This transcript has been edited for clarity.
Jessica Sparks Lilley, MD: Hi there. This is Dr Jessica Lilley. I'm a pediatric endocrinologist and the director of pediatric endocrinology at the Mississippi Center for Advanced Medicine. I'm interviewing my long-time friend and mentor, Dr Craig Alter, from the Children's Hospital of Philadelphia (CHOP). I was a resident there and rotated through his endocrine clinic, which solidified my desire to go into pediatric endocrinology.
We're here this morning to talk about the current shortage of pediatric endocrinologists, a shortage that seems to be looming larger as we look into the future. As the former president of the Pediatric Endocrine Society, Dr Alter has spoken widely about this issue and is an expert in what we need to do next.
Good morning. It's so good to see you again, Craig. I've missed seeing my CHOP family.
Craig Alter, MD: Thank you. I'm glad we're having this discussion because this is an important discussion and dear to my heart.
Lilley: One of the big issues is how to expand the audience for this conversation to people outside our specialty. Every pediatric endocrinologist knows that there aren't enough of us. We know what our wait times look like. We know how far people have to drive to come see us, and we know what a disruption that is to our patients' lives. We also know how stressful it is for us.
Talking to our colleagues in other areas of medicine will be important, so I'm thankful to Medscape for allowing us the opportunity to disseminate this conversation outside our meetings and work rooms and the places where we are discussing this. I'm sure our colleagues in other pediatric specialties like rheumatology and nephrology are having these same kinds of struggles. What is pertinent to us will be pertinent to everyone taking care of children with chronic diseases.
To get started and to have a better idea of the scope of the problem, tell us what we're facing and what you've worked on in your advocacy. How bad is the problem?
Alter: We're all feeling it. We're feeling the wait times. We can see that our services are definitely needed. There are many people who need pediatric endocrinologists; yet, we have fewer people going into the field. We're still filling most of the positions — it's not like no one is going into this field — we're still getting amazing candidates, but there is no question that we have too many unfilled slots.
My colleagues around the country are also experiencing this shortage. We're all one big family, and my hope is that we can improve this situation. It's not going to change overnight. I'm speaking not as a representative of CHOP, but as a representative of our entire pediatric endocrine family.
Lilley: When I applied for a fellowship, it was program to program, very informal. You would get an offer at one place before you could interview at another and had to hurry up and decide whether to accept it. That was quite some time ago, and we've moved over to a formal match. I think the match system for fellowship applications has illuminated much of the developing problem.
We're seeing that while we're filling most of our match spots at places like CHOP and in places that have a long history, spots at many of our other programs are going unfilled. We're looking at roughly a 50% match rate, which means that we're leaving maybe half of our spots unfilled. Is that what we saw with the most recent match?
Alter: A little better than that, but that's the ballpark.
Lilley: Right, so not 100%, and we all know that we could definitely use every single one of them. Meanwhile, we're thinking about who is going to replace all the giants in the field who will be retiring. We know we want to make sure we are matching that academic rigor and the number of work hours we need.
In addition, more children are getting sick with endocrine conditions. Type 2 diabetes was unheard of in kids in the 80s, and now, about 15% of the patients I see with diabetes have type 2. We're seeing an increase in many other kinds of conditions. We know that type 1 diabetes is increasing gradually year over year, so the needs are growing.
Many of us are trying to get people to think about endocrinology as a specialty, but we're all so busy that we don't have time to talk to medical students and residents and people who might need to see what the specialty is all about. We all know that once people see pediatric endocrinology, they won't want to do anything else. It's the best specialty. We have the best patients.
What do you love about being a pediatric endocrinologist?
Alter: Before I answer that, I just want to make one comment. When you talk about the match rates, some positions are being filled after the match.
Lilley: Yes, that's true.
Alter: I believe some of that energy and excitement to fill the spots after the match should be done before the match. If you're in a program and you say, well, we didn't fill, but let me see, who's out there who is undifferentiated in terms of their careers who we could talk to and get them excited about our amazing field. That has to happen earlier.
Lilley: That's helpful. When you have residents come through your clinic, how do you try to sell them on pediatric endocrinology? What features of our specialty make it an attractive field?
Alter: That's an important question. I'm at a big program. We have about 31 faculty physicians. When people rotate through, they're not always spending time with one person. I think there's an advantage to spending time with one dedicated person, but it's also a disadvantage. The advantage to training with several different mentors is that trainees will see special bone disease; they're going to see hyperinsulinism; they're going to see a variety by working with many doctors. But the intimacy is lost. I recognize that.
Sometimes, I hear more complaining about the computer system, and that's not what the prospective students want to hear about. They want to see the exciting parts of the field. When we have someone "captured," like a resident or even a medical student, our job is not just to show them the experience of that moment but to take out our great stories. Take out that story of that person you thought would have just basic short stature and turned out to have severe hypothyroidism. We all have patients like that.
