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Transcript:
Endocrine Episode:
Dr. Hare: [00:00:00] Hello and welcome to the Be Excited Podcast. I’m Assistant Professor Jason Hare today on our endocrine and diabetes episode, Paige Thompson, who is a graduate of the program. She works in a large multidisciplinary endocrinology and diabetes program since graduation from the mothership in what, 2020, right?
Paige Thompson: Yep, 2020 is when I graduated. 2021 in March is when I started this job.
Dr. Hare: Started working in, in endocrinology. Awesome. And of course, as a graduate of our program, we love to bring folks back and talk to them. I have a lot of gratitude for the folks who are willing to come back and talk to us and, and bring their experiences in the wild back to our program to talk about Well, how things went for them after they graduated.
So tell us a little bit about that transition from Pitt to working in endocrinology.
Paige Thompson: Yeah, I graduated in December of 2020, which happened to be in the middle of a pandemic. So [00:01:00] my class was faced with a lot of challenges you know, with job availability. And I wasn’t necessarily dedicated to endocrine whenever I first graduated, but it is both like a unique specialty and somewhat like primary care.
So when I saw my specific job posting that I ended up applying to, it looked really enticing. I think that endocrine is like the best of both worlds because it allows me to specialize in an area of medicine that I can become an expert in, but also staying up to date on common primary care diagnoses like hypertension, hyperlipidemia to ensure comprehensive diabetes care.
And so in addition with my job, I, it was also unique because since I finished PA school in a pandemic, I missed some of my rotation time. We ended up making them all up and graduating on time, luckily, but I was looking for a little bit of extra training. So my [00:02:00] job specifically came with a six month built-in fellowship to learn endocrinology, which I thought was smart because it is a specialty.
yeah.
Dr. Hare: And so, as far as doing a fellowship or a residency, do you felt that that was in your scenario worthwhile? Do you still feel that way?
Paige Thompson: I do. I think it
was really nice, especially coming out of school, I was already used to that structure of mm-hmm.
Kind of following somebody around like a preceptor and then eventually taking on more responsibility yourself. There’s also a lot of complexity in endocrine and a lot of guidelines that you have to know. So there was built in study time where I got to learn those guidelines and I thought that this was a really great way to start this specific job.
Dr. Hare: One of the things that I’ve heard from some students is that the pay is not as good for say, a residency. And then, the other question becomes, is there a job guaranteed at the far end of that at that training period of time? One question that I always have for [00:03:00] students considering a residency is, well, if you are doing a residency for a year, could you actually just be doing on the job training and being paid the full amount for that job during that time?
The educational side of that is something that you, you would miss some of that, right? You would miss the, the big grand rounds and, and some of the more educational experiences usually built into a residency or a fellowship, but at the same time that pay thing, you know, a lot of folks are hungry to, to start making money and pay off those bills.
The mothership is an expensive place at times. And so we, we, you know, we know that starting those jobs and getting paid is, is an important part of that too.
Paige Thompson: Yeah. Those are definitely very valid concerns. I was advised if I was dead set on an area of medicine that I wanted to go into after graduation to consider those residency programs.
Mm-hmm. Kind of in the programs that I’m speaking to would be, you know, just applying to the residency program, not attached to a job. Mm-hmm. However, it’s [00:04:00] becoming more and more common to actually offer a fellowship or some sort of formalized training within a job position. So that is what I took. So my job.
I applied to this job. I had a dedicated place where I would practice after I’m done. I had dedicated supervising physicians and I was paid just my normal starting salary from the beginning, so Ah-huh.
Dr. Hare: That’s a win-win in that situation. . Excellent. Okay. I do like that idea of both specialty and primary care mixed into one position.
You know, the medicine rarely leaves behind the rest of medicine no matter what you’re doing, but that idea that endocrinology really does have a, a huge use in primary care and vice versa. That is a huge consideration for a lot of students coming out. You know, do I know enough but also.
Am I losing some of my knowledge in primary care and, and the generalist areas if I go straight to the specialty? So it sounds like you feel as if there’s enough overlap.
Paige Thompson: I [00:05:00] do feel that there is enough overlap, and if anything, it’s more concentrated in the areas of primary care I was interested in.
Mm-hmm. Like chronic disease management. I definitely have lost some of the knowledge of other areas that I don’t typically see, but it’s easy enough to review that information and get up to date on it again. So I do that every once in a while. I use some of my required CME credits to study the things that I don’t have in my job too.
Dr. Hare: , you might argue that a lot of PA school is learning where to find the information and how, how the whole system works and Exactly. And that’s not something that you’re gonna, you’re gonna forget.
So what is your clinical and hospital time like? How do you divide that up?
Paige Thompson: Sure. Yeah, that is a good question. Essentially what I do is week to week I will either be all outpatient, seeing patients in the clinic, in person, and via video visits.
And then I have some admin time to help close charts and answer patient phone calls, stuff like that. And then on the opposite weeks, I will [00:06:00] be fully rounding in the hospital there Monday through Friday, eight to five, taking call and working with an attending there. And so it, it switches pretty 50 50, so, For example, the next six weeks, I think I alternate almost exactly inpatient and outpatient.
Dr. Hare: Okay. And then you trade off with another pa, those duties between those two services?
Paige Thompson: My partner is a, an np, but yes. Okay. She, she will take the weeks that I’m not rounding.
Dr. Hare: Excellent. It’s always interesting to me how much communication is involved in being a PA or an NP for that matter.
And that kind of trade off between inpatient and outpatient settings requires even going home at the end of the day, in my setting in family medicine an inpatient setting, I’m handing off to somebody else and giving them a lot of. You know, what’s going on right now on the floors, what’s going on with these patients?
What’s the possible concerns that you might see in this coming week? But handing off from week to week, especially with inpatients has to be very [00:07:00] very well orchestrated, we’ll start off with our, must not miss diagnoses and of course, must not miss diagnoses are our highest morbidity and mortality conditions in any given area of medicine.
And certainly endocrine has its share. So you started off your list for me with D k A and hhs. diabetic ketoacidosis and hyperglycemic, hyper osmolar state. I always have to slow
down when I say that
Paige Thompson: it has many names.
It’s okay.
Dr. Hare: Tell us, What kind of common presentations are you seeing with DKA and HHS in your setting?
Paige Thompson: Sure.
