Hi, everyone, and welcome. We're waiting for a few more to join before we get started. We'll give it just another minute to see if anyone else is joining. All right, Dr. Lo Wong, I think we can go ahead and get started. Perfect. Thank you so much, Jenny. Welcome to everyone, and thank you so much for logging in today for today's ADA Scholars webinar. My name is Dr. Cecilia Lo Wong. I'm a professor of medicine at the University of Colorado, and I have the great pleasure of moderating today's webinar. I also serve as a treasurer for American College of Diabetology, and we are very, very happy to be hosting today's career exploration webinar. So first, before we move on, I wanted to give Jenny McCoy the stage to give a brief introduction. Thank you. Hi, everyone. My name is Jenny McCoy. I'm the director of the American College of Diabetology, and we're very excited to have you all join us tonight to learn more about us and about the diabetologists that we support. We are a physician-led organization that's working to elevate and support education and training for primary care physicians that are working in diabetes care, and we're doing that by expanding and accrediting diabetes fellowship programs, by board certifying the physicians that have completed the training, and by providing education like our annual conferences. Our next one is in September in Denver, Colorado, and with webinars like this. So we're very excited to have you here, and if you have any questions, you're always welcome to reach out and contact us. Thanks for coming. Thank you, Jenny. So what we're going to do is have each of our panelists give a brief introduction, about five minutes with their name, their current position, their training background, their current work and practice setting, and then we'll open things up to your questions. And so we have four panelists today, four distinguished panelists, Dr. Jay Shubrook, Dr. Shazly Nasir, Dr. Carlos Mendez, and Dr. Sterling Ridley. So I think I'd like to start with Dr. Jay Shubrook. Good evening, everyone. We're so delighted you're here, and we're excited to share our kind of journeys with you. I would say that I introduced myself as a board certified family physician and a fellowship trained diabetologist. I did my initial training in family medicine, absolutely loved it. It was a great career for me, but I was in rural Ohio, and basically diabetes ate my practice. More and more people were coming, and I just had to find a way to do it better than I could do it in the current setting. So in 2004, I worked with one of my mentors and did a fellowship. I was the first fellow from Ohio University, and then I continued on and have been doing diabetes exclusively ever since. I have worked in a variety of environments, including university-based settings, private practice, but as an employee, and then now currently in FQHCs. So I can share the kind of breadth of different experiences, and I currently serve as the outgoing chair of the executive board of the American College of Diabetology, and we're so delighted that you're here, and we thank ADA for partnering with us on this webinar. Thank you, Jay. And next, Dr. Nasir. Hi, I'm Dr. Shastri Nasir. Just like Dr. Shubrook, I'm actually also family medicine by background, and I did it from University of Oklahoma, 2006. My inspiration and my journey and my passion all started in diabetes when I started to work for Tribal Health System. That's my first job out of the, you know, residency. Two years I was a faculty, then later I found Tribal Health System. It was so overwhelming. I've never seen so many patients, just like Dr. Shubrook said, eating up our practice. So at that time, we ended up splitting our practice. There was a new concept with my director into family medicine track and into actually diabetes track at that time. We had, we were running two parallel clinics in the clinic. It was so overwhelming. In the rural area, very rural in Oklahoma. Long story short, I was self-taught for a longer period of time. Then I found the fellowship in Eastern Carolina University and I hit the gold mine. So my training was equal to worth of 10 years of training that I could learn. And since then, my 60 to 70 percent practice has been diabetology, but mostly it has been like a created positions for me. Currently, I'm working for a Tribal Health System again for the past two years as a contact provider. And my job, they actually created this position for me because they wanted to restructure their diabetes care center that they had that was not functioning very well. So I have been in different practices, just like Dr. Shubrook said, private practice, but I have found three areas where our need is the most. Tribal Health Systems, VA systems, county health systems, and community clinics. So I was very lucky. I suggest everybody does do their fellowships. Terrific. Thank you so much. And next on my screen is Dr. Mendez. Hi, everyone. Nice to be here. Thanks for the invitation. Yeah. So my story, I'm an internal medicine, basically trained diabetologist as well. Basically, my journey started and doing my internal medicine residency in Chicago and Cook County Hospital. Basically, I always thought I wanted to do cardiology and kind of halfway through my residency, I started changing my mind, even that I was more oriented to, I don't know, the preventative side of things. And I have a very strong family history of diabetes and, you know, in my family. And I started getting interested about metabolic syndrome and started, you know, atherogenic dyslipidemia and found a very interesting fit in the diabetes world. So back then you had to apply for your fellowship in the second year. And I was running a little late for the endocrine fellowship cycle. So I said to myself, I found actually through a friend, the history of the fellowship in East Carolina University, where Nasir also went. And, you know, he put me in touch with this fellow there. And I asked her, Hey, how are you doing? Oh, it's great. She told me all about it. And I said, well, you know, I, if I get in, then I'll do this one year and then I'll do endocrinology after, I guess, I'll try to apply for endocrinology and see how it goes. And, you know, sufficient to say that after I got in and I started my fellowship, my, you