The treatment of diabetes has come a long way since Dr. Elliot Joslin wrote The Treatment of Diabetes Mellitus in 1916. But Dr. Joslin's idea that diet, exercise, and insulin (when it became available as therapy in 1922) are the keys to managing diabetes remains true today. This doesn't mean that diabetes is not a complex illness requiring ongoing education and individualized care. People with diabetes benefit greatly from the services of a team of health care professionals including a certified diabetes educator and an endocrinologist--a doctor who specializes in treating disorders of the endocrine system.

Unfortunately, there is a shortage of endocrinologists and certified diabetes educators in the United States. According to the ABIM (American Board of Internal Medicine), there are a total of 6085 board certified endocrinologists in the US, and the AADE (American Association of Diabetes Educators) places the current workforce of CDE's at approximately 20,000. Diabetes is a great wall of water and the current health care system is a cork in the dam, struggling to hold back the surging water.  

The shortage of diabetes experts is partly due to the history of the specialty, says Dr. Colwell, MD, PhD, a specialist in the field of diabetes who retired this year at age 80. When Dr. Colwell became a doctor in the 1950's, endocrinologists focused on treating thyroid and adrenal issues. It wasn't until the 1960's and 70's that diabetes was placed under the umbrella of endocrinology. Dr. Colwell explained that the shortage is also due to the nature of the business: "`endocrinology is a time-consuming specialty (the average visit is 45 minutes compared to 15 minutes for a principal care provider visit), it's tricky because hypoglycemia increases the risk of malpractice suits; and there is not enough funding. "

"Restrictions began in the 1990's," Kim Higgins, RN, CDE says. "The recommendation was to promote PCP (Primary Care Physicians are capable of handling a variety of health related problems.) care for all. At that time there was talk of an 8% per year reduction of funding to endocrinology specialties." The total number of fellows enrolled in endocrine training programs declined from 459 in 1995 to 393 in 1999. This 14.4% decline was similar to the overall decline in all internal medicine subspecialty training programs (1). The good news is that there is a current increase of endocrinologists entering the workforce. Bryan Campbell, Director of Public and Media Relations for the American Association of Clinical Endocrinologists says, "There are waiting lists for residency programs, meaning more people want to take them than slots are available." However, the demand will continue to rise as many endocrinologists over 50-years-old retire in the next decade.

The increase in demand stems from a variety of root causes. The NAMCS (National Ambulatory Medical Care Survey) indicates that there were twice as many visits to endocrinologists in 1996-1998 as in 1993-1995 (2). This could be attributed to the increase in diabetes diagnoses, as well as overall patient awareness. In 1993, results of the groundbreaking DCCT study were released that showed a drastic reduction in complications with tight blood glucose management. Based on the DCCT findings, education programs were created that focused on tight glucose control. In Charleston, SC Dr. Colwell designed a diabetes program called IDEAL (Intensive, Diabetes, Education, Awareness, Lifestyle) at The Medical University of South Carolina where he was the Diabetes Center's Medical Director. Patients were managed by a team of physician specialists, nurse clinicians, counselors and dietitians. In-depth assessment, teaching and day-to-day management were stressed. This team approach provided patients a well rounded support system.

Programs such as these that emphasize patient education are ideal. Recent clinical trials have shown that it is possible to prevent or delay the onset of type 2 diabetes with education. When type 2's work with an endocrinologist; studies have shown that they are more likely to get a diabetes educator referral. According to an online survey commissioned by the American Association of Diabetes Educators, patients with type 2 who have seen a diabetes educator are more positive about their knowledge of diabetes management and feel more confident about a healthy, balanced diet than patients who have not worked with one (3). However, the average wait time to get an appointment with an endocrinologist is 3 to 9 months, longer than it is for other physicians (4). Currently, 80-90% of diabetics are handled by primary care doctors, many who don't have the time or the resources to educate their patients about diabetes care. So, the question for the future of diabetes care is how to encourage tight blood glucose control in settings outside endocrinology offices.

Certified diabetes educators would seem to be the answer to this problem. The mission of CDE's is to act as the link between the doctor and patient, to teach skills to improve a patient's health, and work to get the patient motivated. Numerous studies show that diabetes educators have a very positive effect on patient's A1c's. However, the approximately 20,000 registered diabetes educators are too small to meet the demand.

Reasons for the shortage of educators are varied. Lyndsay Riffe, CDE says, "To become a CDE, you need two years, and over 1000 hours of experience specifically with diabetes management. Getting the experience can be difficult since a lot of employers require the candidate to already be credentialed. Therefore, it can be difficult for the aspiring CDE to get the necessary hours when they can't get their foot in the door. Second, poor reimbursement for diabetes education equals smaller budget for diabetes educators, and finally, it is a notoriously tough exam to pass."

