Endocrinologists propose diabetes fellowship programs to address growing gap in care
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The incidence of diabetes in the United States continues to rise, straining an overburdened health care system that already reflects a shortage of endocrinologists who specialize in the disease.
An estimated 34.1 million, or 13%, of U.S. adults have diabetes, according to the most recent CDC National Diabetes Statistics report. Yet of the approximately 7,000 endocrinologists practicing in the U.S., 25% to 30% do not treat diabetes, Boris Draznin, MD, PhD, professor of medicine and director of the adult diabetes program at the University of Colorado School of Medicine, and colleagues wrote in a March 2021 commentary published in Endocrine Practice. The result is approximately one endocrinologist for every 6,500 people with diabetes — and an estimated 80% to 90% of patients heading to a primary care physician’s office for their diabetes care.
“The first problem is the population of people with diabetes is growing,” Archana R. Sadhu, MD, FACE, director of the system diabetes program and director of transplant endocrinology at Houston Methodist Hospital and assistant professor of medicine at Weill Cornell Medical College, New York, told Healio. “The second problem is we have had amazing developments in diabetes drugs and technology, but the flipside is the treatment plan is much more complicated. With all these new treatment options, we need experts in diabetes managing patients [but] it is logistically impossible to get an endocrinologist to manage them all. We need to increase the workforce of diabetes experts.”
To address this gap in care, some endocrinologists argue that a multifaceted approach that centers on primary care training in diabetes and its complications is needed. The proposed solution: 1-year diabetology fellowship programs, with funding and accreditation, to train interested family and internal medicine clinicians in intensive diabetes management across the full spectrum of disease. A PCP would complete a fellowship to develop expertise in prescribing insulin analogues, applying the latest guideline recommendations for agents such as SGLT2 inhibitors and GLP-1 receptor agonists, and using technology such as continuous glucose monitors, insulin pumps and hybrid closed-loop insulin delivery systems.
To date, more than 50 PCPs have completed diabetes fellowships at six institutions. Efforts are underway to develop more of these programs across the country.
“Most diabetes is managed in the primary care office — about 85% — and most diabetes cases can be managed in primary care offices, but there are also people who need specialized diabetes care,” Kim Pfotenhauer, DO, director of clerkship curriculum at Michigan State University and a graduate of a diabetes fellowship program, told Healio. “There is not great access to endocrine care in many places. Having the ability to have someone else who specializes in diabetes to provide that access to the patients who need it is important. This is another route to allow physicians who have the interest to go into something that can provide better patient care.”
Not all endocrinologists agree that 1-year fellowship programs will address the gap in diabetes care. In a commentary published in May 2021 in Endocrine Practice, Jonathan D. Leffert, MD, managing partner at North Texas Endocrine Center, past president of the American Association of Clinical Endocrinology, and an Endocrine Today Editorial Board Member, said the number of potential fellows graduating from such programs “do not add up to a significant improvement.”
“This additional workforce would not even be able to keep up with the demand associated with typical yearly increases in diabetes much less make a dent in the overwhelming total numbers of patient with diabetes,” Leffert wrote.
Developing standardized programs
The first diabetes fellowships were launched in 2004, when two endocrinologists, Robert J. Tanenberg, MD, of East Carolina University in Greenville, North Carolina, and Frank Schwartz, MD, at Ohio University Heritage College of Osteopathic Medicine in Athens, Ohio, began training PCPs to become diabetologists, following a model first established at the Joslin Diabetes Center decades earlier.
There are now six programs nationally, including programs at Duke Southern Regional Area Health Education Center, Touro University College of Osteopathic Medicine California, the University of Colorado and the University of Pennsylvania.
“This is not a new concept,” Pfotenhauer, who completed her diabetes fellowship program at Touro University, told Healio. “There used to be diabetes fellowships out of Joslin Diabetes Center in the 1950s. They had a 1-year fellowship, and then it was absorbed in the 1980s. The concept was revived and started to grow.”
An ideal candidate for a diabetes fellowship is a PCP interested in treating diabetes, but who is also committed to their community and their specialty, according to Cecilia C. Low Wang, MD, FACP, professor of medicine at the University of Colorado School of Medicine and director of the glucose management team at University of Colorado Hospital.
“We are looking for people who want to specialize in diabetes care,” Low Wang told Healio. "There are many practices where partners may have a specific interest and develop expertise in that area. There are already primary care physicians doing this. We wanted to offer intensive training for clinicians soon after residency training to allow them to specialize. This is for people who are passionate about diabetes care.”
In a white paper published in the September 2020 issue of Clinical Diabetes, Low Wang and colleagues proposed standardized components for a 1-year diabetes fellowship program. The proposed curriculum was based on recommendations discussed during a 1-day meeting convened by the American Diabetes Association in January 2020 that included program directors from institutions with diabetes fellowships, current and past diabetes fellows, and experts in graduate medical education.
“Currently there are no national standards,” Low Wang said. "Existing primary care fellowships are great, but we wanted to set a standard for what needed to be included. There must be access to enough expertise for the training, and we highlight the patient populations and the didactics that should be included.”
