The shortage of US endocrinologists was first identified in 2003, but it
remains a significant challenge for physicians and patients today. Physicians
must see more patients in less time, and new patients may wait months to see an
In the seminal report on this issue, published in 2003, Robert Rizza,
MD, and colleagues predicted the work force needs of the endocrine
field from 1999 to 2020. They built an interactive model of factors that would
most likely affect the supply and demand of endocrinologists. Their results
showed that by 2010, the number of endocrinologists entering the work force
would probably not meet demand. Unfortunately, their prediction has proved
Andrew F. Stewart, MD, of University of Pittsburgh, said there
is a supply-demand mismatch in the current US endocrinology
Photo courtesy of:
Andrew F. Stewart,
The shortage is significant, according to Andrew F. Stewart, MD,
chief of the division of endocrinology at University of Pittsburgh School of
Medicine. In 2010, American Board of Internal Medicine statistics showed that
there were 5,811 board-certified endocrinologists, he said. The U.S. News
and World Report surveys indicate that there are 6,300 hospitals in the
“So, immediately you can see a problem,” Stewart told
Retirement has eliminated roughly 10% of endocrinologists from the work
force, Stewart said. In addition, gender distribution plays a role. Currently,
there are about 67% women and 33% men in the field. To have family time, many
women have chosen to work less than full-time schedules, reducing the pool of
available endocrinologists even further.
There are about 2,000 academic endocrinologists, who may not see a lot
of patients, Stewart said. In addition, “a whole other group disappears
from the clinical work force because they work for the FDA or at the NIH or at
the VA,” he said. The pharmaceutical industry employs many
endocrinologists, as well, to help with diabetes and osteoporosis medications.
By Stewart’s estimates, that leaves about 1,000 board-certified
endocrinologists to serve 6,000 US hospitals.
Pediatric endocrinologists are also in short supply, according to a 2008
study published in the Journal of Pediatrics. Nationwide, for
every 290 children with diabetes, there is only one board-certified pediatric
endocrinologist available to treat them, according to research by Joyce M.
Lee, MD, MPH, assistant professor of pediatric endocrinology and health
services research at Child Health Evaluation and Research Unit, University of
Michigan, Ann Arbor. In addition, this study showed that the ratio of obese
children to pediatric endocrinologists was about 17,000:1.
Lee and colleagues also found that the geographic distribution of
available endocrinologists did not match demand. The Midwest had the worst
ratio of kids with diabetes to pediatric endocrinologists (370:1); the
Northeast had the highest ratio (144:1). Two states — Montana and Wyoming
— reported no board-certified pediatric endocrinologists.
“Anecdotally, because of the small numbers of endocrinologists in
certain geographic areas, a lot of children with diabetes have to travel long
distances to get their diabetes care,” Lee told Endocrine
Today. “This places a hardship on the family because parents have
to miss more work and kids have to miss more school. The alternative is that
they may have to see providers who do not have as much experience with treating
children with type 1 diabetes, which isn’t ideal for achieving the best
outcomes for their health.”
Many endocrinologists said they are being stretched to their limits.
“Type 1 diabetes can be a difficult disease to manage, particularly
in young children and children who are growing and developing,” Lee said.
“In addition to seeing children with diabetes, endocrinologists also have
to see children with other disorders, such as thyroid problems, short stature
and obesity. Because of the large number of children with obesity, it is
becoming increasingly difficult for endocrinologists to handle the volume of
patients that need to be seen.”
The demand for endocrinologists is especially high. According to the
CDC, nearly 26 million Americans have diabetes; 7 million of these cases are
undiagnosed. In addition, the CDC estimates that 79 million US adults have
prediabetes. If current trends continue, the CDC estimates that as many as one
in three US adults could have diabetes by 2050. In addition, nearly 34% of US
adults are obese, according to the CDC. Add to that the millions who have
metabolic syndrome, osteoporosis and thyroid nodules, and “the number of
people who, in theory, could see an endocrinologist is huge,” Stewart
This shortage has had profound effects on patients and the physicians
who care for them. For new patients, wait times for appointments have increased
“I recently saw a patient who told me she had to wait 4 months to
see an endocrinologist,” Yehuda Handelsman, MD, president of the
American Association of Clinical Endocrinologists, said in an interview, adding
that in some parts of the country, wait times can extend to 6 months.
Further, limited access to care means that getting an accurate diagnosis
will likely take longer, which can affect health, according to Robert A.
Vigersky, MD, director of the Diabetes Institute, Walter Reed Health Care
System, and immediate past-president of The Endocrine Society.
Patients also see the endocrinologist less often, and although that is
not an issue with routine diabetes it can be an issue with more complex cases,
“It is very common for diabetics to have a tough time being managed
in the United States,” he said. “Probably 40% of diabetics are not in
optimal control. Endocrinologists don’t need to see 30 million diabetics,
but probably 10 million of them could benefit from more education, adjustment
of their insulin and other drugs, and so on.”