We’ll do DKA first. This is more common in type one diabetics or severely uncontrolled type two diabetics. I often see this in the hospital. That is when I will get a new consult on my inpatient consult service. Typically it can result from, we are diagnosing somebody with type one diabetes or the person [00:08:00] has uncontrolled type one diabetes that causes Them to go into dk, which is a pretty severe dehydration state caused by high blood sugar leading to acidosis.
oftentimes this can occur from a type one diabetic who maybe their diabetes technology like insulin pump is malfunctioning. So they go several hours without insulin and therefore will slip into D K A. Sometimes it’s due to illness. So if you have an underlying bacterial infection or virus, it can also lead your sugars to become much higher and trigger a type one diabetic to go into d k A.
initially, because I’m a consult service, these patients will come into the ED usually and the ED will screen them and obtain lab work including, you know, basic metabolic panel urine to assess for ketones in the urine and look for markers of acidosis. We have to have a few. Markers checked to truly diagnose [00:09:00] dka such as high blood sugar, typically over 250 markers of acidosis like a altered CO2 level or an elevated ion gap.
And then also evidence of elevated ketones. So either ketones in the urine or the blood test is called beta hydroxybutyrate. Okay.
Dr. Hare: So these are often younger patients who are presenting with, their first episode, their first diagnostic moment for type one diabetes in which you’re seeing a lot of the D K A that’s occurring.
Paige Thompson: I would say it’s a little bit less than half of the time that we’re diagnosing somebody with it.
More so I would say in the adult setting, which I work in, it’s not taking medications appropriately an underlying illness or, a pump failure would be more common.
Dr. Hare: Okay. And this is D K A is a metabolic acidosis, correct? Mm-hmm. Okay. So we’re seeing that on our B M [00:10:00] P. Is able to tell us with the ion gap, in most cases, what’s going on with that patient, or at least one aspect of that.
Paige Thompson: Yes, that is the main thing that I look for. And I also track it as we’re treating the patient to see how they’re progressing and improving.
Dr. Hare: Students often ask me when we talk about ion gap, about what those numbers look like. So what do those numbers generally look like for a patient who’s in
dka?
Paige Thompson: Sure. So typically I see people in the twenties very severe dka. They can be in the thirties wow. But initially in the twenties. And then as we treat them with, you know, hydration fluids as well as insulin it’ll improve. And we’re looking for that number to get at least less than 16.
Dr. Hare: the normal predicted range would be 12, give or take.
Are you often testing albumin so you can get a more specific normal range for that particular patient or not?
Paige Thompson: So we do typically get at least one albumin when they come in through the ed. Okay. So we will look at that, but also the chart sometimes will adjust the level [00:11:00] based on that too.
Mm-hmm.
Dr. Hare: And then the HHS side of things. So what differentiates DKA from hhs?
Paige Thompson: Sure. Dka, like I said, mostly type one. They’re coming in with uncontrolled diabetes. HHS is a very severe form of type two diabetes. It’s pretty rare for somebody with type one to go into hhs.
So HHS typically in type two and the sugars are much more elevated. So DKA you can, have a chance to go into it if you have sugars over 250. But hhs, these patients are coming in, they’re typically very confused, altered and Also have sugars that are very elevated, at least 5 or 600.
And then I’ve seen patients who are in the one thousands .
Dr. Hare: Wow. I, you know, at that level, I assume everyone is symptomatic at that point. Right. So we, we have some symptoms of, of hyperglycemia
Paige Thompson: mostly. You would be surprised, some people come in with elevated blood sugar and they’re doing pretty okay for the time being.
[00:12:00] But most HHS patients will come in a little altered you know, they’ll be in somewhat like coma or, you know, not able to answer questions until we actually treat them. Okay. Similar treatment to DK as well with insulin drip, figuring out what’s going on. These cases typically present because a type two diabetic either has not been diagnosed, so, you know, they’re not.Getting regular primary care follow up to catch this earlier. And so it will accelerate into one of these emergencies or a patient who has a known diagnosis, but they’re not able to obtain proper treatment, whether that’s barriers with cost or you know, not able to afford medications, something like that, or just not taking them.
Dr. Hare: From my perspective talking about students and PA students we talk a bit about understanding that patients who have consistently elevated blood sugars tend to , not [00:13:00] feel the symptoms of hyperglycemia. And then I also see in my work with eating disorder patients, patients who have consistently low blood sugars tend to simply shift their normal range a little bit. So we can talk about normal ranges as much as you like, but in that scenario, they really don’t always respond the way that you think they will. You know, you see really low numbers in patients who, you know, we expect them to be comatose and they are sitting up and talking to you and functioning very well that to me is a, a little scary with my patients. Mm-hmm. At times. Mm-hmm. Especially eating disorder patients.
Paige Thompson: I think it’s important when a patient comes in with elevated blood sugar where you could have a suspicion for one of these diagnoses, kind of go through the criteria, what you need to diagnose it.
And if they do, can we just start them on their home regimen or do they need more advanced
Paige Thompson: care, like an IV insulin infusion. So that’s the main thing. Identifying the patients correctly and treating them cuz they can become fatal if not caught.
Dr. Hare: Let’s talk a little bit about the next [00:14:00] one on your list. Acute adrenal insufficiency and crisis
tell us a little bit about those cases.
Paige Thompson: So this is not a super common diagnosis but patients can present in acute adrenal insufficiency or crisis if they have underlying adrenal insufficiency for. Whatever reason the primary cause the genetic cause would be Addison’s disease.
Where, you have a malfunction in your actual adrenal gland causing your adrenal gland not to be able to produce the appropriate hormones, including cortisol, life-sustaining steroid hormone you produce as well as aldosterone and the other adrenal cortex hormones. So this is oftentimes seen in patients with Addison’s disease, and once again, because I’m a consult service primary teams will have a suspicion for this.
Mm-hmm. And they’ll ask us if it really is Addison’s disease. If there is a suspicion for Addison’s disease acute adrenal insufficiency or adrenal crisis,[00:15:00] then the ICU or the emergency department will just automatically give a very high dose of steroid to see if the patient improves. So that’s, you know, emergency guidelines treatment, and you don’t.
Wait to find out if it’s, if they really have it, you more so give them the steroid to see if it helps them improve. These patients will come in with low blood pressure and electrolyte disturbances as well. So you want to see if they have the electrolyte disturbances that would be common with this.
