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Coming of Age in Endocrinology^b

Pennsylvania State University College of Medicine Hershey, Pennsylvania 17033-0850

Numerous endocrinology meeting sessions have recently been devoted to the medical transition of the growth hormone deficient child to the growth hormone deficient adult (1, 2). For a longer period of time, related discussions have been held regarding the management of adolescent patients with type I diabetes mellitus. A primary focus of these presentations, namely the interplay of the pediatric and adult endocrinologist, is rarely discussed in any detail. We wish to direct attention to wider implications than simply the transition of a patient with endocrine disease from pediatrician to internist.

At issue, we believe, is preservation of the tertiary care advances that have heretofore anchored our U.S. health system while efforts to promote primary care move ahead. Strategies directed to helping pediatrician and internist sub-specialists collaborate more effectively could support many tertiary care advances with considerable economic advantage. Three collaborative avenues exist that favor such potential gains.

The first is the rapidly proliferating internal medicine-pediatric training program. In a recent review of such residencies (3) over twenty percent of graduates had entered sub-specialty training, presumably in either adult or child-directed programs. With the exceptions of allergy/immunology and genetics, no sub-specialty offers board eligibility in both pediatrics and internal medicine. Would it not be reasonable to provide joint (endocrine) training to individuals appropriately prepared in both specialties? A significant number of adult rheumatologists care for children, a setting that may not serve younger patients optimally (4). Is the same thing happening in endocrinology? Parenthetically, while the endocrine sub-specialty boards in medicine mandate exposure to pediatric endocrinology, no comparable guidelines have been promulgated for the pediatricians so trained.

Secondly, disease or system specific "centers of excellence" are now proliferating. For example, sub-specialists from related fields are being asked to join hands in cancer, cardiovascular, and womens’ health centers. There are obvious gains to patients as provider expertise is shared. However, endocrine participation in such groups appears to be exceptional, and there is little indication of the growth of endocrine centers in this movement.

Finally, there are a very few medical schools that have an historical precedent of utilizing interdepartmental sub-specialty units. At Hershey, the faculty was initially organized along such lines, and such a mode continues successfully in endocrinology up to the present time (5). The unit has benefited greatly from the close interplay between pediatric and adult endocrinologists (supplemented with participation from surgery, radiology, and gynecology). Yet, there are few examples of this model—a puzzle to us.

In providing the diagnostic and management principles for most endocrine disease the underlying physiologic and medical basics apply to all ages. Special circumstances and experiences, of course, are relevant; witness the management of ambiguous genitalia in the newborn; and, naturally, short stature in the child. Nonetheless, it is of note that approximately one third of medical schools do not have a pediatric rheumatologist (6); comparable figures for endocrinology are not available, but an increasing number of solo pediatric endocrinologists at academic centers is becoming apparent. Effective sub-specialty expertise, however, requires the opportunity for extensive, on-going peer interactions.

We propose that traditional specialty barriers be weakened to allow for more effective interactions between all interested sub-specialists. We are not trying to detract from the scope of pediatric endocrinology but, rather, to add to it. The need for the pediatrician to work in closer collaboration with an adult colleague seems ever pressing to us in these new times in U.S. health care. Traditional divisional structures should logically cross traditional departmental lines, and the opportunities in endocrinology seem particularly rich. Such organization does not simply mean a common weekly conference but, rather, common clinics where both pediatric and adult endocrinologists can work side by side and share their experiences on demand. Similarly, there is no reason in-house attending schedules cannot be combined. Teaching programs will naturally improve and research accomplishments have a long precedent of being inter-departmental.

It is not only the wealth of experience that the pediatric endocrinologists can supply to internists wishing to furnish growth hormone to adults. Rather, the experience of internists in managing Cushing’s Syndrome, bone disorders, or even Grave’s disease, can be of tremendous assistance to the pediatric endocrinologist. The time has long passed for a better sharing of intellectual and economic resources; pediatric and internal medicine sub-specialists can work together every day. Coming of age in endocrinology is understanding hormone-related disease first and then applying that knowledge throughout the life span by professionals closely sharing their common expertise.

Footnotes

Address correspondence to: Howard E. Kulin, Departments of Pediatrics (H085) and Medicine (H044), Pennsylvania State College of Medicine, The Milton S. Hershey Medical Center, 500 University Drive, P.O. Box 850, Hershey, Pennsylvania 17033-0850.

Received June 10, 1998.

References

1. Medical Controversy: Transition of the adolescent growth hormone deficient patient to adult endocrinology—how and when? Horm Res. 1997 48(Suppl 2):9.
2. Clinical Symposia: Transition of the hypopituitary child to adult management. The 80th Meeting of the Endocrine Society, June 24, 1998, New Orleans, Louisiana.
3. Schubiner H, Lannon C, Manfred L. 1997 Current positions of graduates of internal medicine-pediatrics training programs. Arch Pediatr Adolesc Med. 151:576–579.[Abstract/Free Full Text]
4. Sherry DD, Wallace CA, Kahn SJ. 1996 Pediatric rheumatology in adult rheumatology practices in Washington state. Arthritis Rheum. 39:1218–1221.[Medline]
5. Kulin HE, Skakkebæk NE. 1998 Non-traditional sub-specialty organization: An U.S. and European experience. Medical Educ. 32:60–64.[CrossRef]
6. Cassidy JT. 1997 Pediatric rheumatology: status of the subspecialty in United States medical schools. Arthritis Rheum. 40:1182.[Medline]

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