Speaker 1:

Welcome to AACE Podcasts. Thanks for tuning in as we elevate clinical endocrinology by taking deep dives into trends and topics that can help us improve our patient care and global health. Find the latest episodes on aace.com/podcasts. And now let's meet the endocrine experts who will be talking with us today.

Susan Samson, MD, PhD, FRCPC, FACE:

Hi, I'm Susan Sampson, past president of AACE, and I'm excited today to be talking to my colleagues during this podcast. In the title of our podcast is Meet the Endocrine Care Team. So I will be moderating this session with my guests here today. But first I wanted to kind of set the stage for why we're having this discussion.

So when we think about the population, for example, in the United States, where many of us practice and we care for these patients, we have an epidemic of endocrine diseases and chronic endocrine diseases. So for example, almost 12% of patients in the United States or 12% of people have type two diabetes. And on top of that, we have another nearly a hundred million patients who have pre-diabetes and they may or may not know about that. So this is an incredible number of patients to take care of within the specialty that we call endocrinology.

I think that's why it's been really important to think about how can we serve all of these patients in the United States. If we think about how many endocrinology specialists there are, there are only about 7,000 or 8,000 physicians that have specialized in endocrinology in the United States to take care of these patients. And so this is why we have needed to shift our model to a team approach to take care of all of the endocrine needs for our patients.

And so I have guests today with me who work in all aspects of care for the endocrine care team, and I would just like to go around here today and have them introduce themselves. So Dominique, maybe I'll start with you.

Dominique Uva, MSN, APRN, FNP-C, BC-ADM:

Hello, my name's Dominique Uva. I'm family and acute care trained nurse practitioner who's board certified in Advanced Diabetes Management. I'm the current chair of the endocrine care team for ACE, and I'm also the board liaison. I've been working in the endocrine care space since 2014 providing patient care. I've worked in a variety of settings, including large academic settings, and I'm currently a solo provider in a hospital-based clinic in rural Maine.

Susan Samson, MD, PhD, FRCPC, FACE:

Dominique, when you think about your own practice there, your scope of practice there, how do you work with other physicians, other providers in that local area?

Dominique Uva, MSN, APRN, FNP-C, BC-ADM:

So it's a challenge of rural health. As a solo provider with limited access to specialists, I will say things that I rely on are e-consults with endocrinologists within my health system and within other health systems, along with networking and just having friends and colleagues that are also endocrinologists that I may be able to kind of side consult with. I do not hesitate to refer patients when they become more challenging or I catch something that I can't manage in my small practice. So e-consults have been very helpful, particularly for me.

Susan Samson, MD, PhD, FRCPC, FACE:

Thank you for that. Sonia.

Sonia Bahroo, PA:

I'm Sonia Bahroo, I'm a physician associate. I've been practicing in endocrinology for 20 years now in a variety of settings as well, in a small private practice with only one physician being his first PA to a large academic practice. And then now in a large endocrine private practice, we have eight physicians, three PAs, two NPs, and also vice president of the American Society of Endocrine PAs.

Susan Samson, MD, PhD, FRCPC, FACE:

Excellent. So when you think about the diverse backgrounds of each of these practices where you've worked, how do you manage to confer with your physician colleagues during the day about different patients, or how does that work in your practice there?

Sonia Bahroo, PA:

Sure. Endocrine, as you know, can be very complicated, and so I do not hesitate at all if I need to consult with one of my physician colleagues. Anytime I have questions, anytime I just want to double check on things, I have the physicians readily available, whether they're in person or available by text message or by phone call. They're always accessible to speak to, consult with, answer questions. So that's been a wonderful way of utilizing the physicians. And even NP colleagues, our pharmacist colleagues, other specialists in the care team. It's been a fantastic resource to be able to do that.

Susan Samson, MD, PhD, FRCPC, FACE:

Amazing. Julia?

Julia Blanchette, PhD, RN, BC-ADM, CDCES:

I'm Julia Blanchette. I'm a nurse scientist, but clinically I'm a registered nurse and diabetes care and education specialist. I'm also board certified in advanced Diabetes management and over the past 10 years, I've practiced mostly in the diabetes nurse educator role doing some inpatient diabetes consults, but mostly outpatient education and diabetes technology education at large academic medical centers. And right now I work at a large academic medical center in an outpatient clinic, and I collaborate with all members of the endocrine care team in that role.

Susan Samson, MD, PhD, FRCPC, FACE:

Do you have your own clinics in that role, clinic schedules, and then follow-ups with patients just as you work with them with their diabetes technology and medications?

