I’ve mentioned diabetes guru Kelly Close before. Kelly is the founder of Close Concerns, a healthcare information company based in San Francisco, CA, that is exclusively focused on diabetes and obesity. Close Concerns publishes resources for both industry (Diabetes Close Up and Closer Look) and consumers (diaTribe).
Kelly forwarded a copy of the report that she and her team wrote analyzing the CDC’s (Center for Disease Control) June update on diabetes statistics. (She sent it to me in June, I’m just now writing about it. Mea culpa!) Among the most dramatic news was the new estimate of 57 million people in the US over the age of 20 with pre-diabetes. Other notable findings:
- Estimates of the total number of people with diabetes nationwide (diagnosed and undiagnosed) have risen to 23.6 million in 2007 from 20.8 million people in 2005.
- As a percentage of the population, the number of people diagnosed with diabetes has grown to nearly 8%. This represents 11% growth since 2005 and 24% growth since 2002.
- People with diabetes are being better diagnosed. Since 2002, there has been a 37% increase in diagnosed patients, a 10% decrease in undiagnosed patients, and a 30% increase in the number of patients overall.
- The direct cost of diabetes was estimated at $116 billion for 2007. Including indirect costs such as lost productivity; this cost nears $175 billion.
Shortly afterwards, Kelly sent me a PDF of the poster she and several others presented at the ADA (American Diabetes Association) Scientific Sessions in June called, “Who Will Manage American Patients with Diabetes in the Near Future?” I had no idea what a grave situation is unfolding in our medical system related to diabetes care.
Previous work has estimated that the US has a 12–15% undersupply of endocrinologists, with this shortage predicted to expand to 25–30% by 2020. Fewer than 3000 endocrinologists practice in the US, while approximately 3000 patients are diagnosed with diabetes daily. The aim of this study*, therefore, was to identify factors that are deterring students from specializing in diabetes care, and to understand what can be done to reverse this trend.
The results are astounding. Out of the 524 medical students surveyed as part of the study, only seven students (1.3%) expressed an interest in endocrinology, and only three of those students were interested in pursuing diabetes care.
What is driving this? Students cited the uphill battle of modifying patient behavior as the #1 reason (46%) they are eschewing diabetes. Second was a general lack of interest in the field (42%) and third was lack of procedures (38%). Surprisingly (at least to me), inadequate compensation did not make the top three; it came in fourth place at 35%. When choosing a specialty, the vast majority of medical students indicate that they are concerned primarily with the intellectual satisfaction of the work; compensation and length of training were not cited as major concerns.
So just as the incidence of diabetes is increasing, there will be fewer specialists available to diagnose, treat, monitor and educate these patients. The job will fall to already burdened PCP’s and to the patients themselves. Why should pharma care? Because it’s not clear who is going to take the time to learn about all the new medications in the pipeline let alone prescribe them.
Who Will Manage American Patients with Diabetes in the Near Future?
The study’s authors conclude that increasing physician interest in diabetes will require significant changes to reimbursement structure and physician economics. They also note that new and improved therapies may increase interest in diabetes care if they are able to provide real alternatives to behavior modification.
* Study methodology
Between April and August of 2007, the authors conducted an electronic survey of 524 medical students and inquired about their exposure to diabetes in medical school, their interest in pursuing diabetes care, and the attributes of a specialty that they consider to be most important. Survey respondents represented all four years of medical school, with a small bias toward first year (first: 39%; second: 23%; third: 12%; fourth: 26%).
Recent articles in NEJM underscore the serious long term socioeconomic impact from the growing pandemic of obesity and diabetes. A shortage of health care professionals - most notably physicians - will exacerbate this. We must get our arms around this. See, e.g.,
Bisher Parvez Hossain, M.D., Kawar, M.D., and Meguid El Nahas, M.D., Ph.D. “Obesity and Diabetes in the Developing World — A Growing Challenge.” NEJM. Volume 356:213-215, January 18, 2007. (”Consequently, diabetes is rapidly emerging as a global health care problem that threatens to reach pandemic levels by 2030; the number of people with diabetes worldwide is projected to increase from 171 million in 2000 to 366 million by 2030… . This increase will be most noticeable in developing countries, where the number of people with diabetes is expected to increase from 84 million to 228 million. According to the WHO, Southeast Asia and the Western Pacific region are at the forefront of the current diabetes epidemic, with India and China facing the greatest challenges. In these countries, the incidence and prevalence of type 2 diabetes among children are also increasing at an alarming rate, with potentially devastating consequences.”)
Kirsten Bibbins-Domingo, Ph.D., M.D., Pamela Coxson, Ph.D., Mark J. Pletcher, M.D., M.P.H., James Lightwood, Ph.D., and Lee Goldman, M.D., M.P.H. Adolescent Overweight and Future Adult Coronary Heart Disease. NEJM. Volume 357:2371-2379, December 6, 2007. (”Although projections 25 or more years into the future are subject to innumerable uncertainties, extrapolation from current data suggests that adolescent overweight will increase rates of CHD among future young and middle-aged adults, resulting in substantial morbidity and mortality.”)
Thank you for calling attention to this important study published at ADA. If so few students are planning to enter into the field of diabetes care as the diabetes population explodes, we will encounter a dramatic shortage of endocrinologists. I think the greater danger overall is the notion that diabetes is a one-size-fits-all disease that can appropriately be treated by primary care physicians. Diabetes, particularly type 2 diabetes, is increasingly being recognized as a complex disease, and the interest in treating it with specific agents is being ignored.
The study highlights the shortcomings of how we compensate health care providers. We value procedures that can help someone who is already ill or injured far more than we value the education and training needed for “healthy patientts” who happen to have a chronic disease.
Of course money is a central issue, and until the compensation gap is narrowed for endos, the shortage will persist.
But beyond money, society has to value the work of endos and other providers who rely on cognitive skills.
For example, when Dave Letterman returned to the job after his heart surgery, he brought on his show the surgical team that saved his life — a touching gesture of gratitude for those who in a matter of hours brought him back from the dead.
But I’d like to see a famous TV personality announce that he has diabetes — and then bring on the show the endocrinologist, the nurse educator, and the dietician who has saved HIS life. Granted, what they do lacks the drama an emergency surgical procedure, but it’s no less important, and we need to get that message out.