End of an era, start of a journey

The origins of pediatric endocrinology can be traced back to the mid-20^th century in Europe and North America, and to the late 1980s in India; even though vivid descriptions of goiter appear in the work of the Roman poet Juvenal (2^nd century CE), and early accounts of type 1 diabetes can be found in the Sushruta Samhita (500 BCE) and ancient Chinese texts (1500 BCE).

As an undergraduate student, and later as a postgraduate resident in pediatrics, I found the subject, a maze of hormonal jargons, incomprehensible to the untrained; rooted deeply in organic chemistry, basic biology, and general pediatrics. Despite its complex optics, an accurate diagnosis could be established with fundamental clinical tools of history and examination, and the subject encompassed the most essential concepts in pediatrics, namely nutrition, growth, and puberty. I was also intrigued by just how optimistic the branch appeared, with definitive treatment available for nearly every disease. Here was a subspecialty that conferred close to normal lifespan, where morbidity and mortality were almost always telltale signs of untreated or poorly treated disease, and where future research prospects included optimizing quality of life with the existing arsenal of care.

After completing my MD in pediatrics, I began exploring opportunities for training in the field of pediatric endocrinology. The options at the time included fellowships available in 15 centers across the country, and the DM programs at the Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, and the All India Institute of Medical Sciences (AIIMS), New Delhi. Following a rigorous theoretical examination and an interview conducted as part of the Institutes of National Importance Super-Specialty Entrance Test in the summer of 2022, I was selected for the coveted seat at AIIMS, thus marking the beginning of my journey in pediatric endocrinology.

The DM program, under the aegis of Prof. Vandana Jain and Dr. Rajni Sharma, incorporated multiple elements of patient care, teaching, and research. The clinical responsibilities included providing inpatient care, attending outpatient clinics, daycare and laboratory procedures, elective and emergency consultations, participation in patient education sessions, and a brief rotation in the department of adult endocrinology and metabolism. The program’s teaching activities ranged from intra-divisional academics and sessions/modules for postgraduate trainees to inter-institutional academics in collaboration with the University of Michigan (USA), PGIMER Chandigarh, Bai Jerbai Wadia Hospital, Mumbai, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, and later, AIIMS Kalyani and AIIMS Bhopal. As part of my research, I undertook my DM dissertation on implementing a multidisciplinary care program for patients with disorders of sex development (DSD), under the guidance of Prof. Vandana Jain, with the division offering additional research opportunities at multiple levels.

Akin to my earlier perception, the subject did offer an avalanche of knowledge, capable of being distilled down to the most granular detail. It also involved patients who, for the most part, appeared cheerful. However, the real challenge lay not just in diagnosing and treating conditions, but in ensuring adherence to the latter. The nuances of treating patients with type 1 diabetes were as jarring and perplexing to the patient/caregiver as they were to a postgraduate trainee in pediatrics. Lifelong treatment with multiple daily injections of insulin was never palatable to any child, and repeated blood glucose checks, maintenance of logs, and counting carbohydrates only added to patients’ woes, over and above the pre-existing burnout from the deluge of information, often delivered verbatim from diabetes texts. Irrespective of the amount of time spent imparting education on diabetes care, it often amounted to little if the patient/caregiver was unwilling, unmotivated, or incapable of managing the condition. This was precisely where the residency training shaped my approach to patient care. In diabetes, for instance, the barriers to care were plentiful ranging from myths related to how a functioning pancreas ceased to produce insulin once exposed to the exogenous molecule (thereby eradicating all prospects of a cure); to the inability to purchase diabetes consumables; and to the sheer lack of motivation, to list a few. Observing and learning from my mentors, I gradually imbibed the skill of addressing misbeliefs, discussing financial difficulties and navigating them via the robust system that the division had developed over time, supported by the government and the non-governmental organizations; and most importantly, working towards instilling motivation in patients and their caregivers for taking full responsibility of their care. The latter entailed discussions around the importance of insulin, near-normal longevity with adequate glycemic control, envisaging the dreadful pre-insulin era, drawing inspiration from celebrities with the condition who had made it big, and looking forward to the future with all its promising technological advances and stem cell therapy; all while leading disciplined and productive lives.