So this would be alterations in your sodium level, your potassium level, and then could be a glucose level as well. And so I don’t see this commonly, but it can be fatal if not caught. So typically these patients are coming in already kind of not conscious and you have to figure out what’s wrong with them.
Dr. Hare: And their glucose levels in Addison’s disease would usually be,
Paige Thompson: it would be low, low decrease. Mm-hmm. Okay.
Yeah.
Dr. Hare: I always try to think in case studies and John F. Kennedy.[00:16:00] Had Addison’s disease. Mm-hmm. And he always appeared to be tan. Mm-hmm. Which is one of the, presenting signs mm-hmm.
In Addison’s. And he had back pain. I tried to play golf, but had difficulty playing golf because of his back pain. And so most of those cases caused by autoimmune conditions or are they
primary?
Paige Thompson: I would say most of them would be caused by an autoimmune condition.
So for example, if somebody with Addison’s disease gets sick and they’re not able to take their oral steroids mm-hmm. They need to take every day can quickly become much sicker. Mm-hmm. And then present to the hospital. these patients need steroids. It’s life sustaining for them cuz they’re not producing it on their own.
So this is why in the outpatient setting for our Addison’s disease patients, we give them emergency IV Decadron, kind of like an EpiPen for adrenal insufficiency patients. Okay. So if they, are vomiting or sick from something else, could be anything, they still have a way to get their steroids.
I would say the only other thing is it [00:17:00] doesn’t have to be patients with Addison’s disease. A lot of patients who have like significant pulmonary disease and they’re maintained on high doses of steroids, if you just withdraw that, all of a sudden they’re also at risk for going into this.
Typically, teams are very good about tapering steroids, but if the patient doesn’t listen to that or well, non-compliance, something like that, yeah. Then it could become pretty dangerous.
Dr. Hare: the next one is thyroid storm and acute hyperthyroid patients. Mm-hmm.
What do those patients look like when they arrive?
Paige Thompson: these patients can actually present in a varying amount of ways. again, this is very rare, but you don’t wanna miss it. this occurs typically in undiagnosed or untreated Graves disease which. Presents as hyperthyroidism.
Mm-hmm. So it can quickly cause cardiac issues. Patient could have an elevated temperature and can quickly lead to cardiac and electrolyte abnormalities that can lead to death. If you do suspect this in a patient you [00:18:00] wanna get thyroid tests on there. And if they truly are in thyroid storm, you have to treat them to make sure that their heart is safe.
And also we’re starting to block that thyroid from producing extra thyroid hormone,
Dr. Hare: What is your initial emergent handling of a patient who is hyperthyroid in those moments?
In storm?
Paige Thompson: I haven’t seen a lot of true storm. It’s more so patients who they think that they’re in storm okay.
And they’re not. But you wanna give them thyroid. Blocking agents, methimazole or or ptu, PT U. Yeah. Okay. And then you also wanna make sure that they’re stable from a cardiac standpoint. So blood pressure control, pulse control and cardiology will often help us with that, make sure that they’re getting fluids and keep assessing them rapidly.
Dr. Hare: Yeah. I was talking to a student today about the potassium requirements of those patients and of a lot of patients across the board when it comes to being over driven sympathetic overdrive. And also in the DKA patients, when you have a patient [00:19:00] come in and you’re gonna.
Push insulin into their system via iv along with fluids. If you don’t watch their potassium during that time, that insulin’s gonna push all that potassium into their cells and suddenly they’re gonna be hypokalemic and that low potassium is gonna cause some cardiac issues pretty quickly.
Paige Thompson: Definitely. And our primary teams help with that too. We will as well. But typically they’re the ones who do the monitoring of the electrolytes and they do a good job at, yeah. Mm-hmm. Yeah.
Dr. Hare: So the next on the list there is the opposite of that acute hypothyroid or myxedema, coma. That terminology always bugs me a little bit because it always feels like that is confusing for students when you first learn this terminology.
Paige Thompson: Yeah, so I definitely have seen this one more often. Okay. It’s more common. And I remember learning in PA school, the typical presentation of this, an elderly female patient who in the winter when it’s already cold not taking a thyroid medication for several months and then presenting, [00:20:00] you know, truly in a coma or near coma.
They’re think of very severe hypothyroidism symptoms. So they’re very, very tired or already sleeping. You can see a low body temperature Increased swelling in edema all over their body. And then, you know, in with the workup of these patients, the emergency room or the primary team is looking for causes.
So is it just a cardiac cause or is it a thyroid cause? I have seen some pretty impressive tssh levels with these patients mm-hmm. In the hundreds. And you know, almost non-existent free T4 levels. And so in this case, you know, you have to truly determine is it really a mixed edema coma where it’s severe, you need to give them steroids and fluids as well as IV levothyroxin.
Or is it just really severe hypothyroidism?
Dr. Hare: And do you often see the mix edem the symptom
Paige Thompson: in a true mix edema. Coma. [00:21:00] Yes. But you know, it can just be like some mild edema. Mild in most severe hypothyroidism cases. Okay. Mm-hmm.
Dr. Hare: What is it about myxedema, coma that makes it a must not miss? What’s the potential eventual endpoint of that that’s dangerous?
Paige Thompson: Yeah. So your body without thyroid hormone is shutting down and, you know, you’re just gonna keep, everything’s gonna keep getting lower, like your heart rate and your temperature until it’s not compatible with life. So death is definitely a complication of this, if not caught.
Dr. Hare: Let’s move on to the last one, which is diabetes Insipidus. The name of diabetes Incipidus is always interesting to me as well as with myxedema coma. These are old, old conditions that have been around for a very, very long, we’ve been aware of, I suppose, for a very, very long time.
Tell us about Diabetes Incipidus and how that presents.
Paige Thompson: Yeah, so Diabetes incipidus can be caused either by an issue in the actual pituitary where you’re [00:22:00] not secreting the anti-diuretic hormone needed to regulate your fluid balance. But also it can have origins in the kidneys as well.
So this diagnosis tends to be bounced between my team endocrine and the Nephrology teams to figure out why if a patient is known to have this diabetes insipidous, they’re unable to regulate their fluid balance in their body. And so without any sort of treatment, they will just continually urinate and dehydrate themselves until they have electrolyte disturbances and severe dehydration, which if not caught or treated, can lead to death.
Oftentimes in these patients though if they come into the hospital and they’re not given the treatment or it’s a newer diagnosis, they will quickly improve with the treatment which is synthetic anti-diuretic hormone called D D A V P Suppress.
