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Brief Report  |   August 2018
Diabetes Fellowship in Primary Care: A Survey of Graduates
Author Notes
  • From the Ohio University Heritage College of Osteopathic Medicine and Ohio Health Physician Group Heritage College in Athens (Dr Healy and Schwartz); the East Carolina University Brody School of Medicine and Vidant Medical Center in Greenville, North Carolina (Dr Tanenberg); West Virginia University and Camden Clark Medical Center in Parkersburg (Dr Schwartz); and the Touro University College of Osteopathic Medicine-California in Pomona (Dr Shubrook). 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Amber M. Healy, DO, Ohio University Heritage College of Osteopathic Medicine, Department of Specialty Medicine, 105 Parks Hall, Athens, OH 45701-1359. Email: holdera@ohio.edu
     
Article Information
Endocrinology / Diabetes
Brief Report   |   August 2018
Diabetes Fellowship in Primary Care: A Survey of Graduates
The Journal of the American Osteopathic Association, August 2018, Vol. 118, 538-543. doi:https://doi.org/10.7556/jaoa.2018.122
The Journal of the American Osteopathic Association, August 2018, Vol. 118, 538-543. doi:https://doi.org/10.7556/jaoa.2018.122
Abstract

Context: The diabetes pandemic has outpaced the US supply of diabetes specialists and has overwhelmed primary care providers (physicians, physician assistants, and nurse practitioners). Primary care diabetes fellowships can be used to address this workforce shortage.

Objectives: To determine the skills obtained during 2 diabetes fellowship programs, the barriers encountered in practice, the impact of the programs on career paths, and perceived acceptance by patients and colleagues.

Methods: A Qualtrics link to a 26-item survey was sent via email to all graduates of the Ohio University Heritage College of Osteopathic Medicine and East Carolina University Brody School of Medicine diabetes fellowship programs. Items included demographic information, comfort level with different clinical diabetes skills, and current system barriers encountered in their practices.

Results: Of 39 graduates, 36 completed the survey. The most beneficial skills acquired during the fellowship were insulin pump management (13 [36%]), insulin management (10 [29%]), and diabetes pharmacology (6 [17%]). The most common barrier was the lack of board certification as a diabetologist, which affected time with patients and insurance reimbursement. The perceived acceptance by patients was high (25 [69%]), and the perceived receptiveness by colleagues was mostly neutral (7 [19%]) or positive (10 [29%]). The most common postfellowship career path was primary care medicine (15) followed by hospitalist (7) and diabetologist (5).

Conclusion: Physicians who completed the diabetes fellowship training reported high comfort levels with treating patients with diabetes, but they also reported the barriers faced in an unrecognized specialty.

