Peds Endocrinologist - AMA

[mvenus929]

I have some time to kill and don't frequent pre-med much anymore, so I figured I'd do an AMA.

Background on me:
- I graduated college in 3 years due to having lots of IB/AP credits, and applied to med school my third year and was rejected everywhere.
- I took 2 gap years, working as a phlebotomist, and reapplied with 2 acceptances (and I turned down interviews cause I already had an acceptance)
- I went into a pediatric residency, and stayed an extra year as a chief resident (in peds, you are chosen as chief instead of automatically a chief in your final year, and most programs have you stay for a fourth year rather than chief during third year).
- During my chief year, I worked clinically as an attending in a primary care clinic, as a neonatal hospitalist (taking care of babies in the well baby and level 2 nursery), and in the urgent care portion of our pediatric ED.
- My research and clinical interests are gender affirming therapy and differences of sexual development
- I'm working towards a Masters in Health Professions Education
- As of July 2021, I am an attending pediatric endocrinologist working in both a community hospital and tertiary care academic children's hospital.

So, ask me anything.

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[Lawpy]

What are some tips on doing well on peds rotation as an M3?

 

[mvenus929]

What are some tips on doing well on peds rotation as an M3?

I imagine much the same as any rotation: follow your patients and learn from them. As an MS3, you have the most time out of everyone on your team (perhaps excepting the fourth year, who doesn't have a shelf or didactics looming over their head), so you should really know your patients. Once you have a diagnosis, you can ask your resident if there's a good article they have covering it. Typically for the bread and butter stuff, there's something in pediatrics in review that covers it well. Kids can be difficult to examine, so ask your intern or resident to help you if you are having difficulty, but make an effort. Talk to your resident/intern before rounds to run through the plan, so you both can look good on rounds.

 

[907914]

I have some time to kill and don't frequent pre-med much anymore, so I figured I'd do an AMA.

Background on me:
- I graduated college in 3 years due to having lots of IB/AP credits, and applied to med school my third year and was rejected everywhere.
- I took 2 gap years, working as a phlebotomist, and reapplied with 2 acceptances (and I turned down interviews cause I already had an acceptance)
- I went into a pediatric residency, and stayed an extra year as a chief resident (in peds, you are chosen as chief instead of automatically a chief in your final year, and most programs have you stay for a fourth year rather than chief during third year).
- I'm now a first year fellow in endocrinology (3 year program).
- My research and clinical interests are gender affirming therapy and differences of sexual development
- I'm currently applying for a certificate program in medical education

So, ask me anything.

Are you actively involved in the ER for On-call whenever there is a type 1 diabetic child?

 

[mvenus929]

Are you actively involved in the ER for On-call whenever there is a type 1 diabetic child?

Yes, I take call approximately 2-3 nights per week, and 14 weeks per year. Whenever there is a new onset diabetic in our region, we get called for education and initiation of treatment. Whenever one of our type 1 patients get sick, the EDs call us. We are supposed to be involved in all admissions for diabetic reasons (i.e. DKA or not tolerating PO), but sometimes they slip past us and end up in the PICU or something.

 

[Lifeblood_20]

What motivated you to go into peds?
Thank you for doing this! I have found your posts here very helpful.

 

[mvenus929]

What motivated you to go into peds?
Thank you for doing this! I have found your posts here very helpful.

During third year, I loved inpatient medicine and hated outpatient medicine. I loved all of pediatrics, inpatient and outpatient. When I was on family medicine, I realized that the days when I saw more kids, I was more happy at the end of the day. So it was a lot of gut feeling. But the pathology is also far more interesting overall because the kids are constantly growing and changing.

 

[bearcalbear2019]

What are some other good fields you'd recommend for someone interested in LGBTQ/sexual and gender minority health that interested you?

