What PCPs Should Know About Treating Patients With Diabetes

Medscape

20-05-2025

Primary care plays a crucial role in the treatment of diabetes. Primary care physicians (PCPs) are typically the first line of health care for patients with type 2 diabetes.
But PCPs are often tasked with managing treatment for type 1 diabetes as well, particularly in areas with limited access to endocrinologists and other specialists in diabetes care.
To learn more about how primary care providers handle some of the challenges of treating individuals with diabetes, Medscape Medical News turned to Brent Smith, MD, a family physician in Greenville, MS, board member of the American Association of Family Physicians.
Below are Smith's responses to key questions about diabetes care:
Q: How do you tailor treatment to patients of different socioeconomic backgrounds and health literacy levels?
A: When treating my diabetic patients, ideally, we would treat according to best practices first and adjust from there.
However, in reality, I find myself treating first by what the patient can afford — through the vagaries of payor coverage and then their own financial resources — then by health literacy. The best treatment plan is worthless if the patient cannot understand or implement it.
Last comes best practices. Often, I have had to adjust treatment plans to suboptimal choices because that is what the patient can afford and (at times) to keep the treatment plan reasonable to what the patient can accommodate in their life.
Q: What is a go-to strategy for patients struggling to maintain good glycemic control despite the use of multiple medications?
A: There really isn't a one-size-fits-all approach. The hallmarks of success are simplicity, and the challenge is finding that.
With dietary choices, I try to make the advice simple. Shop from the outside aisles of the store — where fresh food is housed — and try to avoid the middle aisles, where the processed grains and sugars are kept.
When looking at carbohydrates, I encourage them to avoid white foods, such as white rice, white bread, potatoes, and sugar, and try to pick things that are brown — whole grain bread, brown or wild rice, and sweet potatoes. We always encourage more exercise, but that often involves advising how to work it into their life schedule without it being overwhelming.
Q: How are glucagon-like peptide 1 (GLP-1) medications for diabetes and weight loss affecting the way you treat patients?
A: Ironically, the 'new' [GLP-1] weight loss drugs have been around for decades but have just recently achieved prominence. However, what they have changed is a renewed emphasis on weight loss and lifestyle change rather than the emphasis on adding on medications.
Q: How do you coordinate care with endocrinologists, dietitians, and other specialists for more complex patient cases?
A: I live in a rural area, about 2 hours away from an endocrinologist. I refer my type 1 diabetics for assistance but not commonly with my regular patients. Dietitians are great, but in our setting, they are typically hospital-employed, so their main role is educating diabetics in the hospital setting.
Q: What is something that you wish more PCPs understood or put into practice when it comes to treating individuals with diabetes?
A: My biggest request of anyone treating diabetic patients would be to remember 'reality' vs what the book says.
A good example of this for me is the expectation that all patients with diabetes should be checking their blood sugar daily. It is a painful and expensive hassle that we expect patients to take on without question. However, we rely on A1c for grading control.
Until continuous glucose monitors fully take over the market, unless a patient is taking insulin, I only ask them to check a fingerstick if they are feeling ill or worried their blood sugars might be very high or very low.
If we aren't asking them to make regular changes based on their fingerstick readings and their ability to make those changes in lifestyle and diet is often very limited, then why are we asking them to use glucometers daily?