In the United States, 30.3 million people have type 2 diabetes mellitus1 and another 84 million have prediabetes.2 Together, these numbers represent one-third of the US population.2 Primary care providers (physicians, physician assistants, and nurse practitioners) treat the majority (82%) of patients with diabetes.3 Some patients are referred to endocrinologists, but there are not nearly enough endocrinologists to address this growing problem. In 2011, there were 4184 adult endocrinologists and 893 pediatric endocrinologists practicing in the United States.3 Furthermore, the number of endocrinologists is decreasing because more are retiring than graduating.4 
To meet the needs of patients with diabetes, novel mechanisms are needed to train the primary care workforce. Primary care providers are capable of treating patients with diabetes without such a program; however, because diabetes management keeps evolving, with new medications, new insulin products, and advancing technology, it is challenging to keep pace in the context of general medicine.3 In 2013, Casagrande et al5 reported that between 2007 and 2010, hemoglobin A1c levels of 7.0% or less were achieved in only 52.5% of people with diabetes. The production model of the US health care system does not allow health care providers adequate time to address complex chronic diseases like diabetes in the context of other comorbidities.6 
To date, diabetology is not formally recognized as its own specialty in the United States, but it is in other countries. However, in 2004, two 1-year primary care diabetes fellowship programs were created simultaneously: 1 at Ohio University (OU) in Athens and 1 at East Carolina University (ECU) in Greenville, North Carolina.7 The goal of these programs is to provide training in diabetology to give primary care physicians a specialized set of clinical skills to better manage the full spectrum of diabetes and its complications7 and to then serve as mentors for other primary care providers. 
Both programs are located in medically underserved areas, where more than 11% of the population has diabetes.8,9 Eligible candidates for these 2 programs are graduates of residency programs accredited by the American Osteopathic Association or the Accreditation Council for Graduate Medical Education in family medicine, internal medicine, pediatrics, or internal medicine/pediatrics. Applicants must be board certified or eligible for board certification in their primary specialty. Fellows are trained in both inpatient and outpatient diabetes management and spend more than 50% of their time in direct clinical diabetes care. Additionally, they complete didactic training and original research. Most fellows come directly from residency training, but some come from their clinical practices. 
As of 2016, 39 fellows had graduated between the 2 programs. During the 13 years of its existence, 15 fellows graduated from the OU program. Twenty-four fellows have graduated from the ECU program from 2004 to 2016. Graduates have gone on to pursue different paths in medicine in different parts of the country, both inpatient and outpatient. We conducted this study to assess program graduates on their comfort level with managing various aspects of diabetes care, perceived barriers to practicing an unrecognized specialty, postfellowship career paths, and perceived acceptance of their specialty by patients and endocrinology colleagues. 
Methods
This study was approved by the institutional review boards at OU, ECU, and Touro University California. A 26-item survey was developed by the research team and beta tested among faculty diabetologists. No external validation was completed. The survey was then distributed by a Qualtrics survey link via email to all graduates of the 2 programs. Results were collected electronically from July 8, 2016, to August 9, 2016. A reminder email was sent 2 weeks after the initial distribution to increase the number of respondents. Graduates who had completed their fellowships from 2004 to through June 2016 were invited to participate in the survey. 
Demographic items were included to define whom was being surveyed. A Likert-type scale was used to quantify comfort level with clinical skills acquired during the fellowship and to gauge perceived patient and colleague acceptance of their diabetology specialization. Response choices were “very comfortable,” “comfortable,” “neither comfortable nor uncomfortable,” “uncomfortable,” “not comfortable,” or “credentialed.” Item responses regarding patient receptiveness and colleague receptiveness were on a scale from strongly agree to strongly disagree. Text responses were used to describe the most and least helpful aspects of the diabetes fellowship and to elicit barriers encountered by graduates. Descriptive analysis was completed on the survey results and reported as percentages. Further analysis was limited by the maximum denominator of 39 for this project. 
Results
Thirty-six of the 39 graduates completed the survey (92% response rate). Thirteen respondents were osteopathic physicians from the OU diabetology fellowship, and 23 were allopathic physicians from the ECU diabetology fellowship. The respondents included 22 women and 14 men (Table 1). 
Table 1.
Demographic Characteristics of Diabetes Fellowship Graduates (N=36)
Characteristic No. (%)
Program
 East Carolina University 23 (64)
 Ohio University 13 (36)
Gender
 Male 22 (61)
 Female 14 (39)
Degree
 DO 6 (17)
 MD 30 (83)
Practice Setting
 Hospital 12 (33)
 Private 11 (31)
 Academic center 7 (19)
 Community center 6 (17)
