A Look Into Academic Endocrinology and Thyroid Medicine

Session 82

Dr. Brittany Henderson is a former academic Endocrinologist, just switching to private practice and today she discusses her specialty, what she loves, and more.

Our goal for this podcast is to show you what is out there for you once you get through medical school. Too much focus is on the academic setting as you’re going through medical school and the majority of medicine is practiced outside of an academic setting. However, medical students don’t get that exposed that typically. Our goal here, therefore, is to compare and contrast different settings. If you’re still on your journey towards medical school, please also check out all our others podcast on the MedEd Media Network.

Back to our episode today, Brittany is an endocrinologist who has been out of training now for five and a half years. She has mostly been in an academic setting but is now moving to a community setting, opening up her own private practice.

[01:57] An Interest in Endocrinology and Finding a Mentor

Brittany started getting interested in the field during residency when she did an elective rotation with an endocrinologist, although she decided between this and geriatrics. She liked the patient population in geriatrics a lot but didn’t like the subject material as much such as incontinence and the like. She likes endocrinology due to her chemistry background.

During her second year of residency, she worked with an endocrinologist who was in the community and was on staff at the hospital. She got more exposure to endocrine and general endocrine and tried to see what it looked like on a daily basis. She points out the power of mentorship.

'Really narrow it down to subspecialties and really look for those mentors around you to try to see firsthand what it looks like in the real world.'Click To Tweet

[04:00] Traits that Lead to Being a Good Endocrinologist

One must be able to look at the big picture but also be able to look at the little intricacies of how hormone systems work. As with her, Brittany’s chemistry background really helped. You have to have an inquisitive mind and be able to think through things.

[05:25] From Academic to Community Setting

When decided she wanted to be an endocrinologist, she started working on some papers and presentations at some of the national meetings. She sees this as a very important aspect to be able to get into a fellowship.

Once you’ve identified your mentor, ask for cool cases that you’re willing to write up. This would serve as your academic exercise. You’re also going to be able to get publication case reports and poster presentations at some of these national meetings. Then you’re able to put this on your application for a fellowship. Ultimately, this sparked her interest in doing an academic career.

Brittany has always loved the academics but she had an awakening that although she liked it a lot, she didn’t want to be in the laboratory for the rest of her career. She didn’t want to be struggling for grant money, which is a very hard thing to do in their field.

She then decided that as she joined the faculty, she wanted to focus more on clinical endocrinology. She was an academic endocrinologist for ten years and ran the Fellows Thyroid Clinic and the Thyroid Cancer Tumor Board, which are two institutions. She was the medical director for the Thyroid and Endocrine Patient Clinic. She loved it having had the time to do clinical work, write papers, and do research.

'But when you're split between doing a lot of clinic and wanting to do research, it's really really difficult to do everything well and have enough hours in the day.'Click To Tweet

All this being said, she pondered on what she wants better – clinic or research. She chose the clinic and decided to go to her own practice she wants to build a thyroid center. Most of her practice in the academic world focused on thyroid disease along with some general endocrinology. But she wasn’t able to do some of the other components of thyroid medicine that she wanted to do like running specific programs, write a book about thyroid disease, and do integrated medicine approaches to conventional ones. Geographic location was another reason she had to consider. All this became the impetus for her transition to private practice.

'Be confident enough to change your mind and go in a different direction.'Click To Tweet

Coming from strong academics to a clinical career is like jumping off a cliff as she would describe it. She’s just trusting that all is going to work out. Taking risk sometimes is a good thing.

[10:48] Types of Patients

Brittany deals with mostly autoimmune thyroid diseases as well as a lot of thyroid ultrasound and procedures in her clinic. She also sees a lot of thyroid cancer where she does lymph node mapping. They’re also doing minimally invasive procedures such as sclerotherapy or alcohol ablation therapy for patients with thyroid cysts who don’t want to undergo surgery. Alcohol is injected into the thyroid tumor within the lymph node or into the thyroid cyst. This kills the blood supply to the thyroid cyst wall or to the tumor. The patient can then avoid surgery. In fact, they see about 70-80% reduction in the volume of both cysts and cancer lymph nodes.

They also integrate radiofrequency ablation they use for cases that deal with the liver or the spine. The FDA just recently approved a probe for thyroid nodules so surgery can again be avoided in patients with benign thyroid nodules but with symptoms or are less attractive.

For thyroid disease, most of the patients that come to her already know they have an issue so they come to her for further evaluation. Other patients also come in who have thyroid symptoms and want to be assessed without previous diagnosis although this is relatively rare.

'For the more rare endocrine disorders, you're probably starting at square one. For thyroid and diabetes, they usually have a diagnosis by the time they get to you.'Click To Tweet

[14:17] Typical Week

Back in academia, Brittany would be in the clinic for about four half days a week and she spends the rest of the time following up on labs and calling patients back. In the new EHR system, they’re having an in-basket where they’re getting patient emails and emails from nurses. This could take up a lot of time unless you have somebody dedicated to helping you with this. Wednesdays would be an academic day so she’d be teaching fellows and residents. And she’d write proposals and letters. You can also have options as to where your clinics are a lot of times. For instance, she’d have a clinic at the diabetes and endocrine center on Tuesday mornings and she’d see general endocrinology patients. And Thursdays, she be at the cancer center downtown where she’d be seeing all thyroid cancer and endocrine neoplasia patients. Then Fridays would be spent on a collaborative clinic with the ENT surgeon, seeing a lot of the parathyroid and thyroid patients and doing ultrasound and mapping surgeries.

