Medical Specialties - Diabetes & Endocrinology (12 Mar 2025)

SPEAKER_01 0:14

Hello everyone and welcome to another episode of Career Conversations brought to you by the Royal College of Physicians of Edinburgh Training and Members Committee. My name's Dr. Marilene Giannudi and I am on the TNMC. And today I'm delighted to be joined by Dr. Rebecca Sagar, an academic clinical lecturer in diabetes and endocrinology at the University of Leeds and Leeds Teaching Hospitals. So, Becky, good morning. Welcome. Thank you for joining me today. Thank you very much for having me. So today we'll obviously be talking about your specialty, diabetes and endocrine. And could I start by asking you why did you choose your specialty?

SPEAKER_00 0:54

Yeah, so it wasn't something I had wanted to do, sort of join medical school or anything. I did enjoy modules in endocrinology in the early years, sort of biochemical years of medical school. But actually, it wasn't until I was towards the end of my F1 year that I started to think about it. Actually, at that time I'd been really strongly considering surgery, but actually did a general medicine job, which I know typically isn't the most popular, but that was largely staffed by endocrine consultants who got me involved in coming to some clinics, which I personally think is the best way to learn endocrinology and diabetes, but more endocrinology, and started to do some projects, which I continued into F2. At the time, I was an academic foundation doctor in gastroenterology, which is the other career I was actually considering. But having done more and more clinics and got involved in more things, I thought this is a special I wanted to pursue. Yeah. So that's personally why I chose it. I think the big pull for me is that endocrinology is one of the few medical specialties that's sort of multi-granular. So most medical specialties just deal with one organ. So, you know, respiratory do lungs, cardiology do the heart. I know it's a little bit more complicated than that. But endocrinology, there's lots of different aspects to it, lots of different subspecialties to go into. So that was one of the big pulls for me.

SPEAKER_01 2:09

Okay, and I guess because of that, it might be difficult for you to describe a typical day within your specialty, but could you maybe talk us through a typical week?

SPEAKER_00 2:18

Yeah, so as you said, we do both diabetes and endocrinology. The specialty is quite different whether you work in a district general hospital where you tend to do a bit of both as a consultant or a registrar. Whereas for us in Leeds, the tertiary center, it tends to be one or the other for the consultants. So if I do the Leeds one because you get a bit more variation there, most days in Leeds are clinic based. So typically that would look like a subspecialty endocrinology clinic. So that includes things like adrenal clinic, pituitary clinic, late effects of cancer clinics, you know, the list goes on, but something like that. And then we either tend to have like an admin session to cover all the patient admin that comes with clinics, or it could be on referrals. So one day a week, one of the registrars will be on referrals, which takes inpatient referrals from across all of Leeds teaching hospitals. Often, again, because it's a tertiary centre, we also get contact from some of the district general hospitals for more complicated patients. That is quite variable, but because endocrinology comes up in most specialties, you know, a third of patients come into hospital, for example, can have up to a third can have hypoleutrenia, and that's a very common referral, but we get all sorts. Other things include troubleshooting with the diabetes specialist nurses. So most of the referrals for diabetes go directly to them, but they obviously have registrar and consultant input for the more complicated cases or anything where it's sort of like unclear or severe presentation. Other things we do a lot of MDTs, so we're really looking under chronology to work with lots of other specialties. So for example, in adrenal, once a fortnight we have a complex adrenal MDT, which is with the radiologists, endocrine surgeons, and histopathologists. But there's other MDTs for pituitary, bone, thyroid, and then they also have renal diabetes, MDTs, diabetes foot MDTs. And I think they still have a complex diabetes MDT as well. So a bit of everything.

SPEAKER_01 4:05

Okay. So I get the impression that it's more outpatient-based. So more clinics and you know, MDTs that you discussed. What does the inpatient work look like?