This shortage has affected practicing endocrinologists, too. Many are
forced to work late nights and weekends, cramming in as many patients as
“Physicians are getting tired of seeing a lot of patients in a
short amount of time,” Handelsman said. “Some physicians want to
leave their practice. Some doctors are converting their practices from pure
endocrinology to internal medicine. Doctors try to find ways to survive.”
The amount of time a physician can spend with a patient has also been
“If the endocrinologist works for an HMO, instead of having 1 hour
to evaluate the patient initially, they may have only 20 minutes,”
Handelsman said. “The level of care has been affected.”
There are multiple causes for the nationwide shortage of
endocrinologists. First, the number of endocrinology training and fellowship
programs is shrinking. In 1987, there were 140 endocrinology fellowships; in
2010, there were 122.
“In the face of exploding diabetes and metabolic syndrome rates, an
aging population with osteoporosis, and more patients being diagnosed with
thyroid nodules … the number of trainingprograms is actually
declining,” Stewart said.
Large academic medical centers have little incentive to support
endocrinology training, he said. “They’d much rather have cardiology
fellows or gastrointestinal fellows doing invasive procedures that generate
In addition, training support for endocrinology has been increasingly
difficult to secure in recent years, according to David Kendall, MD,
Chief Scientific and Medical Officer of the American Diabetes Association.
“Even groups like the NIH have to make careful decisions as to
where they are going to spend their money, so getting training support from
federal or other sources for the endocrine community has been a
challenge,” Kendall said.
The endocrine specialty is not attracting younger physicians because
salaries are typically low compared to their peers in other specialties.
“There are many reasons to become an endocrinologist, but
remuneration is not one of them,” said Daniel Einhorn, MD,
immediate past president of AACE.
Similar to all cognitive specialties, endocrinology is a relatively low
reimbursing specialty, Einhorn said.
“All cognitive specialties are having a harder time drawing the
same pool as procedure-oriented specialties,” he said. “This
doesn’t seem to be as much of an issue in orthopedics, ophthalmology or
Also, reimbursement is continuing to decrease, with the recent CMS
elimination of consultation codes, which endocrinologists use often.
“Depending on your practice and how many patients you saw in the
hospital … certain physicians saw a 25% to 30% decrease in
reimbursement,” Vigersky said.
This shortage has also limited the pool of academic endocrinologists.
Research funding has been difficult to obtain because NIH budgets have been
“Last year, the percentile of grants that was funded was 17%; that
means 83% didn’t get funded,” Stewart said, noting that this will
likely be an especially tough year for osteoporosis research.
The National Institute on Aging, which funds osteoporosis research, is
going to have a 3% funding rate. “You have a 97% chance of failing if you
want to get a grant from them in osteoporosis,” Stewart said. “Why
would anybody want to do that?”
In 2011, a work force survey by Claude Desjardins, PhD, revealed
that respondents linked research and lowered incomes, another factor driving
candidates away (See
related article here). The researchers estimated an annual earnings drop of
2.8% per half-day spent on research (P<.001).>
Robert A. Vigersky
“That’s another disincentive,” Vigersky said. “There
is very little job security in being an endocrine clinical researcher.”
Pediatric endocrinology researchers have also felt the pinch. About 10
to 12 years ago, it became clear that there were not enough translational
researchers in pediatric diabetes and endocrinology, according to Charles
Stanley, MD, professor of pediatrics at The Children’s Hospital of
“A consequence was that there were few pediatric endocrine faculty
at medical centers who had the training to carry out research, and this was a
particular problem for both type 1 and type 2 diabetes in children,”
There are several ways to address this problem. The first step is to
realign incentives to support prevention and education, Stewart said.
Currently, Medicare and insurance companies spend a great deal of money on
procedures such as coronary artery bypass surgery or dialysis.
“We heavily incentivize the treatment of horrendous late-term
complications,” Stewart said. “If people were thinking rationally,
they would support the preventive, educational activities up front and hope
that the complications don’t happen.”
Community-based support systems must play a larger role, according to
“The patient community, particularly in diabetes, has come to
understand the importance of the broader care teams: the diabetes educator, the
primary care provider, physician assistants and nurse practitioners,” he
Einhorn agreed and said the three physician assistants in his practice
are invaluable, providing in-between care and counseling patients.
Patients in rural areas may face additional challenges in both finding
and traveling long distances to see an endocrinologist. Lee said some pediatric
centers have endocrinologists who travel to these more isolated areas.
Another option is telemedicine, Stewart said.
“We are developing arrangements with community hospitals in rural
areas that have diabetes educators and nurse practitioners to do telemedicine
consults,” he said. “It has been very effective.”
Stewart also called for loan forgiveness.
“If you’re willing to go into programs that have demonstrated
need and health impact, then for every year you practice as an endocrinologist,
Medicare should pay off a portion of your debt,” he said.
To address the dearth of academic pediatric endocrinologists, in 2002,
the NIH awarded T32 training grants and K12 career development grants to
several institutions nationwide, including CHOP.