Julia Blanchette, PhD, RN, BC-ADM, CDCES:

Yeah, that's a great question. So in my previous role also at a large academic medical center outpatient, we did have more clinics set up like for CGM, for diabetes group classes, for new diagnoses. But I'm actually right now in a role where we're still building our programs. So we don't have anything that's super formalized, but I see patients for a variety of reasons. So either primary care or endocrinology will refer to me. I typically see either newly diagnosed individuals, or those who need some education on new diabetes technology.

Susan Samson, MD, PhD, FRCPC, FACE:

Yeah, I've really found, for example, at my institution in our inpatient service, we've been able to expand our diabetes educator services to the weekends now, and that's just been a game-changer because the length of stay is increased if we can't educate patients with new onset diabetes or patients that need a new type of medication for treatment of their diabetes.

And being able to counsel those patients and do demonstrations and teach them about diabetes technology, seven days a week, has just been an amazing addition and has really enabled us to give excellent care to our patients. So really a critical role both outpatient and inpatient and definitely from my experience needing that help. Thank you. Diana.

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES:

Great. Well it's great to be here. So my name is Diana Isaacs and I'm an endocrine pharmacist. I am also board certified in Advanced Diabetes Management and also in DCS. So I am about wrapping up almost nine years at the Cleveland Clinic as part of the Endocrinology and Metabolism Institute. And prior to that I spent about five years in a primary care clinic within the VA.

So in my role, I have a collaborative practice agreement that allows me to be able to prescribe medications and order labs and all of those things. And I really serve as an extension of our endocrinologists and other people on the team. We're a large academic center, so we have a large team. I'm fortunate to get to work with the NPs and the PAs and we even have exercise physiologists and social workers. We have a really nice team.

And where I've really spent a lot of time in my role is specializing in both pregnancy and diabetes technology. Even though I see the gamut of everything diabetes related, pregnancy, there's been a great opportunity just because we're doing this more intensive follow up of every week or every other week, these insulin adjustments or these pump adjustments. And so I spend a lot of time doing that.

And then additionally, for CGM and other insulin pump patients, our technology has gotten so nuanced with all of these different systems, that that's been an area that I've been able to focus on both in educating our team but then also in getting referrals with patients to really help troubleshoot any issues and optimize their settings for their insulin pumps.

Susan Samson, MD, PhD, FRCPC, FACE:

That's so interesting. So I think even though we all work as a team and we all know other team members in all of these different roles, I don't always know how you manage that scope of practice. So I was really intrigued by your collaborative agreement. Is that something that differs from institution to institution or from state to state? How does that work?

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES:

Yeah, there's different laws in different states. Fortunately, almost all states now, allow some level of a collaborative practice agreement with pharmacists. Some states are more progressive than others. So for example, in Ohio, pharmacists actually have provider status, so that allows us to be able to do a little bit more, perhaps, than in some states.

But this is an agreement that is generally signed within the institution and that allows then any of our, like mine is with endocrinology for example, although we also have one with primary care and with maternal fetal medicine as well. But that allows any provider then to be able to refer a patient to me and then we work together, we communicate together on that patient. And it really allows this more coordinated care because otherwise many providers, they maybe every six months they're able to see someone, but someone needs more intensive management. And so we're able to do that through this collaboration.

Susan Samson, MD, PhD, FRCPC, FACE:

Great. Yeah.

Sonia Bahroo, PA:

Actually, I'm glad you mentioned pregnancy because one of my niche roles is managing pregnant patients as well, and I'm glad you brought that up because one of the things is they really do need very, very close monitoring as far as blood sugars, thyroid labs and things like that. And that's a unique role that PAs and NPs can serve as part of the endocrine care team is having the ability in our schedule to be able to schedule these patients very frequently, and that way we can monitor them anytime we run into any issues or there's some complication, we always have our colleagues to go to ask.

But that quick follow up, two weeks, three weeks, one week even. We have that unique ability to be able to put those patients on our schedule and that frees up the doctor's schedule and eases their minds that, okay, somebody is looking at these patients' blood sugars very, very frequently.

Susan Samson, MD, PhD, FRCPC, FACE:

That's a great point. Thank you. Chris.

Chris Yedinak, DNP:

I'm Chris Yedinak and I am a nurse and also an associate professor clinically, and I see apart from everybody else, I actually work at another subspecialty of endocrinology, of which there are many, and I am in pituitary diseases. So we see both patients that have pituitary and adrenal diagnosis.

We have a collaborative neuroendocrine type practice with the neurosurgeons and ophthalmologists, etc. And we don't unfortunately have a pharmacist in our practice, but that would be very helpful. We have two MDs in the program, and we've recently hired a PA, so this is a small practice.

I'm also teaching in online post-master's endocrine program and we have now a number of students in three or four cohorts that we've graduated. So there are two programs in the country and we have a successful online presence at the moment. I'm also the past president of the Endocrine Nurses Society and the Federation of International Nurses in Endocrinology. So very active in both those.

