Interview with Dr. Craig Alter at Ben and Irv’s on December 11, 2010

Dr. Craig Alter is Clinical Associate Professor in the Department of Pediatrics at the University of Pennsylvania. He is the Fellowship Program Director and formerly the Clinical Director of the Endocrinology & Diabetes Division at the Children’s Hospital of Philadelphia. He has served as Chair of the Educational Committee of the Lawson Wilkins Pediatric Endocrine Society. He was voted as one of the regions “Top Docs” by Philadelphia Magazine.

Dr. Alter completed his undergraduate training at the University of Pennsylvania majoring in Mathematics and Chemistry before attending Harvard Medical School where he graduated with honors. After residency at Boston’s Children’s Hospital, he did his fellowship training in Pediatric Endocrinology & Diabetes at the Children’s Hospital of Philadelphia (CHOP). At CHOP, Dr. Alter won the Fellow Teacher of the Year Award in 1991. He served as a clinical endocrinologist at the University of Massachusetts where he was Director of the Children’s Diabetes Center. At the University of Massachusetts, he won the Faculty Teaching Award in 1996 before rejoining the Endocrinology Division at CHOP in 1999. At CHOP, Dr. Alter is a Clinical Pediatric Endocrinologist and is deeply involved in medical education.

Dr. Alter has lectured nationally on various topics in endocrinology. In addition, he enjoys studying methods of education and has taught and run workshops nationally on improving methods of teaching in medicine.

Dr. Alter has three daughters and all enjoy traveling. He speaks French. His major hobbies include tennis and table tennis.

Why did you become a pediatric endocrinologist?

First, I didn’t even know there was a field called endocrinology, let alone pediatric endocrinology. So that wasn’t a consideration while growing up. I always loved math as well as physics and chemistry. I have always enjoyed unique characteristics of effective teachers.

When I went to the University of Pennsylvania, I kept medicine as a possibility, but I really concentrated on math and the sciences. My friends would tell me that it was a waste of my talents to go into medicine, so I pursued the sciences. I worked for two summers in a program at IBM called a “Summer Pre-Professional Program”. One was in New York in East Fishkill NY and the other one was in San Jose California. The programs were great and they were a fun job. But my favorite parts of the jobs were making presentations to other people and just interacting with others. After that, I realized that what moves me was interacting with people, not the science. Intellectually, the science moves, me. But it is interacting with people that really moves me.

I had done well undergraduate, so I applied to medical schools and strong ones, such as Harvard Medical, and when I got Harvard’s application it said “for those of you who are interested in a more mathematically oriented and quantitative approach to medicine”— at which point I started drooling reading this application because it was describing exactly what I was looking for. This was a joint program between Harvard and MIT, and I made it my goal to attend. I wrote 3 essays, got in, — I was very excited!

Why medicine, because there are a lot of jobs where you can interact people?

I think growing up on Long Island I was brought up with the fact that medicine was always a noble thing and a successful thing to do. To be honest, I thought it would be a higher-paying field. “Doctors are always the wealthy, successful, smart people.” So that’s the image I had growing up.

So then when I went to Medical School, at first I felt a little out of place because I had not volunteered at hospitals like other people were doing the last few years. I last volunteered and heard medical language in High School. But I got caught up quickly. I found that I liked physiology. It was the area where one learns about the electrolytes, when the calcium is high, when calcium is low, when the potassium is high, when the potassium is low. Finally I had a formal course on endocrinology, a word I probably didn’t even know how to spell back then, as a second year medical school, where I learned that there were all these controllers of all these minerals in the body. It was pretty fascinating. And the professor was also very funny.

Do you remember his name?

Dr. Bill Kettyle at Mount Auburn Hospital. Interestingly, this course of endocrinology at Harvard Medical had all top national scientists in endocrinology. He was not one from one of the bigger hospitals. But he’s the reason I’m going into endocrinology; he just moved me. I may have gone into endocrinology anyhow, but I really liked him. And then, after that, I declared I wanted to do endocrinology.

At medical school, the first two years you’re in the classroom. You don’t see patients. And the second two years are with patients. I knew I liked kids. Initially, I didn’t really think about pediatrics. I didn’t think that there was a pediatric endocrinology yet. So I thought I was going into an endocrinology which would be of all ages. Why would I know anything else?

So then my first rotation was pediatrics. Coincidentally the person in charge of my rotation, the main doctor in charge, was Dr. Jack Crawford , who was a world famous old-timer in pediatric endocrinology. And then I realized that there was a pediatric endocrinology.

