Experts examine roots of endocrine workforce shortage

Endocrinologists care for some of the most complex patients seen by health care providers, but one problem that they have been unable to solve is the endocrine workforce shortage. After all, experts told Endocrine Today, tackling the larger issues that cause new physicians to hesitate before entering the specialty is slightly more complicated.

“When a young person has spent all the years necessary to go through medical school and an internal medicine residency, and when you look at the numbers in terms of reimbursement that endocrinologists get for their mostly cognitive services, it’s very easy for them and they say, ‘Even though I really like the mental stimulation of taking care of these complicated diseases, I just can’t get paid enough to make it worthwhile,’” R. Mack Harrell, MD, FACP, FACE, ECNU, of Memorial Health Systems in Hollywood, Fla., said in an interview with Endocrine Today.

 

Also, the psychological demands on endocrinologists are unique, according to Harrell. Many patients with endocrine diseases are likely to require long-term care, which places a distinctive burden on the physician.

“The diseases that we treat are chronic, so they require human beings [who] are willing to deal with the same people over and over again. There’s a certain mindset that is required to deal with these patients. Additionally, when you deal with diseases like diabetes that progress, or in which there is progressive loss of function, it can be hard on you mentally,” said Harrell, who is also a clinical associate professor for Nova Southeastern College of Osteopathic Medicine in Davie, Fla.

Nevertheless, the demand for endocrinologists is outstripping the supply. In a commentary published in the Journal of Clinical Endocrinology & Metabolism in 2008, Andrew F. Stewart, MD, chief of the division of endocrinology and metabolism at the University of Pittsburgh School of Medicine, highlighted the importance of increasing the endocrine workforce, especially in the current climate.

“It is important to recognize that this demand for endocrinologists and their services will continue to increase dramatically over the next decade,” he wrote. “Diabetes and obesity are the epidemics of our generation. … Osteoporosis is also increasing in frequency as the population ages. Thyroid cancer detection has tripled over the past 12 years. Moreover, payer and regulatory factors, such as pay for performance and diabetes quality improvement programs, are driving patients from generalists to endocrinologists.”

A persistent problem

In 2003, Robert A. Rizza, MD, of the Mayo Clinic in Rochester, Minn., and colleagues published a paper in the Journal of Clinical Endocrinology & Metabolism evaluating the projected need for endocrinologists from 1999 to 2020. At that time, the researchers estimated that the national supply of endocrinologists was 12% lower than the demand.

According to the data, in 1999, there were 3,623 adult endocrinologists in the workforce, 66% of whom were in office-based practice. Key findings revealed that waiting time for an initial appointment with an endocrinologist was 37 days compared with 10 days for general internists and 17 days for neurologists and dermatologists. Study results also indicated that the median age of endocrinologists was 49 years vs. 44 years for all non-endocrine physicians, with practically no endocrinologists aged younger than 30 years. Older age among endocrinologists is likely related to the length of time required for subspecialty training, the researchers said, but it raised red flags because retirement rates begin to rise as physicians enter their late 40s.

Similarly, in his commentary, Stewart cited information from the American Board of Internal Medicine showing that, in 2006, there were 5,341 board-certified endocrinologists in the United States. Of these, he reported, approximately 1,500 were not clinical care providers and were instead primarily involved in research, administrative, teaching or pharmaceutical industry activities. Further, although the number of first-year endocrine fellows had increased from 185 in 1996 to 263 in 2005, only 80% were expected to remain in the United States after graduation, leaving only about 200 new endocrinologists entering the workforce per year.

Overall, there appear to be only one-half the endocrinologists required to fill the needed positions in the United States,” Stewart wrote. “Demographic, disease prevalence, regulatory, and patient expectation trends will increase the requirement for endocrinology care, a need that the addition of only 160 graduates yearly entering the job market will fall far short of fulfilling.”

Currently, endocrinologists feel the burden, but data on the extent of the problem are outdated.

This is 12 to 13 years later. We have new data and lots has happened since the paper was published in 2003,” Robert A. Vigersky, MD, who worked on the 2003 study, said in an interview.