Dr. Hare: Secondary cause of of this particular issue is often [00:23:00] hypothalamic pituitary axis, correct? Mm-hmm. One of the conditions that I discuss with my undergraduate students is traumatic brain injury mm-hmm. As queuing a diabetes insipidus like picture.
My case study is Diego Marquez from Go Diego. Go. Mm-hmm. Because he, falls off of his vine and hits his head mm-hmm. And then ends up with diabetes incipidus and, and thus go, Diego. Go. Mm-hmm. He’s, he’s constantly going to the bathroom tell me about the endpoints with diabetes insipidus. Are they dehydration related and electrolyte
related?
Paige Thompson: Yeah, they are. So you wanna get frequent metabolic panels to assess their hydration status and electrolytes. And the main thing is you wanna look. To see that sodium and potassium are well-balanced in these patients.
You track them by their sodium and you want to make sure that it’s in the normal range. Oftentimes because they’re severely dehydrated, the sodium can be quite high. So you want to make sure that these patients are being appropriately hydrated.
Dr. Hare: I had a [00:24:00] couple of students discussing this with me the other day. How do we test and how often do we test electrolytes and bmp in that kind of emergency situation? Let’s say they’re in the emergency room, versus on an inpatient floor and you’re going to see them as a consult.
Are you asking for Q2 hours often are we testing electrolytes in those folks?
Paige Thompson: I would say typically in the hospital, maybe in the emergency room it’s a little bit more acute and frequent, maybe up to two hours. But I would say at most it’s every four hours in the hospital. Okay. Otherwise, once they’re stable, we can move to every like eight to 12 hours and then eventually, once they’re stable, probably just hold it 12 hours for the hospital.
Dr. Hare: Okay, so through the must not miss diagnosis list today. Let’s move on, over to the full case discussions
type two is first on your list and I assume first in incidents in your setting. It’s a broad topic. There’s a lot of things going on, as you say, pretty meaty [00:25:00] topic. Tell me about the presentation of type two diabetes for these folks.
Paige Thompson: Since I’m a specialty we tend to get referrals for type two diabetics, or we’ll follow up from hospital cases that we’re consulted on.
So initial presentation to pcp, this would be caught on yearly lab work. Patients could have symptoms of hyperglycemia such as polyuria, frequent urination, polydipsia, increased thirst. You can have blurry vision if your sugar is very high and you know, you could have weight changes as well.
So those are the most common. I would say that they will initially present with a pcp will. Go through the guidelines, start the appropriate therapy, trying to start depending on how severely they find the patient. Either trying lifestyle such as increased exercise, weight loss, diet control, sometimes adding metformin.
And then primary care is typically pretty good at starting the newer medications that we recommend, such as SGLT two [00:26:00] inhibitors and GLP one agonists. So typically we’ll either get patients just freshly diagnosed, very severely uncontrolled diabetes or after a few attempts to control with the pcp.
This is first on my list cuz it is the most common thing that I see. I see probably 50% type two diabetes every day in clinic and every day in the hospital too. Hmm. So very, very common. Our job is the specialist to focus on diabetes.
So I get to spend the whole half an hour appointment I have with them talking about their diabetes, whereas their primary care doesn’t. So that’s kind of our use there. I, brought in some case diagnoses. I’ve kind of combined a few of my patients cuz of course I couldn’t figure out just one to talk about.
for example, a 40 year old male patient with uncontrolled type two diabetes and neuropathy presents to the endocrine clinic for evaluation. He has an A1C of [00:27:00] 11%, takes Metformin a thousand milligrams twice daily, which is the max dose lantis insulin, 40 units daily and Humalog 15 units with meals plus a correction scale.
So he is, comes to us on a pretty extensive regimen already, but A1C is still control uncontrolled at 11%. He is struggling with consistency of dosing and adhering to a low carb diet. When I saw this patient we talked about his current regimen, ways to improve His adherence.
we also have a lot of resources for patients at my clinic such as diabetes education using diabetes technology, which is becoming much more common. referring him for placement of a continuous glucose monitor. And then also for this patient, starting him on one of the newer medications screening to see if he’s appropriate.
So for this patient, he’s already on four shots a day of insulin, [00:28:00] metformin, but he’s not on any of the newer medications. I elected to start him on a GLP one agonist. over time, patients starts to become more consistent with dosing because he’s motivated by the cgm. This is very common to see that patients like seeing the data, they feel empowered with it.
Yeah. And even just adding a CGM alone can improve an A1C up to 1%. Wow. for this patient, in addition, we added the GLP one agonist. So this takes some of the work off of the insulin. I’m actually able to lower some of his doses and eventually got A1C down to 6.5%. Wow. On lower insulin doses, max dose of GLP agonist.
And because he feels more motivated, his lifestyle has improved with increased exercise watching his diet and his blood sugars closely.
Dr. Hare: So what specific medications were you giving him?
Paige Thompson: In terms of the glp typically for this patient, his A1C is 11%. So I started to hit him on Ozempic. .
Typically the most effective with [00:29:00] a1c currently and what his insurance would cover. Ah-huh Yeah.
Dr. Hare: And was he significantly overweight on
presentation to you?
Paige Thompson: He was, yep. He, he does have obesity. Oftentimes my type two diabetic patients, not all will come with comorbidity of obesity. So this, these medications oftentimes help them lose weight, which also helps with motivation to continue,
Dr. Hare: it’s interesting ozempic has been a thing lately. Have you seen. Availability is a problem
lately.
Paige Thompson: We had a big shortage around Christmas of this past year, and that was pretty tough. We changed patients to different GLP medications or had to pause therapy for a little bit.
We will, continue to see sporadic shortages of these medications, but I’ve been told that both major companies that produce them are increasing production, moving production to the United States. So hoping that they aren’t as common going forward,
Dr. Hare: Anything else about type two you wanted to talk about?
Paige Thompson: I [00:30:00] typically talk about all the yearly screenings extensively mm-hmm. In some of my lectures and so, mm-hmm. You know, it’s important for every type two. Patient to make sure that they’re getting all the yearly screenings. That’s where the primary care aspect comes into it. So checking off the yearly eye exam, the foot exam this patient has neuropathy, so watching that he still has protective sensation on his feet and referring to podiatry if needed.
