Mar 4, 2020

Dr. Chan: What's it like to move from the East Coast to the stunning Rocky Mountains of Utah? How does one decide to become a pediatric endocrinologist? Why is there such a demand for creating exceptional learning experiences and excellent educators in medicine? What is the Bills Mafia, and how does one associate with the Bills Mafia? Today on "Talking Admissions and Med Student Life," I interview Dr. Kathleen Timme, an attending physician in pediatric endocrinology here at the University of Utah School of Medicine.

Announcer: Helping you prepare for one of the most rewarding careers in the world, this is "Talking Admissions and Med Student Life" with your host, the Dean of Admissions at the University of Utah School of Medicine, Dr. Benjamin Chan.

Dr. Chan: Well, welcome to another edition of "Talking Admissions and Med Student Life." I've got Dr. Timme. How are you doing, Dr. Timme?

Dr. Timme: Great. Good to be here.

Dr. Chan: And so you're actually an attending physician, and what field are you in?

Dr. Timme: I'm a pediatric endocrinologist.

Dr. Chan: So take us back to medical school. How did you end up becoming a pediatric endocrinologist? What did that look like? What was your decision-making process?

Dr. Timme: So I actually was exposed to endocrine in undergrad. I took a bio-elective in endocrinology, and I thought it was one of the most interesting things I had learned about. I think the hormone pathways are really intuitive and just kind of fascinating with all these feedback loops. So I was exposed to the content kind of early on. And then at my medical school, our pediatrics department chair was an endocrinologist, and I really admired her and was able to spend some time with her in clinic and just liked that you could be a subspecialist but also have really good continuity and good relationships with your patients. For me, I see most of the kids that I treat every, you know, three to six months, so sometimes even more often than their general pediatrician. And I like being a subspecialist. I like knowing a lot about a more narrow arena but still feeling like I treat a lot of different conditions. I see a good variety of patients, so it keeps it really interesting.

Dr. Chan: When you mentioned the hormone pathways, I barely remember those. I remember there was a lot of arrows, you know, like TSH, you know, a lot of feedback loops and things like that. So you felt that came just naturally to you during school?

Dr. Timme: Yeah. I just thought it was really fascinating how the body works with these feedback systems and kind of keeping everything in checks and balances, and I thought it was really intuitive.

Dr. Chan: Now you went to med school back East. Where were you at?

Dr. Timme: I was at the University of Buffalo.

Dr. Chan: Okay.

Dr. Timme: And I'm from Buffalo, so that was my hometown school.

Dr. Chan: And then as you started looking at residency programs in pediatrics, how did you wind up in Utah? I mean, like, walk us through that. What was that like?

Dr. Timme: Yeah, so I made a stop in Connecticut before coming to Utah. I was in Buffalo both for undergrad and medical school, grew up in Buffalo, so really thought that it was time to, you know, experience living somewhere else. And I was looking for, you know, a medium-sized program that was close-knit, with great academic opportunities and ended up really falling in love with the program at Yale. So I went there for a pediatrics residency and started some really interesting projects in medical education that I wanted to see through during fellowship, and ended up staying there for endocrine fellowship as well.

And then after that, I realized I've only lived in the Northeast, and I really only knew Yale's way of practicing pediatrics and endocrine. And I always admired physicians who had kind of diversity in their training, experienced, you know, different ways of practicing, and I wanted that for myself. I didn't want to just stay in one institution. I wanted to kind of, you know, expand my horizons, see what else was out there, and also just personally experience living in another part of the country. By that point, I had met my husband who lived in Colorado during grad school and Arizona and New Mexico before we met in Connecticut, and he was really itching to come back to these mountains and it just took, you know, an interview trip out here to see what he meant by that. And I think Utah fits us really well in terms of our hobbies and hiking, camping, running and being able to be outside all parts of the year.

Dr. Chan: So you did all of your training back East and then you moved out West to become an attending physician.

Dr. Timme: I did.

Dr. Chan: Wow. It's a huge jump. Yeah.