 

To address this knowledge gap, The Endocrine Society commissioned a new workforce study that included a survey of members. Vigersky, past-president of The Endocrine Society and director of the Diabetes Institute at the Walter Reed National Military Medical Center in Bethesda, Md., and colleagues served as the Technical Expert Panel. Working with the healthcare consulting firm The Lewin Group, they developed supply-and-demand curves, basing supply projections on data from the American Medical Association master file, the number of filled fellowship trainee slots, retirement rates and more. To assess demand, the researchers evaluated Medicare utilization rates, waiting times to initial appointment with an endocrinologist and the number of endocrinologists who were looking to hire physicians during the next few years. They also crafted different scenarios accounting for events that may significantly affect health care, such as the Affordable Care Act (ACA).

Ultimately, the researchers’ goal was to find out how many endocrinologists are currently caring for patients.

“There are a lot of numbers floating out there in terms of the number of endocrinologists, but what we really want to know is how many full-time equivalent endocrinologists are out there because the total number is diminished by those who are not actually in practice and further diminished by those who are only practicing part time,” Vigersky said.

Although the data are still being reviewed for publication, not much has changed.

“It’s fair to say that there is a shortage now and there will be continued shortages under almost all these various scenarios out through 2026, where our projections extend,” he said.

An economic issue

One major factor that has perpetuated the endocrine workforce shortage is a downward trend in the number of physicians enrolled in endocrine fellowships. From 1995 to 1999, this number decreased from 459 to 393 or about 200 per year, according to the 2003 study.

In the past 10 to 15 years, the number of fellows who have graduated increased significantly, Vigersky said, but during the past 2 years, it has plateaued and may potentially be decreasing. Currently, there are 280 fellows entering the specialty .

The reasons for this decline may be manifold.

“Fellowship positions are training positions that are funded through Medicare in many cases, and hospitals have a finite amount of money to spend on training physicians,” Vigersky said. “We speculate that if a hospital wants to train specialists who are going to then become more productive, such as those who perform high-profit procedures for the hospital, they’re going to train more cardiologists, for example, than endocrinologists, even though we know that endocrinologists essentially serve as gatekeepers, by feeding lots of invasive specialists and procedural specialists for hospitals and large groups.”

For instance, patients with diabetes often need cardiovascular evaluations prior to undergoing cardiac surgery, he said, whereas those with thyroid problems may require a number of laboratory studies.

This logic, however, is symptomatic of a larger, more complex issue, according to Alan J. Garber, MD, PhD, president of the American Association of Clinical Endocrinologists and Chief Medical Editor of Endocrine Today.

“Reimbursement is a constant problem right now, when the government programs do not tend to pay for non-procedural endeavors,” Garber said in an interview. “They don’t pay for thought; they don’t pay for complex multisystem management at a level commensurate with the time, training and effort required. … Society seems not to value this.”

With this sentiment, reimbursement acts as yet another hurdle that new physicians would rather not face, Jonathan D. Leffert, MD, FACP, FACE, ECNU, chair of the socioeconomic committee and member of the board of directors for AACE, told Endocrine Today. He said both the current and future states of reimbursement offer unappealing options for endocrinologists.

“The cognitive specialties like endocrinology are the ones that require spending a lot of time with patients and require a lot of expertise over a period of time and, therefore, are not nearly as easily reimbursed. Our codes are basically for evaluation and management, so we get paid at the same level as, or sometimes at lower levels than, primary care physicians. In the current payment scheme, there’s not the value associated with our services, and as we go to future payment options, such as bundling and value-based payments, it potentially becomes an even lesser payment for physicians who do what we do,” said Leffert, who is also a managing partner at North Texas Endocrine Center in Dallas.

“Younger physicians who are just starting to make decisions about their careers are certainly going to take that into account,” he said.

Chronic disease care conundrums

New physicians are also not likely to overlook the psychological demands of treating patients with chronic diseases, Harrell said, which can serve as another barrier.

Patients with diabetes, for instance, often have various comorbidities or struggle with compliance issues, he said, and the endocrinologist sees them for follow-up appointments every 3 months for perhaps the rest of the patients’ lives.

“We need to concentrate on the psychological demands of providing diabetes care to patients because there’s a demand on the psyche of the person who’s delivering that care. When 15 to 25 people in various degrees of decay walk into your office every 3 months, that takes a toll,” Harrell said. “Granted, some physicians and patients will form beautiful, long-term relationships, but it’s tough.”

