications, interpretation, ordering, and insurance consideration; and a voluntary, experiential learning module in which the residents wore a CGM.

Evaluation

We conducted a retrospective pre-post survey with a 4-point Likert scale. Average self-reported scores in knowledge increased for CGM (1) indications from 1.85 to 3.45, (2) ordering from 1.35 to 3.05, (3) functioning from 2.20 to 3.50, and (4) data interpretation from 1.85 to 3.25 (all p < 0.0001). Confidence for “describing CGM monitoring” and “fielding questions about CGM” increased from 2.25 to 3.65 (p < 0.0001) and 1.90 to 3.30 (p < 0.0001).

Discussion

Given the demand for DM management in the PC setting, this targeted CGM curriculum has promise to help residents adopt CGM into their practice.

INTRODUCTION

Diabetes mellitus (DM) is a chronic, progressive, disabling, and costly condition that is a serious public health burden in the United States with significant health inequity.^1–4 Effectively managing DM has major implications for addressing diabetes-related morbidity and reducing health disparities.⁵ The use of technology in DM care has been growing over the past decade with the demand and indications for continuous glucose monitoring (CGM) devices increasing.⁶ CGM has been shown to lower hemoglobin A1c and reduce hypoglycemic events.^7–11 As of May 2023, Medicare has expanded its coverage of CGM to include any patients receiving insulin and patients with a history of hypoglycemia.¹² Medicaid, in select states, and commercial insurances are following suit.^13–15 With this expansion of coverage, many more patients will now qualify for CGM.

Primary care clinics, including internal medicine (IM) resident continuity clinics, are the frontline for DM management; however, primary care clinics struggle to adopt CGM due to physician and patient barriers.¹⁶ Evaluation of IM and family medicine residents has also identified low confidence in CGM ordering and monitoring.¹⁷ The American Academy of Family Physicians has developed CGM training materials to provide education for primary care clinicians to adopt CGM into their prescribing habits.¹⁸ However, we found limited information or published literature on curricula specifically for resident physicians on CGM implementation in resident continuity clinics.¹⁹ CGM education was also absent from the curriculum of our academic hospital-based IM residency program. Our objective was to create a curriculum to help residents better understand this technology and feel empowered to use it in their clinical practice.

SETTING AND PARTICIPANTS

A 3-day CGM curriculum was piloted in August 2023 with IM residents at our institution at one resident clinical practice site. This clinical site had 24 residents in total rotating through an X + Y training program scheduling model. The training was conducted in person during their ambulatory training week. To allow for full participation in didactic sessions related to the curriculum, the first patient slot of the afternoon was blocked for all residents during the time of the curriculum implementation. In addition, residents have dedicated time within the ambulatory block to complete assignments and reflections.

DESCRIPTION

We designed a hybrid 3-day curriculum using Kern’s six-step curriculum development for medical education model.²⁰ The program was devised to be part didactic and part experiential for an enhanced learning experience and to allow residents to apply their knowledge in real time. On day 1, we delivered a 30-min didactic lecture about CGM indications, interpretation, and logistical and insurance considerations. This session was co-led by one primary care physician and one certified diabetes care and education specialist (CDCES). Both were trained in CGM via a local institution CME-accredited program.

Immediately after the didactic session, the residents learned how to apply the CGM sensors using sample devices. Samples of the two types of CGM sensors most commonly prescribed in our clinic were supplied by device companies. Residents learned how to apply the sensor, address patient frequently asked questions, and provide trouble shooting advice for common CGM-related issues.

Next, the residents participated in the “Life with Diabetes” section of the curriculum. This was a self-learning module wherein IM residents role-played for a 48-h period as a patient with type 2 DM on insulin. They had the opportunity to voluntarily wear a CGM sensor for these 2 days to practice using the sensor and associated phone application to track their glucose. Regardless of use of the CGM, the residents were given role-play details about their hypothetical diabetic treatment plan including an insulin to carbohydrate ratio for mealtime insulin dosing with a correction factor. They were required to read through patient material on the carbohydrate counting and insulin to carbohydrate ratios. Information was provided on typical phone applications that patients use for their DM management. For the next 2 days, they used this information, in conjunction with their CGM data, to count carbohydrates using a phone application and calculate a hypothetical mealtime insulin dose. On day 3 of the program, residents participated in small group discussions on their experience with CGM and carbohydrate counting. At the end of the session, residents provided feedback and evaluation of the curriculum.