You also wanna screen for all of the complications of diabetes. So that’s where the eye exam comes in. A yearly urine test to check for kidney complications. And like I said, neuropathy, we also wanna check their blood pressure control as well as their lipid control too.
Dr. Hare: Students have in the past said to me, oh, the complications, you know, why, why is all the discussion in diabetes about complications?
And, to my mind, yeah, you have to catch it. Yes, you have to treat it, but. Patients don’t realize that those complications are brewing for years, [00:31:00] often before there’s any diagnosis made or there’s an understanding of the pre-diabetic changes that have occurred in any form.
And so that to me, is one of the most important parts of diabetic care, is knowing what to watch for and what to keep them up on their screenings, , making sure their cholesterol levels are where they need to be and starting ’em on a statin if need be.
and the weight loss lifestyle modifications that they may need to help their entire health and and the inflammation that goes along with it is an incredibly important part of that, I would say.
Paige Thompson: there’s a lot attached to diabetes care, and I’m not gonna lie, some of it is a hard sell to have a patient take a medication that, maybe on paper their lipids look normal to them.
It’s not flagged on their report, but we have a much more aggressive goal for a diabetic patient. So that tends to be a hard sell, to get patient to take medication for prevention. And then also just motivating patients to add extra medications, sometimes including insulin. They say, why do I have to do this?
we have extensive discussions about the [00:32:00] complications that are brewing, if not controlled.
Dr. Hare: Yeah, that whole I feel fine. Aspect is sometimes very challenging, yeah. Whether it’s blood pressure or blood sugar or a, a variety of different areas in medicine. So talking about the motivational aspect, I think the next one, With type one diabetes?
Probably not. Well, not nearly as common, right. It was what, 10 to 15% of our diabetics?
Paige Thompson: It’s definitely more like, it feels more common to me just cuz I’m in specialty. But, but yeah. Not as common, but definitely can be more severe.
Dr. Hare: And this, this, to me, the motivation with type one is sometimes surprisingly difficult to get inpatients, especially those 15 year olds or 13 year olds who are just diagnosed because the understanding and acknowledgement that this is a lifelong condition that I’m going to have to keep up with and continue to be very vigilant about for the rest of my life it’s a hard pill to swallow.
Absolutely. And so that, that to me is one of the biggest challenging [00:33:00] aspects. And working in a psych hospital, have frequently seen patients who come in with type one diabetes. A teenager’s life is often difficult enough and you add on top of that glucose monitoring and and insulin injections, which is, gonna be a type one necessity and those folks are really gonna have a difficult time with that.
We talked about D K A and some of those initial presentations. How else do these type one s present to medicine?
Paige Thompson: I don’t work in pediatrics where a lot of them will present. Mm-hmm. But Pediatricians will often catch these before they escalate to dk.
Whether the patient just has symptoms of hyperglycemia like polyuria or polydipsia, the patient should be growing along that pediatric growth chart, but they’re not, they’re losing a lot of weight. Mm-hmm. Without a clear cause. And so oftentimes the pediatricians are pretty good at screening for this and catching it before it escalates to an emergency.
[00:34:00] However, something I was not aware of in PA school was how many adults are diagnosed with type one diabetes. It’s called latent autoimmune diabetes of adulthood, or we abbreviate it as lada. these patients don’t have to be kids to be diagnosed. We diagnose a lot of people in their twenties, thirties, sixties, and suddenly, you know, again, with the, you know, abrupt lifestyle change.These people at any age when diagnosed have to. Commit to a lifelong glucose monitoring, lifelong insulin administration because their body won’t produce insulin anymore. Mm-hmm. So we o we often see the psychiatric complications of this and you know, we actually have programs in our department that screen for this and make sure to identify patients who are having trouble.
Dr. Hare: The type one diabetes treatment, when you start these patients out, are they going on continuous glucose monitoring, the back of the tricep patch. Immediately in most cases.
Paige Thompson: In pediatrics there is [00:35:00] generally a short term where they need to learn it, take sugars manually, and give injections of insulin manually. Mm-hmm. But the goal is to get these people on diabetes technology as quickly as possible if they are willing to do so.
Mm-hmm. It oftentimes makes their lives, which are significantly harder now with diabetes. It actually takes some of the work off of them and helps fit the diabetes into their life, not make diabetes the, the focus of their life. That’s kind of what I talk to these patients about. The goal is to get them on a CGM as quick as possible for my adult patients.
Or if I get patients who are kids and graduating to adult endo, sometimes you have patients who didn’t want one prior to this or are wary of the technology. So just making sure patients are aware of all of their options. And trying to help them see if it’s a good fit for their life.
Dr. Hare: That’s interesting helping them to understand the basics of the manual testing, whether it’s [00:36:00] finger stick or injecting insulin. If their technology fails, they need to be able to have that backup. Yes. I hadn’t thought about that aspect as much that you need to be able to go back to that.
I see it in patients who come into the psych hospital will come in usually not a glucose monitor so much that I have to worry about it is the pumps. Mm-hmm. That I have to worry about. Right. And a patient who comes in with depression, for instance, or bipolar disorder or suicidality
An insulin pump has the potential Well, you push that button often enough and you can cause yourself some significant issues absolutely up to including suicide. And so we re usually remove that when they come into the hospital. One of the things I had to learn in my family medicine practice at the psych hospital was removing that pump for all patients coming into the hospital and then translating everything into injected insulin on our end.
And of course, nursing is doing most of the injections in that setting, certainly. I wasn’t having to teach the [00:37:00] individual, but we would often teach the individual how to do that. In those moments we’d ask nursing and, and diabetic education to come along
I think it always helps to know those things for those situations. You really do have to do even more diabetic education because diabetes education seems to me to be a very significant portion of the medicine that you do with these folks.
Paige Thompson: Absolutely. During my training, I spent many days with the diabetic educators in the office. We also have dedicated hospital-based educators that are vital in those situations that you mentioned. Hmm. Where, you know, we’re having to take the pump off or put it back on. And so our educators are invaluable and You know, I still work with them a lot and ask them questions almost every day.
Cuz they’re just such a wealth of knowledge.
Dr. Hare: Talking about the interprofessional side of things, how much do you work with nutrition for instance?
Paige Thompson: Yeah, we refer, our main referrals are to the dietician as well as educators for our diabetic patients.
Dr. Hare: That [00:38:00] is presumably hours in the clinic to to get through all of that education for a new diagnosis, for instance?