Talk about those. Have those cases at your fingertips because they're all super exciting. Talk to the learner — the student, the resident — and find out what things interest them. Find out more about them because if you think you're going to model them into your own research mold, maybe they're not interested in the research world. They're interested in more clinical issues. I think we have to spend time with each person; learn what they're interested in; share some of your excitement, not just the day-to-day events; and throw the complaining out until the next day.
Lilley: It would help if we all had protected time to teach. So many times, we have an overrun schedule because of the shortage and because of the demand, and so we're seeing double- and triple-booked clinics while we have a learner with us. I think it's important to have protected time so we can provide some exposure to the field and have even our residents who rotate through be able to spend more time with each patient and have those conversations.
As a first-year medical student, I heard an early lecture from Dr Jennifer Najjar on congenital adrenal hyperplasia. It's one of the most fascinating conditions in any field, I would argue, and to have a queen like her lead me through the pathway was wonderful. I had come into medical school interested in pediatric endocrinology because I had some family members with type 1 diabetes, growth hormone deficiency, and Addison disease — kind of an unusual personal exposure.
I walked up to her and said, "Gosh, that was an interesting lecture. I'd love to come to clinic with you." She took me to clinic with her. I started going as a first-year medical student, and she was a wonderful mentor to me through all of medical school and drew me back to do my fellowship at Vanderbilt too. That long-standing relationship is so important. I still call her to discuss cases after a decade into practice.
If everybody had someone like that to talk with about all the things we love about what we do. She understood that. She had many residents who came to diabetes camp with her or who did learning sessions with her as medical students to increase their exposure to what we do. I think once people get a glimpse of a specialty, then they can consider it.
There are so many other highly demanding rotations that grab people's attention, and there's all this hand-waving about how we don't make any money and it's such a long fellowship, and all these negatives, that people don't even look. I believe we do need to talk about things like workload, call schedules, reimbursement, and all those important things. But for me, once I fell in love with pediatric endocrinology, the rest didn't matter so much.
I remember coming into your clinic as a resident, and you looked like you had so much fun every day at work. Even though you were working very hard, you loved taking care of your patients. It was contagious. I thought, Gosh, if everybody could come through here, we would have many more pediatric endocrinologists.
Alter: I'm glad you have that memory. I love my job. Do I love every minute of it? No. When I talked about spending time with each learner, that was about someone who's already interested. The next question is how do we find more people to expose? The Pediatric Endocrine Society has the discovery program. Are you familiar with that program?
Lilley: Yes.
Alter: It's relatively new. We came up with it knowing we need more people to enter the field and part of the work force issues. That program, which is still in its infancy — we have up to 60 either medical students or young residents right now, first- and sometimes second-year — where we're essentially giving them some travel allowance and also free entrance to our annual meeting.
Last year, the program went really well. We don't have any tracking numbers to see if this is going to make a difference in the future, but right now, we think it's a great program. It still involves each institution finding candidates. It's not like the medical students are going to open an email and say sure, we'll do this. It's not the answer to the whole issue, but it's a great program that led to a lot of excitement. I look forward to seeing if some of those candidates from last year enter our field down the road.
Lilley: You mentioned our annual meeting. It's so important that we all get together and don't remain siloed in our own experiences. There are many ways to practice pediatric endocrinology. I'm in a multispecialist group. I have some friends who went that direction too. As a resident and fellow, all you see are academic pediatric endocrinologists who are balancing research and patient care.
There are a variety of ways to impact patient care with our expertise. I know good friends who went into industry and who are impacting from that direction, people who are practicing in rural areas, like me, or in private practice in metropolitan areas. There are so many different opportunities for experience that I think are important to shine a light on. We can do that better at annual meetings rather than at the places where the learning is taking place.
I was nervous about pursuing pediatric endocrinology because I care about the plight of children in Mississippi. I grew up here. We have many challenges and struggles, and I knew that there were many kids here who were going without care. Many people told me, "You'll never be able to practice medicine there. There's no way that model is going to work." But we figured it out.
We can share this with one another by coming to national meetings and staying engaged with the society so we can talk to each other about ways we can improve access, improve care delivery, and everything we have learned on our own. We can share that information.
Alter: Those are amazing points. The annual meeting is just so much fun. We see people we were fellows with across the country and people we met at previous meetings and meet new people too. We hear many stories. It's a great opportunity to be excited by the field and to learn things. It's not even just about learning information. I think half of it is the concept that we're seeing each other, meeting new and old friends.
Lilley: I'm near a military base, and so often patients are asking for a recommendation for the next city they're moving to. It's been interesting to say, "Oh, yes, I do know somebody in that city," because we're such a small field, we know each other. It feels like a family. If people ask, "Oh, do you know so-and-so," usually the answer is yes. We get to interact with each other often.
Alter: I also like what you said a few minutes ago, that the role of a pediatric endocrinologist changes over time, and sometimes it's unique to the situation. I will tell you — this is going to sound funny — but when I started as a medical student, I was working with the amazing Dr John Crigler at Boston Children's Hospital. I said that I wanted to do a fellowship in pediatric endocrinology with the goal of having a clinical role. I wanted to do just a small amount of research and be mostly clinical.
