Richard M. Plotzker, MD


January 13, 2023

Ten years have elapsed since my first Medscape "Hormone Happenings" column. Retirement, now 4 years along, shifted my perspective on endocrinology considerably. Being on-site most days offered immersion into the pageant of both in- and outpatient care, along with a solemn responsibility to nurture my medical successors and follow the teachings of my own sages, who were always willing to incorporate the new. And new had a way of dangling itself for easy entry into people's awareness.

"This is great," referring to new treatment options, mingled with "this is a medical reversal," when my residents began imaging everything that can be captured internally without actually examining patients who have surfaces that various scans can overlook. Once I no longer had to check into the office every day and with patient data on the computer my medical center provided, the perspective of endocrinology and what to include in this column each month shifted considerably.

Although I was still involved in some professional interaction at regional endocrine society meetings, most exploration of endocrinology required personal effort performed in isolation. Because I continued to renew my two state licenses every other year, the search for CME, primarily in endocrinology as my mental interest, took me to clusters of programming.

If there were a lot of videos on SGLT2 inhibitors for heart and kidney protection, first for people with diabetes and later expanding to everyone, this must be endocrinology's cutting edge, something I would have been enthusiastically pursuing with my patients. I may be retired, but lots of people continue to be medically creative after retirement. So, I did what I should have been doing when I was still seeing patients: those daily briefings from the Endocrine Society that never got opened, and a full title review of my key journals kept mostly in a pile, often unopened, now were opened each month. My mind shifted from relating experiences I had to describing pioneering results that others reported. Being part of the experience and looking in from the outside both have value. As a consequence, Hormone Happenings completes a 10-year run in a different place from where it began.

As we enter each new calendar year, numerous sources provide high points of what happened in the past year. Examining a 10-year span generates themes more than a series of random events. The 10 years of "Hormone Happenings" also progressed amid themes. Perhaps we have more external impositions than before, some introduced by those with financial authority over us, some by groups with electoral authority over us, some by a global pandemic. But I believe we also resisted appropriately, sometimes successfully, and acquiesced when it was expedient to move on to things we could influence.

I believe the record will show that we acquired more sensitivity to our patients during that interval and a determination to advocate for them when we could. I also believe we have increased our camaraderie as physicians, as many of us gave up our individual practices to accept salaries from medical institutions, to say nothing of rising to the occasion in the most ominous months of COVID-19, which acclimated us to assessing patients on a screen.

Illustrations to support this conclusion abound, but I'll select a few. For those old enough to remember, our approach to people with obesity was once one of despair, sending somebody to the shop for C-clamps to merge two stretchers or beds. We did damage control, maximizing PaO2, minimizing glucose, bringing in the dietitian as a formality. As our treatment options became more effective, we replaced frustration with challenge. Choosing who to refer for surgery, or carving into our days considerable phone time to sweet-talk the prescription plan rep to authorize hypoglycemic agents that were not on the insurer's cascade but would promote the desired weight reduction.

We moved U500 insulin, an underused option for generations, to mainstream use. Every patient waiting area now has double seats. Large blood pressure cuffs have become standard equipment. In these 10 (or more) years, we or our organizations have used our professional stature to mitigate some of the financial meltdown that many of our patients experience from escalating insulin pricing, either by using our individual expertise to adapt prescriptions to less expensive but still effective human insulins, or organizationally by advocating for caps on out-of-pocket expenditures to what we think would best serve our patients with diabetes. Much of this has been provider-generated, not imposed by external forces.

This 10-year interval began with an onerous external imposition: Certification every 10 years could be managed with little difficulty other than the uncertainties of a single high-stakes exam. Replace that with rigid MOC obligations, all to be absorbed into schedules squeezed by our mandatory EHRs, and we now need our professional societies to intervene.

Although it might be in the organizations' interests to sell us more CME, for the most part the organizations we joined had our backs. Likewise, the medical networks that brought us aboard did not ignore our mostly negative feedback on particular EHRs. Mine changed vendors three times, at considerable institutional disruption and expense. When we indicated an inability to express on the EHR our thoughtful summary as free text, an investment in voice recognition capability soon relieved this limitation. At least parts of our records, mostly the summary conclusions, now read like a trained expert thought out the problem and what needed to be done about it.

During these 10 years, committee work, at least for me, became more purposeful and less perfunctory. And those fellows currently being trained to join the endocrinology mainstream will be able to get in on the ground floor of Big Data. They will gain insights that can only be obtained from computer sorting of massive datasets that will disclose new insights into our common conditions and which treatment options are really most helpful. Their next 10 years should be very professionally rewarding.

It has been a privilege to contribute elements of experience and insight and sometimes literature exploration to the many readers of Medscape Endocrinology for so long. May you all go from strength to strength.

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