Table 1.
Demographic Characteristics of Diabetes Fellowship Graduates (N=36)
Characteristic No. (%)
Program
 East Carolina University 23 (64)
 Ohio University 13 (36)
Gender
 Male 22 (61)
 Female 14 (39)
Degree
 DO 6 (17)
 MD 30 (83)
Practice Setting
 Hospital 12 (33)
 Private 11 (31)
 Academic center 7 (19)
 Community center 6 (17)
×
All respondents were comfortable or very comfortable managing type 1 diabetes, type 2 diabetes, prediabetes, and metabolic syndrome. Almost all respondents (35 [97%]) were comfortable or very comfortable managing insulin pump therapy, and 2 respondents achieved certification as an insulin pump trainer. Continuous glucose monitor management comfort levels were comparably high (33 [92%]), and 1 respondent reported being credentialed. The great majority of respondents (31 [86%]) were also comfortable or very comfortable in managing gestational diabetes. Thirty-one respondents (86%) were comfortable with the management of atypical forms of diabetes. Almost all respondents (35 [97%]) were comfortable with the management of microvascular complications and macrovascular complications associated with diabetes and with inpatient diabetes management (35 [97%]). Thirty-four respondents reporting being comfortable or very comfortable with outpatient diabetes management. More variability was reported with the comfort levels in treating patients with pediatric diabetes or patients with pancreatic transplantation. Comfort level with adolescent diabetes was reported as higher (33 [92%]) than with pediatric diabetes (24 [67%]). Management of diabetes in patients with pancreatic transplants was reported as being comfortable or very comfortable by 20 respondents (56%), neither comfortable nor uncomfortable by 8 (22%), and not being comfortable by 8 (22%). 
The most helpful skills reported included insulin pump management (13), insulin management (10), and diabetes pharmacology (6). The least helpful skills were reported by 5 (14%) respondents and included faculty development, homeostatic model assessment, management of diabetes through addressing social determinants of health, and documentation of long notes. Of these 5 respondents, 1 also felt that he or she needed more exposure to pediatrics. The remaining respondents either did not respond to the item (25) or stated that no skill was the least helpful (6). 
Open-ended items addressed barriers to practice after fellowship training. The most common barriers included issues related to specialty recognition, board certification, defining the specialty, insurance reimbursement, time needed to manage a chronic disease, and the lack of financial incentives to pursue diabetes management/diabetology. One respondent stated that the lack of recognition as a specialty affected health insurance reimbursement. Another respondent stated that it is hard to find a job as a diabetologist because related job offers are either for primary care providers or endocrinologists, but little to no opportunities exist specifically for diabetologists. Without accreditation, the respondents thought that the fellowship did not allow for graduates to be considered specialists. Of the 27 text responses, recognition as a specialty was the most reported barrier. 
Defining what a diabetologist does was a recurring theme in the text responses. Being used beyond the expertise of the diabetology training was reported, specifically to practice endocrinology. Text responses also revealed that respondents still felt that they had difficulty with the lack of time and resources to treat a patient with a chronic disease. Time and resource constraints made it difficult to adequately address diabetes in the way that they had been trained, especially in patients with several comorbidities. In primary care practice, they are responsible for all of their patients’ comorbid conditions in addition to diabetes. Getting more time than 10 to 15 minutes per appointment was another reported barrier. One respondent also stated that support from diabetes educators and nurses was important, and another stated that recruiting these support personnel had been a challenge with diabetology not being recognized as a specialty. All of the respondents reported satisfaction with having completed their respective fellowship program despite these barriers. 
Regarding practice type and location after graduating from the fellowship, 15 (41%) returned to practice primary care. Of those 15 respondents, 7 practiced family medicine; 6, internal medicine; 1, pediatrics; and 1, internal medicine/pediatrics. Of all respondents, 5 (14%) reported that they were full-time diabetologists; 7 (20%) reported practicing as hospitalists, and 8 (22%) went on to complete endocrine fellowships and practice endocrinology. One-third (12/36) of the respondents worked in hospital-owned practices, 11 (31%) were in private practice, 7 (20%) worked at academic centers, and 6 (17%) worked at community health centers (Table 2). 
Table 2.
Diabetes Fellowship Graduates’ Confidence in Skills (N=36)a
Skills Very Comfortable Comfortable Neutral Not Comfortable Uncomfortable Credentialed
Adolescent diabetes 23 10 3 0 0 0
Atypical diabetes 19 12 4 0 0 1
CGM 22 10 2 0 0 1
Diabetic foot care 21 11 3 0 1 0
GDM/diabetes in pregnancy 17 14 2 2 0 1
Inpatient diabetes 29 5 0 1 0 0
Insulin pumps 25 8 1 0 0 2
Macrocomplications 28 7 0 1 0 0
Metabolic syndrome 28 7 0 0 0 1
Microcomplications 28 7 0 1 0 0
Pancreatic transplantations 5 14 8 8 0 0
Pediatric diabetes 11 13 10 1 1 0
Prediabetes 33 3 0 0 0 0
T1DM 33 2 0 0 0 1
T2DM 34 1 0 0 0 1

