FORMAL INAUGURATION OF JOSLIN DIABETES CENTER
Inaugural Address
Martin Abrahamson, MD
Chief Medical Officer and Senior Vice President
Diabetes Center of Excellence Affiliated with Harvard Medical School
November 30, 2010

Dr. Holly:

My pleasure now is to introduce our keynote speaker. Dr. Martin Abrahamson is the Chief Medical Officer and Senior Vice President for Joslin. He is a native of Zimbabwe, South Africa, and he is an associate professor at The School of Medicine at Harvard University. He is a gracious and charming person personally and a highly acclaimed physician professionally.

In March of 2010, the American College of Physicians awarded him the Inaugural Samuel Eichold Memorial Award for contribution to diabetes, recognizing Dr. Abrahamson's stellar career. The award is bestowed upon an ACP member or an organization that has made important health care delivery innovations for diabetic patients resulting in improved clinical or economic outcomes; or an ACP member who has conducted research. Dr. Abrahamson has done all of those. SETMA and all of southeast Texas are honored to have Dr. Abrahamson here and to have all the other Joslin team members as well. Dr. Abrahamson will come and share his thoughts about this occasion and about the whole field of diabetes care which is his life's passion. Dr. Abrahamson please come and join us.

Dr. Abrahamson:

Dr. Holly, Distinguished Guests, Friends, Colleagues;

It is indeed an honor for me to standing here before you and to say a few words about:

• Dr. Joslin,
• About his vision,
• About the way he approached the management of people with diabetes which still holds true today and
• Then to talk to you a little bit about the enormous problem of diabetes that we are facing in the United States and in the world, and
• Finally how we look forward to working with SETMA to develop models of care that are examples for the rest of the United States and the world to follow.

It is indeed amazing to think that a man like Elliott Joslin as long ago as 1921 foresaw the incredible epidemic of diabetes. Let me quote to you what he said about the quiet march of this epidemic and he was talking about his own town of Oxford where he was living in New England:

"Although 6 of the 7 persons, all head of families living in three adjoining houses on a peaceful elm-lined street in a country town in New England, succumbs to diabetes, no one spoke of an epidemic. Consider the measure which would have been adopted to discover the source of the outbreak to prevent a recurrence if these deaths had occurred from scarlet fever, typhoid fever or tuberculosis. Because the disease was diabetes and because the deaths occurred over a considerable interval of time, the fatalities passed unnoticed."

That was in 1921, a year before the discovery of insulin and as you heard from Dr. Holly, Dr. Joslin's approach to managing people with Type 1 diabetes at that time prior to 1922 was that of a protein diet, low in carbohydrate. The survival rates were pathetic.

But in 1922, after Banting and Best had discovered insulin, it soon became apparent that people with Type 1 diabetes could live longer and much more meaningful lives. Unfortunately, I don't have pictures that I can show you here, but the transformation of young children and adolescents before and after the treatment with insulin was an incredible thing to see. Of course, that led to the realization that if you didn't die from the acute complications of diabetes, you would develop the chronic complications of diabetes.

As you heard from Dr. Holly earlier, it was Dr. Joslin who foresaw the fact that if you controlled your diabetes well, and, believe me the tools that were available in those days to control diabetes were far more limited than we have today, you could live even longer and more meaningful lives. Mr. Isaacson is a fitting example of someone who has taken good care of himself and survived to live an incredibly long and productive life.

Furthermore, Dr. Joslin embraced the concept that people with diabetes:

• needed to receive education,
• needed to become self-empowered in their own management,
• needed to have a team approach to manage their diabetes.

He indeed had a vision of the chronic-care model we utilize today and models of care examples for which SETMA has received awards. He said and I quote "the diabetic who knows the most lives the longest." He also said "Don't tell me how little you ate today but rather how far you walked."

And finally as another example of words of wisdom that came from his mouth, he spoke about the team approach as not only including some healthcare members but also members of the family and again I quote "Experience, the nurse, the doctor, the parents, the grandparents, the brothers and sisters working together will finally bring success."

