In November 2022, a New York-based charitable trust granted $2.99 million dollars to a group of primary care physicians (PCPs) hell-bent on creating an educational pathway for those PCPs who, like them, wanted to devote their careers to better diabetes management and care.

These physicians decried the medical status quo’s treat-in-15 (or so) to manage the ever-growing number of patients entering their practices. They found that having patients with type 1 diabetes in their clinics, with their pumps, sensors, and continuous glucose monitors, was a whole new, patient-individualized ballgame.

In short, as the scope of diabetes management was changing, these physicians knew that the system of managing patients had to change. PCPs would not be able to effectively handle the waves of new diabetes patients, along with their other patients with chronic disease.

“It is a lot to ask a PCP to [handle] all of that,” said Jay Shubrook, DO, professor at the College of Osteopathic Medicine, Touro University California in Vallejo, California. “There is a lot that goes into the management of diabetes. We can meet those needs and challenges patients face, if we have more time,” he added.

With some of that funding, from the Leona M. and Harry B. Helmsley Charitable Trust, these physicians, including Shubrook, created the American College of Diabetology (ACD). Just 2 months ago, the American Medical Association awarded this new college the taxonomy of diabetologist.

The rest of the funding is seeding hospitals and medical schools interested in starting their own diabetes fellowship programs, whose graduates would be board certified. At least 10 exist already throughout the country, though some started before the grant award.

“If you can find a way to spread [this knowledge] to a PCP, then you are spreading its access by the thousands,” said Jenny McCoy, the college’s executive director, who added that the founders of the ACD did so “outside of the five minutes they have free everyday.”

So far, under the aegis of the ACD, 39 board-certified diabetologists, who passed the exam in 2023 and 2024, are now spreading that access.

Recognizing a Growing Crisis

Family physicians and PCPs in various parts of the country felt the sand shifting under their feet in the early 2000s. Shubrook was one of them.

In 1999, his practice in the Appalachians in Ohio had gotten “swallowed up with diabetes,” he said.

Lightening the load via referrals wasn’t an option. The nearest endocrinologist, Shubrook said, was in West Virginia, an hour away. When that endocrinologist suggested to Shubrook that he visit West Virginia and learn from him, Shubrook did so: He pivoted, as he put it, between his family practice and the endocrinology practice for a year.

As for what he learned: “Though I had a good handle on type 2, I struggled with time for patients. I didn’t have exposure to type 1, the technologies, there was little of this, even managing people on insulin, and the unique needs for type 1.”

His goal, after the year was over, was to help his colleagues with their diabetes patients, but even that effort faltered because of high patient demand. Counting on new medical school graduates wasn’t an option, as most, said Shubrook, won’t do an endocrinology rotation.

And thus began Shubrook’s efforts, along with others, including Robert J. Tanenberg, MD, professor at East Carolina University in Greenville, North Carolina — who had created a PCP-diabetes focused program a few years before — to establish diabetology as a board-certified specialty for PCPs.

“There was a group of us, mostly home grown,” said Shubrook. “I was active in the ADA [American Diabetes Association] so I asked, can you convene this group to establish standards?”

And in 2020, the ADA did, bringing together these physicians from various locations as well as some endocrinologists. The group’s white paper was published in 2020.

Getting the taxonomy “is huge,” Shubrook said, because, for one thing, the certified diabetologists can get paid for referrals. Before, PCPs with diabetes expertise couldn’t bill for advising colleagues with troubling cases and faced invoice restrictions if helping a colleague with inpatient care, Shubrook and McCoy said.

But some diabetologists have found that certification means a lot more, and making more money has nothing to do with it. Certification allows them to spend more time with patients — which in today’s provider payment system, means diabetologists could be getting less money than they did before.

McCoy commented on the common denominators among fellowship applicants and diplomates.

“What I have noticed, it takes the right person. Some make less money…I don’t think they realize how much diabetes they will see.…They do the fellowship to get to that comfort level.

