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  2. 2. Pediatric-Endocrinology Fellow Handbook July 2006 TABLE OF CONTENTS Introduction Mission, Vision, and Values 4 Section I Orientation Activities for New Fellows A. Orientation Activities for New Fellows 6 B. Baylor Endocrine Conference Schedule 7-9 Section II Policies and Guidelines A. Guidelines for Fellow Responsibilities 11-14 B. Dictation/Discharge Summaries 15-16 C. Policy on Resident Supervision 17-18 D. Faculty Responsibilities 18-19 E. Duty Hours 19 F. Time Off 19-20 G. Professional Trips, Meetings and Courses 21-22 H. Reporting Change of Address 22 Section III Outline of the Pediatric Endocrinology Fellowship A. Outline of Clinical Curriculum 24 B. Goals and Objectives at each level of training 25-27 C. ACGME Core Competencies 28-31 D. Curriculum Goals and description 32-50 Section IV Recommended Reading See Other File 2
  3. 3. Pediatric-Endocrinology Fellow Handbook July 2006 INTRODUCTION: Mission, Vision, and Values 3
  4. 4. Pediatric-Endocrinology Fellow Handbook July 2006 MISSION •To prevent short and long term complications of endocrine diseases and their associated physical and emotional sequelae by providing exceptional and innovative patient care as well as appropriate education of our patients, their families, and health care professionals. •To promote a standard of excellent teaching for pediatric endocrinology fellows that will provide them with a well-rounded experience both in the diagnosis and management of pediatric endocrine disorders as well as in performing clinical and/or basic science research in related areas. VISION To become a world-class Pediatric Endocrinology/Metabolism Division. VALUES Tempus Fugit--- Carpe Diem •Confidence –Trust, Integrity, Accountability, Accuracy, Loyalty, Punctuality, and Professionalism •Competence –Training, Knowledge, Empowerment, Efficiency, Prudence, Wisdom, Quality •Completion –Goal Setting, Implementation, Closure•Commitment –Flexibility, Adaptability, Dedication, Teaching, Initiative, and Exceptional Service •Courtesy –Teamwork, Mutual Respect, Listening, Patience, Humility, and Non-Judgmental Communications •Creativity –Imagination, Originality, Thrust for knowledge, “Outside The Box Thinking” 4
  5. 5. Pediatric-Endocrinology Fellow Handbook July 2006 SECTION 1: ORIENTATION ACTIVITIES FOR NEW FELLOWS 5
  6. 6. Pediatric-Endocrinology Fellow Handbook July 2006 Orientation Activities for New Pediatric-Endocrinology Fellows During the first month of Fellowship (July), it is the new fellows’ responsibility to: 1) Attend the following activities i. Orientation to the hospital and to the clinic ii. New Fellow Lecture Series iii. The Fundamentals of Clinical Investigation course (Monday to Thursday, 5.30-7.30 pm) iv. Logician Orientation with Jill Simon (ext. 2-4875) v. Oasis orientation vi. Stentor orientation vii. Ebill orientation viii. Ben Taub Computer Orientation 2) Participate in the following Diabetes Education Classes i. Follow a new onset Type 1 and Type 2 patient completely through their care and educational process. ii. Participate in the Advanced Pump Class, Carb Counting (CHO), Insulin dose adjustment (IDA) and and intensive insulin management (IIM) class iii. Shadow the on call Clinical Diabetes Educator (CDE) class 3) Obtain ID badges for: i. TCH ii. Baylor iii. Ben Taub iv. Remote Access v. Obtain Parking Card vi. Security access to Children’s Nutrition Research Center (CNRC) as needed for research. 6
  7. 7. Pediatric-Endocrinology Fellow Handbook July 2006 Baylor Endocrine Conferences Mondays 8-9am, weekly, MD Anderson Faculty Center FC3.3061 Core Curriculum Conference. These are didactic lectures or conferences conducted by Adult Endocrine Faculty. In July, the topics are Endocrine Emergencies. For the rest of the year, two conferences per month are devoted to covering key endocrine topics (48 in all); the remaining monthly conferences consist of a Journal Club (Dr. Rena Sellin) and a special discussion of Thyroid (Dr. Steven Sherman) or Bone (Drs. Steven Wauguespack and Dr. Ana Hoff) topics. The 48 topical lectures include all the topics required by the ACGME for endocrinology fellowship programs and the approved curriculum of the Association of Program Directors in Endocrinology and Metabolism (APDEM), and are covered over a 2 year period – i.e., 24 topics per year. Tuesdays – 8:00 – 9:00 a.m., weekly, VA research building Clinical Case Conference This conference is run by the Adult Endocrine Fellows. This is intended to be a clinical conference. Dr. Marco Marcelli and 1 or 2 other faculty members are in attendance. One