a Numbers may not total 36 because of missing responses.

Abbreviations: CGM, continuous glucose monitoring; GDM, gestational diabetes mellitus; T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus.

Table 2.
Diabetes Fellowship Graduates’ Confidence in Skills (N=36)a
Skills Very Comfortable Comfortable Neutral Not Comfortable Uncomfortable Credentialed
Adolescent diabetes 23 10 3 0 0 0
Atypical diabetes 19 12 4 0 0 1
CGM 22 10 2 0 0 1
Diabetic foot care 21 11 3 0 1 0
GDM/diabetes in pregnancy 17 14 2 2 0 1
Inpatient diabetes 29 5 0 1 0 0
Insulin pumps 25 8 1 0 0 2
Macrocomplications 28 7 0 1 0 0
Metabolic syndrome 28 7 0 0 0 1
Microcomplications 28 7 0 1 0 0
Pancreatic transplantations 5 14 8 8 0 0
Pediatric diabetes 11 13 10 1 1 0
Prediabetes 33 3 0 0 0 0
T1DM 33 2 0 0 0 1
T2DM 34 1 0 0 0 1

a Numbers may not total 36 because of missing responses.

Abbreviations: CGM, continuous glucose monitoring; GDM, gestational diabetes mellitus; T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus.

×
The majority of the respondents (27 [77%]) reported spending more than 75% of their time providing direct patient care for diabetes, and 13 of those 27 were spending more than 91% of their time providing direct patient care for diabetes. The great majority of the respondents (31 [86%]) agreed or strongly agreed that their patients were receptive to their having diabetes-specific training. The responses were much more mixed regarding endocrinology colleagues’ receptiveness to their specialty status. Ten respondents (28%) reported that they agreed or strongly agreed that colleagues were receptive to their diabetes training. Seven (19%) responded “neutral” for this item, and 7 (19%) disagreed or strongly disagreed that their colleagues were receptive to their training. Twelve respondents (33%) left this item blank. 
Discussion
Elliot P. Joslin, MD (1869-1962), was the first diabetologist in the United States.10 He dedicated his career to diabetes and created a diabetology program to train others in his methods. His programs evolved into today's endocrinology fellowships. The diabetes programs in the current study seem to successfully increase physicians’ confidence in managing all types of diabetes and working with patients and families with many of the modern technological advances that help manage diabetes. 
In the current study, comfort levels were high across the skillsets surveyed. However, graduates still felt frustrated by the lack of health system and payer recognition. The lack of recognition as a specialty is also a significant factor in the lack of standardization between the programs. An encouraging finding was that most of the graduates reported working in primary care or as hospitalists. In these specialties, they can better collaborate with colleagues in diabetes management and can also serve as diabetology mentors to other clinicians. It was surprising to see that the next largest number of respondents reported working as endocrinologists. After graduating from the diabetology program, they completed an endocrinology fellowship. Although both programs support the graduates and their career paths, the diabetes fellowships were not designed to serve as a prerequisite to an endocrinology fellowship. 
This survey study has several limitations and flaws. First, the sample was small. The items gauged comfort levels in skills that were acquired in the 2 fellowships, but there was no measure that could show whether comfort level equated to better patient outcomes. Two of the comfort-level options were the same—uncomfortable and not comfortable; thus, both answers were rated the same. 