 

[Deecee2DO]

M1 interested in Endo. I’ll be a DO, so how competitive is Endo? Why did you choose it? I have always loved endo physiology/path and I love variety and seeing objective clinical changes/results in patients as opposed to more subjective feedback dictating patient progress. I love labwork and definitely am a “thinker”/like figuring out puzzles. I heard endos are some of the happiest docs. Are you able to find all of this in endo?

 

[Raryn]

M1 interested in Endo. I’ll be a DO, so how competitive is Endo? Why did you choose it? I have always loved endo physiology/path and I love variety and seeing objective clinical changes/results in patients as opposed to more subjective feedback dictating patient progress. I love labwork and definitely am a “thinker”/like figuring out puzzles. I heard endos are some of the happiest docs. Are you able to find all of this in endo?

Neither pediatric nor adult endocrinology are particularly competitive because both specialties don't really increase your income over just working as a pediatrician (or an internist). It's 2 (for adults) to 3 (for kids) years extra training - so you actually lose money pursuing it due to opportunity cost. (Reproductive endocrinology, a subspecialty of Ob/Gyn, is very different here - they make tons of $$$)

The fields are interesting and there is a lot of it that is truly applied physiology and puzzle solving - but the day to day for any field can get repetitive.

Going back to the $$$ question, since that isn't a motivation, people do the specialties because they're interested in the field. Hence, most endocrinologists love their subject matter. But there are a lot of administrative hassles, and I don't think we're any happier than the average physician. Probably less grumpy overall, but that's a personality thing.

The happiest physicians in surveys like Medscape are inevitably those that make above average money and don't work very many hours - Dermatologists. Emergency Medicine doctors. Allergists. But I wouldn't want to do their jobs - I like mine.

 

[initialize]

I really like endocrinology as well.

However, I'm more interested in becoming a TRT/hormone replacement doc because I feel like these doctors are a rarity nowadays, plus I love the interplay between hormones and exercise/working out. How does one specialize in becoming a TRT-specialized doc?

 

[Raryn]

I really like endocrinology as well.

However, I'm more interested in becoming a TRT/hormone replacement doc because I feel like these doctors are a rarity nowadays, plus I love the interplay between hormones and exercise/working out. How does one specialize in becoming a TRT-specialized doc?

Are you speaking TRT in the context of hypogonadal men or in the context of transgender health?

 

[initialize]

Are you speaking TRT in the context of hypogonadal men or in the context of transgender health?

hypogonadal men

 

[Deecee2DO]

Neither pediatric nor adult endocrinology are particularly competitive because both specialties don't really increase your income over just working as a pediatrician (or an internist). It's 2 (for adults) to 3 (for kids) years extra training - so you actually lose money pursuing it due to opportunity cost. (Reproductive endocrinology, a subspecialty of Ob/Gyn, is very different here - they make tons of $$$)

The fields are interesting and there is a lot of it that is truly applied physiology and puzzle solving - but the day to day for any field can get repetitive.

Going back to the $$$ question, since that isn't a motivation, people do the specialties because they're interested in the field. Hence, most endocrinologists love their subject matter. But there are a lot of administrative hassles, and I don't think we're any happier than the average physician. Probably less grumpy overall, but that's a personality thing.

The happiest physicians in surveys like Medscape are inevitably those that make above average money and don't work very many hours - Dermatologists. Emergency Medicine doctors. Allergists. But I wouldn't want to do their jobs - I like mine.

Thank you very much for the insight!

 

[Raryn]

I really like endocrinology as well.

However, I'm more interested in becoming a TRT/hormone replacement doc because I feel like these doctors are a rarity nowadays, plus I love the interplay between hormones and exercise/working out. How does one specialize in becoming a TRT-specialized doc?

hypogonadal men

I'll help the OP out here then, as this isn't a pediatric issue.

So if you just want to address hypogonadism as part of general health, many people who are primary care doctors evaluate and treat it every day. There's probably more patients on testosterone prescribed by their PCP than there are from anyone else. Now, whether all of them are being prescribed it appropriately is another question - but if you're interested in the topic, it's easy enough to seek out resources to educate yourself about it.