know, career really, you know, basically found what I wanted to do. And I fell in love with it. I was very passionate and I, I didn't really see that there was a big gap where, you know, you know, internal medicine or primary care physicians were really struggling to cover. And in a way endocrinology wasn't reaching there either. So with that, I was really happy to not apply for an endocrinology fellowship, but to see if, if there was career paths and it was daunting at the beginning, I wasn't sure on the halfway up through my fellowship, what I was going to do with my life, but I Googled a diabetologist job. And for some crazy reason in upstate New York and all, and I wasn't a J1 visa in case anybody knows what that is. So I needed somebody to sponsor a visa too. So I found the VA in upstate New York and Albany was hiring for a diabetologist, believe it or not. And in their requirements, it was not necessarily that you needed to be an endocrinologist. So I just picked up the phone or email and say, Hey, it sounds like, you know, it could be a match or a good fit. And right after my fellowship, I went, my first job was at the VA in Albany, upstate New York. That was in 2009. So that tells a little bit how old it goes back. And then I basically been with a VA ever since. I took a, so my first job was basically, I was in charge of the diabetes program of a VA. I needed to basically design and lifted, you know, and I felt very well equipped to do stuff that nobody was doing. And I, and I, and I, you know, I was very fortunate to have that opportunity. I moved to Milwaukee 2015. My wife is from here, so we had to move. And basically since then, I've also worked for the medical college of Wisconsin, which is my academic affiliate. And I still work for a VA as well. And yeah, I think that's kind of summarizes my experience. Thank you. Terrific. Thank you. And Dr. Ridley. Hello, good evening, everyone. My name is Sterling Ridley. I'm a board certified family medicine physician. I completed my family medicine residency in 2018. I became interested in diabetes actually during my residency. So my second year, I was a junior chief resident and they had something called a diabetes summit. So we went to a diabetes summit in Tampa, Florida, where we got to learn about all the different diabetes medications, the insulin pumps and the continuous glucose monitors. And I was like, you know, this is really, really interesting. Also had some faculty that were on staff at that time, Dr. Eugene Wright, who kind of talked to me all about my interest in diabetes. And at that time, we had a fellow at Southern Regional AHEC in Fayetteville, North Carolina. So after I completed my family medicine residency, I went on to do my diabetes fellowship at Southern Regional AHEC and completed the fellowship. I stayed on as clinical faculty for the residents and also as clinical faculty for our diabetes fellowship program. So there's been, it was generally, primarily outpatient that I was managing type one, type two diabetes, atypical diabetes, but also going into the hospital with our residents for teaching opportunities for difficult to manage patients. During that time, we've also been able to have residents that do rotations with us for diabetes or medical students. And then since then, I've kind of gone on to do more administrative stuff. So I did full-time diabetology for about three years. And then since then, I've done about half the time in diabetology, other half as medical director and vice president of clinical education for our family medicine residency and clinical practice. So a lot more time with administrative projects and quality improvement projects, a lot of them related to diabetes, whether it be getting A1Cs down or foot exams, retinal exams. So trying to help identify areas for improvement and opportunities or different trials that we can do to kind of improve some clinical outcomes within our clinic. So it's kind of been my journey so far. I really enjoyed my experience and kind of what it allows me to do within the realm of primary care. Perfect. Thank you all. So I'm hearing some common threads. So when you first got interested in diabetes, but I also hear that you have a variety of different backgrounds. So I wanted to ask the attendees to, I wanted to welcome you guys to type questions into the Q&A. What I'm not sure is if we're able to hear people if they unmute themselves, but for sure, I've got the Q&A box open. So if you've got any questions, please go ahead and type them in. But I do have a bunch of questions for our panelists. So what I was wondering if we could start with Dr. Shoebrook, if you could tell us, I know you wear a variety of different hats and what, I guess, what's a typical day or typical week like and for you and what are some of the different hats you wear? Sure. And I think we'll have probably good variety here. So I'm at an academic institution. So that really defines kind of some of my activities. So I do diabetes consults and co-management two days a week. So Tuesday, Thursday are my clinical days, and I go to different centers in the region with our diabetes fellow and, and provide those services. On Monday and Friday, they're typically my research days. And so I do a number of clinical trials. Some of them are from pharma, some of them are NIH funded, some of them are ones that we've written. And so those are typically my research days. And then Wednesday is my administrative and teaching day. And my teaching is a relatively small part of my job. Most of the teaching we do is with residents and with fellows. And so unlike many other medical school faculty, I'm more research and less teaching. Interesting. And we have a question from the chat. So, or from the Q&A. So the question, actually, I'm going to go ahead and ask Dr. Ridley this question. So are we starting to see any cardiology groups who are interested in hiring a diabetologist to help manage heart patients with diabetes? I wonder if you're seeing that in your, your practice setting. Um, I've definitely seen increase in recruitment in regards to cardiology groups or obesity centers, things of that nature, endocrinology groups as well for diabetes. You know, for me, once I became a diabetologist and, and, and kind of had some, you