Careers in diabetes and endocrinology

Bulging eye from thyrotoxicosis

Diabetes and endocrinology is one of the most challenging and rewarding of all medical specialties. In addition to the management of diabetes mellitus, it concerns disease management in relation to other key endocrine glands—pituitary, thyroid, adrenal, and gonad—as well as most aspects of metabolic disease. Endocrinologists also have a central role in coordinating the multidisciplinary teams involved in dealing with structural lesions of endocrine organs, including known or suspected cancers. Most endocrinologists also train in internal medicine. Given the ubiquity of endocrine systems modulating body tissues and organs, this makes a consultant endocrinologist a “true general physician,” as well as a dedicated specialist.

Why is the specialty important?

Endocrine disease is common and expensive to the National Health Service and society. Diabetes is archetypal given an estimated 2.35 million people with diabetes in the United Kingdom. Diabetes care accounts for 5% of NHS resources, a figure that is set to increase. The opportunity to diagnose and manage the more esoteric endocrine diseases adds spice to the lives of practising endocrinologists, but thyroid and gonadal disorders combined have a prevalence approaching that of diabetes and on-going management of most endocrine conditions cannot be done in primary care. Furthermore, regional experience has shown that over 15% of the acute medicine take consists of patients with diabetes and metabolic or electrolyte derangements, in addition to the rarer acute presentations of endocrine disease. Therefore, there remains a need for highly skilled professionals able to tackle these challenges.

What do endocrinologists actually do?

Thanks to past clinical, technological, and organisational advances, endocrinology is based mainly in the outpatient department. There is an increasing trend to develop specialised (often multidisciplinary) clinics—for example, adolescent handover; obstetric medical; diabetic renal, foot, or eye; insulin pump; thyroid lump; combined pituitary; adult Turner’s; late endocrine effects in survivors of childhood cancer; and neuroendocrine tumours. Clinical services consist of specialist clinics with a consultative service for transitional care, secondary care, and the community (sometimes also in the community). In addition to doing ward based consultations, most endocrinologists also look after medical inpatients and participate in the acute medicine take, all contributing to a variable and rewarding working environment.

Why is the specialty different?

Rudy Bilous, professor of clinical medicine and past chair of the specialist advisory committee in diabetics and endocrinology, says: “This is an exciting time for the specialty with new therapeutic avenues opening up as molecular biology unlocks many of the mysteries of endocrine disease. There are few specialties where there is such a combination of intellectual stimulation for diagnosis combined with practical solutions for our patients.”

The specialty is particularly challenging as diabetic and endocrine manifestations may not be localised to a particular organ system and can present with initially subtle features. Service development enhancing diabetes services enable practise of “true preventive medicine” targeting prevention of complications such as renal failure, myocardial infarction, lower limb amputations, and blindness. The patient cohort ranges from adolescents to the elderly, and challenging problems arise even in everyday clinics. Supervising and interpreting the results of dynamic endocrine testing for suspected pituitary or adrenal dysfunction is an exciting remit for the endocrine trainee, offering excellent integration of biochemistry and physiology with practical medicine. Part of the learning experience, though, is to understand when simpler diagnostic measures will suffice.

Future challenges for the specialty include attracting junior doctors who have a genuine interest in the specialty. In the second world war, prospective code breakers were innovatively recruited to Bletchley Park, having been identified as winners of national newspaper crossword competitions. We plan to use innovative approaches for selection into our training programme. Research and innovation have always constituted important strands running through diabetes and endocrinology. The specialty needs to work actively to dispel the myth that diabetes management is being entirely devolved to primary care, with the onus being on the specialist teams to develop new ways of delivering care in the community. Cost effective integration of novel therapies such as anti-obesity drugs, inhaled insulin, gliptins, and incretins within the NHS framework remains an essential, if slightly daunting, prospect. The specialty must remain ready to contribute to acute medical admissions by offering expertise in areas such as hypoglycaemia, glycaemic control in patients in intensive treatment units and coronary care units, in addition to traditional roles in managing diabetic ketoacidosis, adrenal or pituitary crises, and so on.

Maintaining the existing multidisciplinary networks will be essential to delivering safe, innovative, and auditable high quality care. These activities will continue to test the interpersonal working skills of the consultant endocrinologist.

How can you train in this specialty?

In 2003, there were about 536 consultant posts, a ratio of 1:6 for number of consultants per national training number.¹ This is comparable to most other medical specialties. With Modernising Medical Careers, trainees will do two years in a foundation programme, followed by seven years of specialist training: two years of core medical training (specialist training years 1-2) and five years of higher training (specialist training years 3-7). This will lead to a certificate of completion of training in diabetes and endocrinology along with level 2 competency in acute medicine. Dedicated academic training programmes may provide single accreditation. Two years of generic core medical training will determine eligibility for competitive entry into run-through specialty training or fixed term specialist training (FTSTA) posts (up to two years). Full membership of the Royal College of Physicians is likely to inform selection into specialist training year 3.

Successful completion of higher specialist training will include work based assessments, a knowledge based assessment, and evidence assembled for the record of in-training assessment. Trainees will typically spend three years in district general hospitals and two years in traditional teaching hospitals. Up to a year of out of programme experience can be offset against training.

Conclusion

Diabetes and endocrinology is a great specialty with a balanced exposure to general medicine and a dazzling array of specialty options in endocrinology. If you are looking for a truly rewarding career that can fire your imagination and deliver practical solutions for your patients, your search ends here.

This article was first published in BMJ Careers (2008 Feb 26; http://careers.bmj.com/careers/advice/view-article.html?id=2837).

1. Coward R. Mind the gap! Too many specialist registrars for consultant vacancies? www.rcplondon.ac.uk/professional/Spr/Spr_prospects04.htm

       

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