Dr. Timme: So my first job after training was here. So it was a big move. I didn't really know much about Utah, Salt Lake, and, you know, I just kind of sent a cold email out this way, seeing if there was any opportunities available. And then, as I got further into the process, I realized I had a lot of, you know, mutual colleagues with some of the people here, and it's been a really nice fit so far.

Dr. Chan: And your passion for education, what I heard is that it started in med school, but also continued throughout your residency training.

Dr. Timme: Yeah.

Dr. Chan: What kind of opportunities did you have as a resident to be involved in teaching and education?

Dr. Timme: So I've always really loved teaching. I grew up in a dance studio. I loved kind of teaching the younger dancers, and there were even points where I thought that I might become a teacher instead of a physician. But in residency, my favorite part of interning was always having a medical student on the team because I felt like I finally had a piece of knowledge to share, and it was just really exciting to be able to share that and also for, you know, the few students that ended up going into pediatrics after rotating with us, it was just a really neat experience to watch somebody go through that process. So during residency, I got involved in the GME. I sat on a subcommittee for the executive subcommittees, so I got to see a little bit about what happens behind the scenes in curriculum development and program structure, which I thought was really interesting.

Dr. Chan: And GME is Graduate Medical Education?

Dr. Timme: Graduate Medical Education.

Dr. Chan: So UME is Undergraduate Medical Education, that's like medical school, and GME is like the residency afterwards? Okay.

Dr. Timme: Yeah. And then through networking, I was able to sit on the LCME faculty subcommittee later on in residency and just kind of see what process was like to review a medical school curriculum, which was really neat. And I just always connected with the people who were in education. I thought they were enthusiastic about the same kind of things that I was. And, you know, it just kind of blossomed from there into a research project and fellowship, and then I decided to pursue my master's in education at that point.

Dr. Chan: Wow. So you were able to get a master's in education while back East or . . .

Dr. Timme: Yeah, so I'm in the process . . .

Dr. Chan: Oh, you're still in the process, okay.

Dr. Timme: Yeah, from doing the Cincinnati program, the online master's, and I have 2 more courses of 10 left. So I was able to start it in fellowship, and I'm still working through it.

Dr. Chan: Okay.

Dr. Timme: Yeah.

Dr. Chan: And then, Dr. Timme, like, because I think back to my, like, a lot of my peers, you know, we graduated med school, and, like, I had this core group of friends, I don't know, like all of us who just love kids, a core group of us went into pediatrics. I went into child psychiatry. But I remember very clearly that all my friends who went to pediatrics, they were very excited about doing a fellowship one day, and then bless their hearts, residency was just long, it was hard, and most of them decided not to do a fellowship. So did you ever waver in this endocrine dream, or were you ever tempted just to become a general pediatrician and just . . . Do you understand what I'm saying, like . . .

Dr. Timme: Yeah, I understand what you're saying.

Dr. Chan: Yeah, like, how did you weather that? How'd you get through that? Like, what did that look like for you?

Dr. Timme: I mean, I think the temptation is there to stop training and finally start your life, but I was just so enthusiastic about the topic and I liked endocrine so much I even thought about OB/GYN and reproductive endocrinology and infertility. So for me, that was as important as the pediatric side of things. And I also really enjoyed my residency training. So I, you know, enjoyed the relationships that I made. I loved being in New Haven. I loved learning and taking care of kids. So I think sometimes there's also a temptation in the other direction too, like I just want to keep being a trainee for a little while longer and then, you know, face the real world after that.

And I just . . . for me, I have a ton of respect for anybody who practices more general fields, general pediatrics, but I would have been very overwhelmed having to know a lot, you know, about everything. I feel like pediatricians are the great gatekeepers to everything else, and I think I would be afraid of missing something or, you know, not knowing enough about every system or every possible thing that a patient could come in with.

Dr. Chan: So the fellowship is it . . . How long is it?

Dr. Timme: Three years.

