My Journey in Training to be an Endocrinologist

By Luisa Duran, MD

For my second year of training in the medical specialty of diabetes and metabolism problems (endocrinology), I had the honor of being the recipient of the Bender Fellowship at the University of Washington. This gave me a unique opportunity to focus my training on how to care for people who could not afford the latest and greatest in diabetes care, people who have may not have a home to go to at night, people who might have to get their food from the local food bank. Let me share some stories.

The other day I met a very kind older gentleman named Alvin. Alvin lives with HIV and type 2 diabetes, two chronic diseases that could easily overwhelm anyone--but not Alvin! He reminds me constantly that he could not be happier living in Seattle, his dream city, having grown up in Louisiana working hard each day as a janitor.

It didn’t scare him to live with HIV, but when he was diagnosed with type 2 diabetes he feared losing his life. He explained to me that his pastor, whom he greatly admired, lived with uncontrolled diabetes for many years and slowly lost his limbs one by one, then died from his diabetes. This scared Alvin, so he took his diabetes very seriously.

When I first saw him in the clinic, we talked about his life--where does he live? What does he like to eat? What does he like to drink? How does he like to spend his free time? Alvin seemed to enjoy our conversations, particularly when we discussed his food choices and what he could get to eat on his very limited income and what he splurged on as a treat. Unfortunately, Alvin told me that his favorite treat was soda pop! And he had a habit of drinking 40 ounces of regular soda pop rather too frequently. “Alvin, do you know that amount is equal to two pounds of sugar?” Alvin’s eyes widened. I explained to Alvin if he were to drink less soda pop, that may help lower his blood sugars. We came up with an action plan for Alvin to drink less Pepsi and Mountain Dew-his absolute favorites.

A couple of months later, Alvin’s hemoglobin A1c (a measure of blood sugar control) came down to normal without any diabetes medications. “It’s okay to drink a small amount of diet soda, you know,” I said to him so that he didn’t feel completely deprived of his favorite drinks. “Doc, if eliminating this stuff altogether will keep my diabetes away, then I can live without it!” Wow! A limited income, groceries from the food bank, the one treat he could afford and enjoyed--and yet he could give up the regular pop when he realized the damage it could cause, after I provided information and education about the impact of food choices on diabetes.

But it is not easy to make the changes that could have such a huge impact on diabetes. Jenny discovered this when her blood sugars remained high even after starting medicines, which she thought “would take care of the problem.” Jenny was diagnosed with type 2 diabetes at age 18 years. Her body weight and blood sugars were very high, enough to disrupt her normal hormone cycles, zap her energy and cause her vision to blur. This made it difficult to focus in her college classes as well as being able to take care of her single mother, who was disabled from a stroke. Jenny’s grandmother, who also lived with diabetes, had died recently from a severe infection. Jenny felt overwhelmed and trapped by her diabetes.

Understanding the pressures of being a full-time student and a caretaker while grieving the loss of her grandmother, Jenny needed help to know how to care for herself. We discussed her daily schedule and activities. Jenny mentioned she lived just a few blocks from school but usually took the bus. A McDonald’s was near the bus stop, so often she would stop there on her way home to buy dinner for her mom and herself. I asked Jenny if she felt her neighborhood was safe enough that she could walk to school instead of taking the bus. “Yah, it’s safe and I could try walking on days it doesn’t rain.” So Jenny set a goal to walk to school on non-rain days in addition to taking her medications and checking her blood sugars.

We reviewed the meal choices she was buying and what other types of food were available, but lower in carbohydrates (sugar), salt and fats. Several weeks later, when I saw her in the clinic, Jenny was still just as busy as she had been, but she was several pounds lighter with normal blood sugars, normal hormone cycles and way more energy. “How do you feel?” I asked. “Great!” she said with a smile. “You’re looking happier, what’s changed?” I asked again. “Well, I started walking like we talked about and that helped me clear my mind of all my stress, so I started to walk more and that gave me energy. I’ve been walking now every day for at least half an hour, sometimes an hour, to and from school, sometimes around my block. It’s been good.” And I thought to myself--this feels good to me, too!

Sandra had had type 2 diabetes for many years and thought checking her blood sugars by fingerstick once a day was plenty. But one day she decided to check her blood sugars throughout the day. She came to the clinic with her blood sugar log and showed me that something was off. “My blood sugars are high in the afternoon!” she said. Sandra was on a single injection of long-acting insulin before bedtime. I had asked Sandra to check her blood sugars more often so we could better understand her sugar patterns throughout the day. Her morning sugar levels were on target (the only time of day she was checking), but something was missing, as her hemoglobin A1c was high. But despite many months of encouragement, today she showed me she had done what I had recommended! And she was amazed to see much higher blood sugars, particularly after eating tortillas.

We discussed adding a short-acting insulin shot before her biggest meal of her day. She was hesitant to take more insulin because she did not want to gain weight. After discussing the benefits of short-acting insulin as protection from very high blood sugars after meals and the importance of eating tortillas in moderation to avoid excess sugar and weight gain, Sandra agreed to this change in her diabetes regimen. Weeks later, Sandra returned with a more detailed log of her blood sugars, foods that she was eating and her exercise routine. I was happy to see Sandra with more confidence about her diabetes treatment and self-care. She had discovered she has the ability to lower her blood sugars by changing her food choices and using insulin, and she now felt more in control of her diabetes.

Listening to Alvin, Jenny and Sandra helped me learn that diabetes is not just about pills or injectables, but learning how to find out what can help someone with limited income, limited food choices and much daily stress deal with and manage a chronic condition from day to day. Every day is different, and there are incredible challenges in life! Understanding how Alvin, Jenny and Sandra lived each day with diabetes provided opportunities to ease fears, clarify confusions, learn new facts, set important goals and provide support. I am humbled by these teachers--my patients--and am grateful to have been supported by the Bender Fellowship in my journey to become an endocrinologist!

Dr. Luisa Duran is a Senior Fellow in Endocrinology, Diabetes and Metabolism at the University of Washington Medical Center in Seattle. She is the recipient of the Benders Fellowship which supports diabetes care for underserved communities. She is a graduate of Brown University, Brown Medical School and completed her internal medicine residency at Santa Clara Valley Medical Center in her hometown, San Jose, CA. Dr. Duran is board certified in internal medicine and is interested in all aspects of clinical endocrinology, particularly management of type 2 diabetes.