Curricula content was updated iteratively as Medicare CGM coverage indications and electronic medical record (EMR) ordering processes changed during the study.

EVALUATION

The primary purpose of this small pilot study was to assess the feasibility and acceptability of a novel curriculum focused on CGM education for residents. Preliminary effectiveness was assessed using a retrospective pre-post study design, wherein data was collected only at post intervention by asking the learner to self-assess aspects in learning before and after participating. This methodology was chosen to mitigate response shift bias. The pre-post survey was designed to assess resident CGM management knowledge and confidence before and after the course. We used a 4-point Likert scale with 1 being “I have no knowledge of the content” and 4 being “I consider myself very knowledgeable.” Objectives that were evaluated for knowledge change were (1) describe how CGM functions, (2) list the indications of CGM in the clinical setting, (3) review CGM reports and discuss their interpretation, and (4) identify how to order CGM in our electronic medical record. Responses to the retrospective pre-post survey were summarized as an average score for each question across all residents. Differences between the pre- and post scores were analyzed using a paired samples T-test. The survey also included open-ended questions for residents to submit feedback about the curriculum. Comments were reviewed and key ideas grouped into themes. The survey was administered online via REDCap™ on the last day of the program. The institutional review board (IRB) approved this study as part of a larger project. The IRB did not deem that consent was needed because of the voluntary nature of the study.

RESULTS

A total of 24 residents participated in the pilot curriculum, with 8 per post-graduate year class. Twenty-one residents completed the full program, and 20 surveys were included in the analysis (1 incomplete survey was excluded). Three residents were unable to participate in day 3 of the program due to clinic duties, so no survey data was available to include in analysis. One of those 3 residents additionally did wear the CGM sensor but still participated in the didactic session and carbohydrate counting portion of the self-learning module. It was not disclosed why they choose not to wear a CGM sensor.

We demonstrated improvements in CGM-related knowledge in all four domains (Table 1). The largest changes in score were seen for knowledge of CGM indications where score averages increased from 1.85 (s.d. = 0.75) to 3.45 (s.d. = 0.26), p < 0.0001, and for CGM ordering with an increase from 1.35 (s.d. = 0.22) to 3.05 (s.d. = 0.31), p < 0.0001. Knowledge of CGM functioning score increased from a mean score of 2.20 (s.d. = 0.29) to 3.50 (s.d. = 0.26), p < 0.0001, and knowledge in CGM data interpretation score increased from 1.85 (s.d. = 0.44) to 3.25 (s.d. = 0.38), p < 0.0001. The subjective confidence scores for “being able to describe CGM monitoring” increased from 2.25 (s.d. = 0.42) to 3.65 (s.d. = 0.26), p < 0.0001, and “fielding questions about CGM from patients in their primary care practice” from 1.90 (s.d. = 0.38) to 3.30 (s.d. = 0.22), p < 0.0001.

Table 1.

Results of Retrospective Pre-post Knowledge and Confidence Assessment

	Pre (s.d.)	Post (s.d.)	p-value
Pre-post change in knowledge*
CGM purpose/function	2.20 (0.29)	3.50 (0.26)	< 0.0001
Indications of CGM in clinical setting	1.85 (0.75)	3.45 (0.26)	< 0.0001
Interpretation of CGM reports	1.85 (0.44)	3.25 (0.38)	< 0.0001
How to order CGM on EMR	1.35 (0.22)	3.05 (0.31)	< 0.0001
Pre-post change in confidence*
Describing to patients how to use CGM	2.25 (0.42)	3.65 (0.26)	< 0.0001
Fielding questions from patients about CGM	1.90 (0.38)	3.30 (0.22)	< 0.0001

*Likert scale 1–4 with a 4 as “Consider oneself highly knowledgeable/confident”

Resident comments from the open-ended sections of the survey are summarized in Table 2. The feedback was overwhelmingly positive towards the curriculum. Themes that emerged from reviewing the responses included realization of the complexity of daily diabetes management, empathy towards the experience of patients living with diabetes, and the value of CGM in diabetes management.

Table 2.

