In Flux: The State of Endocrinology 2014

While many endocrinologists face the challenges of government red tape and often less-than-desirable pay scales, research breakthroughs and their impact on costs and patient outcomes make endocrinology a rewarding field. 

It is the best of times for endocrinology; it is the worst of times for endocrinology. The pace of discovery is accelerating at an unprecedented rate, with many game-changing genetic therapies visible on the horizon. New treatments appear to be surpassed in growth only by the incidence of diabetes and the price tag of medical school. While the field continues to increase in global importance and lead the way in medical technologies, endocrinology also faces a serious workforce shortage and other challenges, making it overdue for a check-up.

William F. Crowley, MD, director of Clinical Research for the Massachusetts General Hospital, in Boston, the NICHD-funded Harvard Reproductive Endocrine Sciences Center of Excellence, and former president of the Endocrine Society, likens the current paradox to Dickens’ A Tale of Two Cities. He sees the best of our times as the historic levels of discovery and the ability to alleviate human suffering and reduce the impact of disease and its cost, and the worst as the lowering of National Institutes of Health (NIH) pay lines, dysfunction of the government surrounding healthcare matters like research funding, and an “entanglement of clinical investigators by Lilliputian regulations.”

“We have rare and unparalleled opportunities and tools, and suddenly a manpower shortage in this country and a regulatory proliferation that’s fettering them,” Crowley explains.

Supply & Demand

The worldwide shortage of endocrinologists has been exacerbated by exploding rates of diabetes and obesity. Currently, endocrinologists number 6,869 in the U.S., according to listings by the U.S. News & World Report — more than past decades, but not nearly enough to serve demand. A waiting period of three to nine months to get an appointment with a clinical endocrinologist is considered standard.

“One of the problems is that there are not enough endocrinologists in the world, or in the U.S. for sure, to take care of all these patients with diabetes,” says Robert A. Vigersky, MD, director of the Diabetes Institute at Walter Reed National Military Medical Center and another past president of the Endocrine Society. As a result, endocrinologists tend only to see the most difficult cases and must rely on physician extenders like nurse practitioners and physician’s assistants to maximize their patient capacity.

Vigersky does not expect demand to slow anytime soon. The aging population and other factors in the U.S. are pushing the incidence of three major endocrine diseases higher and higher: diabetes, osteoporosis, and obesity.

Estimates from the American Diabetes Association claim that 25.8 million Americans, or 8.3% of the population, had diabetes as of 2013. When looking at people 65 years of age or older, the rate climbs to 26.9%. These numbers are, of course, tied closely to obesity, with 34.9% of American adults considered obese by the U.S. Centers for Disease Control and Prevention. Another 10 million people suffer from osteoporosis in the U.S., and 18 million more are at risk for the disease, according to the American Academy of Orthopaedic Surgeons. The international incidence of all of these diseases has also grown at an alarming speed.

With such an enormous need for physicians with endocrine expertise, one might expect an influx of trainees. Unfortunately, several factors continue to impede potential endocrinologists.

“Number one is loan indebtedness,” Crowley explains. “Young physicians tell me ‘I have a mortgage on my career, I just don’t have a house.’”

Vigersky seconded this theory. “Of all the medical specialties, we are with rheumatologists and infectious disease specialists as the lowest paid. That wouldn’t be so important except for that trainees come out with just huge amounts of debt from medical school and even college. It exacerbates the discrepancy between what they owe and what the possibility of earnings are as a physician.” If an endocrinologist is making $200,000 a year and a cardiologist is making $500,000 a year, that difference offers a powerful incentive to pick another specialty.

A 2013 survey by Medscape showed that the largest cohort of U.S. endocrinologists, 27%, make $200,000 to $250,000. But the second largest group, 17%, makes $100,000 or less. The median annual income was $178,000. The average cardiologist, on the other hand, made $357,000, and 23% of cardiologists earned $500,000 or more.

Meanwhile, the median U.S. medical student pays about $287,000 over the course of four years and graduates with about $174,500 in debt, according to 2013 numbers from the Association of American Medical Colleges.

