After years of concern about endocrine care access there is an uncomfortable but unavoidable conclusion: the system is working exactly as it is designed to work.
Note: This publication is no longer active.
All new essays are published here → [threadmedicine.substack.com]
Subscribe there to receive future work.
Thanks!!
Prolonged wait times, oversized panels, and chronic backlog in endocrinology are not isolated operational failures. They are the predictable result of fixed workforce capacity colliding with steadily rising demand for chronic disease care.
This is not a temporary disruption. It is a structural condition.
📊 Workforce Capacity Has Lagged Demand for Decades
Workforce analyses have warned for years that the supply of endocrinologists would not keep pace with population needs. The Endocrine Society’s commissioned analyses suggest there are approximately 5,000–8,000 practicing clinical endocrinologists in the United States for a population of more than 330 million people with rising or sustained high prevalence of diabetes, obesity, thyroid disease, osteoporosis, PCOS, metabolic liver disease, and hypogonadism (Endocrine Society, 2014; Vigersky et al., 2008).
The Endocrine Society has repeatedly highlighted a persistent national shortage and projected that demand for endocrine services would continue to grow faster than training output due to:
• Slow fellowship expansion
• An aging specialty workforce
• Increasing chronic disease burden
• Lower compensation relative to procedural specialties
Earlier analyses in the Journal of Clinical Endocrinology & Metabolism described widespread access constraints—including multi-month wait times and practices closed to new patients—more than a decade ago (Vigersky et al., 2014). The pattern has not meaningfully improved since.
Despite modest growth in board-certified endocrinologists, access remains constrained because demand has expanded faster than capacity.
💰 The Cardiology Contrast Clarifies the Structural Issue
The difference becomes clearer when contrasted with cardiology.
There are roughly 30,000–35,000 practicing cardiologists in the United States—five to six times the size of the endocrine workforce—serving the same population. Cardiology access problems certainly exist, but median wait times are typically shorter and capacity expansion occurs more rapidly.
Procedural specialties generate downstream revenue through imaging, catheterization, and hospital services. Cognitive specialties like endocrinology generate most of their value through longitudinal decision-making, medication management, and risk reduction—activities that historically receive lower reimbursement (MedPAC, 2023).
When capacity expansion is financially attractive, systems build it.
When it is not, capacity lags demand.
⚖️ Evidence-Based Cognitive Care Does Not Scale Under Current Economics
Endocrinology is defined by longitudinal management of complex chronic disease:
• Diabetes technology and medication titration
• Thyroid and osteoporosis management
• Pituitary and adrenal disorders
• Cardiometabolic risk reduction
These visits require interpretation, counseling, and follow-up over years or decades.
Time-motion studies show physicians already spend as much or more time on documentation and care coordination as in direct patient care (Tai-Seale et al., 2017; Sinsky et al., 2016). There is limited safe room to increase throughput without degrading quality or accelerating burnout.
Under these constraints, shorter visits and larger panels do not solve access. They shift the cost elsewhere. Where that cost lands—primary care, emergency departments, parallel markets, or the quality of decision-making—is the downstream story of this structural mismatch.
🌊 The Demand Reservoir
Endocrinology demand behaves less like a queue and more like a reservoir.
Chronic disease generates ongoing follow-up requirements. As prevalence rises, the number of required visits accumulates faster than incremental capacity can drain (Bodenheimer & Pham, 2010).
This explains why:
• Adding clinic sessions rarely fixes backlog
• Urgent slots do not change long-term access
• Panels refill quickly after temporary relief
The system returns to equilibrium.
* * *
🏥 This Pattern Extends Beyond Endocrinology
Endocrinology is simply an early and visible example.
Primary care workforce projections estimate shortages of tens of thousands of physicians over the coming decade (AAMC, 2023). Behavioral health faces similar structural deficits, with many U.S. counties lacking adequate psychiatric coverage.
Across cognitive specialties, the pattern is consistent:
• Rising chronic disease burden
• Finite clinician supply
• Increasing longitudinal complexity
• Expanding unmet need
These are not isolated operational failures. They reflect a system operating beyond workforce limits. The lines of emergency department patients in chairs and make- shift beds in hallways is a striking reflection of sustained systematic dysfunction.
