Leadership and innovation in the navigation plan of the Endocrinology and Nutrition specialty

This issue of the journal EDN publishes the article: ‘Quo Vadis, Endocrinology and Nutrition?’,¹ which describes the evolution of the mean Spanish internal resident physician examination (médico interno residente [MIR]) ranking with which newly-graduated physicians choose the specialty of Endocrinology and Nutrition (EN). The results show a progressive worsening of the choice of EN over recent years. Acknowledging the influence of multiple factors, this fact may be interpreted as a decrease in the attractiveness of Endocrinology and Nutrition compared to previous years.² The article reports interesting additional information about the opinion of fourth year residents in the specialty, providing evidence of considerable satisfaction with the choice and development of Endocrinology and Nutrition. At the same time, the study underlines a series of aspects considered to be negative by some of the residents, such as the scarcity of instrumental techniques in the specialty and a perceived lessened relevance of EN as compared to other specialties. These findings represent an opportunity for the endocrinological community to consider new challenges in the future development of Endocrinology and Nutrition.

The trajectory of EN in recent decades has been very fruitful, with the opening of new perspectives with modern diagnostic and therapeutic options in both the EN setting and in other medical disciplines. It is this progress in the identification of new physiopathological mechanisms and diagnostic and therapeutic applications that has provided the catalyst for the marked expansion of the specialty into other disciplines. This “endocrinolization” phenomenon, found in most areas of medicine and surgery, such as neurodegenerative, cardiovascular or psychiatric disease, cancer, gastrointestinal surgery, and transplantation, among others, has generated much interest from other specialists who are attracted to the wealth and appeal of hormonal physiopathology in resolving complicated dilemmas in clinical practice. This new scenario, characterized by a considerable expansion of Endocrinology and Nutrition, requires reconsideration of the role of specialists in the general clinical setting. The comparatively insufficient provision of techniques and the transition of the specialty towards a modern and predominantly ambulatory care approach are potential factors causing the specialty to have a reduced standing vis-à-vis other disciplines. On the other hand, while the classical deficiency in the number of specialists in EN in Spain and in other countries has decreased, it has not yet been fully corrected.^3–6 All these elements require us to cope with the challenge of adaptation to further the progress of Endocrinology and Nutrition while at the same time maintaining its unitary identity and depth of knowledge in concrete areas, in order to ensure the excellence of its specialists in patient care, teaching, research and management.

With this purpose in mind, the first step, forming a continuum with other strategic supports, is university teaching. The homogenization of teaching programs in Endocrinology and Nutrition in medical schools is a crucial issue. In this regard, EN specialists are the individuals best qualified to teach the specialty. This aspect must be firmly emphasized if we want medical students to have the possibility of obtaining a clear understanding of the implication of the speciality in healthcare and research, and a fuller appreciation of the opportunities to be found in the job market. The educational programs of the different medical schools are characterized by their heterogeneity, which conditions the skills and competencies accumulated by each student. Ensuring the uniformity of teaching activity in the specialty with the desired multidisciplinary orientation^7–9 is a complex challenge that needs to be addressed in order to provide all medical students with a similar basic knowledge of the specialty. In the same way that initiatives of great interest and proven value, such as the Manual of Endocrinology and Nutrition of the Spanish Society of Endocrinology and Nutrition (Sociedad Española de Endocrinología y Nutrición [SEEN]), play a fundamental role in balancing the knowledge of residents and specialists, a teaching program based on a common proposal would improve the quality of university teaching of the specialty. The same can be said of the importance of clinical practices in the Departments of Endocrinology and Nutrition, which open the way for students to practice the specialty for the first time. All teaching services should be made fully aware of the importance of structured programs. Although these need to be adapted to the resources of each hospital or medical school, they should have a common basis guaranteeing an effective and attractive program for students, capable of resulting in adequate attitudes and aptitudes.

In a second step closely related to university teaching, emphasis should be placed on the strategic importance of the organization of Departments of Endocrinology and Nutrition. Multidisciplinary work, as well as clinical, monographic and literature sessions and clinical, basic and translational research, should be firmly structured in each department. The disparate availability of sections dedicated to basic and translational research can be overcome through collaborative studies among different departments and centres, thereby making it possible for more clinically oriented departments to participate in translational research projects and thus advance in the excellence of integral activities. This perspective would offer students and residents a further dimension regarding the development of Endocrinology and Nutrition, with the opening of new horizons for national and international cooperation. Interdisciplinary cooperation within hospitals – a field in which EN has a relevant part to play – should contribute to revealing the role which the specialty plays in primarily endocrinological disorders and its key involvement in a growing range of diseases in collaboration with other specialists. The initiative and leadership of Endocrinology and Nutrition in transverse but specific areas such as diabetes, obesity or osteoporosis, are both unquestionable. The coordination of external rotations in centres of excellence provides residents with greater opportunities for interaction and the discovery of new lines of work. The healthcare and research perspectives which students and residents should contemplate in any department with accredited teaching functions are the genuine references conditioning a successful professional trajectory.

The third step to consider is with regard to the further development of the specialty itself. Endocrinology and Nutrition has evolved due to the needs of the population. Progress has expanded from preferential attention focused on classical diseases (e.g., hypothalamic–pituitary, thyroid, adrenal and gonadal disorders) towards other areas of considerable strategic importance for public health, such as nutrition, obesity, diabetes or altered phosphorus and calcium metabolism, where specialists in Endocrinology and Nutrition are required to exhibit incontestable leadership skills. In this regard, interaction with primary care is essential.¹⁰ However, our specialty must also make moves towards other disciplines such as neurology, psychiatry, oncology, urology, gynaecology and intensive care medicine, among others. In these areas, specialists in Endocrinology and Nutrition should form part of the care, teaching and research teams in order to consolidate the multidisciplinary interaction that is crucial nowadays.^7–9 It is the responsibility of all its specialists to demonstrate the added value of Endocrinology and Nutrition, including the use of new techniques and approaches such as those related to body composition, ultrasound, diabetes day hospital, high-resolution consultations, diagnostic interpretative capacity and therapeutic excellence.⁸ The essential collaboration with patients pertaining to the specialty – most of whom suffer chronic conditions – strengthens Endocrinology and Nutrition and multiplies its impact upon society, with a marked influence on the quality of life and life expectancy of the population.

In this context, the SEEN is the most qualified guide for this journey. Our organization, which comprises specialists and other professionals related to Endocrinology and Nutrition, provides guidelines focused on the progress and consolidation of the specialty. The development of its areas of knowledge and its working groups, and fluid interactions with related organizations at both national and international level, serve to enrich the training of specialists and show the road to progress. The roles of the SEEN in promoting the resources and quality of the departments, in developing guides and consensuses, in generating continued training material, and in facilitating research activity throughout Spain are only some examples of its binding capacity. Initiatives in innovation and leadership have long been attributes of the SEEN, and have promoted the development of the specialty. The SEEN is an excellent catalyst of initiatives that should extend from university teaching to the organization of Departments of Endocrinology and Nutrition, making the specialty more visible among professionals, administrators and the general population, and finally driving its strategic expansion into new fields.

In conclusion, initiative, leadership and personal and institutional innovation at the teaching level, in graduate and post-graduate settings, as well as care and research activities in a proprietary unit context, are the elements that will lead the speciality to adapt to new challenges and to strengthen its attractiveness in the further course of the journey which Endocrinology and Nutrition has already experienced, ever since its origins in the development of medicine.