In contrast, an acute care model may be more appealing for some physicians, according to Harrell. He said treating a patient who could be cured and would not require regular follow-up appointments can be satisfying.

“It’s nice to deliver a service that is curative or nearly curative, and you can watch people walk away and be happy,” he said. “That doesn’t happen as much with diabetes.”

Additionally, caring for patients with chronic diseases such as diabetes further complicates reimbursement, especially with the introduction of the ACA.

“In the Obamacare model, with pay for performance, the idea is that if you do something really well, the outcomes are really good and you’re going to get paid better. But what if the disease is terrible, and no matter how well you do your job, you’re still going to have bad outcomes eventually?” Harrell said, emphasizing that the patient’s ability and willingness to comply with diabetes treatments are essential to achieving favorable outcomes. “That’s just distressing for a young physician to see.”

Even endocrinologists who have been practicing for years, however, are shying away from treating patients with diabetes due to reimbursement, according to Endocrine Today Editorial Board member Richard O. Dolinar, MD.

“For the amount of time and effort that you put into treating a diabetic patient, you get paid very little,” he said in an interview. “On the other hand, endocrinologists can make a little more money by treating patients with other endocrine conditions, like adrenal or thyroid disease. So, unfortunately, we have endocrinologists and we have diabetic patients who need endocrinologists, but because of the economics, we have endocrinologists who don’t see diabetic patients.”

Health care’s changing landscape

Although the ACA will expand coverage, it is unlikely to improve the situation. In fact, it may exacerbate the shortage of endocrinologists, according to Vigersky.

“The ACA is going to drive the demand for endocrinology specialty services among those who didn’t have insurance. In particular, that will probably affect people in urban areas and previously underserved populations. This will drive up the demand for endocrine services because people in those categories are short of Medicare age and have a rising incidence of diabetes, or a lot of women in that age range have concerns about osteoporosis. The ACA will flood the offices of endocrinologists over the next 5 years if they’re able to handle it, and our projections are that they probably won’t be [able to] because there just aren’t enough endocrinologists,” he said.

The ACA has also inspired new concerns about government’s involvement with medicine, according to Dolinar. Some physicians are concerned that the independent payment advisory board, for example, may soon dictate the type of care that can be given and to which patients it will be given. Dolinar cited academic detailing — in which health care professionals are paid to educate physicians on prescribing or other aspects of clinical practice — as another potential problem. In many cases, he said, new physicians may not want to operate within that box.

“With the ACA, you’re going to see more and more government intervention in the actual medical decision-making process, and that can only harm the patient,” Dolinar said.

Even so, Leffert said, in light of the increasing prevalence of endocrine diseases, the workforce shortage would have worsened regardless of health care reform.

“Overall, we’ll be reimbursed less per patient, and it’s going to be hard on the current practicing clinical endocrinologists to keep up. There are going to be situations where small physicians groups who are limited by the number of patients they can see in a day may not be able to make it. We think that it may eventually be necessary to be part of a larger group or a niche practice. We also think there are going to be endocrinologists who only see private insurance patients. Honestly, however, these things would have happened with or without the ACA. The ACA just set a timeline,” Leffert said.

Solving the problem

Although the shortage is expected to persist, there are ways of ameliorating the problem, according to Vigersky.

The obvious answer to strengthening the endocrine workforce is training more endocrinologists, he said, but providing adequate incentive is the biggest obstacle. Currently, endocrinologists serving in underserved areas may qualify for loan forgiveness programs, which will hopefully make a career in endocrinology seem more attractive for new physicians.

Additionally, the concept of shortening the internal medicine residency to 2 years and having the third year overlap with the first year of a 3-year endocrine fellowship program has been proposed, Vigersky said.

Leffert also advocates quantifying the value of an endocrinologist’s services to improve remuneration and reimbursement. “The solution is to try to show the value of the clinical endocrinologist and try to find metrics and propose a way to assign the metrics to particular physicians’ practices to see whether or not you can show that the endocrinologist is having a beneficial effect on the patient and the system overall,” he said.

Finally, addressing the psychological stresses experienced by endocrinologists dealing with chronically ill patients and working long hours is essential, according to Harrell. With the appropriate support, entering the field of endocrinology may not seem as daunting for new physicians.

