When Heidi Terzo took over as manager of talent acquisition and senior physician recruiter at the bustling Deborah Heart and Lung Center in Philadelphia five years ago, she was given a top directive: Find a new staff endocrinologist.

“I inherited the search when I arrived,” she says.

Five years later that spot is still open, and this month their busy diabetes center will close due to lack of staffing.

“Our medical director (of the diabetes program) relocated last June, and we’ve not been able to fill that spot either,” she tells DiabetesMine.

Their busy and substantial diabetes program will now have to turn patients away. These are mostly folks with type 2 diabetes, and they will now have to travel long miles to find the medical support they need. Terzo hopes this won’t be a permanent change.

“Until we find someone — when and if we do — we will open up again. The need is too great,” she says.

What Terzo and her clinic are up against isn’t new: An increasing lack of endocrinologists is paired up with what the U.S. Centers for Disease Control and Prevention (CDC) says is a rapidly growing patient population. This leaves many wondering: Where have all the endos gone?

Across America, the need for more diabetes doctors is real. Patients have to wait longer for appointments, while programs supporting those entering the field see the numbers waning.

“For more than 20 years, a shortage of endocrinologists has been recognized,” says Dr. SethuReddy, vice president of the American Association of Clinical Endocrinologists.

“This is due to several factors, including a flat rate on endocrinologists being trained, a rate of about 8 percent per year of retirement, and an increasing incidence of endocrine and metabolic disorders in the U.S. population,” Reddy says.

Steve Marsh, CEO of M3 Executive Search, who’s been involved in numerous endocrine hiring searches, says it’s getting more challenging by the day.

“With the increased demand due to the aging U.S. population, increased obesity in the U.S., more endocrinologists are needed,” he says.

Reddy says the pandemic may be exacerbating the situation.

“The COVID-19 pandemic has increased demands on endocrinologists providing in-patient care. Reduced outpatient volume and increased number of hygiene procedures to keep clinics clean have led to greater pressures in the clinic,” he says. “There may be a COVID-19 sequel during the recovery phase of COVID-19, which may require endocrine care. So there may be… increased pressure on the existing endocrinology resources.”

Dr. Robert W. Lash, an endocrinologist with more than 25 years of experience and the current interim CEO of the Endocrine Society, points to high retirement rates.

“Like all (medical) specialties, there is a retirement epidemic going on among physicians, so in executive search, the endocrinology leaders are more scarce, as many doctors are ‘hanging up the stethoscope,’” Lash says.

To understand what’s happening, it’s important to clarify which type of doctors are in question here.

To simplify, an endocrinologist is a doctor trained in-depth on the human endocrine system — its hormones and hormonal diseases. As such, diabetes is one of many conditions in which they are experts, alongside Cushing’s disease, pedophilic obsessive-compulsive disorder (POCD), Addison’s disease, thyroid diseases, and more.

A diabetologist is a physician — usually an internist or endocrinologist — who focuses specifically and solely on diabetes care. In other words, a diabetologist is the most highly trained specialist in diabetes you can find. Few patients have the good fortune to see one.

A primary care doctor or family doctor is the go-to provider for general health, regular checkups, and more. Many people with diabetes across the country see these generalists because they don’t have access to a more specialized endocrinologist. The downside of this is that these general physicians are not always up-to-date with the latest diabetes technologies and treatments.

“People with type 1 diabetes [T1D] should ideally be seen by an endocrinologist. Their access to technology and access to other experts to help is important,” says Lash.

“Type 2 is different,” he adds. “If you have an A1C of 7 on metformin, you probably can do well seeing your primary care doctor. But if you are on three meds and not at goal, you need to be seen and guided by an endocrinologist.”

Dr. Henry Anhalt, a pediatric endocrinology specialist and lead member of the Endocrine Society, agrees that most cases of T1D, particularly pediatrics, should be treated by an endocrinologist, while the rest of the diabetes population probably has more flexibility.

“Just because someone is trained in endocrinology does not mean they give the best care. The criteria should not be about training, it should be about curiosity,” Anhalt says. “I’d be reluctant to say that only endocrinologists should take care of diabetes.”

But with the numbers of type 2 cases rapidly increasing, and a push for earlier insulin use among those with type 2, the demand is strong for physicians well-versed in diabetes, especially trained endocrinologists.

And yet the number of endocrinologists is down.

Lash says that less than a decade ago, there was an average of 16 medical students vying for every 10 endocrine positions. Now, he says, the Endocrine Society stats put that closer to 11 students for every 10 positions, a problem when you consider the growing population and needs.

There’s no doubt, endocrinologists say, that their career choice has its negatives. A recent Medscape report confirms that endocrinologists are among the lowest paid of medical providers. And diabetes patients can be needy at off times, requiring extra phone calls, email, and more that may not be billable.

But those in the field do see a bright side.

“Honestly, there’s nothing more rewarding (than guiding a person with diabetes to success),” Anhalt says. “I can take the knocks, like having to deal with prior authorizations and all the paperwork.”