In the first month, maybe three times I had this experience that I would go into a room and the mother would say to me, “You’ll never get near my child because she hates doctors. She had an operation on her leg and she never lets anyone touch her legs.” And my instinct was, “Of course, I can get near your child. I have a way with kids.” It didn’t even cross my mind. This challenge was a fun challenge. It was so natural to me. Three times that first month, a parent said to me “Oh my God, this has never happened before”. So that was such amazing feedback to me that I realized that I am definitely going into pediatrics. And I loved endocrine and now I knew that there was a pediatric endocrine, so there I was going into pediatric endocrine. Knowing what subspecialty that one is going into this early is a little unusual, because most medical students, even residents after that, which is the next stage, don’t decide their specialty until they’ve been in the system for a while. I decided it really quite quickly, which helped me learn a lot about my field and concentrate early on. It’s like if you want to study magnesium and you’re in 7th grade you’ll pick up everything that has the word “magnesium” in it.

After medical school I then, of course you have to go residency, so I went to Boston Children’s, which is the Harvard’s Children’s Hospital and spent three years there. And subsequently, I went to Children’s Hospital of Philadelphia, where I did my undergraduate at the same university, and did my fellowship training at endocrinology. So that’s kind of standard plan for any sub-specialist. They do three years residency, three years specialty.

Now there’s another dilemma there. Just like with the sciences, when I started doing endocrinology, everyone was telling me “So you’re gonna research. Of course, you’re gonna do research. You were in the Harvard-MIT program that’s designed to build strong science, and you’re like the perfect researcher. And I said, “Yeah, but I don’t want to do that.” If I wanted to do research I would have not gone into medicine in the first place. I would have stayed in math or physics. So I pursued a clinical career in pediatric endocrinology. After three years of fellowship I went to the University of Massachusetts.

You got into this field of endocrinology. And you liked the clinical aspect of it. What was it that fascinated you about endocrinology?

It’s a field where there are a lot of intellectual diagnostic challenges. It’s like a Sherlock Holmes. You have to say, “Well, this person is gaining weight excessively. Is there a reason for it? What are the possible reasons for it? This person is having some visual changes and their potassium is low. Could they have a condition where there is hormone deficiency? I went into it because I liked the diagnostic challenges.

But was there one particular aspect of it? For example, some people go into oncology because they want to cure cancer. Was there a particular problem, or were you just interested in general?

There was no particular problem, but I remember when Dr. Kettyle, when he came to class, as a teacher, not only was he a good instructor and humorous, but he brought in patients – very unusual to do that in the first few years of medical school– and I remember his teaching patients very well.

One was a adult male with hyperthyroidism – overactive thyroid – and he was walking around the room as if he was in a walking race. Just walking so hyperactively. And he was speaking very quickly. He was very excited about life. He would go out with his friends, and they would be worried about getting fat after having just one ice cream. But he could have 2 ice creams and lose weight. He just thought it was amazing. But after a while, he realized that had something wrong with him. And after he started getting treatment, he realized he had been feeling sick for 5 years. Very fascinating.

There was a 27 year old woman who came in who was blind from diabetes. That was obviously quite moving. And so these are patients who stick in my mind. Bringing in patients early on in a medical student’s life hits very deeply. And I don’t forget that. The very first patient I saw was someone who had pancreatic cancer, in my first week in medical school. I was told he had no chance of survival. Zero. That was my wake-up to medicine.

Do these kind of things still intrigue you and excite you? The things that got you into the field still drive you. Or is it a “seen that, done that” kind of thing? Is it getting old, a little bit? Now that you’ve been doing this for how many years?

17 years.

Do those things that initially excited you, do they excite you anymore? The other question, on the flip side, is what frustrates you?

Like most things, the field is very different than I expected initially. It’s not like every day I have a diagnostic challenge. I would say, maybe, once every 2 weeks I see something that really puzzles me, where I have to look things up, see what the current literature is. Most of the time those are genetic syndromes where information is just obtained, and you have to always keep up to date. For example, with a chromosome 9 problem – I’ve seen people with that, but I don’t know much about it. I’d have to look it up, and it’s more specific now. I may find out that it’s a chromosome 9 problem on the 3rd section. So I have to look up what’s known on that. It’s not really diagnostic dilemmas so much. I would say my field is not really one of diagnostic dilemmas, but giving people treatment for conditions.

And I think that things that move me the most right now are conditions known as Graves disease, and that’s a condition where a person has an overactive thyroid. And the reason I like it is because kids have a lot of symptoms and people don’t realize that it’s because of the thyroid. So the history is very interesting. Take a 10-year old girl, who is former A-student, now getting D’s, skip the B’s and C’s, goes to the D’s. She’s having a lot of emotional problems. She’s lost weight even though she’s eating a lot. She’s very shaky, sometimes dizzy. Her eyes are becoming more prominent and no one realizes it, except in retrospect, for the past year that this is happening. They’ve been to psychologists because of behavioral changes. When in fact this is all because of the thyroid.