Paige Thompson: Definitely It is in the guidelines to have a dedicated diabetes education session for a newly diagnosed patient within six months or so.
Mm-hmm. But typically we do it much sooner.
Dr. Hare: Is that one-to-one, do they do groups or something like that? One-to-one. Anything else about type one that you wanted to discuss?
Paige Thompson: For type one s just making sure that they know all of their options.
I always have discussions with type one s who I’m meeting for the first time, making sure they’re up to date on all of the technology options. I do have a lot of type one patients who don’t want any technology, they don’t want something attached to them, and that’s valid. This is their diabetes and their life.
But this field is evolving. The diabetes tech world is evolving so quickly. There have, I’ve only been in my job for two years and I think there’s been like maybe one or two updates to [00:39:00] CGMs and then at least two updates to pumps. And that’s just within two years. Patients might have a previous understanding of pumps or worries about them that our educators and myself can help to address.
Dr. Hare: Shall we move on to Grave’s Disease? Sure. And hyperthyroidism as one of our major cases here?
Paige Thompson: Yeah. Grave’s disease is pretty common. I I do see probably at least one or two, maybe up to five a week with Graves disease. we can go through a case This is a 29 year old female patient presents to the P C P with palpitations, eye irritation and fatigue.
The PCP completes a workup. Ruling out cardiac abnormalities and finds the patient to have hyperthyroidism. So the tsh in this case would be low and the patient would have an elevated free T4 and or t3. He starts a patient on methimazole, which is the most commonly used antithyroid [00:40:00] medication, and then also adds on a beta blocker for the palpitations and symptoms and then refers this patient to endocrinology.
This is the typical way that we get hyperthyroidism patients. So whenever they come to the endocrine clinic, we tend to ask why this is happening in rule out causes. So during this time we’re monitoring the thyroid function tests every four weeks until normalized and we assess if there’s an autoimmune cause.
The most common cause is Graves disease with an elevated thyroid stimulating immunoglobulin. And so this is one of the antibodies to prove that it’s Graves disease. And we also check out everything else that’s going on with the patient. If it’s not Grave’s disease, do they have a nodule in their thyroid that is producing too much thyroid hormone?
Do they have a goiter at all in their neck or is it normal?
Dr. Hare: Is that an automatic ultrasound in those cases?
Paige Thompson: Yeah, we typically refer the patients for, TFTs and then [00:41:00] usually a presentation, a thyroid ultrasound if the PCP hasn’t already obtained one. Mm-hmm. With Graves disease, you’re gonna see just either a mild enlargement or a little bit of heterogeneity in the thyroid ultrasound.
So instead of being nice and smooth it’ll be a little bit lumpy and bumpy as I typically term it in the clinic. Mm-hmm. And so the patients typically will improve on methimazole over time. This patient had normalized TFTs over time, but she did have a positive TSI at diagnosis confirming the reason she has this is graves.
This improved to normal with treatment, like I said, and the thyroid ultrasound with her showed that mildly enlarged lumpy and bumpy thyroid, she did not have any nodules, so we weren’t concerned about that. Then the goal becomes we need to keep her as normal as possible on the least amount of medication.
So then we start tapering down the methimazole and closely monitoring the [00:42:00] TFTs. We can also use the TSI to track patient’s progression here as well. So it’s a little bit counterintuitive to track an antibody, but in this case, the antibody will normalize when you treat the patient uhhuh and as they improve.
And then we usually say for these patients, about a third of patients are able to achieve remission and get off of the medication entirely. About a third will have a recurrence when this happens. And then a third will need kind of continued medication or never go into remission. And eventually need a permanent therapy like radioactive iodine or thyroid surgery to take the thyroid out.
Also in these patients, this particular patient presented with irritation in her eyes, and so we wanna refer all of the graves patients for ophthalmology evaluation to rule out thyroid eye disease. And we’re looking on exam for, bulging eyes, exophthalmos that we can measure in clinic
Dr. Hare: How does that present for the patient?[00:43:00]
How do they describe as a symptom that particular graves ophthalm apathy.
Paige Thompson: Yeah. So they will have some irritation in their eyes. They’ll feel like their eyes are swollen, and that’s because those muscles behind the eyes are inflamed and angry, so they’re pushing the eye out. Mm-hmm. I had a patient the other week who described this increased swelling because his thyroid eye disease was returning.
And you can sometimes see an on exam, but patients are typically more sensitive to it if it’s a recurrence. The ophthalmologist is able to kind screen, look behind the eye, see what’s going on there.
Dr. Hare: What is the, likelihood of progressing to radioactive iodine?
Thyroidectomy,
Paige Thompson: I would say about a third of the patients. Some, were able to achieve remission in about a third third’s in that gray area. And the the remaining third will need that permanent therapy.
Dr. Hare: And so you moved then from hyperthyroid treatment to hypothyroid treatment?
Paige Thompson: Right. One of the hard cells to have patients wanna swallow radioactive. [00:44:00] Pill or get this major surgery just to still have to take a pill every day. We talk about how overall supplementing thyroid hormone level of thyroxin and hypothyroidism is generally much safer than continued therapy on methimazole.
Although it is appropriate for some patients. And then we talk about overall just the continuation of Grave’s disease and how that can be harmful and just more difficult to manage for us and for the patient over a long period of time.
Dr. Hare: And then you have to worry about the parathyroid glands getting potentially removed with the thyroid gland as well, right?
Correct. So then you have to worry about parathyroid hormone and calcium levels?
Paige Thompson: Yes. My department is lucky in that we have a partnership and a referral program to specialized endocrine surgeons. So we don’t see a lot of those complications because we have specialized surgeons at our disposal.
Dr. Hare: They’re able to spare the parathyroid glands during that surgery then?
Paige Thompson: Almost always. Yeah. Almost always.
Dr. Hare: The next one on your list is thyroid [00:45:00] cancer. Mm-hmm.
What are the kind of symptoms, what do you usually see in thyroid cancer patients initially?
Paige Thompson: So it is a wide range. Some patients don’t even know that they have a nodule in their neck.
The PCP will just find it on a yearly neck exam during their well visit. And this also can range to a patient like having a very large nodule in their neck, feeling compressive symptoms such as shortness of breath, a hoarseness in the voice or trouble swallowing. But our main job is whether the patient comes to us with diagnosed thyroid cancer or evaluating, we wanna know if they have a nodule in their neck.
