Endocrinology and diabetes, we have a problem…
Helen Simpson and Louise Hunter | Features
In case you didn’t know, in 2018, endocrinology and diabetes saw only 39% of ST3 posts (the point at which clinical trainees choose their medical specialty) filled after Round 1.
This figure went up to 73% after Round 2. However, these are worrying statistics, showing that many posts in our discipline were left unfilled. Regional overall fill-rates range from 20 to 100%.1 Clearly many do not see a career in endocrinology and diabetes as attractive, yet we know it is the most interesting medical specialty, with vast opportunities, both clinically and academically.
Specialties of comparable size (e.g. respiratory medicine, cardiology, gastroenterology, acute internal medicine) achieved 2018 fill-rates of 80−100%.
A LACK OF EXPOSURE
Some of us have been involved in the two taster days organised by the Society for Endocrinology, the Young Diabetologists and Endocrinologists’ Forum (YDEF) and the Association of British Clinical Diabetologists (ABCD).2 Questionnaires circulated prior to those events suggested that there is little exposure to our specialty for many at undergraduate level or foundation year (FY)/core medical trainee (CMT) grades:
- 64% had done a diabetes and endocrinology placement
- 50% had little or no experience of diabetes/endocrine clinics, and
- 78% did not feel that they had had enough diabetes and endocrinology experience.
Anna Mitchell, Amar Puttanna and others have also looked at the statistics. They surveyed 316 medical students and reported that exposure to all aspects of endocrinology appears to be poor:
- 217 of 316 (69%) reported ‘no’ or ‘little’ exposure to endocrine outpatient clinics
- 197 of 316 (62%) reported ‘no’ or ‘little’ exposure to inpatient endocrinology work
- 131 of 316 (42%) reported ‘no’ or ‘little’ exposure to formal endocrinology teaching.
Of the 98 who reported ‘some’ or ‘plenty of’ exposure to endocrinology outpatient clinics, 14 (14%) were considering a career in the specialty. In comparison, 15 (7%) of the 217 individuals who reported ‘no’ or ‘little’ exposure to endocrinology outpatient clinics were considering diabetes and endocrinology.
Recently, we also held a recruitment ‘fringe’ meeting in Glasgow at the Society for Endocrinology BES conference 2018. In addition to 30 attendees, others contributed by email. Again, a key theme that arose was a lack of exposure of potential recruits to endocrinology and diabetes.
Of those of us working in endocrinology, anecdotal evidence suggests that exposure to endocrinology – and, in particular, attendance at endocrinology clinics and having a mentor or senior person who took an interest in us – contributed to our choice of endocrinology as a career.
SUGGESTIONS FOR CHANGE
None of this is new, so what can we do to improve the situation? It is clear we need to engage with medical students and junior doctors. Suggestions that have been discussed include the following.
- Encouraging student endocrinology societies, with students undertaking projects with us, as part of special study models, etc. There are no data to show that these increase uptake into endocrinology but, anecdotally, it does encourage some.
- Teaching FY trainees.
- Considering initiating FY3 diabetes and endocrinology modules or posts.
- Encouraging individuals at CMT/internal medicine trainee (IMT) grades to attend clinic. This is a challenge but is crucial. Clinic is where many of us had our first experiences of endocrinology and, without it, many will never see what our specialty has to offer.
- Running taster days − locally, regionally and nationally – the next one is in September 2019 in Newcastle upon Tyne.
- Trying different styles of recruitment: we can challenge the status quo in the way we do things. North Wales had no middle grades in their Emergency Departments. However, after a ‘guerrilla’ advertising campaign by Linda Dykes and others, and developing an unofficial website extolling the virtues of living and working in North Wales, they now have no rota gaps.
- Developing jobs with separate funding, such as clinical fellow posts. Funding for these is often linked to general internal medicine (GIM), and uptake can be variable, but they offer a different route by which to recruit into diabetes and endocrinology.
THE IMPACT OF GIM
Perhaps unsurprisingly, another emergent theme was the amount of GIM at specialty trainee level. Endocrinology and diabetes trainees, in the vast majority of their training rotations, participate in the GIM on-call rota. The prospect of being the medical registrar on-call does influence career choices.3 All agreed that making the life of the medical registrar on-call less miserable was crucial. Increased activity, a smaller workforce and a lack of team-working make it a very stressful role in hospital.
Many medical specialties have opted out of GIM, potentially making those fields more attractive to trainees who are put off by the medical registrar role. The implementation of Shape of Training (www.shapeoftraining.co.uk) will change how many specialties contribute to providing GIM care, so the hope is that rota gaps reduce. However, it is noteworthy that some specialties which do currently participate in GIM still have better recruitment statistics than ours. This may be because some of these are procedure-based specialties which have time off the GIM rota, and so do not contribute as many years as part of their training. The Association of British Clinical Diabetologists and the Society for Endocrinology recently published a position statement on the ‘Shape of Training’, read more at www.endocrinology.org/media/3167/sfe_abcd-position-statement.docx.
LOOKING CLOSER TO HOME
However, we have agreed that we can’t attribute poor recruitment purely to GIM. We need to look at ourselves, and examine how we act and what we do. Discussions also considered the current diabetes and endocrinology workforce. Is there widespread recognition of a recruitment problem and widespread willingness to do something about it? Are we (consultants and current trainees) good role models?
As one contributor said, ‘Happy specialist registrars are a particularly good recruiting tool’ –this sums it up! And the same can be said for consultants. What do we project about our work on our ward rounds, in clinics and at meetings with our juniors?
We have a working group within the Society for Endocrinology’s Clinical Committee to move this topic forward. To find out more, email email@example.com.
We will liaise with the Specialist Advisory Committee, the ABCD, the Clinical Reference Group and others. We are also compiling a list of opportunities that endocrine units are offering, so we can identify useful strategies that others can follow. Several people contacted us after the last Society for Endocrinology BES conference to tell us about positive actions they are already undertaking. We will work with the ABCD and the YDEF to have a joint voice nationally.
Together, as a group, we are much more powerful in lobbying for change. The NHS landscape, as always, is changing rapidly, with ever-increasing pressures on its workforce and finances. However, we should not lose hope. Sometimes small changes can make a difference: the FY1 trainee we help today might be the endocrinologist of the future.
Helen Simpson, Consultant Endocrinologist, Department of Diabetes and Endocrinology, UCLH NHS Foundation Trust, London
Louise Hunter, Clinical Research Fellow, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester
- NHS 2018 Endocrinology & Diabetes Mellitus Fill-rates 2013−18 www.st3recruitment.org.uk/webapp/data/media/5c0aa441c2523 E&D_fill-rates_2013-18.pdf.
- Hunter L & Hussain S 2017 The Endocrinologist 126 27.
- Puttanna A et al. 2017 Diabetic Medicine 34 Suppl 1 P260 doi:10.1111/ dme.24_13304.