know, publishings and things of that nature out there, you know, I have seen some open recruitment for that because they are seeing the benefit in, you know, looking at the whole cardiometabolic, you know, combination. So I would say that you're seeing more and more areas of focus in regards to, you know, trying to get the, you know, blood sugar or diabetes under control within other specialties. Absolutely. Yeah. And, um, I think certainly, uh, places that I've heard this happening, this happening, um, the university of Colorado has hired some, you know, has endocrinologists on faculty to manage, help manage the GLP-1 receptor agonists. And I know that Baylor has done that as well. I'm seeing Dr. Nasir nodding. I wonder if you've noticed that in your practice setting as well. What I've learned over the past few years was that the endocrinology practices, they need diabetologists. There's a huge need. I was in private practice for almost two years, uh, after I finished my fellowship, but the problem is with the corporate culture. I mean, I was working with an endocrinologist and we were the only two people serving 200 mile radius. And there was like a, like, you know, you see these, uh, like, uh, food deserts. That's how it felt like there was a desert out there and there was nobody to take care of them. So I was very happy when they hired me and it was, I had a hundred referrals sitting on my desk, right on day one. But the problem was, you know, it cost them a budget and then they let you go, but there is a huge need if they work. And if they would like to collaborate with us, we can serve them. They can do their endocrine part. We can take over the diabetes part. He was overwhelmed. He was seeing 30 to 35 patients a day. And he was relieved when I joined the practice, not every system recognizes this. Unfortunately in Texas, Dallas area, I've tried and tried to convince a lot of practices when I interviewed with them that I can start a diabetes track for them. They were really not into it when they actually had a huge need. So they have actually shut down their diabetes practices because of poor reimbursement. So, but there is a need definitely, and it works really well. It's a win-win situation. I've done that for two years. He was happy. I was happy. The corporate wasn't happy. So I think that definitely different settings can be quite different. And I wonder if Dr. Mendez, there's a question also, you know, and I think we've heard some of the challenges. What are some either challenging aspects you've found from being a clinical diabetologist and or rewarding aspects as well? Yeah. So I'd say that the challenge is obviously the need to be creative and, you know, to really basically carve your way, you know, out or in and negotiate, negotiate, talk to people, collaborate that, that it can be a little tricky because things are not necessarily pre set for you. Having said that, that I think opens to, you know, the most basically rewarding things, which is then you are walking a path that it hasn't necessarily been walked before. And you are, you know, really kind of seeing a lot of results or, you know, like basically taking fruits really early of things that you're doing. So, I mean, for me, it has been a really, you know, yeah, great basically having the opportunity to work with alongside endocrinologists many times, work alongside, you know, chief of medicine and so forth who have given me their basically trust to, well, let's see what we can do and how can we can work together. And, you know, I think that's been, yeah, the highlights, I would say, of being a clinical diabetologist for me. So being able to kind of design your niche, I guess, and then also seeing the patients that you see and then working with people who are really passionate about this, sounds like. So, Dr. Shoebrook, here's a question that I would love to hear your answer for. So how do you navigate a system when there's an endocrine or multispecialty practice? And so how do you tailor patients appropriately for being a diabetes provider? Just so I understand the question. So joining an existing practice that already has multispecialty, how do you fit? Exactly. Okay. Well, I think that, you know, first and most important, we need every one of us. We need every one of those specialists and we still need more. So I think that you're becoming part of a team and in, at least in my experience, you're often the bridge builder. So I have brought nephrologists and cardiologists together because I can share that space between them. And I, you know, having, and this is my personal opinion, I'm not assuming this is everyone's opinion, that my primary care training allows me to have that longitudinal view of a patient and a condition. And so I'm very much focused on that. And so I can help with the transactional occurrences that occur with the other specialties and communicate with them regularly. And so I think, you know, you had asked earlier about where people fit. We've had nephrologists community, or recruiting diabetologists, but I think you fit right in the middle and could be on any one of those teams. And you could be a bridge builder and again, make sure you stay in your lane. I think I'm very clear that I am not an endocrinologist. I don't do all those other endocrines beyond what I was trained in my primary specialty. I'm really just focused on diabetes and it's sufficiently complicated enough that giving it a focus makes everyone else's job easier. So would you say that this answer can kind of vary depending on the practice setting that you're in whether you're in. So, you know, this question was about endocrine or multi-specialty practices, but I think that, I think one of the questions that we'll often get is, you know, are you still seeing patients as a primary care provider? Are you focusing on diabetes patients? And then which, what do those diabetes patients look like? Is it more of the complex ones or, you know, more type one or does it really vary? And so I was going to ask Dr. Ridley if you could kind of describe the patients that you see in your practice. Is it, I guess, what different kinds of diabetes patients might you see? And then do you see any primary care patients? Yeah, so I actually do still see some primary care patients. They're