If you want more specialized training, your options end up being either Endocrinology (Internal medicine -> Adult endocrinology) or Urology. Endocrinologists are the medical side of things, and we frequently evaluate and treat hypogonadal men - but it's not a common *focus* of practice. About half of our patients are being treated for diabetes, the majority of the rest are thyroid conditions, and the remainder is a smorgasbord of pituitary/adrenal/parathyroid/yes, testicular pathologies. I prescribe testosterone to a few patients a week, but it's not something I even do every single day.

Urologists are primarily the surgical side of things, but many do treat hypogonadism, and there exist a subset of urologists that specifically focus on Andrology, which is both hypogonadism as well as the treatment of male infertility (with medications, surgery, etc). There's just less of a focus on that because male infertility isn't nearly as difficult of a problem to treat as female infertility is - if you can get a few viable sperm, you can always do IVF with ICSI. Or if you're infertile, use donor sperm. There's much less money funding research into the XY side of things.

Through any of the above paths, you are able to see men with possible hypogonadism, work them up to confirm the diagnosis and the likely cause, and initiate them on therapy (whether testosterone or one of the adjunct therapies that can also be used).

But here's the thing - unless you completely sell out and just do a "wellness" clinic (which is very common these days, not a rarity at all), it's quite unlikely you'd be able to sustain a practice doing only that. Maybe in academia if you were an andrology-focused urologist, but even then probably not. And if you do a "wellness" clinic - well you can do that with any specialty - or no specialty at all, as long as you're licensed. But those places are basically drug dispensaries - they just see everybody, diagnose them all with a wink and a nod (when most of them are actually within the normal range), then put them on huge doses of multiple medications to try to make them feel like they're in their 20s again.

 

[RTC19]

Thanks so much for making this thread!

1.) I'm really interested in Peds. I am a female quasi non-trad who isn't getting any younger and will probably find myself needing to have a baby during residency. I have heard that people can use FMLA for their three months' maternity leave after they have worked there for a year. I was wondering: How do programs work around OB appointments for pregnant residents? Is it socially acceptable to bug someone else to cover for you? For lack of better phrasing, would that make me look bad?

2.) Any tips for succeeding in pre-clinical years of medical school?

3.) Any tips for dealing with medical professional anxiety in peds patients? (I wonder if some of it is stranger anxiety too.)

4.) Can you describe a typical day on peds wards?

ETA: I know this is a lot of questions. It's okay to answer as many or as few as you have time for.

 

[mvenus929]

What are some other good fields you'd recommend for someone interested in LGBTQ/sexual and gender minority health that interested you?

Primary care providers (of all types, Peds, IM, and FM) are still desperately needed. In Peds, I know you can develop a pretty good niche if you are open to treating patients. Adolescent medicine also tends to deal with the sexual health stuff because a lot of generalists don’t want to or don’t feel comfortable managing it. Psychiatry is needed given that a good portion of these individuals have mental health comorbidities. And, of course, OB and IVF is an important aspect of reproductive health in sexual minorities.

Realistically, LGBTQ health is important for everyone to know about, and culture competency surrounding these individuals is a key thing that is missing in a lot of medical curriculums.

Thanks so much for making this thread!

1.) I'm really interested in Peds. I am a female quasi non-trad who isn't getting any younger and will probably find myself needing to have a baby during residency. I have heard that people can use FMLA for their three months' maternity leave after they have worked there for a year. I was wondering: How do programs work around OB appointments for pregnant residents? Is it socially acceptable to bug someone else to cover for you? For lack of better phrasing, would that make me look bad?

It will depend on the program, but most Peds programs are baby friendly. Even if you’re on wards, Yu can generally get away for an OB appointment if needed. I think you can only have 6 weeks off for maternity leave before you have to extend training, but a lot of programs have rotations that you can come back to with a lighter load so you can ease back into residency. My old program had 3 or 4 babies born all around the same time, so it happens.