The white paper outlined components of a 1-year diabetes fellowship program, which would include a fellowship director who is an endocrinologist or diabetologist; a patient population that includes type 1 and type 2 diabetes with a variety of stages of disease, complications and comorbidities ; a requirement for a quality improvement or research project that can be presented regionally or nationally; access to diabetes technology and education; and a requirement for conference attendance at a national diabetes meeting.
Sadhu, who said there has been “wavering interest” in the idea from some professional societies, said fellowships should not be looked at as something that could take away from the endocrine specialty — rather, the opposite.
“I would like to see endocrinologists be the leaders in the training process, not the sideline watchers fearing losing something,” Sadhu said. “Everyone is going to have a hand in this disease. Endocrinologists are going to lead this, building what is needed to fight this disease. This is where our expertise is so valuable.”
‘A drop in the bucket’: The case against fellowships
In a separate commentary published in April 2021 in Endocrine Practice, Leffert wrote that any proposal for a 1-year diabetes fellowship hinges on funding and board certification for physicians destined for a comprehensive clinical center of excellence in diabetes — ultimately a small group of clinicians that “will not make a difference in the underlying problem” of access to care.
“If the goal is to produce people to take care of this population of 35 million people in the U.S. with diabetes and these fellowships are producing 50 people a year, that is a drop in the bucket,” Leffert told Healio. “It does not address the problem. There are other ways to meet this need.”
Leffert said a more comprehensive approach should consist of two components: specialty society education and mentoring of physicians, and increased reimbursement for physicians who have participated in these programs.
“We should be increasing the numbers of people who have training in the space of physician assistants, nurse practitioners and midlevel providers who can provide the care under the auspice of an endocrinologist, who can then provide the mentorship,” Leffert said. “Going out and independently practicing as a diabetes fellow internist will not do anything for a person’s status. What would be the motivation? It does not make sense, unless this is just something a clinician is really interested in doing. But if that is what you want to do, then take another year — a 2-year fellowship — and become an endocrinologist.”
Low Wang acknowledged that not everyone agrees diabetes fellowships are the answer to meeting a growing need for diabetes care; however, specialty society training is not intensive enough, she said.
“There has been pushback, for several reasons,” Low Wang said. “There are PCPs who may wonder, do I need this further certification to show I can take care of patients with diabetes? No, we are not saying that. This is to offer further training for people who are looking for it. From the endocrine specialty side, some ask, is this really needed? Why not just complete an endocrine fellowship? We feel there are enough people with a divergent interest in endocrinology that there are people who want to only focus on diabetes vs. those who want more broad training. We want to offer more options, especially if it helps address this epidemic.”
Critics of diabetes fellowships often point to a need for funding and accreditation, a cumbersome process that takes years. The costs of a diabetes fellowship program include fellows’ salaries and benefits; faculty compensation; professional education funding for conferences, subscriptions, memberships and educational supplies and resources; and program administration costs.
Pfotenhauer said as more institutions develop programs, the needed funding and accreditation will follow.
“We are still talking about the same issues from years ago — lack of funding and lack of accreditation,” Pfotenhauer said. “The more programs around the country that start doing this on their own, with funding, the more appealing it will be to an ADA or an [American Board of Internal Medicine] to listen to us and say, ‘We will accredit your program,’ similar to an obesity program.”
‘We need to do more’
Low Wang said interest is growing for diabetes fellowship programs among potential fellows and new program sites, and several programs are currently under development.
“[At the University of Colorado] we currently have our second fellow, and we are recruiting a third for next year,” Low Wang said. “Ours is at an academic center, so we have those advantages. I have our fellows rotate in, for example, the neurology clinic and wound care clinic, and our fellowship includes a key component at the Barbara Davis Center, and experience at the VA and Denver Health, which is our safety net hospital.”
For some, the COVID-19 pandemic slowed momentum to get diabetes fellowship programs up and running, Sadhu said. She hopes to continue the push in Houston and nationally.
“The pandemic has taken our attention, but [creating a program] remains a part of our diabetes mission,” Sadhu said. “What we have done thus far [at Houston Methodist] is grow our endocrinology fellowship with a focus more on diabetes. We have a much larger volume of patients with diabetes here in Houston, so increasing providers with training in expert diabetes care is needed. It is not an easy process but there are models for it, such as our preventive cardiology program. However, securing the funding, and the intense efforts needed for the accreditation process have been our limitations."
“We need to get back to our original mission, and we need to do more,” Sadhu said. “Building more of these local programs will lend support to a certification process, which will then lead to more compensation from payors, which in turn drive the demand for these fellowships.”
References:
Draznin B, et al. Endocr Pract. 2021;doi:10.1016/j.eprac.2021.03.007.
Leffert JD. Endocr Pract. 2021; doi: 10.1016/j.eprac.2021.04.882.
Shubrook JH, et al. Clin Diabetes. 2020; doi:10.2337/cd20-0055.
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