“Certification gives you recognition you didn’t have before.”

Apparently medical establishments realize how extensive the diabetes management problem is. McCoy said the college gets three to five phone calls a month to discuss grant applications for starting fellowships. The ACD accepts applications once a year, and are doing so now.

The Graduates

For Kinga Pluta, MD, certification means validation for her chosen profession; the diagnosis of her now teenaged daughter, who developed type 1 diabetes early in her life, inspired Pluta to become a diabetes expert. For Leonard Bertheau, DO, fellowship director at the Brown University-affiliated program, it means that he is training diplomates for now and for the future. He sought out Shubrook for an unofficial fellowship after Shubrook completed his extended education in West Virginia. Bertheau became board certified in 2023.

Pluta, who practices at Cooley Dickinson Hospital, a Mass General Brigham-affiliated hospital in Northampton, Massachusetts, received her board certification last year. The ACD has what it calls the experience pathway. Physicians who have proven clinical experience can forgo the fellowship training and just sit for the boards.

She discussed the advantages of having board certification. For one, she no longer needs to seek out a qualified colleague to sign for her when she wants to prescribe an insulin pump. Insurers, she said, want someone with board certification to sign the request.

“We can wholly do what we do on a daily basis,” she said. She is no longer treated by others as a PCP. “Now, the beauty of this, as more and more of us [get certified]…we will become the go-to.”

Is she a better diabetologist? Not necessarily. She feels validated, even legitimate. “I feel like my practice, my engagement with patients now has this sort of specialty designation.”

To study with Shubrook, Bertheau moved himself and his family from Oregon to Ohio. After the year, they returned to the West Coast, but Bertheau had trouble finding a practice that would allow him to work solely as a “self-proclaimed diabetologist.” “They didn’t know how to support diabetology,” he said.

Now an assistant professor of family medicine, clinician educator, at The Warren Alpert Medical School at Brown University, Providence, Rhode Island, Bertheau did eventually find a diabetes-focused program.

As the years passed, a disturbing fact began nagging him. “I reached a point in my career [knowing] that when I step away, no one here could take my place. I wanted to train others to do what I was interested in.”

That opportunity came about at an ADA conference a few years ago, where Shubrook had put together a meeting of like-minded folk. There, Bertheau met Caroline Richardson, MD, chair of family medicine at The Warren Alpert Medical School.

An offer to start and run a primary care diabetology fellowship came soon after. Bertheau’s first fellow? A former colleague from Oregon, who drove across country to attend.

“Now she is back home in Portland and took over my old practice.”

In 2022, the ADA established its Primary Care Council, bringing together organizations all interested in advancing diabetes care. It meets a few times a year. The ACD was recently added as a member. In a statement, the ADA said, the ACD is also part of another group that is “actively engaged in developing practical recommendations for obesity management in primary care.”

Each fellowship awardee designs its own program. At Brown, prospective fellows are also eligible for an obesity fellowship, and in the future, one in lipidology.

“We have a motivated cardiologist,” Bertheau said. Fellows here learn from dieticians, diabetes educators, pharmacists — “They bring a level of expertise to the table that is eye opening” — podiatrists, nephrologists, ophthalmologists, and pediatricians. “At type 1 diabetes camp, they are taking care of kids on pumps for a week.” Fellows see patients three times a week.

The Future

Some disturbing trends:

• Among all, 14.7% of US adults have diabetes.
• Of these, 89% did not meet guidelines to keep their A1c value below 7, their blood pressure at < 130/80 mm Hg, their nonhigh-density lipoprotein cholesterol at < 130 mg/dL, or rid their smoking habit.
• The US government anticipates a shortage of 87,150 full-time equivalent PCPs by 2037, especially beyond cities.

The present, and the future, management of diabetes will continue to challenge and frustrate healthcare providers. But Bertheau is hopeful.

“Now when I step away, there will be a fleet of physicians who can do what I do,” he said.