Dr. Chan: Three years. And it was it all clinical, or was there some research or some education time built in or . . . What did that look like at Yale?

Dr. Timme: Yeah, the first year typically is heavily clinical and then the last two are a little bit more research-focused. I was the only fellow my year, so I had a very heavy clinical first year and kind of a mix of both in my second year. But by the third year, it was more research-focused and just kind of keeping up with some clinical activities. So, actually, it was a pretty intense first year, but after that, I had a better work-life balance.

Dr. Chan: And then you kind of mentioned at the beginning about that when you came out here to Utah, I mean, when you . . . I mean, this is a great conversation, because I talk to students about this, like, when you signed your first contract, when you were able to kind of become an attending, when you had a, you know, a very clear voice in what your career was . . . what you wanted it to be, like, how did you negotiate that? I mean, what did you ask for? I mean, because I assume that you could ask for more inpatient time or more outpatient time. Or did you ask for, like, you know, if you felt affinity for like, more, like diabetes, as opposed to thyroid issues? I mean, what did that look like? I mean, how did you do that as a fellow coming out to a new area, a new program, and how did you negotiate what you wanted?

Dr. Timme: Yeah, it was definitely a very foreign skill set. I think we're not used to asking for anything other than admission and acceptance and . . .

Dr. Chan: Yeah. We're kind of coached just to take it.

Dr. Timme: . . . you know, "Please just let me come and join the team."

Dr. Chan: So I think a turning of the tables.

Dr. Timme: Yeah, it was a very interesting, you know, process interviewing. Definitely turns the tables and, you know, feeling like you're being recruited or that you're a value to a program rather than, you know, the other way around was really interesting. So for me, my number one priority was having some time to work on medical education-related projects, specifically on helping people develop teaching skills. So any program or any, you know, potential place that didn't offer me those kind of opportunities in the near future, I kind of shied away from. And so that's one of the main reasons why I came out here because there were some really interesting opportunities to get involved, both on the UME and GME side, around training people how to teach. So that was my number one priority.

And then I really liked doing both general endocrine and diabetes, and some endocrinologists or some institutions really divide the two. But especially early on, I didn't want to lose either skill set, so it was really important that I had clinics on both sides and I enjoyed both sides equally. And then also a good mix of, you know, inpatient and outpatient without too much inpatient time, because that can be pretty exhausting.

Dr. Chan: So you mentioned the teaching. So tell us about the Students as Teachers Pathway. Was that already kind of being formed before you got here, or were you kind of the original force behind it? Like, how did that work out? And like, you know, just help people understand what that is.

Dr. Timme: Yeah. So the Students as Teachers Pathway is a really unique longitudinal experience for medical students to be exposed to some of the skills involved in being a clinician-educator. So the idea is that after medical school and even during medical school, we're tasked with teaching our peers, patients, colleagues, and eventually trainee students without much formal training on how to do so. I think medical schools now are a lot more mindful to that. But the pathway is for students who have this particular interest. I think it attracts people who have had experience in teaching and really want that to be a part of their career.

So it's a four-year program. The first couple years are based in these workshops and sessions. There's four every semester. We try to keep them very interactive and help, you know, build a teaching skill set. We also have our students teach in front of a classroom and get some feedback on that. So it's a nice way to sort of practice those skills. And then, as of right now, we just have first years and second years because it started two years ago, but eventually, in the third year, we hope to do more experiential learning alongside the clerkships, and then everything will culminate in a capstone education project where students identify a mentor and are really just trying to create an educational intervention and assess its impact. Their projects are very interesting. I'm very impressed.

Dr. Chan: So could you give me an example what kind of projects they're working on?

Dr. Timme: Yeah, so I'm working with one of our students on evaluating what an exceptional learning environment is through focus groups with students. We have other students who are doing more community-based projects where they're, you know, interacting with students from high schools or elementary schools and people in the community trying to teach on different topics. And a lot of it is tailored to their own clinical interests. So if someone's interested in pediatrics, they might take more of a pediatrics sort of flavor.