We take those so seriously because it could be cancer. Hmm. So, you know, a lot of people have benign thyroid nodules that are just all throughout their thyroid. Close to 30% of the population just has thyroid nodules that will never become cancer. But our job is to evaluate.
Number one, is this nodule cancer or is it not? [00:46:00] We have set guidelines through the American Thyroid Association and typically initial workup includes thyroid function tests. So is this a functional problem? Is the nodule doing anything with thyroid hormone? it overproducing it or blocking production of it?
And then we also get a thyroid ultrasound to see if this is a structural problem. What does the nodule actually look like? The ATA has very specific guidelines on characteristics to look at through the ultrasound, and our radiologists know how to look for those. We’ll have a categorization system, and then based on the TI-RADS system we’ll categorize the nodule.
So TI-RADS is how you would categorize based on the presentation of the nodule. You categorize the risk of. If it’s cancer, potentially cancer causing. Mm-hmm. An ultrasound cannot definitely tell you if it’s cancer or not, but it can tell you the more suspicious looking nodules that you should
Dr. Hare: And then you move to [00:47:00] fna
Paige Thompson: yes, you move to fna. So ultrasound features associated with a higher risk of malignancy would be increased size, solid nodule instead of more liquid or cystic. Cystic. Yeah. Irregular margins, micro calcifications. And that can generally be seen broadly with cancers.
So you want to look for those characteristics and there you go. Go be able to classify them based on that. So if it’s a higher number, like TI-RADS four or five, often. You will refer for a fine needle aspiration biopsy, which we’ll do in our clinic. And with this it’s based on size. So for example, it can be as small as one or 1.5 centimeters, but if it’s a higher risk one, we’re going to do a biopsy.
The biopsy is not a perfect system, but it is pretty good. So the three options when you do a biopsy is you get a report back and it’s either definitely benign, [00:48:00] definitely cancer, and it will tell you what type of cancer it is or this middle questionable categorization. So we have extra genetic testing that we can do if it’s in that questionable category to tell us do we think this is cancer or is it low risk?
Dr. Hare: Fine needle aspiration is the FNA that we were discussing mm-hmm. For that biopsy. And that’s ultrasound driven. It is. And the fine needle that goes into the thyroid are able to get a, a kind of a slurry of that thyroid section.
Mm-hmm. Remove it through with the needle. And of course the, the ultrasound allows us to be safe in the placement of that needle into the neck. Right. So this is a, this can be an, an area where there are a lot of nervous and vascular structures to, to be careful about there.
But making sure we’re also, that we’re inside the actual nodule in question. We’ve identified it and we’re inside the nodule in question to get that And that is one of the more interesting services [00:49:00] that I’ve ever been associated with when I was in PA school, was the interventional radiology section.
And that it was a, a very interesting thing to be a part of. And learn about how all that
works.
Paige Thompson: Yeah, my department has physicians who’ll do it in our clinic, but Wow. Otherwise you would refer to IR for this procedure? I have seen several of them. And actually within our department, you know, they’ll use the ultrasound.
The physician will. Put the needle in to the nodule, get a good sample, and then actually walk it right next door to pathology where they’ll start preserving it. So it’s a pretty good system and typically it doesn’t take too long for results. That’s great. To come back. That’s great. That’s great. And then if it is cancer, we refer them for a thyroidectomy with endocrine surgeon or your nose and throat doctor and treat the patient for hypothyroidism.
That occurs after as the patient won’t have a thyroid. Yeah.
I would say that my department is more so focused on monitoring [00:50:00] the patient afterwards. So important to look for you know, if they don’t have a thyroid, we’re supplementing with a levothyroxin synthetic thyroid hormone, making sure their tsh is nice and low in that low normal range to suppress any future growth of any thyroid tissue that could remain in there.
And then we also assess for levels such as thyroglobulin which will tell us if there’s actual thyroid tissue in there. And, you know, go based on there, there are guidelines of what to do. If a patient has a recurrence or has a questionable recurrence, it would possibly need more advanced therapy.
Dr. Hare: I had a, question mark next to procedures there, because I was curious you had mentioned the FNA being done in the office.
And potentially thinking about CGMs and pumps and things of that nature, any other procedural things that , are common in endocrine?
Paige Thompson: So I would say it’s, it’s pretty uncommon in my department, the physicians will do the fna. The apps don’t. But physician assistants are certainly [00:51:00] capable of doing them.
They’ll do them in IR departments. But , I place a lot of CGMs in the office. the patient learns how to do the pump on their own, so we don’t do a lot of that. And then one of the CGMs that you have to get special training for is called EverSense it actually goes beneath the skin.
So you kind of insert it just beneath the skin, similar to like an Nexplanon birth control that would go in your arm. Interesting. And so that’s like the main procedure that I do.
Dr. Hare: It seems like keeping up with the technology and diabetes especially is, is probably going to be. For a lot of your career. Mm-hmm. , a continuous thing to keep thinking about.
Paige Thompson: Definitely there’s a new pump out and we have a meeting on Friday to learn about it.
Dr. Hare: Well, that is something that we all, as PAs family medicine included, are gonna have to continue to stay on top of, is these the technological advances, but certainly in, in diabetes now across the bottom of my whiteboard there is possible [00:52:00] referrals for primary care in most cases this would be primary care to endocrinology. And you were kind enough to present a list of really common things that a family medicine generalist emergency medicine, you know, variety of different places that a PA would practice would send someone to you in endocrinology. So poorly controlled type two clearly is an issue. Motivation, providing better control with less work, I assume in those situations for you all in endocrinology?
Paige Thompson: Yeah. I would say, , if the patient just has like a lot of complications that are brewing you know, the PCP has tried a few medications, but it’s not working , it’s reasonable to refer to endocrine just because we have dedicated time much more than a PCP would to talk only about diabetes.
Right. And so that specialized care can be helpful even if it’s just for a few visits and then we take ’em back to PCP or discharge them back to [00:53:00] PCP after they’re well controlled. You know, it can, it can be pretty helpful.
Dr. Hare: Realizing that there’s an entire service devoted to your condition might make you take it a little bit more seriously in the long term.
Absolutely. I suppose. Yeah. And then you say all type one s and I think that’s nearly all type one s I think that’s always comforting to me when I look in a patient’s chart and I see that type one diagnosis, and then I can immediately go to the records that tell me where are we with that patient and what kind of insulin needs does that patient have.