Susan Samson, MD, PhD, FRCPC, FACE:

I'm really intrigued by what you're talking about, because it seems a little bit parallel to the nurse practitioners I work with at my institution. So all of our nurse practitioners do see patients for diabetes and diabetes tech, but they choose one area of endocrinology to really focus on and subspecialize on, and that could be pituitary, it could be thyroid, it can also be bone.

And in doing that, really gain a high level of expertise that really serves to work well. We do what is called a collaborative clinic where I'll see a new patient, the nurse practitioner will see a new patient, we'll review that patient together. And that way they're also have the pleasure of seeing new consults and feeling challenged by being able to figure out what the next steps are.

So not only do my nurse practitioners really help me to be able to follow up my patients in detail so that I can move on to a new patient, but they also have that ability to see the new consults and collaboration with the physician. So I'm fascinated that you do pituitary too. That's wonderful.

Chris Yedinak, DNP:

I think it's an excellent opportunity for people to be able to really do more of a deep dive into a particular subspecialty. I also am deeply involved in ongoing research, and so particularly retrospective studies, but we also do some prospective studies.

So, I find that really not only enhancing and engaging for myself for my own purposes, but then I'm able to deliver a little bit more pertinent information to my patients and they contribute to that information. So it's a great opportunity I think, to help patients to understand what their disease process really is.

And beyond that, then we really need to focus on what is it that helps you to adhere to your particular treatment protocol. And I'm very specific about that being a precision type process. So not one size fits all, in terms of education. And for patients, they need to know many different aspects to be able to control their disease, and self-manage. They literally manage themselves a lot more than they see us. And so they really need to understand that process.

From an education perspective, what I found is there is such a dearth of, as you were mentioning before, endocrinologists in rural areas that the nurse practitioners or PAs that are in those areas need the resources. And in particular, we're talking about nurse practitioners that are working in primary care settings. And so they're responsible, and usually the only provider within that area. And so they don't have the resources to connect. And so understanding what endocrinology is and does, and where to go to be able to refer that patient is essential. And connecting those people together has been very, very rewarding.

Susan Samson, MD, PhD, FRCPC, FACE:

Thank you. And I wonder if I could also, I know your involvement with the endocrine nurses, could you also comment a little bit on one or two roles we don't have here today? One is, you brought up research. One would be the endocrine nurse who's the clinical coordinator for studies, and the other would be the endocrine nurse who is specialized in our very complex endocrine dynamic testing.

Chris Yedinak, DNP:

Not only we have RNs that are doing dynamic testing, but they can also help to do teaching in terms of how to administer medication, when to administer medication. Our nurses are very involved in communicating with patients about their disease process. They understand enough to be able to deliver some effective education and be able to problem solve as the patient goes through their care plan. They also then can help to communicate results, answer questions, because now we have such access for patients 24/7, and so they're able to at least be the primary screener and then connect with us should we need to give more in-depth information or more prescriptions, et cetera. And so that's been an essential role for us to include in our practice setting.

Also, you mentioned research nurses that are involved in research. There's so much more to understand about the regulatory process, and so has indeed become his own specialty in that those that are involved need to really understand the specialty as well, or the subspecialty that they're doing the studies for. And so that's a learning curve for nurses that are branching out into that kind of an environment. And it's essential. Otherwise, we wouldn't have the capacity to be able to do the kinds of research that we really need to be able to do to bring the updated information to patients in terms of treatment planning. So it's a great role.

Susan Samson, MD, PhD, FRCPC, FACE:

Thank you for those comments. So I guess my question here, and I'll open up the floor in a round table, how can endocrinologists, like myself, work with the endocrine care team to really provide that comprehensive clinical care for our patients?

Julia Blanchette, PhD, RN, BC-ADM, CDCES:

So, I think one way that you can collaborate with the diabetes educators is, give us referrals. Because what we can do is if you don't have enough time in clinic who has enough time in clinic with everyone you need to see. And with short appointment time slots, we have time to spend with people with diabetes to provide them education on when they're newly diagnosed, if they're taking a new medication, if they're learning a new technology, or if they just need any help or support problem solving, if they need some glycemic pattern management support, anything you can think of related to diabetes, we are here to provide that additional support.

And we're also here to provide additional recommendations back to you and additional second opinions. So love collaborating with you and please send us those referrals.

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES:

Yeah, I'm happy to go next. I guess my advice would be, think about where you could use some help and ask. I know when I came to my role, I was actually the first pharmacist in my role, and so a lot of times pharmacists have been embedded in primary care, but within endocrinology, I was the first one in my hospital.