of the senior fellows is responsible for scheduling 6 months worth of conferences before passing the baton to the next fellow. For the first week of each month, one of the fellows presents a literature review of an endocrine topic (e. g. acromegaly, Turner’s, impaired glucose tolerance, peroxisome periferator-activated receptors, thyroid storm). For the second week, the Ben Taub and MDA fellows each present a case. The third week is usually an outside speaker (e.g. -Growth Disorders in Children; James Pool-Endocrine Causes of Hypertension; Thomas Wheeler-Thyroid Pathology). The fourth week is reserved for case presentations by the VA and Methodist endocrine resident. Each resident gets a half-hour to present a case along with a brief analysis / literature review. Tuesday Teaching Conference 1230p-130p Location to be Announced Weekly. 2nd, 3rd, and 4th year fellows and faculty will alternate running this conference. Wednesday – 12:15 - 1:00 p.m., weekly, Ben Taub Ben Taub Evidence-based Endocrine Management Conference This is a series devoted to developing evidence-based guidelines for endocrine diagnosis, testing and management. The latest evidence-based articles are discussed for each topic, and a consensus document is drawn up or modified. Drs. Ashok Balasubramanyam, R.V. Sekhar and Susan Samson are the moderators. The 9 adult endocrine fellows rotating through the Ben Taub General Endocrine (Continuity) Clinic attend this conference. Thursday – 12:00 – 2:00 p.m., weekly, TBA Section conferences to include fellows clinic conference, faculty and faculty/fellow meetings, journal club and research meetings. 7
  8. 8. Pediatric-Endocrinology Fellow Handbook July 2006 Thursdays – 2:30 to 3:30 p.m., weekly, Case Conference, CCC 10th floor room 100.35conference room Guidelines for Thursday Case Presentations This conference is part of our didactic activities and is devoted to discussing interesting cases or patient related issues. Physicians in training, physicians, medical/nursing students, nurses, social workers and dieticians are to share the presentations. Each Thursday 2 cases will be discussed. Each case should be presented in Power Point format. The time will be distributed to allow 30 minutes for each case discussion. During those 30 minutes the presenter will be required to go through the pertinent findings of the case. The following distribution is recommended: -History, Physical Exam, Labs and Differential Diagnosis focusing on patient related problems (10 min.); -Recent literature published related to the primary diagnosis (10 min.); -Questions and Group Discussion (10 min.). At least 2 conferences/mo. about current hospital pts, even those without a formal diagnosis. Case conference is not meant to be a review of the literature Input at case conference from all attendees is expected Constructive criticism Suggestions for the next steps in evaluation and treatment The presenter can bring articles to be distributed to the audience. The article(s) should be given to Terri with at least 3 days in advance, to allow time for copying and distribution of the material. Thursday – 4:00-5:00pm, weekly, Fellow’s Curriculum, D1000.35 Thursday – – 5:30 – 6:30 p.m., weekly, Jaworski classroom Baylor Endocrine Grand Rounds * Fellows are encouraged to attend all conferences. Of course, they must still be available to complete their assigned clinical duties. *Weekly reminders RE conference Schedule are emailed (see sample) 8
  9. 9. Pediatric-Endocrinology Fellow Handbook July 2006 Weekly Reminders, 2006 Tuesday , 2006 Diabetes/Endo Management Meeting: Dr. Haymond’s Office/CCC 10th Floor 12:00pm (Haymond, Matt, Percival, & Lori) Wednesday , 2006 Speaker: 12:00- 1:00pm Research Seminar Topic: Feigin Center 1st floor conf. room Thursday , 2006 TIME WHAT WHERE WHO 12:00-1:00PM Fellows Conference Fellows Office Fellows & Attending Section, 1:00- 2:00PM Faculty, Faculty/fellow, Journal, Research BREAK-Pharmaceutical Display: D.1000.31 Entire Section Welcome 2:00- 2:30 2:00- 3:00PM CDE Meeting D.1200.31 All CDE’s CASE PRESENTATION Speaker: FACULTY/ FELLOWS 2:30- 3:30PM Title: D.1000.35 Entire Section Welcome 3:30- 4:00PM BREAK Fellows Curriculum All fellows, entire section 4:00- 5:00PM Topic: D.1000.35 welcome GRAND ROUNDS BCM Speaker: Jaworski FACULTY/ FELLOWS 5:30- 6:30PM Topic: Classroom Entire Section Welcome 187A Friday ,2006 Attending for Fellows Clinic: All Day Fellows in Clinic- AM: PM: On Service: OUT OF OFFICE 9
  10. 10. Pediatric-Endocrinology Fellow Handbook July 2006 SECTION 2: POLICIES AND GUIDELINES 10