Less Money, Better Work-Life Balance

When Vigersky and Crowley first selected their specialty, these issues held less influence. “In my era, there was very little awareness of the differential in pay, except that you kind of knew that the surgeons made more money than the internists,” Vigersky explains. This allowed them to choose their professions without the same financial implications that prospective trainees face today.

The disparity is driven by the procedure-based payment system in the U.S. Rather than a salary or outcome-driven structure, the physicians who conduct the most procedures bring in the highest income. American medical students are thus leaning toward the highly procedural specialties that will allow them to pay off educational debt.

“As a result, there has been a huge shift of young researchers from America to trainees who come to the U.S. from overseas. The best and brightest come without any loans because everyone has nationalized their medical education around the world, except us,” says Crowley.

Joanna Spencer-Segal, MD, PhD, fellow in metabolism, endocrinology and diabetes at the University of Michigan, in Ann Arbor, took an academic route to choosing endocrinology, but although she intends to focus the majority of her time on research, she feels strongly that the physician payment system needs reform.

“More recognition of the importance of endocrine care is going to be really crucial,” she says. The current structure does not incentivize the creation of more endocrinologist positions, despite the large demand for care.

Vigersky claims, “We have a lot of people applying to be endocrinologists, but we do not have enough training slots to train them all.”

Another part of the endocrinologist shortage stems from a greater focus on work-life balance. Although there are more endocrinologists in numbers, there are also more working part time. “The number of full-time equivalents has decreased even though bodies are increasing,” says Vigersky.

Crowley describes this trend as one of the biggest shifts he has ever witnessed. “There is always a push and a pull to every career,” he says. Part of the reason many students choose endocrinology is for the more orderly lifestyle, with hours that do not bleed late into the evenings and weekends as often as some other specialties might.

However, even if all part-time clinicians were to take on a full-time load of patients, it would not be possible to see every patient with endocrine-related diseases.

“This raises a lot of interesting points about what an endocrinologist can and can’t do,” Vigersky says. “One of the things that they can’t do is take care of all the patients with diabetes. But, what they can do is try to educate primary care providers and also use physician extenders.”

Research and Technology

To help extend endocrine expertise further, Vigersky has been working on decision support technology that integrates with electronic health records (EHR). These systems aim to assist primary care providers in delivering better and more aggressive care, specifically to patients with diabetes. Physicians input data on the patient such as their blood glucose levels, their A1Cs, their current medications, other factors such as comorbidities, and then the program makes recommendations.

Such advances are bringing improved outcomes to patients with endocrine diseases and disorders, despite workforce shortages. Endocrinologists tend to lead the way for new medical technologies, and few have benefitted more than patients with diabetes.

“In the past, we had only a couple of medications, and now we have a dozen or more classes that can be used in various combinations to treat our patients,” Vigersky says.

Continuous glucose monitors and artificial pancreas systems have also improved considerably. Some artificial pancreases are in the final stages of clinical trials and should arrive on the market in a few short years.

As a reproductive endocrinologist, Crowley and his colleagues have directly contributed to a number of landmark discoveries, especially pertaining to precocious puberty. But, he has never been more excited about the prospects of new gene therapies.

“When I was president of the Endocrine Society in 2001, I chose as the theme of my year ‘the impact of the human genome on the practice of endocrinology.’ Now, a decade in, that’s becoming a part of our daily life,” he explains. “I think we are in an explosive phase of gene discovery, followed in five to 10 years by an explosion of therapies for complicated diseases.”

The ailments filling hospital beds — hypertension, diabetes, stroke, dementia, inflammatory bowel disease (IBD) — are all tied to complex trait genetics where it takes dozens of genes to cause a disease, but “when put together in sort of a daisy chain, concatenate to give you a complex disease trait.” Crowley expects IBD to be the first successful target of such therapies.

Yet, few discoveries arrive without encountering obstacles. He fears that the interference of excessive regulations and limited sources of research funding are stymying this important research. “It now costs us more money to regulate human research than it does to do it. Every time that you have a regulatory process exceeding in cost the production process, you have an overregulated industry,” he says.

The NIH has relied on the same amount of funding, about $30 billion, for several years, with no increase to account for inflation or burgeoning price of studies involving humans.

