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As of late, the number of practicing endocrinologists seems to be dwindling. , director of the Diabetes, Obesity, and Metabolism Institute at the Icahn School of Medicine at Mount Sinai in New York City, addresses why this is -- from primary care physicians taking over diabetes care to the pressures from lack of compensation and reimbursement -- and what can be done to remedy it.

Following is a transcript of his remarks:

Diabetes is becoming much more common now than it was, say, 20 years ago when physician workforce planning processes were in place. No one anticipated that diabetes would take off the way that it has, so that's one thing. The other thing that's very important is that medical school has become more important and students graduating from medical school average about $250,000 in debt from college and medical school. They're under enormous economic pressure when they finish their residencies to start paying off their bills. If they take a low-paying job, they can't do it. They tend to be migrating to higher-paying specialties if they're in debt, and most students graduating from medical school in the U.S. are. That's an important driver.

Endocrinology, it turns out, is not a particularly high-paying -- in fact, it's a rather low-paying -- specialty. Endocrinologists make about the same as family practitioners and internal medicine people, and yet endocrinology requires an additional 2 or 3 years of training. The value added in terms of income for an extra 2 or 3 years of training is essentially zero, and it's also negative in the lost opportunity sense. You actually lose 3 years of higher income by doing endocrine training.

In fact, there's a strong economic incentive not to become an endocrinologist, right? The remedy for that, of course ... well, there are lots, and we can talk about them. One is obviously to raise the reimbursement rates for endocrinologists, which are far below almost every other medical specialty. That's one thing. Of course, you could say, "Well, then maybe people with diabetes can just be taken care of by family practitioners or internal medicine people or pediatricians." Of course, that's happening already, enormously. About 90% of people with diabetes are being taken care of by family practitioners, internal medicine people, and pediatricians. They're also drowning in people with diabetes, and they need help.

It turns out that reimbursement for endocrine procedures is limited. The average payment from an insurer or Medicare for a complete new patient visit is about $100. For a return visit, depending on the complexity of the visit, it's about $35 or $50. You can imagine that if you're a physician in practice and that's what you're being paid, and you need to pay for your office, you need to pay for your office staff, you need to rent your space, you need to buy equipment, you need to have billers who can do the billing for the practice, etc., and you've got a list of 50 things you need to checklist to ask every patient. You're under enormous pressure to see patients as quickly as possible.

From the patient's point of view, that's pretty unsettling. I mean I've got heart disease. I've got eye disease. I've got kidney disease. I have a lot to talk about. I'm having a problem with my glucose control. I'm having problems with my medications, and I don't really understand them, and you don't have any time to talk to me because you've got a waiting room full of people you have to see in order to pay the bills. There's a big mismatch between reimbursement for physician services and ancillary services, nurse practitioners, providers, dietitians, etc.

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