my patients from when I was a resident. So I kind of kept my panel in regards to when I was a resident. So I don't take any new family medicine patients. In my practice, it's a little bit different because we, I get inside consults from providers within our practice. So we have with all the different residents and our mid-levels and other attending physicians. So we may have 35 providers in the clinic. But I would say roughly half of the consults that I get are actually from outside providers. And I just am very clear that, you know, just kind of explaining my role. I'm a family medicine physician. I'm a board certified diabetologist. I deal with just diabetes, kind of explain my role to the patients. For some patients that I see, they're very complicated. So maybe dealing with concentrated insulin or insulin pumps or patients with some forms of atypical diabetes. There's even been times where I've taken care of patients that are pregnant because we don't have a maternal fetal medicine doctor that can kind of manage the diabetes throughout. So I've gotten referrals for that. So I've seen some of the complicated and I've had some of the ones that aren't so complicated. Maybe they just have a lot, maybe their diabetes isn't complicated, but they have a lot of other conditions that the primary care providers are kind of overwhelmed by the sheer amount of other chronic conditions that they're dealing with. They may send them to me so that I can give them, you know, proper education and follow up with their diabetes. But yeah, it's a good mixture. I would say the majority of my patients are usually have some comorbidities, a lot of patients on insulin pumps, even some type, even type two patients on insulin pumps, type one, a lot of CGMs. But then I have some patients that maybe aren't so complicated that are also referred to me. And so I'm more than happy to take care of them. And then I just try to educate for internally, I try to educate our residents so that they're not referring, you know, patients that maybe I need them to kind of learn how to manage because they may go to a place that doesn't have a diabetologist or an endocrinologist, and they're going to be responsible for managing everything. So making sure that if there's learning opportunities, yeah, I'll kind of consult and see the patient, but then try to get them back over to the resident and kind of help guide them, manage the patients. That's kind of the mixture of patients that I see. I see a little bit of peds as well. We still have a pediatric endocrinologist, but during my fellowship, I worked with her. So I have a lot of patients that are kind of aging out of her practice that come in and establish with me as well. That's a pretty wide variety of patients that you're seeing from the primary care patients, which are very complex. I feel like that's some of the most complex patients to patients with type two on insulin pumps, concentrated insulins, probably atypical diabetes, pregnant patients. Dr. Nasir, I wondered in your setting in tribal health, if you could describe what that's like. So I actually, I'm on two tracks. My part-time job is for the tribal health. It's a whole diabetes center that I was hired to restructure. So I have been part administrative, part clinician in a way that their services were there, but they were not functioning. So I have trained a lot of staff over the period of two years, including from creating a flow for the clinic, training a mid-level nurse practitioner, training a diabetes educator right from scratch. Because I was trained as a lifestyle consultant, I'm board certified in the lifestyle medicine. I did my own nutrition counseling. So that was part of my job to train everybody from front to back in the clinic. So that made a huge difference in two years. On top of that, I was seeing now that the services are on board, we see a very high complexity of patients. I mean, the average that we start seeing in our clinic that are referred to us by primary care department, we are trying to collaborate with the primary care in the tribal health. So they have understanding what are, how our clinic and center functions. Average is minimum 12 and the highest I've seen is 17. So we see a whole garden variety of typical diabetes, atypical diabetes, lots of CGMs, insulin pumps that we actually start them on insulin pumps and technology. But it's a very, I would say to me, it's interesting and it's challenging because every day you have a challenge. So pediatric to adult transition patients, we have a pediatric endocrinologist. Then we see a lot of OB patients as well too. So it's quite a variety, all age groups, all types of diabetes that you can find in textbook. We'll see it over here from one end to the other end with a lot of complications. So they have a wound care center, but I had a background in wound care. I did it in my fellowship. I did electives in wound care too. So I do manage some basic and I send them to the wound care center. So it's a very like a full fledged, all service kind of center over here that we have created over two years. Interesting. So in the John Peter Smith hospital system, where my other part is that was employee health clinic, I offered to create a parallel track with the family medicine. So I see half family medicine sometimes, and I see half diabetes patients that want to come and see me. Okay, perfect. So I think this question I'd like to direct to Dr. Shoebrook. So it's about diabetes fellowships. And so as chair of American College of Diabetology, the question is, is there a pathway for fellowships for current primary care physicians who are working and want to continue to work while they're doing a fellowship? Yeah. And that's an important and a very, very common question. So we have a pathway for both people, but I would say that currently all of the fellowships are standardized. So they're one year long and they are full-time fellowships. So if you want to be fellowship trained, all the current fellowships that are part of ACD and there are now 11 in the country, they all follow the same pathway. So there isn't like a weekend warrior version. That being said, we know that we're not going to fix the diabetes epidemic with fellowships alone. And so there is currently a time limited