With respect to items that asked for respondents’ perceptions of their patients’ and colleagues’ receptiveness of their training, it is possible that respondents may have had access to physician satisfaction survey results and were able to be more objective in their answers. Our research team has surveyed colleagues of diabetologists in other studies to gauge the reception of diabetology as a subspecialty.12 Reasons for a lack of peer support included endocrinologists’ concern that they would lose income, the increased risk of burnout due to the complex population served, and the fear of how the quality of care would be affected.11 
Based on the comfort levels reported in the current study, one would think that the quality of care would be higher than before the fellowship; however, more concrete data looking at the quality measures of primary care providers who have trained in these programs vs those who have not would provide more objective evidence. Quality measures include hemoglobin A1c levels; dilated eye examinations; foot examinations that assess neuropathy and ulcer prevention; laboratory tests for cholesterol levels; and urinalysis of albumin levels to detect nephropathy. These measures are all involved in the comprehensive care of a person with diabetes and are now being tracked by the Centers for Medicare and Medicaid Services through the Merit-Based Incentive Payments System.12 
Conclusion
Diabetes fellowship programs address the growing need for health care providers who are skilled in diabetes management. The current study found that physicians who graduated from these programs were confident in the skillset they received. They also reported a number of barriers to practicing as a diabetologist, such as its lack of recognition as a specialty and thus lack of health insurance reimbursement. As more diabetes fellowship programs are created and successfully graduate specialists in diabetes management, and as recognition that primary care providers are increasingly burdened with the growing number of patients with diabetes and prediabetes becomes more widespread, perhaps diabetology may be more widely recognized and accepted as a specialty. 
Author Contributions
All authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; all authors drafted the article or revised it critically for important intellectual content; all authors gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. 
References
National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention; 2017. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Accessed August 1, 2017.
Prediabetes. Centers for Disease Control and Prevention website. https://www.cdc.gov/diabetes/basics/prediabetes.html. Accessed August 1, 2017.
The Lewin Group. Endocrine Workforce: Supply and Demand Projections. Washington, DC: Endocrine Society; 2014. https://www.endocrine.org/-/media/endosociety/files/advocacy-and-outreach/other-documents/2014-06-white-paper--endocrinology-workforce.pdf?la=en DM#554926. Accessed July 6, 2018.
Vigersky, L, Hogan P, et al.  . The clinical endocrinology workforce current status and future projections. J Clin Endocrinol Metab. 2014:99(9):3112-3121. doi: 10.1210/jc.2014-2257 [CrossRef] [PubMed]
Casagrande SS, Fradkin JE, Saydah SH, Rust KF, Cowie CC. The prevalence of meeting A1c, blood pressure, and LDL goals among people with diabetes, 1988-2010. Diabetes Care. 2013:36(8):2271-2279. doi: 10.2337/dc12-2258 [CrossRef] [PubMed]
