Ranting in 2025: It’s Not the Same Rant

As I start my twelfth rant, I am reminded that I have had more than one recurring theme about the inefficiencies of our health care system. While I can’t promise that this and future rants won’t address different aspects of similar problems, the hope is the reader will see how some of these challenges have evolved over time. In addition, this year I’ve made it a priority to focus on new topics.

—Mark Zuckerberg

Conflict of interest is a new topic. Some may find it unusual that the Physician’s Payment Sunshine Act was bipartisan legislation introduced in 2007 by Senators Charles Grassley (R) and Herb Kohl (D). The act failed but was then resurrected as part of the Affordable Care Act (ACA), informally known as “Obamacare.” The fundamental idea was to track all financial relationships with physicians and teaching hospitals with pharmaceutical, medical device, and biological/medical supply companies to uncover potential conflicts of interest. In 2014, the Centers of Medicare and Medicaid Services (CMS) reported payment information on its Open Payment Program website. ^1,2

Over the years, the Open Payment Program has reported an increase in activity. In fiscal year 2023 (for program year 2022) there were $12.59 billion of reported payments for over 588,000 physicians and 1240 teaching hospitals. ³ Penalties for not reporting, especially by industry, can be severe. For example, one device company failed to report CMS of payments made to a physician in direct violation of the Open Payments Program. Although there was a $1.1 million civil settlement resolving the allegations that the company made unreported payments to a physician, there was another $8.1 million to resolve allegations that it violated the Anti-Kickback Statute. ⁴

The Open Payment System also allows the ability to review potential conflicts of interest with reviewers of peer-reviewed journals. For example, when considering British Medical Journal, Journal of the American Medical Association, The Lancet, and The New England Journal of Medicine, 1962 individual reviewers were identified as being conflicted. ⁵ Between 2020 and 2022, 1155 peer reviewers (58.9%) received at least one industry payment. More than half (54%) accepted general payments while 31.8% received research payments. ⁵ The bigger point is, this information is available to the public as a Congressional mandate put this into law almost 15 years ago.

When physicians were first notified about these new laws, both industry and academic institutions interpreted the implementation of these laws differently. For some physicians at academic institutions, rules changed regarding how we could interact with industry. Still, there was a new sense of transparency between industry, physicians, and academic medical centers. The cost for everyone skyrocketed to pay for a new infrastructure to capture these interactions.

So why the rant about the Sunshine Act? No, this is not a whine about transparency and the topic of conflict of interest for U.S. physicians and the public. My personal opinion is that transparency is healthy, and the benefits of bidirectional interaction far outweigh potential negatives (in fact, many prefer “duality of interest” as “conflict of interest” connotes such negativity). Rather, I have a major question how the government, including the Supreme Court, can be so concerned and hypocritical about physicians and the industry that provides pharmaceuticals and devices to health care providers, and not concerned with their own transgressions. ^{6 –8} Is it a coincidence that members of Congress are so brilliant in the stock market ⁹ ? Why don’t members of Congress teach physicians how to best invest? Congress passed the STOCK act, which theoretically prohibits senators and representatives from using information they learn in their official capacities and requires full financial disclosure. As we’ve learned in the past there are enough “loopholes” that this act is ineffective. ¹⁰

—Walter Gropius

When I was an endocrine fellow in the late 1980s, I was told how much easier it was to find a fellowship compared to 20 years earlier. Apparently, only the brightest residents in internal medicine were competitive for an endocrine fellowship in the late 1960s and early 1970s and it was not nearly as difficult for my colleagues and myself to find an endocrine fellowship.

Fast forward to today, where each program waits (on “pins and needles”) in the late fall for the match, with the hope they have filled their slots. Programs needing to go outside of the match are common. A report prepared for the Endocrine Society submitted by the Lewin Group from 2011 data projected a shortage in the endocrine workforce ironically, to 2025. ¹¹ Based on the difficulty in accessing an endocrinologist today, anecdotally the report was accurate even if we don’t have the confirmational data. The report noted the following major reasons for this shortage: aging population, an age and gender shift of endocrinologists, changing lifestyle of physicians, and implementation of health care reform. ¹¹

Still, for the 2024 fellowship class, the vast majority of positions were filled. Considering both clinical and research positions together, 92.3% of positions were filled with 56.6% classified as foreign or U.S. foreign. ¹²

As a strategy to try to improve the number of diabetologists, in 2004 two primary care diabetes programs lasting 1 year were created simultaneously. Given the explosion of diabetes in addition to the fact that in the United States diabetes is not considered a separate specialty like it is in many other countries, the thought was this could help improve diabetes expertise, particularly in underserved areas. The two programs together were a tremendous success when considering acquisition of clinical diabetes expertise. ¹³ Unfortunately, since diabetology is not considered a specialty in the United States, there were many barriers including lack of recognition, especially by payors, and therefore lack of health insurance reimbursement. Despite this extra training, the most common post-fellowship career pathways were primary care and hospitalist. Diabetology was third. To me, this fellowship program has tremendous potential, but it needs greater attention from residency program directors, endocrinologists, but perhaps most importantly hospital administrators and payors. I am delighted the American College of Diabetology is promoting this mission. ¹⁴