At this point, our second years are mostly developing project ideas and identifying mentors, so I haven't seen any through to completion yet, but it's, you know, very interesting. And the pathway started . . . it was developed before I came here, so I co-lead it with a neurologist. And he was working with one of the pediatric chiefs to develop the program, and then she ended up going to another institution. So right around the time that she was leaving, I was coming in. And so I took on kind of the co-director position.

Dr. Chan: When I talk about admissions and talk about our med school a lot, I would say a lot of our applicants and a lot of our students are very interested in teaching in an academic health center, first of all, kind of a career, but also just becoming better teachers. And I've talked about the Students as Teachers Pathways, you know, like teaching is a skill, like you said, and can we teach the students to become better teachers. And it seems to be really popular, and the students, it seems to really resonate with them. And I feel the students have very strong opinions about the quality of their education and who's a good teacher, who's not a good teacher.

So I think that's an excellent opportunity to challenge them, "Okay, you're going to be in front of the class one day. You're going to be in charge of that small group one day. You're going to be leading the clinic and teaching in the clinic one day. How are you going to do it?" I think that's a great impetus for like, change, because I think the students are fairly opinionated about this stuff. Like, does that match with what you see on your end? Yeah.

Dr. Timme: Yeah, I mean, I think even on the GME side, too, there's just more and more interest in becoming good teachers. And I don't know if that stems from kind of who your role models are. So in medical school, we look up to, you know, really great teachers, and I think the same thing in residency training, we really admire the people who teach well and teach effectively and I think we try to model our careers after them. I think that's some of it, and then also, just trying to create some balance in life. So I think people recognize that having a career that's 100% clinical can be really tiring. And for me, I like that every single day is different. I like that I can come and be here with you and then go to clinic in the afternoon. It's just a really nice way to keep my days interesting and keep me motivated and excited on both fronts. And I think the students are seeing that too.

Dr. Chan: If you can identify one thing that students struggle with as they become teachers, what do you see as a common theme? What do they have to work on?

Dr. Timme: I think it's something that we all have to work on, but more of like imposter syndrome, like feeling as a learner, how do you have something to offer? How do you have something to teach a group, and realizing that we're all just acquiring these micro-skills as we go and we do have things to offer and things to teach and even just different ways of approaching things. So I think some of it is just having the confidence to realize that you have something to offer and being able to do that. So I hope that our pathway gives them a safe space to kind of practice some of those skills and receive feedback in a constructive and kind way, so that they feel even more confident when they have residents to teach.

Dr. Chan: Yeah. I love what you said, Dr. Timme, because when I think about it, you know, what do we do as doctors, I mean we teach our patients about their bodies. I mean, my own personal philosophy in a perfect world, you know, everyone would go to med school, everyone would learn about their bodies, and we would take care of our bodies and things like that. You know, it's obviously not set up that way. So a core group of people, you know, go on to health science careers, and to me, they educate, they teach people about their bodies. And to me, that's what you do when you go in to see the doctor. Oh, you learn about your body, and you learn what's working well or not so well. You learn about this medication or that procedure.

And to me, medicine, the health sciences, it's like an educational endeavor. And, you know, I teach in our med school, I can always become better, but I like what you said. It really resonated with me because when I interact with students, sometimes they have this, you know, imposter syndrome. They don't believe they should be here. And I challenge them, like, "Look, look how much you know compared to like a year ago" right? "Look how much you know compared to two years ago. You have so much knowledge. How do you communicate that? How do you share that with others?" So I just love what you're doing. I love this teaching pathway that you're creating. It's beautiful.

Dr. Timme: Yeah, it's really fun. It's, yeah, one of the most exciting things I do.

Dr. Chan: Okay. So a couple of questions before we wrap up. These are kind of fun and silly. So the silly one is anytime I meet someone from Buffalo, I just have to ask about the Bills. So how many games you've been to? Are you part of the Bills Mafia? Do you know what I'm talking about?