He said to me, with his beautiful Southern accent, that there was no such type of position. If you go into endocrinology, you're going to be doing predominantly research. That led to a discussion because if I was going to only do research, I would have stayed in physics and math before medicine. It was very interesting.
Even when I finished my fellowship at CHOP, the great Lester Baker, who was head of our division then, said to me, "Craig, we would love to have you stay here. You won the teaching award of our fellows. But if you stay here, you'll have to do three quarters research." I said, "Well, I want to do mostly clinical care."
I left and went to UMass, which was amazing. They cared about clinical care and teaching. Then, CHOP said: You know what, we're opening all these satellites. We need someone to do all clinical care, education, grand rounds speaking, and chapters. I said: That's the job I'm talking about. The roles have changed, and each person can invent new roles. There are people here who do endocrinology part time and have unique positions within their own institutions. Some are in private practice. We're all part of the same family, but we all find our own answers.
Lilley: Absolutely. I'm excited for the future of our field and for the ways that we're all working to address these issues.
What about reimbursement? I know that's something that comes up often, and that we are at the back of the line when it comes to reimbursement for the work we do. We work hard. For me, having medical school loans and then facing another 3 postgraduate years after residency… Pay in a large city was daunting.
I looked at my friends who were starting to get real jobs and knew that we were getting even further behind. We were living in a higher cost of living area and continuing to work toward those goals. I already felt really behind and then to have a lower compensation than my medical school classmates — I know that's a tough sell sometimes.
Then, we say, "Guess what? You're going to be on call more, you're going to work longer hours, and balance all these other obligations like inpatient service time, research time, and fighting for your own salary with grant applications." We face many challenges coming into practice. What work are we doing as a specialty to better advocate for ourselves at the table?
Alter: We're working with the American Academy of Pediatrics. There are some high-level meetings coming up and ongoing with program directors, and we're trying to push for better reimbursement with more intellectual nonprocedural fields, not just endocrinology but nephrology and other specialties. We're hoping to make progress. It's not going to be overnight. We realize that it's an important issue.
Lilley: It's tough, too, because compared with the average American, we're well compensated for what we do. When you look at other physicians, we know there's inequity, especially when you look at the reimbursement for taking care of a child vs taking care of an adult. I think it shines a light on the importance of children in our society if you look at some of our lowest paid workers across professions, whether you're looking at education or taking into consideration childcare workers, and then those of us who take care of children as physicians.
As a society, we say we care about children, but when the rubber hits the road , we realize that maybe we don't care as much as we say we do. We need to focus on who we're serving here and the importance of all the years of life we have the opportunity to impact. It's a big deal.
Alter: I totally agree with you. We're trying to send some experts to these meetings. I'm not one of those people, but I agree that it's important. It devaluates children if we're getting paid less for this. There are many things that could be said, and I'm hoping we make some progress there. But I agree. It's not like we don't make a good living. We do. But relative to other fields, it's ridiculous how much less we get, even compared with our adult-endocrinology colleagues.
Getting our heads above the water: It's so easy to just put our heads down and work, work, work and deal with the high volume of demands that are coming toward us. We have to take the time to pause and realize that we're advocating for ourselves, yes, but also we're advocating for our patients because the better, the more attractive we can make this specialty, the better care delivery will be for the children we serve.
Lilley: It's not a self-serving interest to make sure that our quality of life as pediatric endocrinologists is desirable to others. We know that the better we make this look, the better it actually is, the more of us there will be. Meanwhile, I'm hopeful for a cure for type 1 diabetes. I'd love to be put out of a job. That would be a good problem to have. For now, the work is there, and we need to address it.
I've enjoyed our time together this morning. I'm hopeful that we can get other people to care as much as we do about pediatric endocrinology and the patients we take care of. I know you have a breadth of information and a wealth of knowledge. Any closing thoughts as we wrap up our time together today?
Alter: I'm one who believes that everyone has something to teach me and to share. If anyone listening has any good ideas about promoting the field, increasing the reimbursements, or just anything to share, don't keep it to yourself. Share it with the Pediatric Endocrine Society.
You can contact the board. If you're a member, just go onto the website and send a message to me, Craig Alter, and I'll share it with the proper person. It may not be me. I'm happy to take your ideas and let them generate some discussion. I appreciate everyone's good thoughts.
Lilley: Keeping this conversation going is so important. COVID-19 slowed down some momentum in trying to solve some of these problems. I believe we're in a new era and a new phase of thinking about what's next in medicine and how to make things better for the people who are coming after us.
Thank you for all that you do for pediatric endocrinology and for all the people you have taught and mentored. We look forward to adding more to those ranks.
Alter: Thank you for doing this interview.
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Cite this: 'Looming' Shortage of Pediatric Endos Offers Challenges - Medscape - Nov 29, 2023.
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