Østbye T1 , Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of chronic diseases in primary care? Ann Fam Med. 2005;3:209-214. doi: 10.1370/afm.310 [CrossRef] [PubMed]
Sadhu AR, Healy AM, Patil SP, Cummings DM, Shubrook JH, Tanenberg RJ. The time is now: diabetes fellowships in the United States. Curr Diab Rep. 2017:17(11):108. doi: 10.1007/s11892-017-0936-6 [CrossRef] [PubMed]
Barker LE, Kirtland KA, Gregg EW, Geiss LS, Thompson TJ. Geographic distribution of diagnosed diabetes in the United States: a diabetes belt. Am J Prev Med . 2011;40(4):434-439. doi: 10.1016/j.amepre.2010.12.019 [CrossRef] [PubMed]
Diagnosed diabetes percentage 2013. Centers for Disease Control and Prevention website. https://www.cdc.gov/diabetes/atlas/countydata/atlas.html. Accessed June 1, 2017.
Elliot P. Joslin, MD. Joslin Diabetes Center website. http://www.joslin.org/about/elliot_p_joslin_md.html. Accessed August 1, 2017.
Healy AM, Shubrook JH, Schwartz FL, Cummings DM, Drake AJ III, Tanenberg RJ. Endocrinologists’ opinion of diabetology as a primary care subspecialty. Clin Diabetes. 2018;36(2):168-173. doi: 10.2337/cd17-0097 [CrossRef] [PubMed]
Diabetes & Endocrinology MIPS Quality Measure Recommendations (2017). Healthmonix website. http://healthmonix.com/mips_by_specialty/diabetes-endocrinology-mips-quality-measure-recommendations-2017/. Accessed July 3, 2018.
Table 1.
Demographic Characteristics of Diabetes Fellowship Graduates (N=36)
Characteristic No. (%)
Program
 East Carolina University 23 (64)
 Ohio University 13 (36)
Gender
 Male 22 (61)
 Female 14 (39)
Degree
 DO 6 (17)
 MD 30 (83)
Practice Setting
 Hospital 12 (33)
 Private 11 (31)
 Academic center 7 (19)
 Community center 6 (17)
Table 1.
Demographic Characteristics of Diabetes Fellowship Graduates (N=36)
Characteristic No. (%)
Program
 East Carolina University 23 (64)
 Ohio University 13 (36)
Gender
 Male 22 (61)
 Female 14 (39)
Degree
 DO 6 (17)
 MD 30 (83)
Practice Setting
 Hospital 12 (33)
 Private 11 (31)
 Academic center 7 (19)
 Community center 6 (17)
×
Table 2.
Diabetes Fellowship Graduates’ Confidence in Skills (N=36)a
Skills Very Comfortable Comfortable Neutral Not Comfortable Uncomfortable Credentialed
Adolescent diabetes 23 10 3 0 0 0
Atypical diabetes 19 12 4 0 0 1
CGM 22 10 2 0 0 1
Diabetic foot care 21 11 3 0 1 0
GDM/diabetes in pregnancy 17 14 2 2 0 1
Inpatient diabetes 29 5 0 1 0 0
Insulin pumps 25 8 1 0 0 2
Macrocomplications 28 7 0 1 0 0
Metabolic syndrome 28 7 0 0 0 1
Microcomplications 28 7 0 1 0 0
Pancreatic transplantations 5 14 8 8 0 0
Pediatric diabetes 11 13 10 1 1 0
Prediabetes 33 3 0 0 0 0
T1DM 33 2 0 0 0 1
T2DM 34 1 0 0 0 1

a Numbers may not total 36 because of missing responses.

Abbreviations: CGM, continuous glucose monitoring; GDM, gestational diabetes mellitus; T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus.

Table 2.
Diabetes Fellowship Graduates’ Confidence in Skills (N=36)a
Skills Very Comfortable Comfortable Neutral Not Comfortable Uncomfortable Credentialed
Adolescent diabetes 23 10 3 0 0 0
Atypical diabetes 19 12 4 0 0 1
CGM 22 10 2 0 0 1
Diabetic foot care 21 11 3 0 1 0
GDM/diabetes in pregnancy 17 14 2 2 0 1
Inpatient diabetes 29 5 0 1 0 0
Insulin pumps 25 8 1 0 0 2
Macrocomplications 28 7 0 1 0 0
Metabolic syndrome 28 7 0 0 0 1
Microcomplications 28 7 0 1 0 0
Pancreatic transplantations 5 14 8 8 0 0
Pediatric diabetes 11 13 10 1 1 0
Prediabetes 33 3 0 0 0 0
T1DM 33 2 0 0 0 1
T2DM 34 1 0 0 0 1

a Numbers may not total 36 because of missing responses.

Abbreviations: CGM, continuous glucose monitoring; GDM, gestational diabetes mellitus; T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus.

×