So indeed it was Dr. Elliott Joslin who embraced the concept of team approach to care which we so readily endorse today. When we think about team approach to care, we are not creating something new. We are reinventing the wheel that was created many years ago. Harriet McKay was the first diabetes educator trained by Dr. Joslin when he realized that he needed help and he needed a team to help manage people with diabetes. Harriet McKay was a nurse at the New England Hospital, then the New England Deaconess Hospital.

He trained her to go to homes of members recently diagnosed with diabetes so that she could teach them aspects of diabetes self-care:

• how to inject insulin,
• how to boil and sterilize syringes, something we don't do today,
• how to monitor and
• how to follow diets and so on.

And so, while his team was a far smaller team, the team today that we use to manage diabetes, which SETMA embraces as well, includes not just the patient and not just a nurse educator but many, many other healthcare providers: nutritionists, nurse practitioners, care coordinators and so on. And in addition to that, while Dr. Joslin didn't have an electronic medical record, he took copious notes and made copious notes of all his patients and those records still stand and are available in the archives of the Diabetes Center of Excellence for all to see.

Today of course, we have much greater better technology. We have electronic medical records, once again SETMA is an example of an organization that has embraced technology and used it well before many other organizations even began to think about using this technology. But this technology and the electronic record that forms the core of it, is an incredibly important process and component of the care model that that we continued to develop. Because it enables much closer communication amongst clinicians and providers of care so that patients can be monitored far more closely and the results of that is as you heard today, a continual improvement in healthcare outcomes for patients with diabetes.

But let me turn now to talk a little bit about the magnitude of the problem and then to talk about ways in which I think we can all work together to achieve greater success for our patients. Today in the world, there are probably just under two-hundred-million people with diabetes. 90% of them have type 2, 10% of them have type 1. In less than 20 years that number is going to double to at least four-hundred-million people worldwide. If we look at the United States, we have in our country about 24 million people with diabetes. Unfortunately, 25% of those people don't even know they have the disease. It is a silent epidemic for many people.

The Center for Diabetes Control predicts that by the year 2050, one in three Americans will have diabetes. At SETMA and in some parts of this country, there are already one in three people with diabetes belonging to certain ethnic population groups. The cost of this disease in 2007 was 174 billion dollars to treat people with diabetes and that represents a 32% increase over the preceding five years. So when we think about the cost of managing diabetes and its complications, in the next few years, we can see we can imagine just how expensive this disease is going to be. It is estimated that 1 in 5 US healthcare dollars is going to be spent managing diabetes or its complications, and of course those complications can be varied. They can include cardiac disease.

Poorly controlled diabetes today:

• is the commonest cause of blindness in the western world
• it is the commonest cause of end-stage renal disease and
• is the commonest cause of lower limb loss in people who have not had trauma to their limbs.

Three out of five people will have at least one complication of diabetes. One out of three will have two complications and one in thirteen people with have five complications of this disease.

In addition to that, we have another problem and that is how we are going to manage all of the people with diabetes in this country when we realize that in the next 10 to 20 years the number of people is going to more than double. We have at the moment just over 300,000 primary care physicians in the United States. We have under 3,000 endocrinologists. Today, we have one of those rare examples, or a few of those rare examples of endocrinologists sitting on this podium. By the year 2030, when we have more than a doubling of the number of people with diabetes and less than a 30% increase in the number of primary care physicians and endocrinologists in this country, I think you can just imagine how difficult it is going to be manage all the people with diabetes. I'll come back to that in a minute.

Elliott Joslin would agree therefore that the team approach to care must now include people that are not just physicians and specialists but other people involved in healthcare as well and once again SETMA and The Joslin are working together to insure that that in fact will take place.

But to go back to Dr. Joslin once again, the words of wisdom from this man were really representative of his visionary insight. He said and I quote again "The number of cases is so great that their care must rest in the hands of the general practitioner, it is ridiculous to expect that the treatment of all diabetics should be under the supervision of a specialist."