pathway for those primary care clinicians that have ample experience with diabetes. They can meet the CME requirements and the experience requirements and test in so that they would become a board certified diabetologist. And so you'll notice that we say fellowship trained, and then we'll eventually take in the boards or board certified, and you can be board certified either by the exam or the fellowship. We do hope that we will offer educational offerings, even for people who aren't going to specialize in diabetes. But that will be coming down the road. We want to sure up the taxonomy and the accreditation for this program, and then we'll continue to expand to include other people who might want to have just more experience with diabetes, because we have a lot to offer educationally. Did I answer what you were looking for? Yeah, I think so. So it sounds like there's a pathway for people who would like to become board certified in diabetology to be able to do that while they're doing their work. But then in terms of fellowships, these are right now dedicated one-year fellowships that you would need to do full-time. Yeah, and if you do a fellowship and complete it, you are automatically board eligible, and there is no time limit to that because you did the training. It's just a matter when you take the boards. If you did not do a fellowship, you have this small window to meet CMS requirements to say that you can test in. So if you're interested, now's the time. Absolutely. And now the next question is for Dr. Mendez, because you have background in internal medicine. So the question is, for people who do diabetology after internal medicine, so as opposed to doing this after family practice, do you anticipate having to take care of kids, or is it reasonable to say that one might not have the expertise to care for PEDS patients? Yeah, great question. I think it's going to depend on the program that you choose. At ECU, East Carolina University, we had a pretty good exposure to pediatric endocrine diabetology. We would rotate at least once or twice a week in a clinic, outpatient. That was only outpatient. I never did any inpatient. And we saw a lot of pediatric, which is, to be honest, I didn't think it was that different for the most part, especially when we didn't do any neonates or any super early. We did do OB-GYN, now that I think about it, so we did help manage patients in labor and delivery, basically obstetric patients. So anyway, I think if you want to, for sure, you could. That's the last kid I saw was there, and since I went to the VA, I've never seen anybody younger than 18. And in my practice at the medical college, it's about the same. So I've only done adult diabetes since. Okay, terrific. And so my next question is for Dr. Ridley. So who are some of the people that you might interact with in the course of a typical day as part of your professional work? So who are some of the other team members? And then in terms of the administrative work that you do, who are you interacting with, so both clinical as well as the administrative? So clinical, generally, I start the day, I kind of prep my notes because I'm in clinic every day, but it's just a half day every day. And I will speak with my medical assistant to kind of make sure that all my stuff is printed out. So my insulin pump, CGMs are printed out ahead of time so that I can review before I go in the room. We have multiple other specialists within our clinic. So there may be patients that I refer over to podiatry or have a question. So we have podiatrists in house that I will ask questions if I have wounds or something of that nature within a patient that I may see. I also have an endocrinologist also in house that used to be a diabetologist. And so there's some times that I'll bounce ideas off where they're having other endocrine issues. And I'm like, hey, take care of this diabetes, but this is an endocrine issue that I don't feel comfortable taking care of. And so I may refer over to you. I talk a lot to cardiologists, nephrologists on a regular basis. I just have them in my cell phone in regards to medication changes. A lot of OBGYN doctors as well on a regular basis. So I may not talk to every one of those on a daily basis, but usually I'm picking up the phone and talking to one of the other providers in regards to a mutual patient we're caring for, or if it's in the primary care doctor as well. And ortho as well, if they're doing injections. So there's a lot of stuff. As far as administrative, let me see. So a lot of meetings. So talking with the president and CEO of our company, setting up and also discussing with our specialty clinic manager and going over budgets and looking at just the overall clinic operations. So we have a lot of quality information that we get and we have quality information meetings that we go over certain metrics. And then it's my job to take all that information, come up with plans that we can all agree about or agree with, and then disseminate that information to the different providers within the clinic. So yeah, some days are very busy. Some days, I would say the clinic part is the fun part. I would say that seeing the patients is definitely the fun part. The administrative stuff, that's where I think that I've kind of learned the most over the most recent years. And I would say if I were in residency, I would never kind of envision myself in the position that I am now. I just kind of naturally grew. I started off doing the diabetes and then I needed somebody that was in clinic and had a lot of exposure to be the medical director. I did that for a couple of years and then needed the vice president for clinical education and just kind of grew upon from the previous experience. And I've enjoyed it, but it's definitely wearing a lot of different hats and trying to manage it. Some days are easier than others, that's for sure. That sounds incredibly multifaceted. I mean, what I'm hearing from all of you is that as diabetologists, you're really kind of interacting with lots of other different specialties and then kind of the center or maybe a hub because our diabetes patients end up having to often deal with many different specialties, many different complications, comorbidities, et cetera. And then lots of different staff. So for