SPEAKER_00 4:16

So again, because it's both diabetes endocrinology, the main place you'll see the specialty as an inpatient would be in the form of the diabetes patients. Again, type 2 diabetes and type 1 diabetes are quite prevalent in the UK. So lots and lots of patients have it. Again, our diabetes nurse specialist colleagues are fantastic at managing the vast majority of those cases. You know, things like changing insulin while people are unwell and more stress-induced hyperglycemia, things like that. But there are more complicated cases to get involved with. Like I said, a lot of inpatient referrals come through about things like hyponeutremia. So we see a lot of that, but other things as well. So we get some sort of adrenal insufficiency queries. And then certain specialties tend to refer to us more so for better inpatients. So things like oncology with a lot of the new immunotherapies, the side effects are endocrinopathies, and we often get referred to about them and other electrolyte disturbances. So things like hypercalcemia often come through. So there is a lot of inpatient work, but I think it's hard for sort of more junior colleagues to see the in-depth side of particular endocrinology if they only see the impatient, because I don't think they see the true breadth or the, you know, really interesting stuff that drew me to the specialty.

SPEAKER_01 5:25

And I appreciate that this might be different in different parts of the country and in different trusts. But are there specific diabetes and endocrine wards, or is it just, you know, that these patients will end up on the general medical ward and then the diabetes and endocrinologist will support them, or do you have specific wards that your specialty look after?

SPEAKER_00 5:45

So in Leeds, yes, there is a diabetes and endocrine ward. It is, again, is a point of contention within the specialty because a lot of the sort of general medical wards end up staffed by endocrine consultants, which is changing, particularly with internal medicine training changing and more group one specialties contributing to general medicine. That is improving for us. We're really lucky in Leeds, and there are a couple of other degrees around the country that have that, that the registrars are largely protected from general medicine with the year they do in Leeds, which is an absolute must to get proper training, particularly within a four-year programme. And I think that is something that's trying to be mirrored in other places. But yeah, in theory, there should be diabetes endocrine wards with a focus on those sorts of cases we've talked about. But I think that's a work in progress. There's a big push with a lot of the diabetes leaders in the country to make sure that diabetes patients are coming to a diabetes ward so that they are safe because we still keep seeing patients who are, you know, end up getting too much insulin and going for hypoglycemic or going into DK in hospital, which should never happen, but still does. And those cases are far less likely to happen if they're being seen on a diabetes and endocrine ward. But unfortunately, I think with the NHS pressures, bed pressures, things like that, again, it is a work in progress. But that's part of it is safety as much as you know the expertise of those consultants managing the cases.

SPEAKER_01 7:04

Thank you. What I will say here to our listeners, we do actually have a managing the diabetic patient on the ward podcast over on our other channel, Clinical Conversations. So if you haven't heard that and it's of interest to you, then please go and listen to the episode. But back to this episode and actually the career of diabetes and endocrinology. Becky, what advice would you give to medical students or doctors in training that are interested in getting involved in the specialty?

SPEAKER_00 7:32

So the reason I fell into it was because I got involved in projects early on. I sound like a stuck record, but I think the absolute must is to come to clinics. We're really lucky in this country to have a trainee network called Young Diabetologists and Endocrinologist Forum, which I'm part of. Anybody can just Google YDEF. Well, make sure it's in the footnotes of our episode. Great. So that's got lots of resources for sort of medical students, junior doctors to find out what they can get involved in. Every year we partner with the Society for Endocrinology to run taster webinars, and they happen every year. They're really great ways to hear a bit more about the specialty from people working within the specialty with a focus on those who are thinking of applying. Are they recorded? They are recorded. So you can always listen to them on playback. Yeah, absolutely. But my best advice is just to go to local either registrars or consultants who are approachable and enthusiastic. I would say generally, diabetes and endocrine consultants are really nice consultants. We're definitely not one of the specialties that have like a bit of a reputation to be fierce or anything. I think they're really, really approachable on the whole. So I would just definitely say, oh, you know, I'm thinking of getting involved in this or thinking of the specialty. Do you have any projects I could get involved in? The projects are what drew me in because I think you get such a better understanding of what the specialty is. And from there, you can go to clinics. I think if you're a medical student on a placement, taking that opportunity to actually go to the clinics, you don't necessarily think of it at the time, but actually that's the place to learn it. And then moving into the foundation and IMT, getting to the clinic, also trying to see patients yourself gives you a better appreciation of the sort of breadth of things you can see. And equally shadowing the registrars, seeing inpatient referrals is still interesting, but you will come across those cases. Whereas, you know, a new presentation of acromegaly or a rare adrenal cancer, you will not see on the wards. So you need to go to clinics to see those. Yeah, I think that that'll be my best advice. But yeah, just ask and there's lots of enthusiastic people around. Thank you.