That is a frustration for incoming fellows like Spencer-Segal as well. She selected the specialty largely because of the strong research component. “Endocrinology is a really attractive specialty because it lends itself well to combining clinical care and research, partly because it is not entirely procedural. It is very intellectual,” she says.

Crowley was drawn to endocrinology for similar reasons. “From my point of view, it is like they pay me to come to work every day and play the parlor game Clue,” he says. “So we find Professor Plum in the library with the dagger all the time, we just have to figure out who did it, and that to me is discovering new genes. It is all one interesting intellectual problem and puzzle.”

The inquisitive nature of endocrinologists offers one possible explanation for continued publications in times of limited financial resources. Funding restrictions do not seem to be stifling the steady rise in endocrine-related research. Articles related to diabetes in PubMed increased by nearly 134% from 2002 to 2012. The number of articles containing the term “endocrine” in PubMed climbed by 46% over the same time period, with the only dip occurring in 2013. Although raw numbers of publications cannot provide comprehensive insight into the state of endocrinerelated research, it does indicate sustained progress.

What’s Next for Endocrinology?

Crowley believes that better tools and other positives existent today far outweigh the challenges facing the field of endocrinology. In fact, he feels that now is a better era than ever to be an endocrinologist. “It’s a terrifically exciting time to be playing the game of Clue,” he says.

In order to free up more time for his research puzzles, he has decided to step down from his role as the director of Clinical Research at Massachusetts General Hospital after 17 years of service.

Crowley feels confident, though, in the next generation of endocrinology leaders. Much of his career has focused on teaching and mentoring young physician scientists, and he was the first male to win the Women in Endocrinology Mentor Award in 2001. “I recognized that the future of endocrinology relied on training women.” He has mentored approximately 85 fellows to date, 60% of whom are women.

The Federation of State Medical Boards (FSMB) took a census in 2012, which showed that women now comprise over 30% of actively licensed physicians in the U.S. In medical schools, about 50% of students are female. This demographic shift is occurring across medicine, but in few specialties is the change as pronounced as endocrinology. Among active listings for U.S. endocrinologists, nearly 41% are female.

In addition to a greater percentage of women, international physicians have also become more commonplace. The same FSMB report found that 22% of physicians practicing in the U.S. attended medical school outside of the U.S. and Canada.

Diversity in the field has grown in tandem with a more global approach to research. The Endocrine Society instituted an Ambassador Exchange program last year to facilitate such projects, which sends two teams of American physicians and trainees to separate foreign locales with a high demand for endocrinologists, and later brings their hosts, two teams of international physicians and trainees, back to the U.S.

“A Fabulously Interesting Time”

The exchange is just one example of many partnerships developing across the endocrine community. Spencer-Segal claims that some of the most exciting developments are coming from multidisciplinary endeavors. “The collaborative programs are the ones that are really taking off,” she says.

“The specialties are distinctive in some ways,” Spencer-Segal says, “but it is a mistake to think of them as completely separate areas of medicine.”

She sees endocrinology as particularly well positioned for emerging collaborations because of its holistic nature. “Endocrinologists have to think about the whole body of the patient rather than a specific part,” she explains.

This fact underlies perhaps the greatest difficulty and the largest reward of becoming an endocrinologist, according to Vigersky. “I still think endocrinology is the most fascinating specialty, and also the most challenging — on both a clinical and intellectual level — since hormones travel throughout the body and affect every organ system,” he says. “You have to really understand how patients feel and respond to these hormone levels.”

No matter the advances and the obstacles that the field of endocrinology may experience, the exhilarating riddles that it offers as a profession remain. The growth rate of diabetes has outstripped the increase in experts available to treat it but has not surpassed the innovation of endocrinologists in creating better therapies, nor their ability to affect widespread improvements in millions of lives.

While reflecting upon his career and the leaps and bounds the specialty has made to reach its current state, Crowley summed up the refrain of many endocrinologists, past and present. “I have to say, it has been a fabulously interesting time.”

— Mapes is a Washington, D.C.-based freelance writer and a frequent contributor to Endocrine News. She wrote about how to choose the best EMR system in the May issue.

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