🔄 System-Level Consequences
When specialty access is constrained, demand does not disappear. It redistributes.
Primary care absorbs higher complexity without additional time or staffing. Emergency departments become default access points (Merritt Hawkins, 2022). Fragmented telehealth and direct-to-consumer services expand into the gap.
These are not purely innovations. They are predictable adaptations to a capacity bottleneck.
* * *
⚖️ A Stable Equilibrium—Not a Temporary Crisis
When:
• Training pipelines expand slowly
• Chronic disease prevalence rises
• Cognitive work is reimbursed less than procedures
• Workforce retirement accelerates
then prolonged wait times are not an anomaly. They are a stable equilibrium.
In systems terms, endocrine access reflects a low-elasticity demand reservoir constrained by finite clinical labor. The same dynamics now shape primary care, mental health, and other cognitive specialties.
📐 SIDEBAR: What One Full-Time Endocrinologist Can Realistically Support
Why access problems persist even when clinicians “work harder.”
Typical health system outpatient template:
• New patient: 45–60 minutes, • Return visit: 20–30 minutes • Documentation, inbox, care coordination: 1–2 additional hours/day
ANNUAL CLINICAL CAPACITY (REALISTIC):
Clinical days per week: 4 days, Working weeks per year: 46 weeks, Patient slots per day: 18–22 slots
Annual visit capacity: 3,500–4,000 visits (Time-motion studies suggest this already pushes sustainable limits.)
Chronic disease follow-up demand:
Typical endocrine follow-up frequency:
• Diabetes on insulin or CGM: 3–4 visits/year
• Osteoporosis: 1–2 visits/year
• Thyroid disease: 1–2 visits/year
• Complex pituitary/adrenal: 2–4 visits/year
Average across a mixed panel: ≈ 2–3 visits per patient per year.
RESULTING SUSTAINABLE PANEL SIZE:
Annual visit capacity: 3,800 visits/year
Visits per patient: 2–3 visits/year
───────────────────────────────────
SUSTAINABLE PANEL: 1,200–1,800 patients
What happens above that threshold:
Once panels exceed ~1,500–1,800:
• Return intervals lengthen
• New patient access collapses
• Inbox volume rises non-linearly
• Clinician cognitive load increases
• Burnout risk accelerates
• Downstream utilization increases
❓ The Real Question
The question is no longer whether large health systems can provide rapid access to cognitive, longitudinal specialty care at scale under current incentives. The data suggest they cannot.
The more relevant question is who absorbs the cost of that structural mismatch:
• Patients
• Primary care
• Cognitive specialists
• Emergency departments
• Parallel care models and telehealth markets
• Or the quality of longitudinal medical decision-making itself
The answer is increasingly ‘all of the above’—and that redistribution is reshaping how endocrine care is delivered outside traditional health systems.
Until the underlying workforce equation changes, the outcome is unlikely to change with it.
——————————————————————————————————————
References
Association of American Medical Colleges (AAMC). (2023). The Complexities of Physician Supply and Demand: Projections from 2021 to 2036.
Bodenheimer T, Pham HH. Primary care: current problems and proposed solutions. Health Aff. 2010;29(5):799-805.
Endocrine Society. (2014). The Endocrinology Workforce: Supply and Demand Projections. Lewin Group white paper. Available at: https://www.endocrine.org/advocacy/workforce
Medicare Payment Advisory Commission (MedPAC). (2023). Report to Congress: Medicare Payment Policy.
Merritt Hawkins. (2022). Survey of Physician Appointment Wait Times and Medicare and Medicaid Acceptance Rates.
Sinsky C, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med. 2016;165(11):753-760.
Tai-Seale M, et al. Electronic health record logs indicate that physicians split time evenly between seeing patients and desktop medicine. Health Aff. 2017;36(4):655-662.
Vigersky RA, et al. Evolving diabetes clinical care: The endocrinologist and the general internist. J Clin Endocrinol Metab. 2008;93(4):1164-1171.
Vigersky RA, et al. The endocrinology workforce in the United States: a supply-demand analysis. J Clin Endocrinol Metab. 2014;99(9):3112-3121.