Dr. Timme: I do know what you're talking about. I hope nobody from Buffalo is listening because I will not do the city justice, but, I'm, you know, an associate of the Bills Mafia. I'm not really a football fan. I don't have cable. I don't really watch games on weekends. But my brother is definitely like a rank and file member of the Bills Mafia. He's had season tickets since high school. He lives in Minneapolis and flies home for games and . . .

Dr. Chan: Wow. And for people who don't know what the Bills Mafia is, can you explain it to them? Because I have this image, but I'm not sure this image is the correct image, so . . .

Dr. Timme: Yeah, I mean, it's just the cult that follows the Buffalo Bills, you know, rain or shine, good or bad. You won't find truer fans than Buffalo fans.

Dr. Chan: And also I get the sense just watching clips online, they tend to get really rowdy pre- and post-game to the point where like, they're intentionally, unintentionally hurting themselves because they jump into tables. That seems to be a thing.

Dr. Timme: Yeah, jumping on tables. I mean, the tailgate is, you know, even more important than the game, so it's just a full day.

Dr. Chan: Does your brother jump on the tables?

Dr. Timme: You know, he probably wouldn't be the one jumping on the table.

Dr. Chan: Because it seems really dangerous.

Dr. Timme: But he might be, like, videotaping people jumping . . .

Dr. Chan: Cheering it on.

Dr. Timme: Yeah. He definitely would be a part of it.

Dr. Chan: Okay. And then in a more serious question, like, talking about diabetes. I'm just curious, like, what do you see with kids and teenagers nowadays with their diet? Is it getting better? Is it getting worse? I read about these insulin shortages. I mean, what's your take on all this?

Dr. Timme: Yeah, that's a difficult question. So, you know, in terms of type 1 diabetes, I think things are headed in the right direction. So there's definitely a lot more technology for patients and families to take ownership of their condition. There's continuous glucose monitors now, whereas, you know, not that long ago, the only way we could check glucose was through urine test strips. So we have a lot more real-time data, which I think allows us as clinicians to make more informed choices about insulin dosing and make more meaningful changes. And then insulin pumps, I think it really revolutionized things where you're able to just take a little bit more control of the diabetes and also go about living your regular day-to-day life. So I think, in general, things are getting better. There's definitely an increase in type 2 diabetes, and I think that's related to the fact that kids are more sedentary than they've ever been, you know, spending more time in front of the TV and less time outside . . .

Dr. Chan: So you see more type 2 in kids?

Dr. Timme: More type 2. Yeah.

Dr. Chan: Okay.

Dr. Timme: And, you know, even a fair amount of it here in Utah, so . . .

Dr. Chan: Is that reversible if the children eat healthy and exercise and lose weight? Because I remember learning about that with adults that, you know, there's, again, I'm not an endocrinologist, so I use very poor terms, but like there's this zone, where it's kind of reversible, if there's some things that start happening and like, you know, you can take the Metformin, but then kind of back off before you're full-blown on insulin-dependent. Is there still, like, a zone or . . .

Dr. Timme: Yeah, with type 2, I mean, there's still hope in coming off of insulin. So by the time I see kids with type 2, we're probably having that conversation about starting insulin and doing full teaching on diabetes, but with lifestyle modifications, a little bit of weight loss, exercise, oftentimes they can come off of insulin and maybe just maintain things on Metformin, or, you know, completely off of everything. So, yeah, but doing that is easier said than done.

Dr. Chan: In the past when I've talked to you, I've made jokes because as a child psychiatrist, I manage kids' diabetes from time to time inside Uni when people get a med for more of a psychiatric reason. I think it's really hard. I mean, I've seen, you know, because when you think about teenage adolescence and wanting to be your own person and having control over your life, and not all teenagers, but there seems to be this core subset, where this control issue kind of spills over into diabetic food control. And I think it's really rough. It's really difficult growing up, and again, like, everyone, I mean, people making choices, some people are making bad choices, and then just throw in this pretty serious disease and this need for constant management, it could be really combustible at times. So I don't know if you've seen that on your side at all, like, this control issue where teenagers kind of get into it with their parents and the diabetes, then it's kind of on the table to kind of manipulate or argue or fight over. Have you seen that at all?

