Dr. Bernstein cannot say which was more jarring: the news or the way it arrived.

Numb, he kept his composure for 25 minutes, he said. The administrators explained that the hospital was running a deficit. The diabetes program was not helping matters.

"It was really not about the medicine but the business," Dr. Fink said recently about the meeting. "That didn't make it any easier to deliver the news, especially since I had been one of the main advocates behind getting the center started."

After the meeting, as Dr. Bernstein walked back to his office, he wondered where he would direct the program's 300 or so patients. Still, he remained sympathetic to the hospital's plight.

"I was not of the belief that we should save the center only to end up losing the hospital," he said.

For many of the patients, the news was a second strike of lightning. They had come to Dr. Bernstein only after being cut loose by the closing of the St Luke's diabetes center earlier that year. Now they were being cut loose again, to drift back to a life of limited care options: understaffed and overwhelmed clinics; general practitioners with too little time; a city with about 100 overbooked diabetes educators surrounded by 800,000 patients; and a shortage of endocrinologists, the specialists who are often critical providers of diabetes care.

Since endocrinology is one of the lower-paying specialties, there is a national shortage of such doctors. In New York, with its armies of diabetics, patients must often wait months for an appointment with one of fewer than 200 endocrinologists. The poorest patients face the biggest problem, as only a fraction of the specialists accept Medicaid.

Once the center had closed, Dr. Bernstein continued to teach at Beth Israel, but he began to devote more and more time to a side project. He was working on an inhaler that delivers insulin in the form of a mist. The product is being developed by Generex, and it is designed to appeal to patients who are reluctant to use insulin because they do not like the idea of injections or needles.