Lea Sorensen is a diabetes educator who works at the Royal Prince Alfred Hospital in New South Wales, Australia. The Centre has a major interest in the complications of diabetes, especially diabetic neuropathy and foot disease. Ms Sorensen is currently undertaking doctoral studies investigating small nerve fiber abnormalities in painful and non-painful diabetic neuropathy. She hopes that her work will identify pathways for neuropathic pain in diabetes, leading to more effective treatment for the condition.

The major issues in patient management being addressed at the Centre where Ms Sorensen works relate to the growing prevalence of diabetes. Difficulties lie in coping with the increased volume of patients and demand for services without jeopardising the standard of care. This relies on achieving a successful integration of the educational needs and clinical care in the diverse multicultural patient population. Primary care physicians, educators, patients and diabetologists are joined by a shared care programme, underpinned by a computerised database and communication record.

Ms Sorensen feels that seeing people develop skills to manage a chronic disease as demanding as diabetes is an exciting aspect of patient education, but that helping them achieve that confidence remains a challenge.

The Diabetes Centre where Ms Sorensen works offers an ambulatory care service and adopts the philosophy of integrating nursing and education roles with the traditional medical and clinical management of diabetes. To achieve this, the educators and allied health professionals have a high level of ongoing training to keep abreast with modern issues of Type 1 and Type 2 diabetes. This results in a melding of the professional boundaries of the multidisciplinary team and helps to overcome some of the fragmentation that can occur managing a complex chronic disease. This model, incorporating clinical, educational, and research services is also attractive to visitors attending for training, as it fosters development of a "complete package". The Centre has been conducting training programmes for local, national and international health professionals in the management of diabetes and diabetic foot disease for some years. Participation in these programmes has not only enabled individuals to achieve accreditation to professional bodies but also assisted in improving local services in a diverse number of regional countries.

This approach to widening the scope of diabetes education has enabled Ms Sorensen to pursue her interests in physiology and undertaking doctural studies in small fibre diabetic neuropathy. One other project she has been involved with is the development of a web site addressing the practical aspects of diagnosing and managing diabetic foot disease including painful neuropathy. The interest in painful neuropathy has complemented the long-standing involvement the Centre has in managing the problems of the insensate neuropathy and foot disease.

In recent years, the Centre has developed and successfully implemented two related projects in this area. The first, working with local healthcare providers, resulted in the establishment of three High Risk Foot Services in the Fiji Islands, and the development of a Footcare Manual and Training Programme for their local health professionals. These specialist foot clinics continue to be self-sustaining and have resulted in a considerable reduction in amputation rates. In one region, Lautoka, the rates of amputation were reduced by 50% over a 3-year period. More importantly, above knee amputations were reduced by 90%, enabling people undergoing amputation to be more easily fitted for a prosthesis, and therefore remain functional and less dependent.

The second initiative utilises advances in technology to conduct consultations via telemedicine. Local personnel in four selected rural regions of New South Wales have been trained in the project, with funding being granted to train a further four major and four minor centres. It involves the transmission of photographs of foot ulcers by email to the Diabetes Centre. Consultation takes place between the endocrinologist and podiatrists with local personnel on a scheduled basis over the phone discussing each case. Feedback is direct and local doctors are provided with a formal letter detailing treatment decisions. Evaluation of this project over the past 18 months has showed that there is a high level of satisfaction from patients and their healthcare team. Costs of travel are reduced, patients can stay in their own homes and the medical team is receiving on the spot training and support.