Geographic proximity to diabetes educators is another challenge to diabetes management. According to U.S. News & World Report, the top hospitals for endocrinology are clustered in the North while the majority of people living with diabetes are in the South. (Nine out of sixteen states in the south region have the highest percentile of diabetes including Alabama, Florida, Georgia, Kentucky, Louisiana, South Carolina, Tennessee, Texas and West Virginia.) The following are the U.S. News & World Report's top five endocrinology hospitals:

• Mayo Clinic in Rochester, MN
  
• Massachusetts General, Boston, MA
  
• Johns Hopkins, Baltimore, MD
  
• University of California, San Francisco, CA
  
• New York Presbyterian University Hospital of Columbia and Cornell, New York, NY  
  

Sometimes it takes a hurricane to build a stronger levee. For people with diabetes, education, diet, medication and exercise are the tools that keep complications from flooding our bodies. Because of the disparity in supply and demand, endocrinologists can no longer treat their patients with the traditional office model. According to Dr. Colwell, "It has to be a volume solution."

Solutions for the future will require a variety of changes to both patient education and access to care. As the link between the doctor and patient, Certified Diabetes Educators are an imperative component in successful management. Resources such as:

Solutions for the Future:

Patient Education:

•  Better Diabetes Care is a website that was created by the NDEP (National Diabetes Education Program) http://www.betterdiabetescare.nih.gov/ with a long-term goal of comprehensive systems change for diabetes management.

•  Web-based patient monitoring/education: patients can upload data onto secure websites that can be accessed and evaluated by endocrinology practices. Some endocrinologists such as Dr. J. Joseph Pendergast, an endocrinologist in Palo Alto, CA says, "There are only two options. Either massively increase the number of endocrinologists in the world, which isn't going to happen, or use technology to expand what we can do." (4) His education videos can be seen at: http://enews.endocrinemetabolic.com)

•  Primary Care: cluster diabetes appointments into one day develop and train staff to work with type 2 patients.

•  Encourage group education; management centers such as Weight Watchers are often more effective at helping people lose weight.

Access to Care:

• There is increasing interest in the field of diabetes education. There is a "Grass-roots initiative to train" Kim Higgins says about a push in California to promote diabetes educator programs across the state. The San Francisco Bay Area Association of Diabetes Educators was formed in 1985 with the goal of advancing diabetes education. The membership offers classes for healthcare professionals, lecture and interactive training for nurses, dietitians, pharmacists, PA's, NP's and anyone else who would like to learn more about diabetes. The website for the SFBAADE is http://www.diabetesed.org/.

•  Increased training and recruitment for diabetes educators.

•  Team approach-collaborative, multidisciplinary teams to empower patients' self-management. Team care and diabetes self-management training have been proven to yield positive results. Clustering doctor visits to a single day.

•  CDE's in primary care and non-traditional offices- Lyndsay Riffe says, "Recently I have seen job postings targeting diabetes education in the primary care setting which I think is a great approach and well needed." Non-traditional settings for educators could include community based wellness centers and retail clinics.

•  Reform the process of CDE certification and compensation- The AADE is working to pass legislation that would allow Medicare to recognize CDE's as providers.

•  Marketing efforts-Increase awareness of diabetes education benefits.

•  Increase educator referrals from PCP offices.

As a pioneer in diabetes management, Dr. Joslin understood the importance of patient education. He dedicated his entire life to improving the health of his patients. Diet, insulin and exercise are still the foundations for good blood sugar control. As diabetes diagnoses continue to increase, the pressure for change will mount, and the demand for improved care will inspire change. We may be in crisis mode today, but improved patient education and access to care are clearly the way to go.  

Footnotes:

• ROBERT A. RIZZA, MD, ROBERT A. VIGERSKY, MD, HELENA W. RODBARD, MD, PAUL W. LADENSON, MD, WILLIAM F. YOUNG, JR., MD, MARTIN I. SURKS, MD, RICHARD KAHN, PHD, PAUL F. HOGAN, PHD(ABD).  A Model to Determine Workforce Needs for Endocrinologists in the United States until 2020. Diabetes Care, Volume 26, number 5, May 2003. http://care.diabetesjournals.org/cgi/reprint/26/5/1545.pdf 
  
• IBID 
  
• Type 2 Diabetes Nationwide Survey Summary. http://www.harrisinteractive.com/NEWS/newsletters/clientnews/2006_AADE.pdf 
  
• Gabriel, Barbara, MA. New Frontiers In Diabetes Education. Feb. 2008. www.patientcenteredpractice.com. American Association of Clinical Endocrinologists. 
  
• ROBERT A. RIZZA, MD, ROBERT A. VIGERSKY, MD, HELENA W. RODBARD, MD, PAUL W. LADENSON, MD, WILLIAM F. YOUNG, JR., MD, MARTIN I. SURKS, MD, RICHARD KAHN, PHD, PAUL F. HOGAN, PHD(ABD).  A Model to Determine Workforce Needs for Endocrinologists in the United States until 2020. Diabetes Care, Volume 26, number 5, May 2003. http://care.diabetesjournals.org/cgi/reprint/26/5/1545.pdf