Where have all the endocrinologists gone?

I’ve mentioned diabetes guru Kelly Close before. Kelly is the founder of Close Concerns, a healthcare information company based in San Francisco, CA, that is exclusively focused on diabetes and obesity. Close Concerns publishes resources for both industry (Diabetes Close Up and Closer Look) and consumers (diaTribe). Kelly forwarded a copy of the report that she and her team wrote analyzing the CDC’s (Center for Disease Control) June update on diabetes statistics. (She sent it to me in June, I’m just now writing about it. Mea culpa!) Among the most dramatic news was the new estimate of 57 million people in the US over the age of 20 with pre-diabetes. Other notable findings:

  • Estimates of the total number of people with diabetes nationwide (diagnosed and undiagnosed) have risen to 23.6 million in 2007 from 20.8 million people in 2005.
  • As a percentage of the population, the number of people diagnosed with diabetes has grown to nearly 8%. This represents 11% growth since 2005 and 24% growth since 2002.
  • People with diabetes are being better diagnosed. Since 2002, there has been a 37% increase in diagnosed patients, a 10% decrease in undiagnosed patients, and a 30% increase in the number of patients overall.
  • The direct cost of diabetes was estimated at $116 billion for 2007. Including indirect costs such as lost productivity; this cost nears $175 billion.

Shortly afterwards, Kelly sent me a PDF of the poster she and several others presented at the ADA (American Diabetes Association) Scientific Sessions in June called, “Who Will Manage American Patients with Diabetes in the Near Future?” I had no idea what a grave situation is unfolding in our medical system related to diabetes care.

Previous work has estimated that the US has a 12–15% undersupply of endocrinologists, with this shortage predicted to expand to 25–30% by 2020. Fewer than 3000 endocrinologists practice in the US, while approximately 3000 patients are diagnosed with diabetes daily. The aim of this study*, therefore, was to identify factors that are deterring students from specializing in diabetes care, and to understand what can be done to reverse this trend.

The results are astounding. Out of the 524 medical students surveyed as part of the study, only seven students (1.3%) expressed an interest in endocrinology, and only three of those students were interested in pursuing diabetes care.

What is driving this? Students cited the uphill battle of modifying patient behavior as the #1 reason (46%) they are eschewing diabetes. Second was a general lack of interest in the field (42%) and third was lack of procedures (38%). Surprisingly (at least to me), inadequate compensation did not make the top three; it came in fourth place at 35%. When choosing a specialty, the vast majority of medical students indicate that they are concerned primarily with the intellectual satisfaction of the work; compensation and length of training were not cited as major concerns.

So just as the incidence of diabetes is increasing, there will be fewer specialists available to diagnose, treat, monitor and educate these patients. The job will fall to already burdened PCP’s and to the patients themselves. Why should pharma care? Because it’s not clear who is going to take the time to learn about all the new medications in the pipeline let alone prescribe them.

The study’s authors conclude that increasing physician interest in diabetes will require significant changes to reimbursement structure and physician economics. They also note that new and improved therapies may increase interest in diabetes care if they are able to provide real alternatives to behavior modification.

* Study methodology Between April and August of 2007, the authors conducted an electronic survey of 524 medical students and inquired about their exposure to diabetes in medical school, their interest in pursuing diabetes care, and the attributes of a specialty that they consider to be most important. Survey respondents represented all four years of medical school, with a small bias toward first year (first: 39%; second: 23%; third: 12%; fourth: 26%).