Paige Thompson: Yeah, we would recommend it for all type one s. Certainly, you know, in more rural areas, the PCPs obviously need to know how to manage type one. Everyone should know how, how it differs and how to roughly manage it. But for that more specialized up-to-date care, especially with the technology definitely recommend type one diabetics to come to endocrinology.
Dr. Hare: Okay. And then you have essentially all addison’s disease patients?
Paige Thompson: Yes. once again, we can make sure that they’re up to date. Their [00:54:00] monitoring is good, they have appropriate emergency treatment. And, you know we will just continually monitor them at least once a year for these patients.
Dr. Hare: Okay. And then uncontrolled hyperthyroid Graves
disease?
Paige Thompson: Yes. So like the case that we discussed, if the PCP is starting some methimazole, but still struggling to manage the hyperthyroidism or doesn’t have time to dig into the cause you know, endocrine referral is appropriate especially when we don’t know exactly what’s causing the hyperthyroidism.
Dr. Hare: And then presumably you’re sending folks for potential next step surgery, et
cetera?
Paige Thompson: Yes. Yeah, and that’s on the other side when we know it’s graves, if they need that permanent therapy you know, we will stay with them. I would say we discharge back to P C P if the patient wants to remain on medication or is stable after a permanent therapy.
Dr. Hare: You list suspected thyroid cancer, which I think kind of speak for itself. And the needs, [00:55:00] as you’ve already discussed those needs that seems to me to be an obvious one as well. Mm-hmm. Pituitary adenoma is an interesting one. I know that there are a variety of ways in which of that presents.
What do you see as most common?
Paige Thompson: So we again see a wide variety. The most common would be a prolactinoma where you have excess prolactin from a tumor in the pituitary in those group of cells. And so that’s the most common one we get for an adenoma. But patients can. Technically have tumors of the pituitary in any of the groups of cells, a lot of times we will get hypo pituitary patients.
Mm-hmm. So this is a patient who maybe had a traumatic brain injury or brain surgery and either the pituitary is cut off from the hypothalamus or it was taken out during surgery. And so these patients can be really complex, need all of their endocrine [00:56:00] hormones supplemented and it’s most appropriate to be with an endocrinologist.
Dr. Hare: Yeah. That’s a significant number of replacements that you’re doing for that. I have seen patients with galactorrhea mm-hmm. And breast formation. And then I’ve also seen patients who have a little bit of that bilateral hemianopia, the bi temporal, excuse me.
Mm-hmm. Hemianopsia where their, vision is starting to clamp down a little bit. Mm-hmm. And that’s because where that pituitary adenoma lives in the sella turcica can push on the optic chiasm and can present with that very characteristic, , peripheral vision being lost over time.
The last one on your list here is the genetic endocrine side of things.
MEN one and two.
Paige Thompson: Yeah. So this is very rare, but I’d like to mention it just because MEN one and MEN two are mentioned on a lot of drug commercials. So I think I’m, I might have one patient with MEN one but this is multiple endocrine neoplasia syndrome, type one or type two. Type two has several [00:57:00] kinds, but MEN one tends to have tumors in the pituitary, the parathyroid, and the pancreas, whereas MEN two can have variations of tumors on the thyroid, parathyroid and adrenal.
So typically when we have a patient with this, we’ll have A family of patients because it is genetic, it’s dominant, it’s gonna be passed down. And so I have lots of patients with multiple endocrine problems, but you wanna make sure it’s not following one of these types. Okay. Where you would need to send them to genetic testing and, and tell their family members that they would have a chance to develop some of these tumors.
So we would increase monitoring for them.
Dr. Hare: How common is genetic testing in general amongst all of the conditions that we have discussed today? Is it a frequent referral for genetic testing or not?
Paige Thompson: The genetic testing I mentioned in thyroid cancer is just like an extra pathology test that they will do.
But otherwise other types of genetic [00:58:00] testing, it’s fairly common. There are some genetic diabetes syndromes that you can screen for Maybe about 10% of our total patients at some point will be referred for genetic testing, but it’s probably a little less than that.
Dr. Hare: That’s good to know. Mm-hmm. That’s, you know, it is, it is certainly becoming more common across specialties.
Paige Thompson: Yes. And it’s hard to get into. Yeah. I do have a patient now that I think of it, who has really very rare parathyroid carcinoma. And so she is being referred to genetic testing just because of how rare that diagnosis is.
So if we have rare stuff, we will typically send them.
Dr. Hare: Yeah. The zebras show up and it’s time to start looking at all avenues for potential causation.
What’s your advice to PA students in general?
Paige Thompson: My advice to PA students in general during the first year is definitely to have a good group of friends that you can study with. That definitely helped me get through the [00:59:00] didactic year. And then you also bond with some of your classmates who will know what you’re going through as a PA as well.
And then a major piece of advice for clinical year is to really just go into a rotation and ask for what you want. Seek out opportunities, make the rotation your own.
I became more interested in diabetes in my transplant surgery rotation and my family medicine rotation because I had preceptors who had a special interest in it and told me about it.
So that didn’t happen. I don’t know that I would be in this job.
Dr. Hare: Keeping an open mind to those kind of things, you know, you’re a good example of how you can get out in the community, see something that you really like, never realized and and run with
Paige Thompson: it. Yeah. I thought I wanted to go into surgery or cardiology when I came in, and I liked those rotations, but I like endocrine a lot more.
Dr. Hare: Well, I’m sure that our students and our listeners as well, appreciate your experience and and your willingness to share with us today. [01:00:00] Certainly this has been a a joy to speak with you and I really appreciate you coming back. It, it is, as I said before, it is a really humbling experience to have my.
Graduates come back and, and to be able to tell me all about the things that I taught ’em a little bit about. But then they come back and tell me all about the ways in which they’re using that and taking it to significant heights , after graduation. So really appreciate your time today.
Paige Thompson: Yeah, thank you for having me. I enjoyed it too.
Dr. Hare: Many thanks to our esteemed guest, Paige Thompson, Endocrinology and Diabetes Physician Assistant. That’s it for now, Be sure to check out the podcast website, at beexcitedHQ.com for more episodes, show notes and full transcripts of every show. Email us at [email protected], with questions, comments, or future show suggestions. And of course, follow us on Facebook and Instragram at Be Excited podcast for news, new episode notifications, and maybe a picture or 2. Thanks for listening, and…..Remain Excited!
