US endocrinologist shortage affects access to care, physician satisfaction
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 endocrinologist.
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 true.
Andrew F. Stewart, MD, of University of Pittsburgh, said there is a supply-demand mismatch in the current US endocrinology workforce.
Andrew F. Stewart, MD
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 United States.
“So, immediately you can see a problem,” Stewart told Endocrine Today.
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.”
Overwhelming patient volume
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 said.
Limited access to care
This shortage has had profound effects on patients and the physicians who care for them. For new patients, wait times for appointments have increased dramatically.
“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, Stewart said.
“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 possible.
“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 reduced.
“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.”
Origins of the shortage
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 money.”
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 dermatology.”
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 dramatically reduced.
“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).
“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 Philadelphia (CHOP).
“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,” Stanley said.
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 Kendall.
“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 said.
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 Owens
For more information:
- Desjardins C. 2011;96:923-933.
- Lee JM. J Pediatr. 2008;152;331-336.
- Rizza RA. J Clin Endocrinol Metab. 2003;88:1979-1987.
- Stewart AF. J Clin Endocrinol Metab. 2008;93:1164-1166.
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 ultimately suffer.
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 disclosure.
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 leadership.
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 disclosures.