“The psychological support has to be built systematically into the way care is delivered,” he said. “If the accountable care organization (ACO) is the model of the future, we need to build it into the working structure of the ACO. Maybe this should include forced vacations or forced vacations with other people who are in the same situation dealing with the same stresses.”

In any case, as the population continues to age and obesity and diabetes become more prevalent, the need to find a solution is urgent, according to Vigersky.

“Endocrinologists really are the key specialists who can potentially make a difference in fighting the epidemic of diabetes and metabolic diseases, as well as other general endocrine diseases that have increased over the last decade or so,” he said. “We will be shooting ourselves in the foot if we don’t find ways to get more endocrine specialists out in the community and help reduce the burden of endocrine diseases.” – by Melissa Foster

Disclosures:

• Dolinar, Garber, Harrell, Leffert and Vigersky report no relevant financial disclosures.

Will shortening residency training to 2 years for endocrine fellows allow sufficient training?

Consider an alternative.

Endocrinologists are a dwindling species. National Resident Matching Program (NRMP) data show 218 residents matching into Accreditation Council for Graduate Medical Education (ACGME) accredited fellowship programs in 2012. With the brunt of diabetes care falling on the shoulders of endocrinologists, there is clearly a disparity between the need for and supply of trained professionals for treating patients with diabetes.

I do not believe that substituting the last year of residency as the first year of endocrine fellowship is a viable option for tackling this situation. Internal medicine is a vast specialty, and 3 years of training is a minimum prerequisite for gaining competence to function as an internist. All endocrinologists are internists first and subspecialists second. Given the pan-systemic involvement of most endocrine disorders, a thorough understanding of internal medicine is a must for any endocrinologist.

Also, most residents would opt for endocrine fellowship only if they are truly interested in the subspecialty, especially since the earnings are not significantly more than that of a general internist, so shaving off a year of fellowship training will not vastly increase the number of fellowship candidates.

However, I do have a suggestion for the predicament under discussion. Clearly, the severe shortage of endocrinologists is being felt due to the raging epidemic of diabetes. I would propose the introduction of a 1-year ACGME-accredited Diabetes Fellowship after completion of 3 years of residency training in internal medicine. Such fellowship training will help raise a new breed of ‘diabetologists’ — internists with special training in diabetes. These physicians would learn the usage of continuous glucose monitors, insulin pumps, interdisciplinary care coordination required in treatment of diabetes and the finer aspects of therapy in diabetes in the fellowship year that would include both inpatient and outpatient training. This would address the immediate need of physicians treating diabetes in the community without compromising the quality of education required for training endocrinologists.

Akshay B. Jain, MD, is an endocrinology, diabetes and metabolism fellow at the UCLA/City of Hope National Medical Center in Los Angeles. He is also a Fellows’ Representative 2012-2013 for the American Association of Clinical Endocrinologists. He can be reached at Harbor UCLA Medical Center, Division of Endocrinology, Box 446, 1000 W Carson St., Torrance, CA 90509; email: oxyjain@gmail.com

A 2-year program would not eliminate our goal of becoming well-educated generalists.

Many physicians whom I know, myself included, would likely be more interested in an endocrine fellowship if they knew that the general residency training would be a little bit shorter. Once a resident commits to a specialty, a shorter residency training would be a more attractive option.

Although I agree that both internal medicine and, in my case, pediatrics are vast fields that require quite a bit of time to learn, shortening the residency does not mean that the training is cut short. In fact, a 2-year residency of combined internal medicine and pediatrics has been offered for many years.

A resident could still do all of the necessary rotations, but could focus on the endocrine problems pertaining to diseases. He or she could perhaps become part of the endocrine team who would primarily be consulted or called for medical issues pertaining to endocrinology. Many diseases in internal medicine and general pediatrics have an endocrine aspect and the resident could perhaps become the resident assigned to those patients when possible. In this case, you are not cutting short your general training; it just means that you are focusing on the specialty as it pertains to general practice. A 2-year training program may actually strengthen our direction by allowing us to focus on what we will actually become.

At the end of the day, even though the bigger focus would always remain on our general specialty of either pediatrics or internal medicine, a majority of our time will be dedicated to endocrinology.

Dina Belachew, MD, is a fellow in the department of endocrinology at Children’s Hospital of Pittsburgh. She can be reached at dina.belachew@chp.edu. Disclosure: Belachew reports no relevant financial disclosures.