Cardiometabolic Health Fellowships: The Answer or Part of the Problem?

Melissa Young, MD

Diabetes mellitus is an increasingly common disease in the United States and is one of the leading causes of death. It is more than just elevated glucose levels. Type 2 diabetes mellitus, as part of the metabolic syndrome, is often accompanied by obesity, hyperlipidemia and hypertension. It is a complex metabolic disease and is considered a heart disease equivalent.

Diabetes has such a huge impact on cardiovascular health that over a decade ago, the FDA started requiring cardiovascular outcomes data for any new antihyperglycemic drugs. While we have known for many years that improved glycemic control decreased cardiovascular risk, we did not have specific data that any particular drug decreased the incidence of cardiac morbidity or mortality. Now, several newer diabetes drugs have been shown to decrease the risk of either hospitalization due to cardiac events or cardiac death. This has changed the way pharmaceutical companies have been marketing their drugs and it has changed the way people look at diabetes.

People other than endocrinologists, that is. Endocrinologists have always treated diabetes as a cardiometabolic disease. As a matter of fact, the American Diabetes Association’s (ADA) Standards of Medical Care in Diabetes includes a whole section on managing cardiac risk. For years, endocrinologists have been treating hyperlipidemia and hypertension as part and parcel of their diabetes management.

Ask an endocrinologist how many times they have started a patient on a statin after that patient had been told by other physicians that his cholesterol is “normal”. Or worse, how often another physician stops the patient’s statin because his “level is good”. Too many. I’ve even had patients refuse statin therapy because their cardiologist told them they don’t need it.

Patients with diabetes comprise a large portion of the population that endocrinologists see. There is now a push to create a new specialty, a new fellowship in cardiometabolic medicine. Most endocrinologists I’ve communicated with are asking “why?” Why do we need this new separate fellowship? Isn’t this what we’ve been doing all along?

If the argument is that there aren’t enough endocrinologists to go around (see my earlier post), then the answer isn’t training more people in a different specialty, the answer is creating more endocrinologists. The answer is making endocrinology more attractive to medical students and residents.

Why go into endocrinology when our healthcare system rewards people for procedures and not cognitive work? It is my hope that the new CMS physician fee schedule and the new visit codes will correct some of this. In addition, we need more funding for endocrinology fellowship programs.

Only about 300 new endocrinologists complete training each year, meanwhile 1.5 million new cases of diabetes are diagnosed in the same time frame. Wouldn’t it save the healthcare system millions of dollars to better compensate endocrinologists for managing diabetes and its comorbidities in order to decrease the need for cardiac testing and procedures and to prevent hospitalizations for cardiac events?

Diabetes is definitely a cardiometabolic disease. But we don’t need a whole other specialty to start managing it. Endocrinologists have been at the front line of this all along.