One of the worst and most feared complications of diabetes is a diabetic foot ulcer (DFU). It is the most common reason for non-traumatic lower-limb amputations in the US, and the numbers are scary: the five-year death rate after a major amputation is higher than for many common cancers. But the most important thing to know is that most of these amputations could have been avoided. To avoid this terrible complication, you need to work closely with your primary care doctor all the time and be on the lookout for problems. The Direct Primary Care (DPC) model is meant to provide this kind of intensive, prevention-focused care.
A DFU is an open sore or wound that happens to people with diabetes, usually on the bottom of the foot. About 15% of people with diabetes will get a foot ulcer at some point in their lives. These ulcers aren't just cuts; they are the result of a "perfect storm" of problems that come with diabetes.
The "Perfect Storm" of Reasons:
Neuropathy (nerve damage): Diabetes can hurt the nerves in your feet, making you lose the "gift of pain" that protects you. You might not even feel it if you step on something sharp or get a blister from a shoe that doesn't fit right.
Diabetes hurts blood vessels, which makes it hard for blood to flow to the feet. This is called Peripheral Artery Disease (PAD). This means that not enough blood that is rich in oxygen can get to a wound to help it heal.
Foot Deformities: Damage to the nerves can also make the muscles in the feet weaker, which can change their shape (like hammertoes or bunions) and make pressure points that aren't normal.
This combination of not feeling an injury and not having enough blood flow to heal it is what lets a small spot of pressure turn into a non-healing ulcer that can easily get infected and spread to the bone.
Direct Primary Care (DPC) is a membership-based system that lets patients talk to their doctor whenever they want. DPC's focus on proactive prevention and quick response coordination is a game-changer for a problem as serious as a DFU. Here are some reasons why DPC is the best way to keep your feet safe:
Stop, stop, stop: The DPC Superpower: This is the most important thing your DPC doctor does. They are always trying to stop an ulcer before it starts.
The Comprehensive Foot Exam Once a Year: Every time you go to your DPC doctor, they have time to quickly check your feet and take off your shoes and socks. They should also do a full foot exam at least once a year, as recommended by the American Diabetes Association. This means using a monofilament to check for neuropathy.
Intensive Diabetes Control: They work with you to get the best possible control of your blood sugar, blood pressure, and cholesterol. This is the most important thing you can do to slow the progression of neuropathy and PAD.
Constantly teaching patients: They will teach you the most important thing you can do to avoid DFU: how to check your own feet every day.
Quick response and expert coordination for an active ulcer: If you do get an ulcer, speed and coordination are very important.
Immediate Access: You can get seen right away for a new blister, red spot, or open wound on your foot at DPC.
Quick Start of Care: Your doctor can start the most important parts of your treatment right away, like arranging for wound care and, most importantly, off-loading (taking all the pressure off the ulcer).
The Team Quarterback: They will be your "quarterback," making sure that you get quick, smooth referrals to the right multidisciplinary team, which could include a podiatrist, a specialized wound care center, an infectious disease doctor, and a vascular surgeon.
In Case 1 (Prevention), David's doctor does a monofilament exam during his annual DPC physical and finds that David has lost the feeling in his feet that protects him. The doctor spends the next 20 minutes teaching David and his wife how to check their feet every day, how to pick the right diabetic shoes, and how to get therapeutic shoes and nail care from a podiatrist. This thorough, preventive visit stops an ulcer from ever forming.
Case 2 (Management): Linda, 72, is a DPC member who has diabetes. On Sunday, she sees a small sore on the bottom of her foot that won't heal. She sends her DPC doctor a picture. The doctor sees that it is an early DFU and calls her to set up an appointment for her to be seen first thing Monday morning at a trusted local wound care center. This quick triage and coordination gets Linda into full care right away, which greatly increases her chances of healing the ulcer and not having to have her leg cut off.
Q: My feet feel fine. Why do I have to see my doctor every year? A: This is because of diabetic neuropathy. The first thing that goes away is often the ability to feel light touch and pain. You might be hurt badly and not even know it because you can't feel it. The yearly foot exam, especially the monofilament test, is meant to find this loss of feeling so you can be extra careful.
Q: What is the one thing I can do at home to keep my foot from getting an ulcer? A: There are two things that are just as important: 1) Work closely with your DPC doctor to keep your blood sugar and blood pressure as low as possible. 2) Look at the bottoms and sides of your feet every day. If you need to, use a mirror. You are the first line of defense for yourself. Check for any new red spots, blisters, calluses, or open wounds.
Q: What does "off-loading" mean, and why is it so important? A: Off-loading means taking all the pressure off the ulcerated area so it can heal. If you walk on a hole in the bottom of your foot every day, you can't heal it. This is the most important part of treatment. It may involve using crutches, a wheelchair, or wearing a special boot or cast (like a "total contact cast") that is made to move pressure away from the wound.
DPC has a clear advantage when it comes to keeping your feet safe from the effects of diabetes because:
Being great at prevention: The best way for us to provide the intensive preventive care that can stop DFUs before they even start is through DPC's proactive, longitudinal model.
Filling in the "Care Gap": Making sure that every person with diabetes gets the yearly foot exam and education that is recommended. This is something that is often missed in a system that is rushed and not well coordinated.
Providing quick triage and coordination: Acting as an important first responder and team leader when an ulcer does appear, getting you to the right group of specialists right away.
A diabetic foot ulcer is a tragedy that can be avoided. A dedicated primary care doctor and an engaged patient can work together to save limbs and lives. Direct Primary Care gives you the time, access, and constant focus on prevention that you need to keep your feet safe for life.
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