2.) Any tips for succeeding in pre-clinical years of medical school?

Figure out how you study and your goals. I was not particularly interested in getting the top grades because Peds isn’t super competitive (and it was either Peds or FM for me when I started), so I didn’t spend time learning all the little things that you might get one question on, and focused instead on learning concepts. I passed and did average on Step 1.

If you learn by listening, replay lectures. If you learn by writing or drawing, develop a system that allows you to do that. If you need to teach, get in a study group and teach concepts to other people.

3.) Any tips for dealing with medical professional anxiety in peds patients? (I wonder if some of it is stranger anxiety too.)

It’s a lot of stranger anxiety, especially in the “normal” kids. But some associate shots with the doctor, which makes them scared too. I do my best to appear non threatening. I start on the opposite side of the room and ignore them initially. Then, as I’m getting closer to doing my exam, I’ll pay a little more attention to them. This piques their interest most of the time. For the really nervous ones, I start the exam on parent’s lap, and do things not necessarily associated with an exam—tickling or asking them to jump up and down or run around the room or something. Heart and lung exam is next while they are still calm. HEENT exam is always last because most kids hate the ear exam.

Of course, now that I’m Endo, I don’t do ears, which means I can show the flashlight as a more benign thing by just checking their pupils or mouth.

It’s a skill that takes time to develop, and each person will do a little differently. And some kids will scream no matter what you do. Just don’t take it personally and try to emulate those who do it well.

4.) Can you describe a typical day on peds wards?.

It may vary a bit between institutions, but it’s not much different than medicine wards. We would preround in the morning before conference, and check in on the patients (doing at least a basic exam, not necessarily a full exam at 6:30 when they are still dead asleep). We would have an hour long conference in the morning, then do rounds from 9ish til noonish. We were pushed to get discharges done before noon, which means the afternoons were spent prepping for discharges the next day, then checking in to see how things were going in the afternoon. What that means depends a lot on the structure of the wards team and the time of year. Pulm has a lot of CF kids that hang out while getting antibiotics. For Endo, we have diabetics that come in overnight in DKA, usually correct in the morning, and as long as they are known diabetics and are able to tolerate PO intake without significant ketones forming, we’d discharge in the afternoon or evening. Or if they required a PICU stay or were new onset, we would watch them overnight and discharge them the next morning (for education in the case of the new onsets).

 

[mvenus929]

I really like endocrinology as well.

However, I'm more interested in becoming a TRT/hormone replacement doc because I feel like these doctors are a rarity nowadays, plus I love the interplay between hormones and exercise/working out. How does one specialize in becoming a TRT-specialized doc?

hypogonadal men

I appreciate @Raryn ‘s input on that question. I send kids to the adult world before this really becomes an issue. I prescribe testosterone with some regularity, but it is usually in the context of an adolescent with delayed puberty or multiple pituitary hormone deficiencies. Or the FTM trans adolescents.

I have heard of some horror stories of teenage boys out in high doses of testosterone, so if this is a path that you pursue and you don’t go through formal endocrine training, make sure you figure out when you should be stopping or decreasing testosterone doses. Just because a man has symptoms of hypogonadism doesn't necessarily mean they need testosterone.

 

[mvenus929]

M1 interested in Endo. I’ll be a DO, so how competitive is Endo? Why did you choose it? I have always loved endo physiology/path and I love variety and seeing objective clinical changes/results in patients as opposed to more subjective feedback dictating patient progress. I love labwork and definitely am a “thinker”/like figuring out puzzles. I heard endos are some of the happiest docs. Are you able to find all of this in endo?

Peds Endo is not competitive. We had less than 50% of our positions open after the last match, nationwide. Adult Endo I hear is similar. Peds Endo actually generally makes less than general Peds because we all tend to work in academic centers (there are some private practices, but they aren’t super common because of all the support needed).

