Does the U.S. Need More Diabetes Specialists?

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Every year, we get more comprehensive and alarming statistics about diabetes in the U.S, but we never really seem to know what to do with them. Even with these elegant graphs and meticulously calculated percentages, it’s easy to sometimes forget that real people are struggling day in and day out with diabetes. Friends and family are fighting for their health and we often feel helpless in being able to address the systemic problems of treating diabetes in the U.S. health care system. By one estimate, more than 50 million Americans may have diabetes by 2030. The real question is: are we ready to face this possibility?

Who takes care of people with diabetes?

To understand what diabetes care might look like in 2030, we need an honest assessment of standard diabetes care in America. In some ways, there’s no better time in history for someone managing diabetes than right now: there are plenty of new technological improvements and new medications that have vastly improved many people’s quality of life. But it has also come at a cost that many people have been straining to manage. Access to health care has become a key issue in America and diabetes has become an example of a pain point in the health care system.

Most people will get a diabetes or prediabetes diagnosis from a primary care doctor. Relatively simple blood tests will show elevated blood glucose (blood sugar levels) and will be consistent with diabetes symptoms. Many patients will be treated for diabetes by their primary care doctor for most of their life, but some may also be referred to an endocrinologist, a doctor that specializes in hormonal health. In an ideal world, a doctor should be able to handle all the curveballs of treating diabetes and its complications. Unfortunately, because diabetes is a chronic condition, it often requires doctors with specialized knowledge who are constantly keeping up to date with new treatments, medications, and tools.

Ideally, we would also expect for anyone with diabetes to be able to consult with an endocrinologist whenever they needed. Unfortunately, this is not usually in the cards. The endocrinology workforce is not projected to be able to keep up with the demand of the healthcare system. Amber Healy, D.O. told HealthCentral in an email interview, “the diabetes pandemic has outpaced the growth of endocrinology programs.” On top of this, some endocrinologists are more focused on treating other hormonal issues, such as thyroid disorders. It begs the question: why is diabetes under the umbrella of endocrinology in the first place?

What do endocrinologists do and are they spread too thin?

Endocrinologists specialize in treating hormone-related disorders, which includes but isn’t limited to diabetes. An endocrinologist might be more inclined to specialize in treating thyroid, pituitary gland, or sex hormone disorders. If you’re lucky, you might be able to find an endocrinology practice with  multiple doctors who represent each of these specialties. Otherwise, if you can only find a single endocrinologist in your area, you should look for one who is also a certified diabetes educator (CDE).

For people in rural areas, the outlook is drastically different. Diabetes and heart disease disproportionately affect people living in rural America. A primary care physician (PCP) is often the first and last line of defense for rural communities. Robert Gabbay M.D., Chief Medical Officer of Joslin Diabetes Center, related in an email interview that some primary physicians may struggle with “helping guide patients with adherence, advancing therapy, [and] using insulin.” Limited financial resources and limited access to health care only serve to exacerbate the situation for our friends and family who live outside major cities. In fact, we know that minority communities and people in the South are facing much higher diabetes rates.

Unfortunately, the people that need specialized diabetes care the most are often separated the furthest geographically from these resources. It’s unrealistic for endocrinologists who are already stretched thin to go out to serve rural communities. Similarly, it’s unrealistic for people in these communities to travel frequently in and out of cities for better access to medical care. Health disparities and the rising demand for access to diabetes care forces us to look harder at how we might be able to improve this gap between primary care and endocrinologists.

Board certifications and integrated care

While there are fellowships for diabetes care, there is no board certification like there is for dermatology or psychiatry. Board certifications are meant to demonstrate that a doctor has mastered a specific set of skills to treat a specific set of conditions. They also represent physicians’ strong commitment to stay up to date with changing treatment protocols over the course of their careers. Considering the growing complexities of treating diabetes, it’s possible that creating a new board certification for diabetes care could help close the gap in treatment disparities.

A 2018 survey of doctors who went through a diabetes fellowship training showed that lack of board certification was seen as a barrier in providing care. In short, there’s not a universal, easy way for primary care doctors to show that they are an expert in diabetes care or get compensated for it. Patients can be left wondering if their primary care doctor is staying up to date on diabetes treatments and new products like insulin pumps and blood glucose monitors. Time is also a factor. “Most patients are allotted a 10-15 minute appointment time and their [doctor] is supposed to adequately address diabetes plus [any] other comorbid conditions,” says Amber Healy, D.O., the lead author of the survey. Ultimately, the U.S. healthcare system puts a lot of the responsibilities on patients to manage their own diabetes care.

In comparison, some countries take a more integrated approach to diabetes care. For example, the Netherlands has diabetes treatment programs that coordinate care between teams of health professionals to minimize the possibility of patients getting lost in between different types of doctors. While a universal health care system in the U.S. is currently outside the realm of possibility, we could certainly implement a more coordinated system for treating chronic conditions, especially the economically challenging ones like diabetes.

Looking ahead again to 2030, it’s hard to tell where we will be. Will people be able afford insulin? Will rural communities get better access to health care? Will diabetes specialists be able to etch out a more defined position to improve diabetes care in the U.S.? Let’s hope so on all three counts. 50 million Americans might be depending on it.