Alongside counseling, I came to appreciate the value of working hands-on with patients’ diabetes devices, a crucial part of training capable of providing solutions to the most vexing questions of patients and physicians alike, and rarely found in textbooks. In my earlier days of residency, for example, I recall attending to a brilliant 15-year-old with long-standing diabetes who had recently started using the subcutaneous insulin pump, and appeared to face difficulties with glycemic control at a certain time of the day. As we both sat through the Herculean session, tinkering with the device, breaking down its settings piece by piece, brainstorming over what might have happened, and discussing new features that he had unlocked and experimented with, we were finally able to crack the code! This was just one among the many instances that peppered my residency, each reinforcing the importance of counseling, encouraging, and engaging in meaningful problem-solving. Mastering the art of counseling extended even to conditions such as non-congenital adrenal hyperplasia DSD, which typically required no immediate medical or surgical intervention. The goal was to educate caregivers, provide them with options weighing in on the pros and cons of each, and empower them to make informed decisions. In the process, this approach brought forth a plethora of research opportunities, grounded in addressing obstacles within the existing standard of care, and extending far beyond conventional assessments of novel diagnostics and therapeutics.

In addition to clinical work and research, over the course of my training, I was also fortunate to participate in several enriching extracurricular activities. The Indian Society for Pediatric and Adolescent Endocrinology organizes a biennial training school, along the lines of a gurukul, where a group of students engages in didactic and dialogic sessions with the finest faculty from across the country and the world. I attended its 3-day session in the fall of 2023, amid the lush and picturesque landscape of Devanahalli on the outskirts of Bengaluru, and returned with heightened enthusiasm, a deeper understanding of the subject, and lasting memories. Yet not all extracurricular activities were confined to the theoretical and practical aspects of the subject; some indeed served as eye-openers in their own right. In February 2025, well into the final semester of my training, I was offered the opportunity to travel to Raipur, Chhattisgarh, as a trainer at a capacity-building workshop on the management of type 1 diabetes. The 2-day program, organized by the government of Chhattisgarh, was directed at doctors serving at primary and secondary levels of healthcare across fourteen districts of the state. As I set out to address a group of healthcare providers, I realized that the stakes were high, and there was no room for error or ambiguity in educating professionals who would apply this knowledge while treating patients from some of the most remote parts of the state. I spent hours working on how best to engage participants while walking them through treatment algorithms, striving to make the sessions as useful as possible, a skill I had likewise acquired under the guidance of my mentors. The experience also brought me closer to the realization that managing an endocrine emergency, such as diabetic ketoacidosis, differed significantly in resource-limited settings and demanded an additional set of skills rooted in the fundamentals of medicine. The program, nonetheless, set the stage for generating awareness and identifying existing lacunae in local medical infrastructure and resources, in an effort to achieve the highest standards of care.

In what I found to be an exhilarating exercise, I also had the opportunity to assist in reviewing, editing, and proofreading several chapters of the 2^nd edition of Case-Based Reviews in Pediatric Endocrinology, a textbook edited by Prof. Vandana Jain and Prof. Ram K Menon, and directed at postgraduate students. As I set out with one of my colleagues to undertake this monumental task, we found ourselves devouring numerous texts to fact-check every minute detail, while carefully refining the chapters to make them as engaging to the readers as possible. Even as these academic pursuits were deeply fulfilling, not everything was smooth sailing, and working in the subspecialty came with its own share of challenges.

The cost of treating many endocrinological conditions is enormous, often exceeding the average per capita income of the country, and chiefly including diseases requiring therapy with growth hormone or gonadotropin-releasing hormone agonists. For some exceedingly rare entities, treatment options are either unavailable in India, prohibitively expensive, or both. While the disorders may be ‘rare,’ the thought of encountering a single patient with one of these conditions, and counseling them that there is no hope, even as curative treatments are sold abroad for millions, is unfathomable. One such condition that resonated the most with me was familial homozygous hypercholesterolemia (FHH), a disorder that is uniformly fatal when blood levels of cholesterol are not normalized. I saw quite a few patients with FHH, all awaiting access to highly efficacious but exorbitantly priced pharmacotherapy.

Another concerning issue that I encountered was the inconvenience faced by patients who had to travel long distances for seeking care. While there are several hubs across the country where pediatric endocrinologists are concentrated, there are entire states without a single one of them, thereby explaining the constant back-and-forth for consultations and the growing expenses incurred by patients. Like in any nascent branch, this problem seems fleeting at best and is likely to ease with the current expansion of training programs in the country.

Looking back at the difficulties and the countless learning opportunities, the list of anecdotes and learnings from this 3-year journey is perhaps endless. Suffice it to say, the experience has been profoundly enlightening, one that has shaped and refined my beliefs and perspectives, and something that I look forward to passing on to the next generation with sincerity and enthusiasm. For me, it marks not the end, but the very beginning.