While an Endocrine Society study predicts a persistent shortage of endocrinologists in the coming years, some interesting stop-gap measures like additional training and better reimbursement could make a difference.
A significant shortage of endocrinologists will persist for the foreseeable future, according to a new Endocrine Society workforce analysis. The number of endocrinologists who treat adults is not growing nearly fast enough to keep up with the surging demand driven by a growing and aging population compounded by the continuing obesity epidemic.
The study — Endocrine Clinical Workforce: Supply and Demand Projections — proposes several measures to combat this shortage, including creating more endocrinology fellowships, making the specialty more attractive by raising compensation, and extending the reach of specialists through greater use of mid-level providers.
Society leaders decided it was time for another look at endocrinology supply and demand because strong forces have been altering the healthcare environment since its last study more than a decade ago. Continued implementation of the Affordable Care Act, with its goal of increasing the number of people with health insurance, is expected to drive up demand. And endocrinologists are bearing the brunt of one of the most noteworthy trends of recent years — the inexorably rising incidence of type 2 diabetes. To work with its own experts, the Endocrine Society enlisted the Lewin Group, a consulting firm with experience in a broad range of healthcare issues that also collaborated on the Society’s 2003 workforce study.
Findings No Surprise
Most practicing endocrinologists experience the shortage firsthand, says Robert A. Vigersky, MD, director of the diabetes center at Walter Reed National Military Medical Center, one of the study authors, and a former Endocrine Society president. “The wait time for a new patient to be seen is much greater than in almost any other specialty in medicine by a factor of two. You can get in to see a cardiologist in 15 days, but it’ll take you 37 days to get in to see an endocrinologist,” Vigersky says.
This wait time has persisted for years — a 50% increase in the number of endocrinologists over the past 15 years has done nothing to diminish it.
The study projects that in 2015, the shortfall in endocrinologists who treat adults will be almost 1,500 full-time equivalents, a substantial number, considering that there are only about 5,000 endocrinologists who treat adults. If endocrinologists continue to graduate at present rates and the incidence of diabetes holds steady at today’s rate, by 2025 the shortage will decline slightly to about 1,350 full-time equivalents.
But under a more likely scenario, that the incidence of diabetes continues to grow at its current rate — rising from 7.4% today to 12% in 2025 — the shortfall will almost double to some 2,850 full-time equivalents.
“If you wanted to try to close these gaps in the next five to 10 years, you’d have to have a huge increase in the number of endocrinology fellows,” Vigersky says.
Demographic factors within the profession could also affect the shortage. The current cohort of endocrinologists is dominated by male baby boomers, many of whom report that they are considering retiring soon.
“This aging and predominantly male population is being replaced by a younger, predominantly female population. And the reason that is important is because, according to our survey data, women see fewer patients. In general, men tend to work more hours per week,” Vigersky says.
One controversial finding of the study was its projection of no shortage among pediatric endocrinologists — that the supply could catch up with the demand in a couple of years. As with adult endocrinologists, the number of pediatric endocrinologists has been increasing, but the study said that the demand-driving factors of the aging population and soaring type 2 diabetes rates do not affect children to the same degree as adults.
However, leaders of the Pediatric Endocrine Society responded that these “surprising” findings “do not seem to jibe with what we see on a day-to-day basis.” They noted that both type 1 and type 2 diabetes are on the rise in children and pointed to a lack of involvement of practicing pediatric endocrinologists in the study and flaws in the study’s full-time equivalent modeling techniques for pediatric endocrinologists that could lead to misleading results because “few pediatric endocrinologists are in private practice.”
Expanding the Supply
The study suggested several ways to increase the supply of endocrinologists, starting by augmenting the number who graduate from training programs each year. “We estimated that we would have to increase the number of adult endocrinology fellows by 14% per year to close the gap in five years. If we wanted to close it in 10 years, we’d have to increase the number of fellows by 5.5%,” Vigersky says. “The problem is that graduate medical education positions are funded primarily by the Centers for Medicare and Medicaid Services, and that number is not going to go up in general.”
The Endocrine Society is not the only group interested in expanding training slots to combat looming shortages. Christiane Mitchell, director of federal affairs at the Association of American Medical Colleges (AAMC), says that the Endocrine Society’s projections are in line with those of other studies. The AAMC projects that in 10 years there will be a shortage of about 130,000 physicians, evenly split between primary care and other specialties.
AAMC backs legislation now in Congress that would support additional training slots for all specialties, but the likelihood of any bills that call for increased federal spending passing in the current political and budget climate is extremely low.
Vigersky says the Endocrine Society is also exploring alternative sources of funding, including “from the private sector, pharmaceutical companies, foundations, or private individuals.”
Another way to increase the supply would be to shorten from three years to two years the internal medicine component of endocrinology training. That would speed the rate of entry of endocrinologists into the workforce, lessen the cost of training, and increase the length of an endocrinologist’s career by a year. “Endocrinologists are not alone in considering how they might alter the duration of a residency,” Mitchell says. “This conversation is happening in different specialty societies.”
Better Financial Incentives
A change that could make the endocrine field more attractive to potential recruits would be to improve the financial incentives. For example, increasing the payments for treatment of diabetes, obesity, and metabolic syndrome; for continuous glucose monitoring and insulin pump care; and for telephone calls to patients and telemedicine consults could help raise endocrinologist salaries compared with procedure-based specialties.
Many of the endocrinologists surveyed said that they are considering accelerating their retirement plans because of dissatisfaction with practice conditions, including payment levels. Higher payments could keep some of them practicing.
“Endocrinologists tend to do a lot of phone calls and emails to patients, essentially doing telemedicine in one way or another, but the third-party payers including Medicare rarely pay for that kind of service,” Vigersky says. “If we could figure out a way to get that compensated, it would certainly keep people in the practice of endocrinology longer and would make it more attractive for people to enter endocrinology.”
Extending the Reach
A final measure that is already gaining traction is “to use more midlevel providers such as nurse practitioners and physician assistants to see the routine endocrine problems,” Vigersky says. This approach has helped extend care in Massachusetts, which expanded its insurance coverage several years ago in a program that served as a model for the Affordable Care Act. Vigersky notes that “a very high percentage” of the endocrinologists surveyed for the study said they planned to hire more midlevel providers.
“We are in a precarious position in terms of being able to meet the demand,” Vigersky concludes. “We are going to have to make some changes in the way things are funded and the way we practice medicine, and the Endocrine Society is working on those things.”
— Seaborg is a freelance writer based in Charlottesville, Va. He wrote about Vitamin D in the November issue.