The necessary evolution of diabetes fellowships in the United States

ABSTRACT

The number of Americans affected by diabetes continues to increase but the number of endocrinologists with specialty training to treat this population has not kept up with demand. Primary care outpatient visits can also not meet the projected diabetes population demands or the needs for other complex diabetes management issues. Treatments for diabetes including both medications and technologies continue to expand and become more complex. In response to these challenges there have been primary care physicians seeking specialized training to become diabetologists. This can fill some of the gaps left by a lack of resources in the U.S. healthcare system.

KEYWORDS:

• Diabetes
• diabetes management
• primary care training
• graduate medical education

Introduction

Diabetes mellitus is an expensive and complex chronic disease that is sometimes preventable and it has seen progression in the quality and quantity of management options. Costs have been estimated at 327 USD billion dollars per year, which is 1 USD for every 7 USD spent on healthcare in this country [1]. Despite decades of robust research in the field, we have neither learned to completely prevent nor cure diabetes mellitus. Further, only about half of people with diabetes achieve treatment targets [2]. Novel pharmacologic treatments continue to evolve for this complex chronic condition. Most people with diabetes are managed by primary care providers as the number of endocrinologists is not increasing to keep pace with the increasing rates of diabetes. Exacerbating the problem (i.e. increasing rates of diabetes and diabetes complexity), as early as 2002 the diabetes specialist was referred to as an endangered species within endocrinology owing to most endocrinologists specializing in thyroid and other glandular conditions [3]. While primary care is equipped to manage diabetes the specialty-trained providers for complex cases have not grown with the demand. This gap in resources is where the field of diabetology can aid our healthcare system by improving access and management of patients who have diabetes while helping to decrease the incidence of diabetic complications.

Primary care diabetology

Primary care diabetology is an underrecognized specialty in the United States, albeit a known specialty in other countries. Diabetology provides specialized training for primary care physicians to be able to serve as diabetes experts. There are currently six diabetology fellowship programs in the United States, and to date there have been 50 graduates of those programs since 2005 [4]. The concept of diabetology is not completely new. Elliot Joslin, MD started the first diabetology fellowship in the country, and this program remained a 1-year program for at least 30 years. In 1955 the first physician requested a certificate of completion for the program as postgraduate medical education was not formalized until after World War II and by the 1980s the 1-year diabetes program merged into a 2-year endocrinology program [4]. More recently, the concept of a diabetology fellowship reemerged in the U.S. In 2004, diabetology fellowship programs were simultaneously started at East Carolina Brody School of Medicine and Ohio University Heritage College of Osteopathic Medicine [4,5]. They both saw an opportunity to train primary care physicians to serve in areas where an endocrinologist might not be available. Since that time there have been 4 more programs created. The 6 programs are: Duke Southern Regional AHEC, East Carolina University, Ohio University Heritage College of Osteopathic Medicine, Touro University California College of Osteopathic Medicine, University of Colorado, and University of Pennsylvania [5].

The diabetology programs are 1 year in duration. Physicians are eligible after the completion of an accredited family medicine or internal medicine residency program [4,5]. The candidates need to be board certified or board eligible in their respective primary care specialty. Programs train 1–2 fellows per year. The curriculum covers inpatient and outpatient management of type 1 diabetes, type 2 diabetes, gestational diabetes, atypical forms of diabetes, counseling on health behaviors, diabetes pharmacology, diabetes technologies, co-management of diabetes complications, as well as management of blood pressure, lipids, and weight. Diabetology fellows engage in a research or quality improvement project during their year of training. Faculty in these programs include endocrinologists and diabetologists. Most programs have interdisciplinary teams including dietitians, diabetes educators, health coaches, pharmacists, and other health professionals. Recently a position paper was published in Clinical Diabetes outlining the need, history, and structure, both current and future, of diabetology fellowship programs in the US [5]. This paper provides standards for new and existing training programs and provides consistency across programs to work toward future accreditation of these training programs.

Despite the existence of these programs for over a decade, they are not yet recognized or accredited. This is something that a working group including the program directors have set out to change. Specialized diabetes training for primary care physicians provides an opportunity to help with the diabetes burden in the U.S. While these programs will not be enough to solve the entire growing burden of diabetes in this country, it is one solution that needs closer consideration. Currently, one of the biggest barriers to the growth of these programs is the lack of recognition as a specialty and board certification, a notion corroborated by a survey of diabetology fellowship graduates [6]. Endocrinology is not well compensated compared to procedure-based specialties, it was listed fourth from the bottom in the Medscape Physician Compensation report in 2020, whereas family medicine was listed third from the bottom and internal medicine was ranked 2 higher on the list [7]. More incentive with respect to both recognition and compensation could increase the number of physicians interested in chronic diabetes mellitus management and prevent complications of this chronic disease.

Better trained healthcare providers for diabetes treatment could save the U.S. healthcare system money over time. In addition, population health can be significantly improved. Diabetic nephropathy can lead to end-stage renal disease. Estimates for dialysis are 90,000 USD per year per patient [8]. Retinopathy from diabetes is a leading cause of blindness in the U.S. in adults ages 20–74 [9]. Medicare costs alone are 3.5 USD billion per year just on anti-vascular endothelial growth factor (anti-VEGF) drugs for retinopathy, which are used in the treatment of diabetic retinopathy [10]. Peripheral neuropathy treatments including, foot ulcer management with and without cellulitis and osteomyelitis and amputation cost 4.6–13.7 USD billion per year [11]. Better glycemic control (hemoglobin A1c less than 7.0%) has been shown to decrease the development of these complications [12,13]. Fewer complications translate to better patient outcomes and cost savings to the system.

Discussion

As the prevalence of diabetes continues to increase in this country, so does the complexity of the patient with diabetes. There are now 34.2 million Americans with diabetes [14]. There are about 4,000 adult endocrinologists [15,16]. This would mean every endocrinologist would have to manage 8550 people with diabetes in addition to all of the other endocrine problems. Eighty-two percent of people with diabetes are managed by their primary care providers often without the opportunity for care by a physician with specialized training in the field [15,16]. Most cases of diabetes are and should be managed by primary care providers. Diabetes has become an increasingly complex disease state with new medications and advances in technology. Expanding the diabetology workforce could improve the available specialized care critical to the health of a segment of the population of people with diabetes. The concept of diabetes fellowships has gained momentum. Previous graduates of these programs are overcoming barriers that they have faced from primary care colleagues through proof of concept in the quality of care provided [5]. One study showed that primary care providers (without diabetes-specific training) who have higher volumes of diabetes-specific visits have better outcomes in their patients who have diabetes [17]. In our opinion, it would be to the benefit of the medical profession to consider recognizing a specialty that subspecializes in this chronic complex condition. Diabetes mellitus and the need for physicians with specialty training in this disease continues to increase both domestically and internationally. These fellowship trained diabetes specialists can work in a primary care, FQHCs, specialty care offices as well as in the hospital with the skills gained in such training.

Conclusion

Since the rates of diabetes continue to climb without a corresponding rise in endocrinologists, it is time to consider more specialized primary care training in the spectrum of diabetes disorders. Specialized diabetology training may provide better disease understanding and more in-depth knowledge of treatment options as these options evolve. With the increasing incidence of diabetes, diabetology can help provide better care to select patients improving outcomes and preventing diabetes-related complications.

Declaration of funding

No funding was received to produce this article.

Declaration of financial/other relationships

AH is the diabetes fellowship program director at Ohio University

SA is the diabetes fellowship program director at Touro

JS is the former diabetes fellowship program director at Ohio University and Touro University.

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.