example, our diabetes educators and other specialists, pharmacists. So I wonder, let's see. Oh, actually here's a great question for Dr. Shubrik. So this is a little bit related to something that you may have been answering a little earlier. So can you speak to co-managing other endocrine concerns when practicing diabetes? So where does everyone draw the line in diabetes versus endocrinology? And this may be individualized depending on comfort level, but we can start by maybe asking Dr. Shubrik to answer this and then I'll ask everyone else on the panel as well. Yeah, as one of the early diabetologists, I've tried to be very, very particular about what I did and what I did not do because I had like, for example, one of the private practices was an endocrinologist and myself and the endocrinologist retired. And they said, well, can you just manage those things? And I said, that's actually not what my training was. And he says, well, the endocrinologist thinks you've got it. And I'm like, well, I appreciate that, but that's, you know, I want to make sure that whoever's getting the care is getting the right person for that particular thing. So I might have some opinions based on my training in family medicine. And certainly I can talk to say, hey, you need to see an endocrinologist for this, or you can go back to your primary because I don't do any primary care. But I think as a young profession, especially as people don't know us, I have taken the more conservative route to say, I'm going to be very clear that I do diabetes and diabetes related conditions, but the other endocrine problems, I really want to make sure you see an endocrinologist, or if it's something that your primary care can handle comfortably, go back to your primary care, because I want to make sure my role is very clear. And I'm, I'm guessing that maybe it's a little bit easier to do that if you are not seeing primary care patients because there is so much, I mean, they're blurring of the lines with endocrine and primary care. So many of the, for example, osteoporosis or thyroid disorders and things like that, you know, lipid disorders, one would see those in primary care as well. But I think that if you were to, you know, focus only on diabetes, then maybe it's a little bit easier to not be doing these other endocrine issues. But I wonder if Dr. Nasir, what is, how does this look like for you? Do you need to, how do you draw the line between diabetes and endocrinology? Exactly the same way like Dr. Shabroop does, because when I was hired, they actually put me under endocrine. I said, I'm not an endocrinologist. I have to draw the line here. So I explained them what a diabetologist is. So luckily at that time, when I joined the tribal health practice, they had a full-time endocrinologist. So anybody that had endocrine issues like adrenal glands, pituitary gland, or a thyroid that I suspected was a tumor, I would put her on a referral with the endocrinology. So she and I were working parallel. I took her diabetes load. She was doing more endocrine until she went on maternity leave. But we have to draw a line. In primary care, unfortunately, we end up wearing that hat where I have to take some responsibility of the endocrine issues and send them to an endocrinologist or figure something out. In diabetology, we have to draw a clear line. But I tell them, like, for example, I'll give you an example. I got a patient. The primary care pushed a patient on me with hypoglycemia. They think it was adrenal insufficiency. So I saw the patient because the endocrinologist was not there. I said, and I told the patient clearly that I'm a diabetologist. I'll do the evaluation of hypoglycemia workup. If I seemed it was necessary that she had an endocrine issue, I'll actually refer you to an outside endocrinologist. Luckily, she didn't have that. She had no indication of any adrenal insufficiency. So fellowship has trained us enough to separate these two and kind of, like, sort it out. At least we can do some basic workup, which I wasn't able to do much in detail as a primary care. But as a diabetologist, I trained diabetologist, I'm able to, you know, do that. So, yeah, we have to draw a line. And we have to actually sometimes the primary care don't understand. But I actually tell the patients that I'm a diabetologist. I don't deal with endocrine issues. So I don't want you to get your expectations up. But I'll send you in the right direction if I find something. Perfect. And Dr. Mendez, I wonder, has this question come up for you? And how do you navigate that? I think very similarly. I would say very important from the very beginning to kind of set the limits and the boundaries and kind of like what you're willing to do and not do. I'd say I did a lot of inpatient. I was fortunate to have an inpatient endocrinologist. So we got to a point where we were basically we had fellows and we had residents. So we ended up having a diabetes service and then an endocrine service for the inpatient. You know, that got a little complicated, but it worked best like that. And now, like I seen it, for example, in my academic affiliate where I don't do an inpatient. They have that, you know, before I got there. So they had a good inpatient diabetes service and then they had a regular endocrine consult. So for outpatient it's similar. I mean, if you're going to just do diabetes, you do diabetes. And, you know, and if you basically don't do endocrine, then you just basically. So, for example, in the routing of my consults in the triage, it says something like, for example, endocrine consult comes and it would say, you know, any fellow or attending except Dr. Mendez, it says that if it's a thyroid or if it's adrenal. And then if it's diabetes, it say any fellow attending, including Dr. Mendez, to give you an example. So, I mean, it is, you know, a little bit of until the work of Dr. Shoebrook is, you know, putting in this college, it's all sorted out. Some creativity and details have to be filled in, but that's how it's worked for me so far. Okay, thanks. And Dr. Ridley, has this come up for you as well? It has. I would say that for any of my consults, either internally or externally, I deal with only the diabetes. If it's for my chronic patients that I have for family medicine, anything that