Lessons from collaboration between adult and pediatric endocrinologists
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Multidisciplinary, cross-departmental teams create synergy by enhancing the productivity, knowledge, experience, innovation and intellectual vision of the individual members.
These cooperative units maximize specialty resources for patient care, teaching and research. Prismatic examples of this approach are the cardiovascular and cancer centers developed during the past 3 decades in the U.S. and Europe. The same synergy should result when pediatric and adult endocrinologists work together in unified divisions structurally involving both pediatric and medicine departments.
Howard E. Kulin, MD, preeminent pediatric endocrinologist who passed away on Aug. 17, worked for many years in such a unified division and strongly espoused its utility. The development of the combined pediatric and adult endocrine division that he worked in, the concepts behind this approach, and its strengths and weaknesses provide important lesions for today.
From vision to practice
The concept of multidisciplinary units was espoused early by a true visionary, George Harrell, MD, founding dean at both the University of Florida at Gainesville and later the Penn State Hershey Medical Center. Having the authority to design a new hospital and academic building at Hershey in 1963, he implemented an innovative structure that located multidisciplinary, multidepartmental groups in adjoining offices. Axiomatic was that subspecialists should work intimately together across conventional departmental lines. As an example, the medical and surgical gastroenterologists, GI radiologists and GI pathologists all shared a suite with adjoining offices.
With respect to endocrinology, Harrell designed adjoining offices for both pediatric and adult endocrinologists. Complementing this physical structure, the respective department chairs allowed the formation of a combined pediatric/adult endocrine division. With an integrated endocrine service, adult endocrinologists evaluated both adults and children in the inpatient, but not outpatient, setting and pediatric endocrinologists the same.
C. Wayne Bardin, MD, a past president of the Endocrine Society and the first division chief, knew the integrated pediatric/adult system at the NIH and recruited Kulin, James Hammond, MD, and me: Adult endocrinologists who could function in this multidisciplinary mode, both clinically and in research.
The collaboration worked well with respect to patient care and provided protected time for innovative research and a rich background for teaching. For children with severe conditions, such as isolated aldosterone deficiency, adult endocrinologists always had backup from a pediatrician and vice versa. Sexual identity disorders in newborns required the close evaluation by the pediatric endocrinologist. The students, residents and fellows in training had the advantage of learning about the differing presentations in children and adults of various disorders, such as Graves’ disease. Clinical conferences emphasized the common physiologic basis of all endocrine disease while pointing out the unique, age-based needs.
Communication among physicians and patients is a key to successful patient care. Kulin proved the leaven to facilitate communication at all levels. Known as a great communicator, he had the ability to explain simply the most complicated physiologic concepts in a manner understandable to children, their parents and trainees at all levels.
Insights from integration
This integrated system served exceptionally well for adolescent endocrinology where transition from a pediatrician to an internist was important. The close interaction between pediatric and adult endocrinologists proved most effective in the evaluation of disorders of reproduction and led to the concept that reproductive processes fall under one umbrella from fetal life to adulthood.
Kulin had developed ultrasensitive assays for luteinizing hormone and follicle-stimulating hormone by concentrating urine and measuring gonadotropins in the extracts, a method that enhanced sensitivity by a factor of 100. These assays provided a tool for precise assessment of gonadotropin production during puberty in patients with Kallmann, Turner, Klinefelter and Prader-Willi syndromes; anorexia nervosa; malnutrition; hypothalamic amenorrhea; and other reproductive disorders with manifestations in both children and adults. The highly sensitive assays allowed the demonstration that hypogonadotropic hypogonadism represents a spectrum of severity as reflected by the 20-fold differences in gonadotropin concentrations among patients with this disorder. This methodology allowed Kulin to study effects of malnutrition in Africa while on sabbatical and changes in the timing of sexual maturation related to racial and socioeconomic factors.
Past and future
Combined pediatric and adult endocrine divisions had been implemented by programs at the NIH and UCLA as well as in Denmark at the National University Hospital in Copenhagen and their rationale is well described in Kulin’s review published in 1998. In the Penn State program, the multidepartmental housing arrangements gradually evolved during the 1970s and 1980s as new space and programs took priority and only the combined endocrine division concept survived. Later, department chairmen expressed concern about the ability of adults to take care of children and vice versa and articulated the challenges provided by structural authority, funding and salaries.
The passing of Kulin brings to mind the need to review the lessons gained from combined pediatric and adult endocrine divisions. Firstly, the pathophysiologic concepts of endocrinology are similar in patients at all ages, and the teaching of endocrinology is enhanced by an understanding of both pediatric and adult endocrinology. Secondly, cross-pollination intellectually results from pediatric and adult endocrinologists interacting closely together. Thirdly, integrated clinical conferences, where both pediatric and adult endocrinologists participate, serve to widen the breadth of understanding of endocrinology. The final lesson is that children with pediatric disorders grow up and require adult endocrinologists later and that the close collaborations between adult and pediatric endocrinologists facilitate that transition.
How should we apply these lessons today? While unified pediatric and adult endocrinology divisions may not be feasible today, based on the constraints of existing academic structures, the ability to develop collaborations still exist. Clinical endocrinology conferences should be fully integrated between adult and pediatric endocrine divisions. Adolescent endocrinology clinics should be jointly administered and provide training for both pediatric and adult endocrinologists. Research of endocrine disorders spanning the age ranges should be encouraged. These are all the concepts that Dr. Howard E. Kulin espoused and which need particular attention currently.
Andrea Manni, MD, Laurence Demers, PhD, and Alan Rogol, MD, PhD, provided input into this article.
Reference:
Kulin HE, et al. Med Educ. 1998;doi:10.1046/j.1365-2923.1998.00696.x.
For more information:
Richard J. Santen, MD, is emeritus professor of medicine in the division of endocrinology and metabolism at the University of Virginia. He is a former president of the Endocrine Society. He can be reached at: rjs5y@virginia.edu.
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