Dr. Timme: Absolutely. And I think that technology, you know, also plays in an interesting way. So some of the continuous glucose monitors parents often have a share app where they can see where is the blood sugar. So then you also have, you know, adolescents who are trying to be independent and responsible for their health care, who are maybe out at a friend's house and then their parents are texting or calling saying, "Hey, I see your blood sugar is high. Did you forget your insulin? What's going on?" So it just creates a very interesting dynamic.

Dr. Chan: Fascinating dynamic. So the parents not only are monitoring their kids kind of, like, you know, "What social media sites are you on?" but they're also monitoring your glucose levels. It's fascinating.

Dr. Timme: Yeah and, "Did you give your insulin?" so . . .

Dr. Chan: Wow. So what's your official position? Like, should parents have access to that information? Should they have the app? Or are you kind of agnostic when it comes to this or . . . Or is that a complicated question?

Dr. Timme: I think it's an individual decision. I think for younger kids, it's very helpful for families to have that share app both for their peace of mind and for safety. So in the middle of the night, if their blood sugar's headed low, you know, for a parent to know about that I think is really crucial. But then I think there has to be this thoughtful, letting go process that the endocrinologist should ideally be having conversations with the families about, where you're sort of giving the child more and more responsibility and you're doing less of kind of the hovering and watching over things, and maybe just using that for spot checks every once in a while to make sure that they're doing what they're supposed to do. And certainly, if things are headed in the wrong direction, and you know, when they go to the doctor's office and the A1C is high and we can see on their downloads, whether or not they're bolusing, giving their insulin, then maybe that's time to negotiate some closer supervision.

Dr. Chan: Dr. Timme, I'd love to talk about this. So my last question and like, so, you know, teenagers are very good at, you know, there's parental controls, right? And teenagers can kind of get around those to access websites they shouldn't or whatever. Have you ever seen a teenager, like, I use this word loosely, "hack" the app? Have they been able to manipulate the data in a way? Or is that . . .

Dr. Timme: No, I haven't seen that. So there's two versions of the app.

Dr. Chan: Okay. Interesting.

Dr. Timme: There's the app that the patient downloads, and then there's the share app that the families download, so they're separate and on separate devices. I haven't seen anybody go in and delete their parent's app or something, but I wouldn't be surprised if that happens.

Dr. Chan: Okay. Well, I hope we didn't give that idea to anyone out there. I'm just curious. Because the reason why . . . I'm bringing it all back. The reason why I love medicine is that it's like the intersection of really cool science with people. It's like humanities combined with the scientific knowledge. And, you know, diabetes, insulin, it sounds like it's grown by leaps and bounds, you know, a lot cooler technology, a lot more knowledge. But at the end of the day, you're still interacting with people. And then teenagers and families and dynamics and communication, expectations, things like that. So that's why I love being a doctor, because it kind of combines both those spheres. And that's what I'd like to teach the students because I think they get at times overly focused on the science and I, like, "Well, your science is only as good as people who take the medication or do these things. And there's still this free will and humanity aspect to it."

Dr. Timme: Right, I mean, even with all this technology, we're not making big strides in A1Cs or diabetes control because there is that human aspect to it, which is the most challenging part but also some of the most exciting to navigate.

Dr. Chan: Okay. Well, Dr. Timme, thank you so much for coming on the pod. I think we'll be talking to each other soon, maybe on a future podcast.

Dr. Timme: I hope so.

Dr. Chan: But this has been great. Thank you.

Dr. Timme: Thank you.

Announcer: Thanks for listening to "Talking Admissions and Med Student Life" with Dr. Benjamin Chan, the ultimate resource to help you on your journey to and through medical school. A production of The Scope Health Sciences Radio, online at thescoperadio.com.

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