I feel comfortable in regards to, you know, if it's thyroid condition that's well-controlled or something of that nature, I still manage that for my chronic patients. But for my consults, it is strictly diabetes. Okay, that makes sense. So then I think what I'd like to ask Dr. Shoebrook is, what have you noticed as the most challenging and then also the most rewarding aspects of what you do? Well, most rewarding is easy. I mean, it is so much fun to help somebody with a lifelong condition see the path that works for them and let them thrive. I mean, it just is awesome when people feel like they had a handle on it and they can take care of themselves and they can be healthy. And that to me is, there's nothing more rewarding than that. I think challenges, there's a number of small challenges. I don't know if any of them are insurmountable. You know, you're working with systems that have other agendas. So we're always negotiating the time of patient care. You know, we just implemented a new EMR. And they said, oh, all your visits will be 15 minutes. And I said, well, it doesn't really work. So let's go back and revisit what our visits were before there was a new EMR. And let's kind of stick to that. So you do have to kind of stick to your kind of positions and speak up for yourself. And then I also think, you know, it's still a new world. And often people are trying to figure out what is a diabetologist and how do you fit? And I think we've largely gotten past the taking territory. You know, I actually had more pushback from primary care than I had endocrinology early. Because they said, well, you're doing family medicine and diabetes. And I chose not to do that. And in fact, in California, I had to pick. And that was fine. I think that I was no longer a competing primary care physician. I was just doing a consult service. But, you know, it was hard to say goodbye to my long-term patients. I enjoyed them. So I think those are some of the things. Yeah. Thanks. So Dr. Nasir, I'm wondering if you could describe something that you're working on right now that you're excited about. You know, for the past two years, actually, as I said, I was working on a project where I was restructuring the entire clinic. Helped them utilize all their services and increase the patient number. Because the nutritionist wasn't working full-time. So what I did was help them find the resources where they can get certifications and educate themselves. Because I went to the ACDES conference. I'm a big proponent of diabetes health management. So we have tried to focus more on that. Restructured, introduced group health choice classes for patients. We have actually developed, that was kind of my idea. And it seems like the CEO went on board with it. We were trying to collaborate and actually train and help primary care, entire primary care providers across that tribal health system to be, follow one standard guidelines. Rather than doing hodgepodge there, hodgepodge there. Somebody doing their own thing. So we have helped just finish a 20-topic handbook that I selected specifically topics with our pharmacist. And we are going to eventually train all the primary care providers so they can follow one set of guidelines. We also created a guideline for the clinic staff. For example, what to do when the hypoglycemia happens. What to do when a hypoglycemia happens. So they have some idea of how to tackle that urgency when they come in. So it creates a lot more, I would say much higher quality service. With more efficiency, less of a hassle. And I'll be starting teaching grand rounds to primary care as well for the same reason. Because we all want them to be on board and have a good understanding how they can help us. How we can collaborate with them. How can they take care of their patients as well if we are not available. But diabetes self-management education part has been a big project for me. In addition to that, I have trained the diabetes educator myself. I was very lucky that ECU where I was trained, we actually went through a crash course with the diabetes educator. So I learned that part as well. So it was a win-win situation for me. So I could tell them this is where you need to learn. This is where you need to get certified. And I'm doing a lot of one-to-one teaching. They go in with patients with me. We knew how to do everything from scratch. That's what we learned in our fellowship. As I said, it was a gold mine for me. I learned from A to Z everything 360 degrees. So I was able to train a lot more staff. And it's an ongoing challenge. Now I introduced to them that they can actually start a fellowship program eventually in the next coming years. So we'll see where it goes. But education and training, staff, providers, has been my big thing. No, that sounds terrific. And I wonder if any other questions from our attendees? Last call. So as you're thinking about that, I was wondering, and I thought I would maybe stay with Dr. Nasir, if you had any kind of last parting thoughts or advice for trainees on the webinar? On the webinars? Oh, no, I'm sorry. Today's webinar? Yeah, do you have any parting thoughts or advice for trainees who are on right now? Yeah, I strongly encourage doing a fellowship, actually, because coming from a background of family medicine and trying to self-learn, going through workshops and everything, it was not a structured learning. I've learned some, but I wasn't able to do like a jump in the entire spectrum of level of knowledge until I did my fellowship. So I strongly encouraged if they are passionate about it. One thing you have to be passionate about is this requires a lot of patience. Patience can be very difficult. They can have a lot of social determinants. We have to be very patient. And like Dr. Shabook said, this is not a 15-minute visit. So I had to fight with the system to allow me at least 45 to 60 minutes one session, and then we'll figure it out what to do next. So it requires a lot of patience, and it's a constant learning. That's the second thing I would like to teach them. You cannot stop. Every year there's a new CGM. Every year there's a new pump. Every year there is a new medication. So you have to keep on learning and get the wheel going constantly. You cannot stop and just do the fellowship and say, I'm