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perspective

My path to endocrinology fellowship training and community practice

WHY DID I CHOOSE ENDOCRINOLOGY?

Okay, so you have decided or are considering endocrinology as a future career. I will try and address the following questions…how competitive is endocrinology fellowship? Fellowship length, why choose endocrinology, what is a typical workday like for an endocrinologist etc.

Medical School

From the outset, I must confess my naivety during my pre-clinical years. As a newly minted medical student spending most of the first year in the anatomy and physiology labs, I assumed specialization in surgery was a must for me. Interestingly, visualizing and touching anatomic specimens made more sense to me than “abstract” complex biochemical pathways. Oh boy, was I wrong! I spent my first clinical year under the instruction of an astute endocrinologist. His mastery of both internal medicine and clinical endocrinology made those “abstract” physiology concepts interesting. The idea of understanding “first principles,” which in this case would be the numerous endocrine feedback loops and applying them at the point of care, became more and more enjoyable.  Since I have always believed that the mind should be a creative space and not a repository for random facts, specialization in endocrinology therefore made sense.

Residency

I did not see internal medicine (general medicine) as a mere bridge to my final destination, but rather a critical path in my development as a clinician. Internal medicine residency is typically for three years. The incessant hospital pages and the burdens of inpatient medicine were beyond overwhelming. My experiences are no different from those of many internal medicine residents. Outpatient internal medicine was no different. I felt my attendings had less and less time to see more and more problems. These experiences, in general internal medicine, left a real bad taste in my mouth.

 

My month-long rotation in the endocrine service was exciting. The inpatient consult service involved the management of diabetes and complex endocrine conditions. Outpatient endocrinology exposed me to technologies in diabetes care (continuous glucose monitors, insulin pumps), thyroid ultrasound, thyroid fine-needle aspiration, and interpretation of bone density scans. I wrote at least 3 case reports and conducted a retrospective study with my endocrinology attendings. I presented the results of a retrospective study at the annual endocrine society meeting. Although endocrinology is not considered as competitive as gastroenterology, cardiology or oncology, it falls within the category of a medium-tier competitive specialty.  Showing an interest in the field, such as presenting research findings at society meetings and publishing case reports, goes a long way in landing a spot in a “competitive university program.” 

" I chose endocrinology because it was and still is the medical specialty that presents the ultimate challenge in putting an understanding of biochemistry, cell biology, and genetics directly into patient care. "
Robert Vigersky MD
Endocrine news (2015)

FELLOWSHIP

Clinical endocrinology fellowships last two years; however, a research track will require an extra year of training. In my experience, most endocrinology-trainees choose the 2-year path due to restricted funding in this current research environment. I opted for the clinical fellowship track because an extra year of research did not fit into my professional goals. The experience of conducting a major research project under the supervision of seasoned researchers makes sense if your overall goal is to be a clinician-researcher. Over the past few years, there has been a steady decline in research funding, with most clinician-researchers being forced to increase their clinical work hours. You should consider this fact if you decide to pursue a 3-year research track.

Most clinical endocrinology fellowships are not as stressful as internal medicine residencies. The educational experience was indeed an enriching one for me. I had ample time for self-study and research. I co-authored a book chapter under the supervision of my divisional chief – an exciting and humbling experience for me.

As should be expected, the inpatient endocrinology service is type 2 diabetes heavy, no pun intended. There is a diabetes management service that may include advanced practitioners (Nurse practitioners, physician assistants), depending on your training program. Inpatient insulin consults involve the management of insulin resistance, tube feeds, gestational, and peri-operative patients with uncontrolled diabetes. Even in type 2 diabetes management, one size does not fit all. An appreciation of diabetes pathophysiology is critical in choosing the right therapeutic options. Diabetes is more exciting than you think. I will elaborate on this later.

50% of my inpatient experience was spent in the evaluation and management of calcium disorders, thyroid emergencies, adrenal emergencies, neuroendocrine disorders, etc. Depending on your training program, you might gain some experience in peri-operative management of patients who have undergone transsphenoidal surgery.

