The academic and clinical endocrinology physician workforce in the U.S.

In this era of U.S. health care reform, it would be optimal for planning purposes to have a clear picture of the supply/demand balance of the U.S. physician workforce. This is particularly important in endocrinology because of the associated care for chronic and costly medical conditions, such as diabetes and osteoporosis. However, there is no central, reliable, complete, and up-to-date physician database in the United States. In the absence of such data, how can we intelligently plan for a cost-effective and prevention-focused health care system? How can those with a stake in the health care system optimize the future clinical, scientific, and academic workforce? These are questions that prompted the report by Desjardins et al. (1) in this issue of the JCEM. But first, a little background. Can we reasonably estimate the size of the current and future deficit in the endocrinology workforce? We have reviewed this question in the past (2). On the “demand side,” there are 26 million people with diabetes in the United States (3, 4), 10 million have osteoporosis (5), and about 12 million have a thyroid nodule requiring evaluation (6). Nearly 34% of adults have the metabolic syndrome, and one third of the U.S. population is obese ( 100 million). Therefore, the total number of Americans with endocrine disorders comprises a substantial fraction of the population (nearly 150 million), and this figure does not even include other common disorders such as hyperand hypothyroidism, polycystic ovarian syndrome, or less common diseases of the pituitary, parathyroid, and adrenal glands. In hospitals, the caseload is certainly high because approximately 30% of inpatients have diabetes. Obviously, the 2000–2500 practicing clinical endocrinologists in the United States (see below) cannot handle this burden, nor should they in an ideal world. Most patients can be managed by primary care providers and ancillary personnel. But even 10% of those patients (i.e. 15 million) could not be handled by the current pool of endocrinologists; this would yield a panel of approximately 6000 patients per endocrine physician. If a normal physician workload or panel would include 3000–4000 patients, this would predict approximately a 30–50% shortfall for the current demand. One could even argue that this is an underestimation because the population is aging and the diabetes epidemic progresses. Why can’t primary care providers manage patients with diabetes, osteoporosis, thyroid nodules, etc.? Is endocrine care really that complicated? The answer is yes; endocrine diagnosis and management are becoming increasingly complex. For example, there has been an explosion in the number of diabetes and osteoporosis drugs, often used in combination. There are now seven types of insulin and analogs, each with particular characteristics, and that figure does not even include the different premix preparations. It is difficult to maintain expertise on every one of these drugs. And then there are devices and technology: insulin pumps, glucometers, and continuous glucose monitoring systems. Who should get these devices, and more importantly, who will ensure that their use translates into meaningful clinical improvements? Who should be evaluated for islet or pancreas transplantation and how does one make that happen? In the controversial field of thyroid cancer and nodules, endocrinologists are needed to interpret results of aspiration cytology and make cost-effective decisions on utilization of imaging and treatment options. Contemporary treatment of osteoporosis now involves expensive biologicals (e.g., recombinant human PTH and denosumab) that also demand special expertise. Furthermore, there are also multiple complex and sometimes conflicting practice guidelines, and economic incentives, malpractice concerns, and quality assessment measures are all driving outpatients to, not away from, endocrinologists. On the quality improvement side, primary care providers and hospitals are under financial pressure to ISSN Print 0021-972X ISSN Online 1945-7197 Printed in U.S.A. Copyright © 2011 by The Endocrine Society doi: 10.1210/jc.2011-0516 Received February 25, 2011. Accepted February 28, 2011.