SPEAKER_01 9:26

And I always ask the question on this podcast of can you discuss an interesting case? And I appreciate that that's quite difficult given the breadth of your specialty. But is there a case that has kind of stayed with you that can really highlight your specialty?

SPEAKER_00 9:41

Yeah, there's lots of cases that come to mind because, like you say, there's quite a large breadth. So I have a subspecialty interest in adrenal, so that tends to be the things that draw me most or the cases I've been most involved in. There's one really interesting case that actually came from the congenital heart disease team over at LGI. Oh, sorry, at least Jennifer, and they referred her. So, I mean, the complex cardiology, I'm more likely to leave to you, but essentially she had cynotic heart disease since she was born, had had surgeries as a baby in a toddler. But as a result of that, she was obviously under quite close follow-up. And I think she initially presented with some sort of abdominal pressure type symptoms and at some point ended up with a scan which picked up that she had a paraortic mass. So one of the things we think of with paraortic masses is a paragangioma, and someone within the cardiology team sensibly checked some metanephrines, which is sort of the cataclamises, that we can measure, which came back quite elevated. So putting two and two together, they referred to our adrenaline DT, saying, you know, what is this and what do we need to do about it? The complexity and sort of the interesting side of that, you know, these things are rare anyway, so they're interesting. But she also had dextracardia and a lot of her organs were on the wrong side of the body. So as soon as we knew that the she was going to need surgery or at least consideration of surgery, that obviously immediately becomes quite a complex thing. But with her, because of her complex cardiology history, she was hypotensive or tended to run with lowish blood pressures. Whereas we often see with paragangliomas or feochromacytomas, they tend to be hypertensive and we can start on alpha blockade pre-surgery. But for her, the complexity there was if she's already not running with a great blood pressure, how do we alpha block her? Which is done to, you know, allow surgery to happen. Because as soon as you start manipulating a paraganbium or a feochromacytoma, it becomes a potential catechalomia crisis. She has high mortality. So that was one side of it. The other side of it, and actually a lot of this stems from some one of the recent Nobel Prize winners' work, which was around whether the paraganglioma may have sort of arisen as a protective mechanism systemically. So because she runs with a low blood pressure and is cyanotic, whether that paraganglioma is potentially the thing that's keeping her blood pressure up. So if we then took it out, is that going to cause a blood pressure tank? And potentially she could have died. So all of these considerations had to be taken into account. And there was a lot of chewing and frowing. Thankfully, we managed to start on a tiny bit of alpha blockade while while she was admitted under the cardiologists pre-operatively for a week so that we could titrate it up and she was safe because she was in the hospital and we could monitor her really closely. She went for surgery. There were lots of surgeons in there because of, like I said, a lot of her vessels were on the wrong side. They managed to get it out, and her plasma metanephrines went from being pretty raised. I cannot remember off the top of my head the actual value, but to almost normal. We probably wouldn't expect them to be completely normal in her because of medication interference, but essentially completely normal. She's still under very close follow-up. But it's one case that just highlights not only do we deal with rare things, but we deal with quite complex diseases, but we also are very multidisciplinary. So not only are we dealing within our own team, sort of radiologists, histopathologists, the surgeons, us, but we also work with other specialties very closely. So obviously the work with the anesthetist and the cardiologist there was very important. So maybe not the most interesting presentation, but an interesting case for complexity.

SPEAKER_01 13:08

No, definitely. That would have been scary for me on the other side, I must say. And I guess my final question, though you've obviously highlighted what the specialty really includes, is what skills do you think are needed to be a good endocrinologist, diabetologist? Based on what you're saying, I think communication has to be high up there. What else do you think is needed?

