The emerging field of diabetology—a sub-specialty of endocrinology focused on the treatment of people with diabetes—is intended to address an emerging crisis in health care: Nearly one-third of Americans has a type 2 diabetes diagnosis or has prediabetes.
Compounding this problem, numbers of endocrinologists, the physicians who specialize in treating diabetes, are dwindling as the older generation retires with fewer new physicians filling the ranks. This means the burden of care has fallen on primary care physicians, who treat 82 percent of diabetic patients.
Fourteen years after one-year fellowship programs were created to give primary care physicians the clinical skills to better manage diabetes and its complications, new research in the Journal of the American Osteopathic Association finds resistance among payers and other physicians may slow growth of the fledgling specialty.
In 2004, diabetology fellowship programs opened at Ohio University College of Osteopathic Medicine and East Carolina University Brody School of Medicine—both located in underserved communities. As of now there are four diabetes fellowship programs nationwide.
Unknown but not untested
According to researchers who surveyed all 39 physicians who graduated from the first two fellowship programs between 2005 and 2016, diabetologists are filling a much needed gap in patient care, however, acceptance and trust have been slow to come.
The survey tracked graduate physicians’ practice type and location, finding 41 percent in primary care, 20 percent working as hospitalists, 14 percent who are full-time diabetologists and 22 percent who went on to become endocrinologists. The survey also found all respondents were comfortable or very comfortable managing type 1 diabetes, type 2 diabetes, prediabetes, and metabolic syndrome.
However, when it came to perceptions from colleagues, responses were much more mixed. Only 28 percent reported that they agreed or strongly agreed that colleagues were receptive to their diabetes training. There was 19 percent who responded “neutral”, another 19 percent who disagreed or strongly disagreed that their colleagues were receptive to their training, and 33 percent who left this item blank.
“Some primary care physicians have been reluctant to refer diabetic patients to diabetologists because so many diabetologists are also primary care physicians. I think there’s a fear that patients will simply change physicians entirely,” says Amber Healy, DO, who graduated from Ohio University’s diabetology fellowship and co-authored the article in the JAOA. “Endocrinologists, on the other hand, believe that the diabetes fellowship constitutes a dangerous shortcut to becoming an endocrinologist, enabling a scope of practice overreach.”
Jay Shubrook, DO, who practices as a full-time diabetologist and served as a co-author on the JAOA article, believes these issues are improving and will continue to do so through education, advocacy and exposure.
“I think the biggest misconception is that diabetologists are trying to replace anyone. That’s just not true. The sheer number of patients with diabetes makes that impossible; there are way too many for any one group to handle,” says Dr. Shubrook. He adds that a one-to-one patient care model is far from the ideal care delivery model for diabetologists. Instead, he sees them being far more effective as a force multiplier for primary care.
At the federally qualified health center where he practices, Dr. Shubrook can treat patients directly but, more importantly, he can share his expertise with the other primary care physicians, raising their knowledge and proficiency.
Dr. Shubrook acknowledges that endocrinologists have a greater depth of knowledge in certain types of diabetes treatments but also notes they treat many other conditions—and some don’t even treat diabetes. “I realize ideally one option is endocrinologists could exclusively provide diabetes treatment. However, given the massive scope of the problem, that’s simply impossible. I think we are better off sacrificing some depth of knowledge in order to recruit and train physicians who are capable of making an impact.
Perhaps the biggest obstacle facing diabetologists is recognition from payers, who are reluctant to reimburse for a new specialty which is mostly unrecognized even by colleagues from its adjacent specialties. This creates a problem as healthcare is still paid for by volume. Primary care visits last between 10 and 15 minutes, because physicians need to see enough patients in a day in order to have a profitable practice. Unfortunately, that’s not nearly enough time to address the concerns of a patient with diabetes. Further, most diabetologists will actually get paid less as they end up seeing fewer patients in a system that rewards volume of care.
“No one with diabetes has just one health complaint,” says Dr. Shubrook. “The basic diabetes treatment and education could take twice as much time allotted for in a typical primary care visit—but most have multiple chronic conditions that also need attention.”
This creates a difficult position for physicians as they have to decide between giving a patient adequate time and attention within a single visit—which does not get reimbursed by their insurance—or asking the patient to come in for more frequent visits, which isn’t always possible for the patient’s schedule. However, if diabetologists were recognized as specialists, they could get reimbursed at higher rates, which would allow them to spend more time with patients.
“Board certification is the standard for payers to recognize a physician as a specialist,” says Dr. Shubrook. “Right now diabetology just doesn’t have that.”
Dr. Shubrook says diabetologists will likely have their own board and certification exams in the future. Until that happens, he says payers have started to acknowledge and accept board certification in advanced diabetes management, which comes from the National Association of Diabetes Educators. He recommends all new fellows get this recognition.
“Our graduates are doing such good work—and it’s meaningful work that’s having an impact,” says Dr. Shubrook. “Change comes slowly, especially in healthcare, but our patients are seeing a positive difference, so their insurers are too. I would encourage anyone who is passionate about providing care for diabetes and other chronic health conditions to take the leap and join this specialty.”
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Amber M. Healy et al, Diabetes Fellowship in Primary Care: A Survey of Graduates, The Journal of the American Osteopathic Association (2018). DOI: 10.7556/jaoa.2018.122