Author: Ruth Bueter

January is Thyroid Awareness Month. To observe it, Rotation author and Himmelfarb Librarian Ruth Bueter spoke with Dr. Chelsey Baldwin, MD to learn more about the thyroid. Dr. Baldwin is a board-certified endocrinologist at the GW Medical Faculty Associates (GW Medicine) where she treats patients with thyroid conditions. Dr. Baldwin is also an Assistant Professor of Medicine at SMHS and a thyroid expert. 

The Rotation: I’d like to start by saying thank you for meeting with me and helping our readers learn about the thyroid during Thyroid Awareness Month!

Dr. Baldwin: You’re welcome! I’m happy someone wants to talk about it!

Can you tell us a little about what inspired you to become an endocrinologist and how you became interested in the thyroid?

I thought I was going to be a primary care doctor. I enjoy the outpatient setting and I enjoy long-term relationships. I found that I really enjoyed having expertise and that I wanted to be an authority on some topic. I think that primary care is incredibly challenging because you’re in charge of so much, and this gave me a way to keep some of those things that I really wanted - those long-term relationships, and an outpatient setting - and I got to develop an expertise.

The physiology of endocrine is my favorite, so that’s what led me to choose endocrine. And then thyroid, interestingly enough, when I was a fellow I thought I was going to do pituitary. I enjoyed it, and it’s the control center of the endocrine system. But I had a mentor who was a thyroidologist and essentially took me under his wing as far as interest in research, and that’s how it developed, meeting the right person at the right time in my career.

What brought you to GW?

My husband works for the federal government and we were told that we were moving from New York City to DC. I knew I needed to find an academic institution to continue what I had begun at NYU, which is an academic career. I really enjoy seeing patients, but it really balanced things out for me to also have teaching, and to be around people who are thought leaders and are trying to push the envelope, find something new, and are thinking about how to make medicine better than it was 10 years ago. That’s what you find in academic medicine. I actually stayed behind in New York for a year and a half waiting for the right job to open for me, and that was GW.

We at GW are very glad to have you! 

Thank you, Ruth!

Many people outside of medicine might not be familiar with the thyroid. I wasn’t familiar with it until I was diagnosed with hypothyroidism a few years ago. Can you tell us a little bit about it, its role in the body, and how healthy thyroid function contributes to overall health?

Sure. So the thyroid is a relatively small gland, it’s about 15 grams, and it sits in the midline at the base of the neck. So this little gland produces thyroid hormone, and thyroid hormone travels via the blood to all cell types of the body. Of course, I’m a little biased, but what I like to say is that by being a thyroidologist, I have my hand in the physiology of almost every tissue type: the heart beating at the right rate, blood pressure maintenance, how fast the gut moves, or when there’s disease - too slow, too fast - weight management, mental health. The list goes on and on. It makes my job challenging, but also, it’s quite intriguing physiology. 

So again, for people who may not be as familiar with the thyroid, what are some of the things that can go wrong with the thyroid? What are the most common thyroid problems you see with your patients? 

When I’m giving an overview of things that can go wrong with the thyroid, we can think of hormonal problems and we can think about structural problems. For hormonal problems, the thyroid can either not function well enough - the hypothyroidism that you suggested - and again you just think of the metabolism of all of the cell types slowing down, not getting the correct signals. And then the opposite can happen where there’s too much thyroid hormone, and think about being in an overdrive state when it comes to metabolism. And so both [hypothyroidism and hyperthyroidism] are one, incredibly common, and as you shared, can happen to young patients. So I see a large diversity of patients, and interestingly enough, a lot of young patients. 

When we think about structural problems - nodule development. These nodules can be benign, the majority of nodules will be benign. But sometimes, they can one, overproduce hormone and we’re back into that overactive state. Or two, they’re just large enough that they’re causing symptoms due to the fact that the neck is a small space, and they either need to be removed or shrunk in order to alleviate symptoms.

And then finally, thyroid cancer. Thyroid cancer is a passion of mine. I truly am excited about all of the progress we are making in fine-tuning the treatment of thyroid cancer to individualize patient needs. And so that’s kind of a brief overview of what can go wrong with the thyroid.

You talked a little bit about thyroid cancer being a passion of yours. So what are some things that you can do to help patients with thyroid cancer? Are there new treatments, or something that you’re excited about in that area?

Well, interestingly enough, it’s not necessarily new treatments, at least for a majority of patients, it’s learning when treatment isn’t necessary. We’re learning more and more that some of these small cancers and early cancers do not have an aggressive course. And maybe we went a little overboard in the past giving patients treatments that didn’t necessarily change the outcome and took on risk. We’re getting much better at fine-tuning that, making sure that, as one of the famous thyroidologists once said “make sure that the punishment fits the crime.” 

That has been a huge change in thyroid cancer culture, and making sure that the expertise disseminates that practitioners are more comfortable not being aggressive. Because that can actually be really hard on the clinician too, you feel like you’re not doing every little thing you can to prevent recurrence and/or progression. But the bottom line is that knowing when to hold back is truly important.

