Sunday, June 10, 2007

Clinical Innovations - Disruptive Innovations for Diabetes

No Miracles Among Friends

I see the Robert Wood Johnson Foundation is staging an international competition to identify the top “disruptive innovations” in the health care world.

You can find the rules for entry by googling “Robert Wood Johnson, disruptive innovation.” The competition closes on July 8, when the top 12 finalists will be selected. I congratulate the foundation on their effort, and I wish them luck.

Disruptive innovations are likely to be the backbone of improving health care – especially for addressing the epidemic of obesity and diabetes, now so prevalent in the Western World.

Disruptive innovations are innovations that make any product or service more convenient, less expensive, quicker to use, more effective, and more accessible to users. In health care, it’s important to point out that most disruptive innovations are not miracles – like open-heart surgery or multiple organ transplants, or in the case of diabetes, pancreatic transplants or bone marrow transplants to cure juvenile diabetes.

Two stories come to mind to make the point.

•During he early days of the first century, faithful disciples roamed the land preaching and winning converts. One day, St. Peter and St. Paul arrived at an inn in Jerusalem, weary and footsore. They called for wine and refreshed themselves, then fell into an argument as to who should pay. To settle the dispute, they threw dice. Paul shook the box and threw a four and a five. Peter followed and threw two sevens. Paul gave him a long look, and said sadly,”Peter, old man, no miracles among friends, please.”

•The other tale involves three surgeons boasting about their best operations at the height of the Cold War... The English surgeon said, “I once performed brain surgery on a deaf mute and restored him to full hearing and speaking.” The American said, “I did a spinal cord transplant on a quadriplegic and restored him to full movement.” The Russian said,” I removed a man’s tonsils “The English and American surgeons, astonished, asked,”What’s so miraculous about that?” “Because, “explained the Russian, “In my country, people are afraid of opening their mouths, and I have to remove them by coming from a different direction.”

Diabetes is like that. You have to approach it from different directions – high tech and high touch, prevention and maintenance. Many high tech approaches, which are essential disruptive innovations – insulin, inhaled insulin, insulin-pumps, monitoring devices, other drugs, and transplants – have been tried and work for many but often fail to stem the tide of complications.

For most doctors, controlling diabetes demands attention to preventive details and instructing patients ( To get the attention of his patients, Stanley Feld, MD, an endocrinologist in Dallas, had his diabetic patients sign a contract saying they would either abide by his rules or not be his patients. He also issued patients T-shirts bearing the words: “In Control!”).

For doctors, prevention entails,

•Precise blood glucose control

•Inspecting the bottom of patient’s feet – something many obese diabetics can’t do for themselves.

•Assessing loss of sensation in feet and lower limbs.

•Monitoring blood pressure.

•Checking blood lipids, blood creatiine and creatine clearance, and urinary albumin.

•Protecting the kidney with new drugs.

•Making sure patients take oral diabetic agents and insulin correctly.

•Instructing patients on proper diets and having a nutritionist or dietician re-enforce their message.

•Encouraging patients to lose weight and exercise (obesity is considered a precursor to most adult diabetes).

•Managing complications – blindness (the leading cause of adult blindness), heart disease and stroked (causes 65% of deaths among diabetes), kidney disease (accounts for 44% of case of kidney failure), and amputation (more than 60% of lower-limb amputations occur in diabetics).

Among diabetics and their physician friends, there are few miracles, because old habits are hard to break, and treatment regimens are hard to follow. But there are disruptive innovations on the horizon. Until these disruptions mature and take hold, the physicians’ best bet for controlling the vascular catastrophes associated with diabetes is strict adherence to best practice guidelines and rapt attention to clinical details.

1 comment:

Dr Eric Rice said...

Dr. Reece,

I commend your support of the disruptive innovations. I hope that you have participated in the voting at I am part of the UCLA group and I am trying to encourage supporters of the concept to participate in the process ( if you would like to read more). Regardless of whether you vote for our proposal or not, I hope you have gone to view the finalists and placed a vote. I think the process itself represents a disruptive innovation in the grant writing and winning process in health care.

All the best,

Eric Rice, PhD