Endocrinology in crisis?

The physician shortage in the United States is likely to persist, if not worsen, in the foreseeable future. Because the pivotal role played by primary care providers is universally accepted, these providers may experience an increase in reimbursement from the federal government. In a perfect world, the primary care provider should be supported by an available network of subspecialists, yet medical subspecialties, including endocrinology, face a recruiting challenge. Meanwhile, with the burgeoning obesity and diabetes epidemics, waiting lists to see an endocrinologist have become longer and in some communities, difficulties with patient access have reached crisis proportions. One major issue that should be addressed is the fact that a physician has little financial incentive to pursue specialization in endocrinology because an endocrinologist makes an annual salary comparable to that of a general internist; however, an aspiring endocrinologist must undergo an additional 2 to 3 years of training. An endocrinology fellow not only must endure the increased burden of being a ‘‘trainee’’ for a few more years but also face the added financial burden of postponing student debt repayment and settling for a greatly reduced salary as a fellow compared with entering theworkforce as a fully trained internist. Because our healthcare system financially rewards interventional procedures disproportionately, internal medicine residents have a financial incentive to pursue careers in more profitable, procedure-intensive specialties. Although it is predicted that all subspecialties will face staffing shortages, the financial incentive would suggest that procedure-intensive specialties such as cardiology and gastroenterology are likely to endure a lighter burden comparedwith specialties such as endocrinology that are not procedure intensive. The demand for endocrinologists will increase, and to address this shortage, training in endocrinology should be made more attractive. Creative solutions in the workplace, such as clinics with endocrinologists training primary care providers in the optimal management of common disorders, are required. The use of physician extenders such as nurse practitioners and physician assistants using telemedicine may leverage the capabilities of the endocrinologist. These steps, however, do not fully address the fundamental problem of our current healthcare systemVfavoring treatment over preventive measures designed to reduce healthcare costs. This problem has engendered a paradoxical combination of higher costs and outcomes substantially less than expectations. For example, the number of cardiac catheterizations performed has increased, but control of diabetes has not been adequately emphasized, supported, or rewarded. The irony is that if diabetes as awholewere better controlled, then there would be less need for cardiac catheterizations. The preventive approach works best if the healthcare outcome is the primary focus rather than the number of patients evaluated in any given period. Remuneration of endocrinologists is largely based on the latter. Most notably, the Veterans Health Administration has changed diabetesmanagement to an outcomefocused strategy. As a result of amore interactive, patient-provider based approach, theVeteransHealth Administration has produced better outcomes (eg, lower HA1c values) with lower overall costs. If this approach were applied to the US healthcare system as a whole, it would not only improve the recruitment ability of certain medical specialties such as endocrinology but also lead to better healthcare outcomes for Americans and a more costeffective system overall. Changing the focus of health care from intervention to prevention is much like changing the course of a large ocean liner. Given the powerful forces within medicine, will the United States be able to turn the ship around in time to avoid running aground?