Why the poor grades?

Having hyper-thyroidism is like having 7 cups of coffee a day. If you’re on speed, you’re just so hyper that you can’t focus. These kids that go in the room, I say hello to them, they’re sitting on the table, two seconds later they’re on the chair then they’re moving over here. They never sit still. They’re so hyperactive. These, of course, are untreated people.

Tell me what most frustrates you most about the field now? Is it seeing that everyday kind of thing for you boring for you? Most of the things that aren’t that diagnostically challenging, that in two seconds you can diagnose the problem, you can do it in the sleep.

I would say that what frustrates me is how much of my job is spent in trying to get approval for therapies that are indicated. At the same time I understand why that is necessary, and I’m talking mostly about growth hormones. I see probably the three most common complaints, reasons for coming in, that I see are growth, number two would be diabetes, and number three would be thyroid problems and tied for number three are disorders of puberty. I do a lot of growth evaluations looking for disease processes that affect growth. Most of the people I see do not have a disease processes. They are normal, which is fine. I guess it’s frustrating to me when I don’t want to give growth hormones and a family feels like life would be awful without growth hormones. Do I sometimes give growth hormones in that situation? Well, first of all, when I see the family feels that strongly about it, I reevaluate things for sure. It definitely moves me. I have to think, “Well, is this is a situation where growth hormone will help?” I get sometimes people that I don’t consider that when they’re asking for growth hormone. And other times kids are extremely sure that they don’t want growth hormone. Every family is different. But if I prescribe growth hormone in those cases it is guaranteed to be a very difficult sell for the insurance company, understandably.

What do you think helps people in your field of pediatric endocrinology succeed? What are the characteristics that let you succeed? I assume that being able to relate to children, this ability that you have. Is there anything else you want to add?

There are several kinds of pediatric endocrinologists. There are ones that are predominantly into research and they may see patients only ½ day a week. There are some in private practice and see patients all the time. And there are some in between, that do some research. I actually don’t do a lot of research, but I do a lot of education. And I’m well known for that in the region. I would say nationally. And the reason, because I give very creative presentations. What moves me in a day? When you say to me, “What made a great day?” When I gave a lecture, usually the bigger the audience the better, I feel like I can control a room of 3 or 4 hundred people quite well, and even make it interactive despite the numbers.

So what you’re saying is for someone who does your kind of in-between research and clinical work a successful characteristic is someone who can present the material well?

That’s for me specifically. For most people they wouldn’t say that’s what they like

But that’s what you like. Objectively, what would you say is successful? What are the characteristics? Is it say, someone who has a good memory? Do you have to remember all the patients?

I think in my field, even though endocrine is considered intellectual, like anything else, once you get used to it, it’s repetitive. Not many of us have to think a lot when someone presents with a big thyroid gland. There are only a few things that can cause a big thyroid. The challenge is not in making the diagnosis, but in how to explain the complex information to the family. I have to individualize my explanation and even therapy. To me, a successful practitioner is someone that can explain it to the family at their level. And so when they leave they understand how sick, or not sick, their child is. I think that’s really important.

The truth, huh?

It’s the truth. But, for example, let’s say that you had a knee surgery and afterwards you had a knee pain. And for a year you’re complaining “Oh my God, this knee, this surgery went terribly”. When in reality the surgery went great. This is just the way it is. So had someone explained to you ahead of time that you were going to feel knee pain, it’s going to take a few months and it’s going to get better, better, and better. You’re going to have walk through it and try not to focus on it. Then you’d be leaving thinking this is going great. But if no one explained it to you, even if the best surgeon in the world did the most perfect operation in 2010, then you’re thinking this surgery did not go well. So having someone explain things really helps.

Are there any current leading people in endocrinology? So who would you say is the God of endocrinology?

Well, I think when you look for the national thought leaders in endocrinology often it’s not one person. It depends on the topic. So let’s say it’s a calcium problem. Then the head of my division at CHOP, Dr. Michael Levine is known nationally to be one of the country’s experts in calcium, if not the expert.

So am I known for Graves disease, because I told you that was one of my favorite things? I’m known locally for that, but not nationally, because I don’t do research in that. If I put out a study and described some of the things I do and did in a research way then I probably would be known for that. But I choose to have more of a clinical career than a research career.

What particularly about Graves interests you? What is it that is fascinating to you?

That there are so many unique symptoms and that I can actually make them better. But it’s also not easy. I feel that I do this better than many other pediatric endocrinologists, from what I’ve learned over the years. I compare myself now to when two years after I finished my fellowship in mid-1995, for example, I’m much better now than then because I’ve learned stuff.

What would you give advice for students who are thinking about going into pediatric endocrinology?