done. You know, I can manage the best. It's not like that. It's like a, you know, it's like an ongoing battle dealing with the diabetes, and it's actually becoming worse and worse. You will see a lot of atypical cases. So this is where our foundation, if your foundation is good, you can build on it. So the third suggestion that I have is that we have to create our own positions at this time because they are still learning what diabetology is, but it's doable. Where the need is, you can offer them your services, and if they are willing to accept that service, like they did at the county health system and employee health, when I offered it, I thought it was going to take me three months. It took me one month, and my schedule was packed full with employees. So once we offer them what we can do, because I call, Dr. T used to call us, Dr. Tannenberg used to call us, our director. We are a special breed. We are not ordinary people. We have worked our way through the systems. So it's doable. County health systems, community health systems, tribal health systems, VA systems, they have better opportunities than corporate culture because they care more for their patients. Where they care more for their patients and for their community, we have a better position to serve. And that's definitely where the need is. And so, Dr. Ridley, I wonder if you could leave us with some parting thoughts or advice for trainees. I would echo some of the same sentiments that Dr. Nasir mentioned. I think you have to be passionate about diabetes. And then there is enough patients for us all. I mean, the biggest thing is just we're trying to help patients throughout the United States or the world. You know, kind of get a hold of diabetes. And I think the more that you advocate for your position in diabetes, and the more you educate others as far as the value that you bring to not only the patients, but the community, then people will buy in. I think I've seen that, you know, quite a bit, you know, talking with other specialists that were initially maybe a little resistant in regards to diabetology. Now I get referrals from a lot of those same specialists or endocrinologists that weren't maybe sure about what diabetology was to let them know, like, no, this is kind of, you know, I'm staying in my lane, but I'm here to help. And I do offer expertise in diabetes. And so also advocating, you know, for the work that you can provide and are able to provide towards patients, I think it's important to go from there. And then, you know, don't be scared of being part of something new. I think I remember when, you know, finishing my fellowship, we were meeting in California to talk about, you know, setting up the ACD and stuff now. So seeing kind of where it's kind of grown in such a, you know, short period of time, it's, you know, it's really exciting to kind of see the different avenues that have kind of opened up. And so I think it's really neat to see. Absolutely. And Dr. Mendez, I wondered if you could tell us what your parting thoughts are or last advice for trainees. Yeah. Well, I mean, a lot of totally agree with, you know, the comments already made. I guess I would add that if you really, you know, feel this is right for you, that you really are passionate about diabetes, don't be afraid. You know, you will find a way. There will be a path that you will be able to, you know, either create yourself or find that it will allow you to do what you need to do. So be confident that, you know, what you learned and it is needed and you will be helping a lot of people. And don't be afraid to knock on doors, talk to the right people. You know, keep on trying. Some people, you know, have preconceptions. Well, no, that's fine. Nothing happens. Just move on and knock on the next door. And and, you know, you'll be surprised that you will find a place where you will be truly valued. And I'm sure you'll do great things. But being persistent and sticking with it, Dr. Shoebrook, some parting thoughts or advice for trainees? I'm sure. So, first of all, thank you so much for coming and trying to learn more. I think that's the first step. I also very much appreciate all these fabulous diabetologists that are on today and hearing your stories. And I'm so impressed. This is a really fun job. I have a great job and I love what I do and I love all aspects of it. And we need so much more help in diabetes care in this country that we would welcome all team members. So whether you're going to do a fellowship or you're just passionate about diabetes or you're looking for education, we would love to see you be involved with the American College of Diabetology. And for those of you that might want to maintain your primary care, we can offer education. But also the American Diabetes Association has a fabulous platform, the Learning Institute. And they were very important in our inception, in our growth. And so we don't want to duplicate. We want to be supportive and collaborative with other organizations, such as the Endocrine Society and ACE and ADA. So there's room for everyone. And if you're doing primary care and you just need some more help with diabetes, maybe we offer you CME or maybe consultations or just discussions and support. If you want to do diabetes as a focus of your practice, doing a fellowship is going to make you an expert in diabetes. And if you want to do that as the primary focus of your practice, doing a fellowship opens a lot of opportunities for you. But just like other people said, you're a trailblazer. So you do have to kind of stand up for yourself, trust your training and your results will speak for themselves. So we're glad you're here. Absolutely. And I wanted to thank our panelists, Dr. Shoebrook, Nasir, Mendez, Ridley. I really wanted to thank you for your insights today. And I wanted to thank all of our attendees for the questions and for being part of today's webinar. My name, again, is Cecilia Lo Wong. And I think this is the I think we're coming to the end of today's ADA Scholars webinar. And I wanted to thank everyone for being part of this program tonight.

diabetology

career exploration

diabetes prevalence

Dr. Cecilia Lo Wong

board-certified diabetologist

fellowship programs

healthcare advocacy

emerging treatments

continuous education