I chose Endo because I love physiology. Endocrine is relatively simple—if a hormone is missing, we replace it. If there’s too much of a hormone, we block it. Some pathologies aren’t quite that straightforward, but most are. Of course, there is a lot of nuance, which is why fellowship is more than a year long. It’s also a whole body organ system—the symptoms may affect multiple organ systems. It is very much a thinking specialty, which I enjoy.

Pediatricians are generally pretty happy (we certainly don’t do this for the money...), so hard to know if Peds Endos are happier. We have our fair share of difficult patient populations— the teenage diabetics are the worst. I went into endocrine despite diabetes, not because of it, but there are people who love diabetes management.

 

[Raryn]

Peds Endo is not competitive. We had less than 50% of our positions open after the last match, nationwide. Adult Endo I hear is similar.

Not quite that bad - we usually have more applicants than there are spots, but not much more. The fellowships fill, but on the scale of competitiveness, it's fairly low down. Particularly if you primarily look at people who went to med school in the US, MD or DO, the match rate is >90%. (That puts us in the middle tier of adult fellowships - more competitive than say, Nephrology or Geriatrics, but less than the competitive ones)

 

[bearcalbear2019]

I'll help the OP out here then, as this isn't a pediatric issue.

So if you just want to address hypogonadism as part of general health, many people who are primary care doctors evaluate and treat it every day. There's probably more patients on testosterone prescribed by their PCP than there are from anyone else. Now, whether all of them are being prescribed it appropriately is another question - but if you're interested in the topic, it's easy enough to seek out resources to educate yourself about it.

If you want more specialized training, your options end up being either Endocrinology (Internal medicine -> Adult endocrinology) or Urology. Endocrinologists are the medical side of things, and we frequently evaluate and treat hypogonadal men - but it's not a common *focus* of practice. About half of our patients are being treated for diabetes, the majority of the rest are thyroid conditions, and the remainder is a smorgasbord of pituitary/adrenal/parathyroid/yes, testicular pathologies. I prescribe testosterone to a few patients a week, but it's not something I even do every single day.

Urologists are primarily the surgical side of things, but many do treat hypogonadism, and there exist a subset of urologists that specifically focus on Andrology, which is both hypogonadism as well as the treatment of male infertility (with medications, surgery, etc). There's just less of a focus on that because male infertility isn't nearly as difficult of a problem to treat as female infertility is - if you can get a few viable sperm, you can always do IVF with ICSI. Or if you're infertile, use donor sperm. There's much less money funding research into the XY side of things.

Through any of the above paths, you are able to see men with possible hypogonadism, work them up to confirm the diagnosis and the likely cause, and initiate them on therapy (whether testosterone or one of the adjunct therapies that can also be used).

But here's the thing - unless you completely sell out and just do a "wellness" clinic (which is very common these days, not a rarity at all), it's quite unlikely you'd be able to sustain a practice doing only that. Maybe in academia if you were an andrology-focused urologist, but even then probably not. And if you do a "wellness" clinic - well you can do that with any specialty - or no specialty at all, as long as you're licensed. But those places are basically drug dispensaries - they just see everybody, diagnose them all with a wink and a nod (when most of them are actually within the normal range), then put them on huge doses of multiple medications to try to make them feel like they're in their 20s again.

Are urologists very hands on with managing male sexual health asides from the operating room? Is there a lot of opportunity to work with LGBTQ/gender and sex minorities like transgender patients? Endo and urology sound very interesting...

 

[Raryn]

Are urologists very hands on with managing male sexual health asides from the operating room?

Depends on the urologist, but it's one of those specialties that is a decent mix of clinic and the operating room. Everyone builds their own practice pattern

Is there a lot of opportunity to work with LGBTQ/gender and sex minorities like transgender patients? Endo and urology sound very interesting...

Same as any other doctor. They work with a fair number of LGB folks for urogenital issues.

As for transgender health, I don't think many urologists do trans hormone replacement therapy - it's just not their gig. That's usually either a primary care doctor or an endocrinologist who takes an interest. Otherwise, a few are involved in gender affirmation surgery - but there's just not that many people who do genital surgery like that in general.