SPEAKER_00 13:32

So I think because for the vast majority of people they'll do both diabetes and endocrine, I think you have to have, I'll sort of do it in two hearts. Communication skills are absolutely paramount. We deal with people who've been given a lifelong diagnosis of diabetes. Some of those patients are diagnosed as children or young adults, and we deal with those patients. So communication skills and actually probably more than the talking is the listening in that cohort of patients that I've seen done really, really well and I've seen done really, really badly. So having that aspect is super important. I think teamwork, again, stuck record, but I think the fact that I cannot think of a subspecialty within endocrinology that doesn't rely upon the MDT or work closer with the MDT. I can think of other specialties where they can do it with a bit less. So teamwork is absolutely essential and respecting sort of other medical professionals like the nurse specialists that I've mentioned a few times is super important. I think obviously we don't do procedures on the whole, although some places certainly around the world do things like thyroid ultrasound. You can do that sort of thing. In the UK, it's just not part of sort of a mandatory training process. So if you don't like procedures, you like to stay really nice and clean. I think that's one thing, but it is probably something to highlight that if you like procedures like being hands-on, you're probably going to do less of that. I think being able to have time management organization is really important because most people do at least, even if they're doing just endocrinology, they'll be doing multiple subspecialties or at least one or two subspecialties. And endocrinology is a very, and diabetes are both very fast moving specialties in terms of research. And that's probably something I haven't touched on despite being an academic trainee, is they are very fast moving specialties. So even if you Google diabetes, everything at the moment is around closed loops. That's something that some consultants haven't ever been trained in because it's come on within the last five years, probably more so in the last two years. So I think being able to be flexible, but also organized to stay on top of all the latest research, the latest evidence, the latest training is absolutely paramount.

SPEAKER_01 15:27

And just for myself and for our listeners that might not know what's closed loop.

SPEAKER_00 15:32

Oh, sorry. So closed loop is essentially it's what they refer to as like artificial pancreas. So it's essentially using the new sensors, which is, you know, little devices that they can wear on the arms. You may have seen people with like a little white disc on the back of their arms that measures your glucose continuously. Closed loop is then using an insulin pump, which is again a little device, usually on the tummy, backs of legs, buttocks, some on the backs and arms. The sensor talks with the insulin pump and essentially forms a closed loop using an algorithm. So the pump or the algorithm senses what the glucose is or what the glucose is about to do, whether it's going up or down, and it will deliver or withhold insulin based on that. And that's sort of a very brief description of it. But it's revolutionizing type 1 diabetes. And in this country, we're streaks ahead of the rest of the world as a result of some really hard work the diabetes leadership in this country have done to get access to technology for patients around the country. There is still differential access, and that's a work in progress for those that are sort of within NHS England. But it's something that is absolutely revolutionizing how we manage diabetes. The outcomes are from fantastic. All the latest evidence is still sort of being published, but we know it will change the face of diabetes in this country. But as a result, trainees have to know how to manage those. Consultants need to know how to manage those. And with things moving that quickly, it can be really hard to stay on top of it because every single system is different. But again, it's something that people can get involved in, both on a research front but also on the clinical front. And I think it is something that is very exciting for the specialty.

SPEAKER_01 16:59

Definitely sounds like it. And yeah, as you say, you see those devices everywhere now. And it might be good for even people that don't want to do diabetes and endocrinology to have an overall awareness of them because they're definitely patients that we see on a daily basis coming into the uh, you know, medical admission unit. Absolutely. Lovely. So thank you so much for joining me today. Thank you for your pearls of wisdom. Any final remarks from yourself for our listeners? So definitely go check out the YDF website. Anything else from you?

SPEAKER_00 17:34

I would just say it's a great specialty. The way to get involved is to ask people. It's also a specialty that's big on research and teaching. So if you're interested in those things but haven't thought about endocrinology, I definitely would. And chronogiam diabetes, like I said, there is a very fast-moving specialty with lots of research going on that changes clinical practice day to day. So if those are the kind of things you're interested in but haven't thought about it, please do think about it. You can contact us through YDF directly. I think Marlena said she'll put contact details or the information details with this podcast. And hopefully we'll see or hear from you all very, very soon.

SPEAKER_01 18:11

So I don't think I have anything more to add to that. Thank you all for listening. Stay tuned for more career episodes here on Career Conversations. And as I mentioned, we've got loads of interesting clinical cases on our clinical conversations podcast channel. Thank you and see you all soon. Our membership provides you with access to the RCPE educational portal, the live evening medical updates, and you have options to view the symposia both in person or online. If you would like to learn more about this, please go to the Royal College of Physicians of Edinburgh website.