The program has expanded CHOP’s fellowship training program from
one to three fellows per year and allows them to devote more than 80% of their
time to research, Stanley said. The K12 grant allowed CHOP to fund two junior
faculty researchers for 3 years each, which allows them to devote 80% of their
time to research as well.
Since the program began, CHOP has had 25 to 30 fellows and six junior
faculty in these programs. All fellows have completed research with
first-author publications and nearly all have obtained faculty appointments at
prestigious medical schools. All K12 awardees have obtained initial independent
NIH grants and several have obtained R01 funding.
Currently, there are nine fellows in the fellowship training program.
Three new fellows will enter the program in July. – by Colleen
For more information:
- Desjardins C.
- Lee JM. J Pediatr. 2008;152;331-336.
- Rizza RA. J Clin Endocrinol Metab.
- Stewart AF. J Clin Endocrinol Metab.
Disclosures: Drs. Desjardins, Einhorn, Handelsman, Kendall, Lee,
Stanley, Stewart, Vigersky report no relevant financial disclosures.
Who is affected most by the
endocrinologist shortage: Doctor or patient?
Patients suffer most
Because of the shortage of specialists, patients who want to see them,
to get a focused evaluation, to get optimal endocrine care, will not have
access. The problem affects patient care, and patients are the ones who
A study that was conducted and published a few years ago, a
collaboration of different endocrine organizations in the country — AACE,
The Endocrine Society, American Thyroid Association, ADA and others —
showed that there is a shortage of endocrinologists.
However, business has continued as usual. We have not increased manpower
and now it is expected that by 2020 there will be an even greater shortage of
endocrinologists in clinical practice. Therefore, patients who want to see an
endocrinologist for osteoporosis, for a goiter, for fertility, will be put on a
long waiting list. Patients will be frustrated and doctors will be frustrated.
Currently, there are about 120 to 130 endocrine programs in the United
States and most have one or two fellows per year. There has been some increase
in the number of fellows in some programs, but there has not been a systematic,
national increase in the total training slots for endocrinologists. To meet
manpower needs, each program would need to expand, which would result in more
trained clinical endocrinologists.
Institutions, the government and endocrine associations will have to
address this by increasing the pool of physicians who want to go into
endocrinology by increasing incentives, increasing training centers, and
allowing more fellows to train, graduate and practice.
We need a concerted effort to increase manpower.
Hossein Gharib, MD, is professor of medicine at Mayo Clinic College
of Medicine, Rochester, Minn. He is also past president of AACE and ACE.
Disclosure: Dr. Gharib reports no relevant financial
Doctors bear the burden
There is an acute shortage of endocrinologists. The prescient need for
this study originated with Robert Rizza, MD, more than a decade ago. At
the time, I was president of AACE. Dr. Rizza, representing the American
Diabetes Association, approached me and we discussed the concerns regarding the
future of endocrinologists and the patients we serve. We agreed that such a
study would be of utmost importance, and we invited The Endocrine Society to
join us in this endeavor. The study, published simultaneously in Diabetes
Care, the Journal of Clinical Endocrinology &
Metabolism and Endocrine Practice in 2003, estimated
conservatively that there was a 12% shortage of endocrinologists in this
country, and that shortage was projected to grow. The anticipated progressive
shortage of endocrinologists was mostly related to the fact that the population
was aging and developing conditions that are in the realm of
endocrinologists’ expertise, and the number of physicians entering the
field was not offset by the number of endocrinologists retiring.
The problem is definitely getting worse. The calculations made a few
years ago did not consider the epidemic of obesity and diabetes. There are
currently 26 million Americans who have diabetes. Another 79 million have
prediabetes. These figures are on the rise. We estimate that there are about
5,000 endocrinologists in full-time clinical practice. It is clear that they
can only handle a small percentage of the patients with type 2 diabetes. In
addition, with an aging population, diseases such as osteoporosis and
dyslipidemia are on the rise. Further, many endocrinologists only see patients
with a narrow spectrum of conditions.
As a result, treatment of many patients with endocrine problems —
type 2 diabetes, thyroid disease, osteoporosis, lipid disorders — are
handled by primary care physicians. Many PCPs do not have the specialized
training to enable them to remain current with the literature, with the
guidelines and algorithms, and with the standard of practice.
The shortage of endocrinologists already means that the waiting list to
get an appointment with an endocrinologist is commonly measured in months. With
the shortage, it is almost inevitable that the quality of care, on average,
will deteriorate. This is turn will result in increased costs when patients are
not treated appropriately and develop complications. In addition, this will
place a still greater burden on society at large in terms of the costs of
health care. This becomes a vicious circle. Something needs to be done, and
soon. Hopefully, associations such as AACE and ACE, working together with our
colleagues in other associations, will be able to provide some enlightened
Helena Wachslicht Rodbard, MD, FACP, MACE, is past president of ACE
and AACE, and is in private practice in Rockville, Md.
Disclosure: Dr. Rodbard reports no relevant financial