For any resident considering an endocrine fellowship today, it is important to appreciate that they are frequently in debt over $200,000. I have a patient with a daughter who is a hematologist and son-in-law who is a psychiatrist and together they are $1 million in debt. These loan repayments have huge impacts in decisions regarding specialty. It is therefore important to characterize the United States endocrine workforce (2021 was the last available data). As I work with fellows around the country, it was not surprising to me that 70% of endocrinologists are women, which compared to 62% in 2010. ¹⁵ Alarmingly (to me, anyway), women earn 89 cents for every dollar earned by men: $241,429 versus $214,953 for men and women, respectively. How can that be? The differences in salaries based on location are also a surprise. Southern Texas and most parts of the states of South Carolina and Florida show mean salaries in the $180,000–$190,000 range. Most of the state of Alaska, on the contrary, commands salaries north of $400,000.

It is clear to me that we need better incentives to bring the best and brightest both to care for and research diabetes and endocrinology. The increasing numbers in diabetes, especially in youth, is undeniable, ¹⁶ yet I am equally concerned about more esoteric endocrinopathies. The “elephant in the room” is the salary. A 2024 report showed endocrinologists rank 28 out of 28 specialties. ¹⁷ An extra 2 or 3 years of fellowship training provides the opportunity to earn $26,000 per year less than a general internist. Cardiologists, ranked third, earn over twice that of endocrinologists. ¹⁷ Why does anyone wonder why our fellowships are not as competitive as they were 40 and 50 years ago? It is very clear to me.

—Martin Luther King Jr

Most of my rants in the past have revolved around case presentations, and thus one is required here. This is a 54-year-old man with 40 years of type 1 diabetes (T1D). He has had a body mass index above 35 kg/m² for his entire adult life but currently does well with his diabetes control. He wears an automated insulin delivery pump and his hemoglobin A1c (HbA1c) is usually below 7%. He has long-standing hypertension and albuminuria treated with three blood pressure medications.

His primary care physician, without consultation with anyone from his diabetes team, decided to start him on a glucagon-like peptide-1 receptor agonist (GLP-1RA). There was no advice on what to do, if anything, with his insulin dosing or blood pressure medications. Like many, he had nausea and anorexia. He didn’t drink enough water and eventually had a syncopal episode with loss of consciousness. He was found in the emergency room to be hypotensive and severely volume depleted. His blood pressure medications were reduced but no changes were made with his insulin pump settings although it was later determined that his automated basal dosing reduction resulted in a total daily insulin reduction of 140 units at baseline to 70 units, which is when the GLP-1RA dose was increased. Again, there was no discussion from the primary care provider or the patient with the diabetes team. Eventually, he had a hypoglycemic seizure and coma during a sensor change during the warmup. The lack of sensor data resulted in more basal insulin than he needed.

The term “double diabetes” was first noted in 1991 ¹⁸ and given the explosion of both types of diabetes in the past 30 years, it is not surprising to have many individuals with both. Given the success of GLP-1RAs in type 2 diabetes, no one is more excited about their use in type 1 patients than me. The published data on their off-label use is encouraging. ^{19 –22} Recently published data showed beneficial effects on cardiorenal biomarkers in patients with T1D over 21 months of use of GLP-1RA. ²² There are now ongoing trials assessing their use in subjects with T1D and kidney disease. ²³ It is important to note that hypoglycemia and DKA risks are higher in patients with T1D if safer and appropriate changes in insulin dose are not implemented in consultation with a diabetologist. But using these powerful agents for obesity in someone with T1D without any assistance from the diabetes clinician? Interestingly, for the obesity drugs Wegovy® and Zepbound®, on the package insert there is no mention of T1D, whereas for the same molecules, Ozempic® and Mounjaro® it is states clearly that these drugs are not indicated for T1D. Ozempic® is the same drug as Wegovy® and Mounjaro® is the same drug as Zepbound®! I can’t blame our well-meaning primary care physician as this drug was being used for obesity. Not even a hint of caution let alone a warning for T1D on the label with the obesity drugs. I hope I’m wrong, but I’m not convinced our next version of the Food and Drug Association will fix this problem. ²⁴

—Winston Churchill

I have no plans to give up. Over the years I appreciate that my ranting has become more serious as I don’t poke as much fun at the pharmaceutical and device industry, my colleagues, or our dysfunctional health care system. I also appreciate we all have much to be thankful for, especially as I compare our tools for health care management with other parts of the world. Still, we are far from perfect. I also want to thank Dr. Satish Garg who provides me this yearly platform and Dr. Jay Skyler for his decades of mentorship.