 

The outpatient endocrinology service is where I experienced my most joy. Endocrine conditions  such as acromegaly, pheochromocytomas, Cushing’s disease, multiple endocrine neoplasias etc. were no longer rare in our large referral-based endocrinology practice. My attendings were truly invested in my training and went the extra mile to teach me the pearls needed to be a good endocrinologist. They treated me as a colleague and made me feel like a member of the endocrinology family, from day one!

community practice

Why did I choose community practice over an academic-based practice

The decision to embrace community practice was one made long before the completion of my advanced training. There is a shortage of endocrinologists, due to various reasons (Also see a recent opinion piece in JCEM — Giulio et al). I will defer a discussion of these reasons at this time. I believe a community-based endocrinologist is a helpful resource for not only patients with endocrine problems but other generalists with puzzling endocrinology queries and concerns.

My patients exist in a 200-mile radius, and some have to travel a fair distance to seek endocrine care. Within my first few months of community practice, I diagnosed cases of acromegaly, thyroid hormone resistance, insulinoma, Riedel’s thyroiditis, Cushing’s disease, and Kallmann syndrome, to mention a few. You can imagine my pleasant surprise – so it is not all diabetes and hypothyroidism then. Indeed, this issue of diabetes being boring is misleading. I find diabetes care exciting and challenging. Diagnosing insulin-mediated lipodystrophy, Familial partial lipodystrophy, growth hormone excess as causes of poor diabetes control is rewarding. In some instances, poor patient education regarding optimal use of insulin and not a lack of adherence is the cause of poor diabetes control. General medicine and family practitioners are overwhelmed in this climate of modern medicine. Diabetes care becomes an additional clinical problem that is briefly glossed over. This leads to deficiencies in patient education and assessment. Diagnosing latent autoimmune diabetes of adulthood and MODY in patients with presumed type 2 diabetes alters diabetes therapy significantly. My training in endocrinology, I believe, has been helpful to not only my patients but my colleagues in general internal medicine and family practice.

What is my typical workday like?

My typical day includes rounding on the previous day’s consults between 7:30am and 8:30 am. This is dependent on the complexity and number of inpatient cases. I occasionally join a team of endocrinologists at my hospital’s affiliated university program via skype business to discuss unusual cases. 

I see outpatients between 8:30 am and 5:00 pm on 4.5 days of the week – between 14 and 16 patients a day. I have half a day dedicated to administrative work. I juggle inpatient consults alongside my outpatient practice, and this requires proper time management skills. My weekends and weeknights are devoted to myself and my family. I occasionally carry out some clinical documentation outside my usual work hours. This is nothing new for modern-day physicians burdened with the beast called EMR.

What is the compensation for endocrinologists

I am obviously not going to share my reimbursement on this platform due to privacy concerns. Compensation scales differ based on your experience, value to a health system, and professional negotiation skills. Follow this link

 What should influence your decision to choose subspecialty training in endocrinology

Ask yourself, what am I most passionate about? What sort of work schedule makes the most sense for myself and my family? Can I work in a specialty that requires frequent shift changes and pages at ungodly hours? Financial reimbursement should not be the overarching reason for choosing a specialty. The grass is always not greener at the other end, even if your economic liberation is dependent on the “greens” – no pun intended. All clinicians cannot be at the forefront of urgent care; some of us have to be dedicated to slow-paced cognitive-based specialties like endocrinology. I feel fulfilled in my role as an endocrinologist and will not change it for any other specialty.

References

Giulio R Romeo, Irl B Hirsch, Robert W Lash, Robert A Gabbay, Trends in the Endocrinology Fellowship Recruitment: Reasons for Concern and Possible Interventions, The Journal of Clinical Endocrinology & Metabolism, Volume 105, Issue 6, June 2020, dgaa134, https://doi.org/10.1210/clinem/dgaa134

https://endocrinenews.endocrine.org/why-endocrinology-the-perfect-combination-of-science-and-medicine/

https://endocrinenews.endocrine.org/march-2015-why-endocrinology/

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