So as we are standing here today, we have to ask ourselves what would Dr. Joslin do today to manage the problem and the epidemic of diabetes:

• Unequivocally he'd continue the multi-disciplinary care model that we at Joslin and people at SETMA have embraced.
• He would certainly include more healthcare professionals in the management team: pharmacists, nurse practitioners, diabetes educators.
• He would insure that more of these people, more professionals were involved in the care of patients with diabetes.
• He would want to make sure that more people were taught to manage diabetes more effectively.
• He would make use of technology, the internet, electronic medical records to provide care to patients at a distance.
• He'd want to make sure that we were always evaluating how we were doing so that we could continue to improve in our care model and he would work with partners to achieve these goals.

The mission of the Diabetes Center of Excellence is to improve the lives of people with diabetes. It is not just at the Diabetes Center of Excellence where we see about 20,000 unique patients but it is through our various outreaches that we can help other organizations, other people do a better job at managing diabetes. We have an affiliate organization that you heard about a bit briefly that includes now 39 affiliates both in the United States and some internationally as well. Included in those affiliates we have three skilled nursing facilities as well. We provide ongoing professional education through live and on-line continuing medical education programs and we have a healthcare services division that helps primary care physicians and other office workers and healthcare providers do a better job at managing diabetes.

But now to come to Joslin and SETMA, in the final few minutes of my talk. As you heard again from Dr. Holly, SETMA has set the scene and in being one of the first multi-disciplinary or multi-specialty practices to embrace chronic-disease management and to monitor outcomes of people with diabetes. As you heard this has been a process that began many years ago. In 2000, SETMA was one of the first organizations to establish a disease management program for people with diabetes. SETMA got ADA recognition in 2004, one of the first primary care or multi-specialty practices to achieve this recognition. Hiring an endocrinologist was yet the next step in the the road towards managing diabetes more effectively.

But how do you really take care of more than 8,000 people in your practice with diabetes and a number that is growing each day. You align with a partner and Dr. Holly and I have had an ongoing relationship for some years now where when he first e-mailed me and said, "How do we become an affiliate of Joslin?", I was lucky enough to forward the e-mail to Dr. Jackson and his colleagues in the affiliate section. I said, "Please take over and work with Dr. Holly to achieve this."

It is because of the ongoing efforts of our affiliate group that Dr. Jackson, Dr. Snow, Carole Mensing and Loren McLean are all here today to recognize this wonderful relationship between Joslin and SETMA. We've not only developed and achieved an affiliate relationship, but SETMA's also the first organization to achieve certified training for primary care physicians, family practice physicians, nurse practitioners and even non-endocrinology specialists in managing diabetes.

SETMA and Joslin share a vision of the way we should:

• currently manage people with diabetes,
• help people with diabetes and
• look at future care models by leveraging the team approach and technology to provide more care to more people in this ever-burgeoning epidemic that we are dealing with in the United States and indeed in the world as I said earlier.

So indeed, I am honored to be here today to represent the Diabetes Center of Excellence at this inaugural address and to recognize the unique relationship that exists between Joslin and SETMA. Dr. Holly, as we said earlier today, and to quote Winston Churchill, "This is the end of the beginning."

We look forward to a long and fruitful relationship. We look forward to developing new tools and new technologies to help people with diabetes live better, longer and more meaningful and effective lives. So that when we stand here in years to come, we will not only be able to hand out medals for living with diabetes for 50 years and 75 years but please God for even more than 75 years.

We look forward to buying new servers to accommodate the myriad of e-mails that Dr. Holly sends to all of us and one day when we publish those e-mails it certainly isn't going to be the size of this book.

So to conclude:

• this is a wonderful opportunity,
• this is a meaningful relationship, and
• we look forward to many, many years of ongoing, close collaboration where we will learn from each other, and
• where we will be brave enough and wise enough to recognize that there is a lot more that we can learn by doing things together.

Thank you once again for attention. Thank you for giving me this honor and congratulations to SETMA.