What she likes being in an academic center is to be able to do a multidisciplinary clinic which she did in both places she was at. You’re able to have clinic right alongside your surgeon or neurosurgeons and look at scans together.

For thyroid cases, she does ultrasound all day everyday. It’s like her stethoscope where she’s able to actually look at the thyroid gland to help her diagnose the disease. For biopsies and other minimally invasive procedures, she does it on a weekly basis for about 5-10 a week. And for general endocrinology, it’s very procedure-based and technology-based. All of your monitors are talking to your iPhone while you’re looking at trends and a bunch of data.

Ultimately, for diabetes care, it’s more technology-based and for thyroid care, it’s more of procedure-based. There are multiple subspecialties of endocrinology that can appeal to different personality types.

[19:24] Taking Calls and Work-Life Balance

Brittany says one of the perks of being an endocrinologist is the minimal number of calls. There are very few endocrine emergencies and even if there are, usually the endocrinologist is just a consultant. So the primary team is able to stabilize the patient and you’re able to go in the next day to see the patient.

In fellowship, Brittany recalls going once for a patient and had to make plasma freezes. A lot of diabetes ketoacidosis (DKA) treatment nowadays are now protocol-driven and the hospitalist or the admitting physician can start management for that patient. The endocrinologist comes in after their DKA and then gives recommendations on a home regimen the next day. All this being said, thinking through things and being inquisitive are great traits for an endocrinologist.

Brittany considers having a great work-life balance and there is enough time for rest and relaxation.

[23:25] Path to Residency Training

Endocrinology is typically a two-year fellowship. Brittany did a three-year fellowship since there are programs that do this. When she graduated and joined the faculty and was a fellow, she would ask some of other biopsies, offering if she could do extra biopsies and ultrasound. She also got an ACNU certification acknowledged by the AIUM (American Institute of Ultrasound Medicine) as endocrine training for neck ultrasound. As a fellow, you’re supposed to have a certain amount of ultrasound and biopsies and be able to complete the entire panel of ultrasounds and biopsies in your first year as an attending. Then you have to submit a 350-page PowerPoint or documentation that you have done all of it before they approve you for a ten-year ACNu certification.

After getting certified, she was able to run thy hybrid clinic. She volunteered to run the Endocrine Tumor Board and the Thyroid Tumor Board to get more experience and to be able to lead a discussion on it.

Also during fellowship, she elected to go up and do a couple of weeks at a cancer center with a thyroid specialist for thyroid cancer so she could get more advanced training that wasn’t available at her fellowship.

'That's possible to do some away rotations during your fellowship if your program director is amenable to that.'Click To Tweet

And when she moved over to her last academic position, she had enough experience to be the medical director for thyroid and endocrine neoplasia and she was able to run some of the multidisciplinary clinics. Hence, she actually made her own path. Additionally, there is a one-year fellowship in some programs but it’s on endocrine neoplasia focused on chemotherapy, prescription, and administration.

As with the competitiveness in terms of matching, Brittany doesn’t describe it as that competitive. They need more endocrinologists, some of the higher ranked endocrine programs are pretty competitive but there are slots of endocrinology and endocrine fellowships throughout the country. She describes it at 50% as far as the difficulty of getting in to match.

'If you're going into this, you're going to be going into this because you enjoy it, not because of the paycheck.'Click To Tweet

As far as reimbursement goes, sometimes even less than internal medicine and hospitalists. So you really have to love what you do.

[29:45] Other Areas of Focus

You’re able to basically carve out your niche such as diabetes, and obesity and weight loss medicine (a really big and hot topic). Brittany recommends that if you’re going into any fellowship of any type, branch out to other departments and figure out your niche. heat sets you apart from some of these other fellows and other endocrinologists out there.

[32:53] Working with Primary Care

Brittany does all of her thyroid ultrasound and assessment. A lot of times, patients will have a scan done for another reason then they found a thyroid nodule. Then the family practice doctors would send them to radiology. or to ENT for assessment. Figure out if they actually need an intervention or if it’s benign. Because 95% of the time, thyroid nodules are benign and they don’t intervention and they don’t need surgery.

Other specialties she works the closest with include general surgeons that do thyroidectomy, ENT, oncologists, nuclear medicine doctors, and pathologists, and nuclear medicine.

'It's good to know who you're going to be working with. It's also good to know who your patient population is going to be.' Click To Tweet

Most of Brittany’s thyroid patients are women with an average age of about 41 years old. They are otherwise healthy and used to not being sick. For patients with diabetes, she would have a dichotomy of patients – young, type 1 and 2, overweight patients, etc.

[36:10 Special Opportunities and Major Changes in the Field

You can go down the route of pharmaceutical development or molecular testing. These could be pretty rare positions though. And usually, you’d have to build up your reputation as an academic endocrinologist.

What she likes the most about being a thyroid specialist is her patient population, treating women and be able to put them into the right regimen. She finds it as very rewarding. On the flip side, what she likes the least is the number of labs, one on top of another. So you’d have to be looking at these labs frequently.

The major changes to be seen in the future for endocrinology is more minimally invasive techniques that are going to be widely used across the United States.

If she had to do it all over again, Brittany would still be doing it as she loves her specialty. That said, she believes that early exposure really helped solidify her interest in this career path that she had chosen.

Ultimately, if this is something you’re interested in, she recommends finding an endocrinologist that specializes in thyroid disease, as not all of them do, and so work with them and try to get your feet wet early on to try and see if this is something that you really want.