 

[RTC19]

This is maybe more of a General Peds geared question but when I was thinking about different careers before taking classes, I swore I remember Perrotfish mentioning that a con to Pediatrics is that you will catch more coughs/cold/icky viral and bacterial things from patients than you would in other fields. Young children are just too little to really know how to cover their coughs/why you really shouldn't cough in other people's faces.

I am home pretty sick with a stomach bug and wanted to ask you around how many viruses (colds/flus/gasteroenteritis/hopefully nothing more severe like PNA) most peds residents got per year. How about people practicing Primary Care Peds? How about you as a peds subspecialist? Is this something that would be much better in adult primary care?

I am aware there are precautions you can take like universal gloving and being militant about your hand hygiene, but I'm sure accidents happen when you are working with toddlers with upper respiratory infections!

 

[mvenus929]

This is maybe more of a General Peds geared question but when I was thinking about different careers before taking classes, I swore I remember Perrotfish mentioning that a con to Pediatrics is that you will catch more coughs/cold/icky viral and bacterial things from patients than you would in other fields. Young children are just too little to really know how to cover their coughs/why you really shouldn't cough in other people's faces.

I am home pretty sick with a stomach bug and wanted to ask you around how many viruses (colds/flus/gasteroenteritis/hopefully nothing more severe like PNA) most peds residents got per year. How about people practicing Primary Care Peds? How about you as a peds subspecialist? Is this something that would be much better in adult primary care?

I am aware there are precautions you can take like universal gloving and being militant about your hand hygiene, but I'm sure accidents happen when you are working with toddlers with upper respiratory infections!

Your first year in a new location is always the worst. So I got sick a decent amount during my third year (I did Peds and FM in the fall/winter months), was okay my fourth year, got sick a good 2-3 times during intern year (and had chronic congestion for a few months), then maybe one significant illness (with vomiting or fever) per year after that.

Most Peds residents probably get 3-5 colds during intern year, then 1-2 after that. GI illnesses are the worst and spread like wildfire through programs.

My friend is a general pediatrician and says that her first year out, she had one illness that made her stay home from work, but had mild uri symptoms throughout the winter.

 

[RTC19]

With Peds being a less competitive field as a whole, how do people with D.O. degrees do?

Are people with D.O. degrees generally able to get into a competitive enough peds residency as such to be able to get a fellowship?

Do D.O.s struggle to match into competitive peds fellowships like NICU and PICU because of a struggle to get into residencies at freestanding children's hospitals? Or other reasons? Every neonatologist I have met except for one has been an M.D. and that scares me a little as someone who has borderline M.D. stats and will need to dual-apply MD and DO.

For that matter, are people from community peds programs able to match competitive peds fellowships in general?

 

[mvenus929]

With Peds being a less competitive field as a whole, how do people with D.O. degrees do?

Are people with D.O. degrees generally able to get into a competitive enough peds residency as such to be able to get a fellowship?

Do D.O.s struggle to match into competitive peds fellowships like NICU and PICU because of a struggle to get into residencies at freestanding children's hospitals? Or other reasons? Every neonatologist I have met except for one has been an M.D. and that scares me a little as someone who has borderline M.D. stats and will need to dual-apply MD and DO.

For that matter, are people from community peds programs able to match competitive peds fellowships in general?

I didn’t go to a “top” residency, but I was at a stand alone children’s hospital, and I had one classmate who was a DO. In my fellowship, two of my co-fellows are DOs. The fellow in the same year as me is from a community DO program. And we are at a pretty big children’s hospital. But, I’m also in Endocrine, which only filled half their slots and make less than general pediatricians. Also, my children’s hospital seems to take a high number of DOs in general.

That said, DO students do have a harder time getting into competitive residencies and fellowships. Will that change with the merger? Who knows. But making your application as competitive as possible is up to you. Get involved, do research, go to conferences and network.