I think that a person going into any field in medicine needs to find out deep in their heart what moves them in the field of medicine. Is it interacting with people? Is it something that they want quick and exciting things like on the show ER? In which case it’s ICU medicine and ER medicine and some of the surgical fields are the way to go. So the idea you have to answer first, is it sitting down in conferences and discussing how to improve the world of medicine? Is it public health issues, like obesity? All those things are what needs to be answered. Anyone going into endocrinology probably shares the common thing that they like to discuss things, they like to understand how things work.

But do they have to be good at chemistry?

They don’t have to be that good at chemistry. But on certain parts of endocrinology you do have to be an expert. If you want to be an expert at hypoglycemia, you better understand the glucose pathways, the Krebs cycle, and all those gluconeogenesis. That’s really important.

In terms of financially, I think they should research more what fields are better paying or not if they think that’s going to be a stressful thing down the road. If they are Bill Gates’ kid they don’t have to think about that. If they’re going to have a lot of medical school loans, that’s a factor, because pediatrics, psychiatry, and those kind of fields are low paying.

If you were Bill Gates’ kid, do you think you’d go into pediatric endocrinology?

I definitely would go into pediatric endocrinology.

Do you think you’d work as hard? Do you think you would do the exact same thing?

I think you missed my point. Your question should be if I had twice as many student loans as I did leaving medical school do you think I should have reconsidered my field. Because I’m telling you that endocrinology is a low paying field. So you’re telling me I won the lottery, I would do whatever is interesting. I sometimes get frustrated that this field doesn’t get higher pay. When I grew up that doctor figure that I always described is one who is wealthy and I feel like a lot of the expense of medicine, when a family gets a bill for $2000, if you break it down, it’s maybe a hundred dollar goes to the doctor’s practice and then a bunch goes to the hospital, $1500 goes to the drug therapies. That’s where the economics have gone. We’re not economics experts. Somehow that’s the direction it’s gone. And procedural fields, like surgical, they make a lot more. But still the pharmaceutical companies make so much.

If you had no money obligation, you had as much money as you wanted, would you change anything that you’re doing? Would you do more research, more clinical? Less of something? If you could have your ideal situation, what would it be?

First, I would absolutely stay in my field. No question about it! My field is really fun. Only I would really have a slightly different job. Going back to college, when I said I loved math and chemistry, I would teach math. I would want to teach calculus. I would love to teach calculus maybe in the morning, five days a week and then after that go in and do my job. I just love math so much.

So you would teach calculus. But what would you do about endocrinology?

I would do what I do now.

Did you have any misconceptions? When you got into the field you had a certain idea of what it was going be like and then it turned out not to be quite like that? Maybe you expected to see more challenging cases?

Yes, when you learn about endocrinology in medical school you learn about, lets say, what can cause obesity. There’s one condition called Cushing syndrome, named after Harvey Cushing. This is a condition where the body makes steroids too high. Not athletic steroids, but the hydrocortisone class of steroids called glucocorticoids. And these steroids make you gain weight, slow down your growth. They make you have a distinct appearance. It’s very very rare. So I figured that I’d become an expert diagnosing this. The reality is that I see that condition almost never, even though I’m at a major teaching hospital.

Is there anything else that you’re disappointed in any other way?

We have more and more pressure to see so many patients. It really hasn’t bothered me so much. It has bothered other people. I like to see patients.

What kind of impact do you think the research you’re doing in endocrinology will have in the world and in the field of endocrinology? Do you feel like anything you’re doing right now will have an impact?

The short answer is “no” because I don’t research. But I’m in charge of the endocrine fellows. I’m always changing and upgrading the program of which new endocrinologists learn about endocrinology. Some of them will go into the research field. So I think my impact is going to be on a lot of endocrinologists entering the field.

Are there any recent papers or books or new ideas in endocrinology that you’ve found particularly noteworthy?

In diabetes there’s the pumps that are now able to read the blood sugars, which are performed from a blood sugar meter. There are now less invasive ways to get the blood sugar. I think that field which has moved slowly has finally got over one of the hurdles. You can almost see that 20 years down the road that the care of diabetes is going to be very different, that it’s going to be a lot more automated. And that is exciting to see. I haven’t talked a lot about diabetes. But families with diabetes move me all the time. I also run a diabetes camp every year. That’s very special to me.

Does Donovan McNabb still go there?

No, he got traded. Camp Freedom now. The name, it’s called Camp Freedom.

What was it called before?

Donavan McNabb Diabetes Camp for Children.

Is there anything else you’d like to add, something philosophical?

I spend the day teaching families about their children’s health. Also, families teach me many things too, and some of their clever realizations I pass onto others. I feel strongly that a good doctor must acknowledge that patients teach them as well.