Lash, too, believes the field is rewarding, but wonders if part of the problem is that medical students seldom, if ever, get to see that side of the practice.

“I think it starts with… the experience medical students have during medical training,” he says. This is typically in an in-patient (hospital) setting, where students see laid-up patients in need of constant insulin dose adjustments, checks, and rechecks. It’s not always the most compelling scenario.

“This is in their third year, and they’re looking for an intellectually exciting career choice,” he says. “You basically have unhappy fellows waking up in the middle of the night to increase Humalog by a unit.”

If they could see past that to what outpatient diabetes care entails, they’d be more intrigued, Lash believes.

“Taking care of people with diabetes is interesting, fun, and rewarding,” he says. “For example, the woman you’ve treated for years who goes on to have a baby and you see them through it. That’s so rewarding.”

“That’s the aspect I find most appealing,” Lash adds. “The ability to build relationships with patients not just for a few months but longterm. We literally get to have a lifelong bond with somebody. It’s a very special feeling.”

Lash personally doesn’t believe that salary limits are the main reason for the shortage of endos.

“Look at other specialties. Nephrology is the most challenged, with only six applicants on average for every 10 positions, and they can bring in $50,000 to $60,000 more than an endocrinologist can. Lots of groups are underpaid, but I don’t think that’s the big driver here.”

So what’s the solution? The Endocrine Society has set out to create programs to help not just guide medical students toward choosing endocrinology, but staying confident and strong in that decision as they evolve as doctors.

One such program is Future Leaders in Endocrinology (FLARE), which focuses on basic science, clinical research trainees, and junior faculty from underrepresented minority communities who have demonstrated achievement in endocrine research. FLARE provides structured leadership development and in-depth, hands-on training in topics ranging from applying for grants money to lab management. This program is sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases.

Dr. Estelle Everett, a clinical instructor at the Geffen School of Medicine at the University of California Los Angeles (UCLA), just completed her first year in the program.

She says that while she was naturally drawn to diabetes in medical school (her sister was diagnosed with T1D as a child), she still needed support and inspiration.

“I got so much good advice through FLARE on how to approach my career and be successful,” she says.

Did it work? She’s the first Black person on the faculty of UCLA’s endocrine/diabetes/metabolism division.

“Taking care of a patient base that is diverse, you want to have diversity in providers too,” Everett says.

“A colleague in Massachusetts referred a patient to me because they wanted an African American,” she says. “I’ve had that request a few times.”

Still, she can see the challenges that could scare others away if they don’t dig deeper to see the rewards.

“It’s more of a calling,” Everett says of endocrinology. “It’s definitely not for the money. It’s not an easy job, either. The way our health system is structured, it doesn’t work well with diabetes.”

For instance, she mentioned incredibly limited time with patients: “I can’t have a meaningful conversation in 15 minutes.”

And policy, in general, can be a huge barrier, she says, like having to fight with an insurance company over the phone for 2 hours to get someone a pump. “Things that don’t have to do with medicine can take a long time and it can be frustrating.”

FLARE gives Everett a sounding board and an advisory team on all of that and more — and the members stay in touch after the program is over.

“Our goal is to create programs and ways to get medical students interested,” Lash says. “COVID-19 has thrown a huge wrench into that. It’s not like we can say ‘let’s get together for pizza and talk about this.’ Everyone is online now.”

Still, he says, the Endocrine Society is looking to create opportunities for new entrants via meetings, prize competitions, and more.

“We have to show [new students] that the field of endocrinology is exciting,” he says. “We have to help them experience it in that way.”

One of the silver linings of the COVID-19 pandemic is that telemedicine is making healthcare more accessible.

Anhalt has been using it and says, “It has really changed the way I have access to my families and the way they have access to me. There’s no more ‘I am in the clinic on Wednesday.’ Now it’s, ‘Sure, I can see you on Thursday.’”

“If you do telemedicine right, you can do a great job connecting with patients,” he says. “But it’s not for everyone.”

Nor should it be forever in place of in-person visits. But virtual care could help make being an endocrinologist more accessible, as well as more affordable.

“You can save in rent, travel time, and more,” Anhalt says.

Reddy adds that endocrinologists may be particularly well set to adopt telemedicine.

“Endocrinologists are comfortable reviewing glucose monitoring data and have long discussed lab results and other information with their patients remotely,” he says.

Unfortunately, the pandemic may have longterm negative implications for building the field, as well. With overseas students now in many cases unable to come to the United States, the field could see the numbers shrink even more, Lash says.

“Only one-third of current endocrine fellows went to medical school in the United States. These people are just as smart and just as talented. But the fact is, in the U.S., way fewer are considering it,” he says.

What’s someone like Terzo, the physician recruiter who’s trying to fill positions locally in Philadelphia, to do?

She’s tried local and national searches, as well as advertising in journals and with professional associations. And she’s still looking.

“I won’t give up,” she says. “The last thing our aging population needs is to have to travel further to get the medical care they need.”