Resident Qualitative Feedback on the Curriculum

Themes	Comments from residents
Complexity of daily diabetes management	“The simple carbs make larger fluctuations in blood sugar than I expected.”
	“Diabetes management involves quite the time commitment for patients.”
	“It helped me understand how difficult it can be to remember to check your blood glucose.”
Empathizing with patients	“Better understanding of the patient experience of CGM and how to interpret their data.”
	“Much better idea of how glucose changes with diet/lifestyle, short term as opposed to long term.”
	“It very much made me more aware of what it is like to have to monitor BG like a diabetic patient.”
Importance of CGM in diabetes care	“Trends in blood glucose with specific types of meals and sleep.”
	“Having real-time access to blood glucose levels really informs what you eat!”
	“Helping to interpret the data and understand how my own intake affects my sugars.”

DISCUSSION

The routine integration of technology into the care of patients with diabetes is a new reality that is no longer confined to the realm of subspecialty endocrinologists. In particular, the demand for, and utilization of, CGM has risen over the past several years. Primary care physicians are increasingly expected to order and manage CGM as part of their routine care of patients with diabetes. There is also growing interest among primary care providers in the use of CGM as they realize the power and potential of wearable technology in facilitating diabetes management. Despite the demand and interest, there are significant gaps in primary care clinician knowledge of CGM utilization.¹⁶ IM residents not only serve as primary care physicians during their training, but also represent the future workforce of primary care clinicians. We have described the preliminary success of a novel curriculum to increase IM resident knowledge regarding CGM. The curriculum used a combination of didactics and experiential learning to further resident understanding, not only of CGM management, but also the lived experience of patients with diabetes. Evaluation of our curriculum showed success in addressing previously identified barriers to CGM utilization in primary care—namely the ordering of and interpretation of CGM data.¹⁶ The program was also well received by residents who described the value of the experiential learning component which helped them understand the realities of day-to-day management of diabetes and the value of CGM.

Our findings corroborated another study that similarly investigated a program to strengthen knowledge on CGM use, showing that a targeted initiative can increase knowledge with high levels of satisfaction.²¹ However, this was the first study, to our knowledge, to focus on resident physician education to integrate an experiential learning component to improve CGM knowledge. The need for alternative and applied methods of learning for trainees has been previously identified by other educators who are developing curricula for resident diabetes education.²² Our curriculum can serve to fill this resident education gap as well as fill an education gap for primary care providers as a whole.

The results of this one-site pilot showed promise, but there were some limitations. Firstly, this was a small-scale pilot study comprised of 24 IM residents at one of our program’s three resident clinic sites. Future studies are needed to look at changes in resident knowledge among the larger group. We would also like to study if participation in this curriculum changed CGM ordering habits, i.e., were more CGM’s ordered and successfully obtained by patients. Secondly, samples of the CGM sensors were supplied by device companies, which may not be feasible at other institutions. Alternatives for obtaining samples should be explored. Thirdly, the curriculum leads were well-versed in CGM management and were working with well-established clinic protocols for ordering CGM and accessing CGM data. Other programs would initially have to establish these clinic protocols and train educators before adopting this curriculum. Finally, the retrospective pre-intervention data is subject to recall bias.

Given the demand for DM management in the primary care setting and the importance of CGM use in the routine care of patients with diabetes, this targeted, hybrid curriculum showed promise for improving the capability of resident continuity clinics to integrate CGM into patient care. Our next steps are to implement this curriculum across all IM resident continuity clinics at our institution and to evaluate change in knowledge of CGM use as well as change in CGM ordering and utilization in a larger sample size.

Funding

Research reported in this publication was supported in part by the American Diabetes Association grant #CDTR-02. The content is solely the responsibility of the authors and does not necessarily represent the official views of the American Diabetes Association. This research was also supported in part by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under Award Number P30DK111024. Additional faculty support was provided by the Academic Internal Medicine Center from funds donated by the O. Wayne Rollins Foundation.

Data Availability

The data that support the findings of this study are available from the corresponding author, BAM, upon reasonable request.

Declarations:

Conflict of Interest:

Although none of the authors have any financial disclosures or conflicts of interest to report, as part of the curriculum, representatives of the two major companies that commercially supply CGM clinically (Abbott and Dexcom) were present during the experiential learning aspect on day 1 and donated samples of the sensors for the residents to use. We intentionally invited both to avoid possible influence to use any one product. No exchange in monetary value, gifts or food occurred.