And then, advancements in thyroid cancers that are new: There are some really rare, aggressive thyroid cancers. Being at a tertiary care center like we are, I, unfortunately, get to see those more often than many clinicians will. And it is so exciting to see that based on molecular or genetic therapies, we are able to make huge impacts on patient survival. There’s a cancer called anaplastic thyroid cancer, that had a dismal overall survival of about 6 months. We are drastically changing that outcome by being able to target these molecular targets within the tumor. It’s really exciting! We published a paper on a case just like that last year. So again, I’m just excited to be a part of that shift and see real progress.

Are there things that we can do to help maintain healthy thyroid function as patients?

This question is usually the one that is the most difficult. There isn’t a whole lot to do for preventative measures when it comes to the most common hormonal problems which are autoimmune. Unfortunately, those are genetic predisposition risks, and as I tell my patients, there’s nothing you’re gonna do about that. You were born with that code. 

And then that second factor, we’re not totally sure what it is that triggers autoimmune disease. Was it a virus? Was it something environmental? But we don’t know what that is to tell people to avoid it. And maybe can’t even avoid it if it’s something common, like a virus or a cold.

Dietarily, the United States and many developed countries iodinate their salt, so iodine is no longer a concern, which at one point was a nutritional problem with the thyroid. But that is really limited to countries that don’t have a national iodination program and are mountainous. Otherwise, natural iodine from the sea protects populations closer to the ocean.

As far as thyroid cancer risks, those tend to be radiation exposures, are things that we know. Those tend to be things like disasters that are non-intentional. So I’m not sure a patient can do much to avoid that. The tough answer there is that there are not a whole lot of preventative measures. But of course, regular exercise and a good diet are the things that I harp on because those are important for everyone’s health.

What has been the most rewarding aspect of treating patients with thyroid disease? And/or what is your favorite aspect of your work?

I think one that struck me yesterday was when I was seeing a young patient with a recent diagnosis of thyroid cancer, and rightfully so, they were nervous, they were anxious about how is this going to look for them, and what is this going to be. It’s really nice to be that guide for that patient. Essentially setting up expectations, what are we going to do to get the very best outcome? I find that part of my job incredibly rewarding.

And two, while I’m giving this talk to the patient, I’ve got a resident and a fellow with me who are learning how to do the same thing for their patients. So it’s kind of full circle - you serve the patient in front of you, and then you additionally serve patients that benefit from your students.

So you touched a little on some thyroid research you’ve done related to thyroid cancer, but can you tell us about some of the thyroid research you have done?

We did talk about that thyroid cancer paper where we published the first case of using targeted therapies, Dabrafenib and Trametinib, to target a patient with differentiated thyroid cancer that was unresectable harboring a BRAF mutation, using those targeted therapies. The uniqueness of this was that it wasn’t an anaplastic cancer, it was a differentiated thyroid cancer, but we used the prior research to apply there.

Some other projects that I work on, I do a lot with minimally invasive techniques for thyroid structural disease, so that means those big nodules that are bothersome, those nodules that overproduce hormones, and very small thyroid cancers. Within the last 5-10 years, there has been a new modality on the block, minimally invasive techniques like laser therapy, and radio frequency, which is my expertise. Coming down the road even newer things like nanopulsed therapy. I do a lot of work there. 

Currently, we’re working on a project looking at thyroid ultrasonography, and predictive factors for whether or not a patient will end up hypothyroid after removing half of the thyroid. Additionally, I’m working with Dr. Khati in radiology and Dr. Joshi, one of our surgeons. We’re looking at the reliability of a system called TI-RADS - it’s a radiology system for grading thyroid nodules, and how do we make that reproducible not only between providers but interdisciplinary providers, because that has been a critique of the system in the past. We’re trying to say that at GW, we figured out how to make this a reliable system. Those are some of the projects that I’ve worked on and that are still ongoing.

In addition to your clinical duties, you teach first and second-year medical students here at GW. You said you also work with fellows and residents. Can you tell us why you enjoy sharing your passion for medicine and endocrinology with medical students? 

Sure. When teaching, you get to go back over that physiology for endocrine, which is really fun, and it’s fun to see the students kind of find that same passion again. Beyond that, I enjoy working with students, residents, and fellows because they remind me of how important it is to be a lifelong learner, constantly being curious, and constantly being willing to explore and go outside of your comfort zone, especially the students. They’re so altruistic still, and I hope that they continue that, and it actually reignites altruism in me. There are multiple benefits to teaching.

When you aren’t treating patients or teaching medical students, what do you enjoy doing in your free time?

I have a dog that takes up as much time as I can give her. And I’m learning French, so that is something that I’ve been trying to do for self-growth. My husband, whenever he’s not traveling for work, we try to make sure we’re out and about exploring the town. And so I keep myself quite busy outside of work as well.

What advice do you have for students just starting in medicine?

Be curious! Ask any question. There aren’t dumb questions. I remember looking back and being so scared to ask something. Like maybe that wasn’t a good enough question. You wonder what stones you left unturned. And this is that time in your life when you get to ask anything and be curious, and you never know what you might find that sparks your interest, and your passion, and leads you down the path that could be the most rewarding career in medicine.

Is there anything else you’d like to share?

I think I’ve said it all!

Thank you so much for taking the time to speak with us today! Happy Thyroid Awareness Month!