So it was a lot of, well figuring out how can I be useful? What do you need help with? And I did a lot of asking. And so I got several requests from endocrinologists saying, I don't have enough time in my 20-minute visit to review this insulin pump download. Would you be able to do that? Can we have joint visits where they also see you, or can I then refer the patient to you and you look at it and then you can make those insulin pump adjustments?

So that really led to that collaboration. Another one is, we were having a major issue with our post kidney transplant patients, getting them in quickly. Because they were discharged on these high dose steroid tapers and they needed insulin adjustments right away. And so our inpatient, we actually have an inpatient NP team, they were really struggling to figure out who can they get them with. And so I was like, well, I've got availability, I can do that.

And actually this ended up leading to a collaborative clinic with the kidney transplant team, where we just see them together, and that way the patients are already there and now they're getting their insulin adjusted. So I think sometimes the collaborations are going to be unique to the practice, figuring out what is our greatest need, where can we use help and can we plug this person in? Because I think I know as an endocrine care team member, I want to be helpful. I might come in with ideas like, oh, I love this, I love CGM, but if that's not where the need is, I want to be helpful. I want to help as much as I can.

Chris Yedinak, DNP:

I agree, Diana. I think that concept of collaborative practice, and actually having to collaborating together in the same room at the same time, because often you don't necessarily hear what the other team members are telling this patient, and it can be confusing to them. So if we're all in the same space at the same time or relatively so, we can then provide the kinds of information that's more specific, and I think we can deliver that in a faster, more economic and efficient way. I think that that's a very, very good model to develop.

Sonia Bahroo, PA:

When I first got hired, I actually spent a good two to three weeks at the beginning of starting my job, shadowing the physicians that I worked with, and that during that time, the credentialing process was taking place. So it's not like you're wasting time, and why are you not seeing patients yourself?

But I spent a good amount of time shadowing the providers, getting to learn the patients, getting to learn their practice styles because everyone has different styles of management and practice, and even bedside manner, how you approach different things, especially things like trying to tell a patient that they have thyroid cancer. It's very unique to the individual and how that patient will take it. It, to me, was a very valuable learning process to be able to get that exposure and get that experience. And that made a big, big difference when I started seeing patients myself. So I would strongly advise anyone who's even new to practice or has a new PA or NP joining their practice, for them to see how the clinic runs and see how the providers in the practice take care of their patients so that you can also mesh well into that practice.

Dominique Uva, MSN, APRN, FNP-C, BC-ADM:

My perspective is a little different being a rural provider in a solo practice, I think, because I don't have that team approach as readily available to me. So for me, working with the endocrinologist, it's usually based with e-consults or calling another clinic and networking with the provider to provide that comprehensive care.

So oftentimes, for example, I may have someone I was following for a thyroid nodule and it has been stable, but all of a sudden it's not stable and we get a biopsy, we get results, and I kind of just want that second opinion of where... Or I want to send them now on for more comprehensive care with an endocrinologist. So a lot of our hospital systems have this unique system called e-consults where they can look at the patient chart review, make recommendations, and sometimes those patients can continue to be managed in the rural centers and sometimes they'll recommend that they have a formal referral to that practice. So that has been very useful for me and that's the way that I work with endocrinologists often here in the rural setting.

Susan Samson, MD, PhD, FRCPC, FACE:

That's really informative, because I was very interested in how you do that when you're working in an independent practice like that.

So I think for me, when I think about what the endocrine care team model brings to my practice, we have a really large group of NPs and PAs here. And for me, it not only allows me to continue to see new patients that need our help in what we would call complex disease, and know that my own precious patients are also being followed up and cared for by my really well-trained colleagues who are nurse practitioners and PAs in my field.

But also I really enjoy the collaborative clinic. I think it's really a joy to be side by side with your colleague, like my nurse practitioner, and they're seeing a new patient and this is just such a complex patient, but they're really enjoying the challenge of seeing that patient. And so together it feels like a really wonderful teaching moment. I think we've all had great mentors and teachers in our past and it allows me the opportunity to also teach endocrine and broaden other people's education in our specialty.

So, I've really enjoyed the model we have at my institution because of that very large care team that we have together. So, that would be my perspective as a physician working with others in other areas of the team. Does anyone have anything to add? You've had a great discussion.

Sonia Bahroo, PA:

If there are any clinicians who are curious about or interested in hiring a PA, any one of us on the board are happy to answer any questions at any time. So please feel free to reach out to us.

Susan Samson, MD, PhD, FRCPC, FACE:

Thank you, Sonia. Well, I'm just so happy that you were all here today to discuss the endocrine care team and all of our roles in taking care of our endocrine patients, and thank you so much for spending this time with me.

Speaker 1:

Thanks for listening to another great AACE podcast. Join us for another episode at aace.com/podcasts and help us in our mission to elevate clinical endocrinology. Together we are AACE.