  11. 11. Pediatric-Endocrinology Fellow Handbook July 2006 A. Guidelines for Fellow Responsibilities 1) CALL SCHEDULE a) Inpatient Service i) Each of the first year fellows shall be responsible for an average of four months of inpatient service b) Consultation Service i) Each of the first year fellows shall be responsible for an average of four months of consultations service ii) Inpatient and Consultation fellows divide consults equally. iii) Two ½ days clinic/wk including Fellows clinic; usually Wednesday AM or PM and Friday AM. c) Weekend Call i) First year fellows (1) inpatient fellow will take call the weekend before inpt mo. starts (2) total 9-10 calls ii) Second year fellows (1) Total 6 calls (2) Coverage for unanticipated circumstances, as assigned by Dr. Hwu and Dr. Haymond iii) Third year fellows (1) Total 3 calls, plus one weekend on their junior attending month (2) Coverage for unanticipated circumstances as assigned by Dr. Hwu and Dr. Haymond iv) Fourth year fellows (1) Coverage for unanticipated circumstances as assigned by Dr. Hwu and Dr. Haymond v) Fellow on call for the weekend will having morning fellows clinic on Friday if possible. This is coordinated by the senior fellow who is in charge of the inpatient and outpatient fellows schedule d) Outpatient Service i) Clinic will be 6 ½ days per week. ii) The outpatient fellow will attend Clinic at the Memorial Heath Center 2 Mondays (AM and PM) a month (with Dr. Yazdani). iii) On other weekdays, the outpatient fellow will be assigned to a CCC attending. They will review the new patient referrals and see the urgent patients with that attending. If there are no urgent patients, they will see patients scheduled in clinic with that attending iv) They will have fellows clinic Friday afternoons. When they attend the Memorial Clinic, they will not have fellows clinic that week. v) The fellows will see their own patients in the Fellow’s Clinic. First years will have additional days of clinic each week (for a total of 6 ½ days per week). Clinic begins at 8 a.m. You may start when the patients are roomed. You do not need to ask the attending for permission to see the patient. vi) When the fellows see patients in the clinic, they are responsible for writing the note in Logician and following the labs. The notes must be routed to the attending for review PRIOR to signing them. When labs are available, they need to be reviewed with the attending. After this, the fellow must communicate results to the family by phone or letter. This communication must be documented in Logician. If the patient still has not performed the requested labs or studies 1 month after the visit, the fellow will send a reminder letter to the patient and notify the attending of the need for follow up of that patient. vii) Clinic schedule for the outpatient rotation. The fellow will be assigned a physician to work with in clinic by the senior fellow with the associate program director. The schedule will be developed monthly so that the outpatient pediatric and adult fellows and the consult fellow are exposed to a variety of attendings. 11
  12. 12. Pediatric-Endocrinology Fellow Handbook July 2006 Non clinic time should be used for reading and exploring options for the research project. 2) CONSULTATION (C/S) FELLOW RESONSIBILITIES a) The consult fellow will see consults assigned by the inpatient team. b) Consult fellow will contact inpatient fellow/attending upon completion of the consult to staff. Inpatient fellow should be present for consult rounds. c) The fellow who saw the consult will inform primary team of our recommendations. d) If too busy, non-urgent C/S’s can be completed the following day e) Once a week, the consult fellow will have fellows clinic (Fridays). f) Once a week (Wed PM ) the consult fellow will attend the hospital discharge clinic. g) Consult fellow usually has ½ academic day per week; however, urgent consults may require flexibility. ADULT MEDICINE FELLOW ROTATION: Prior to the first day, the fellow should contact Tasha Stevens, Terry Eaves, or Lori Malone in Suite 1022 of the Clinical Care Center of TCH to obtain badge. (832-822-3780). The adult fellow pager is 832-824-7243 x 6971. h) Orientation – performed by Dr. Hwu or Dr. Buggs and administrative staff i) Badges and phone number cards ii) Logician access iii) Local Desktop access iv) Tour of TCH and Clinical Care Center (CCC) v) Ebill orientation vi) Dictation card and attending’s dictation code. i) Outpatient Service The Adult Fellow will usually begin the TCH rotation on an outpatient service. i) Each adult medicine fellow shall be responsible for an average of 1.5 months of outpatient service. ii) Attend clinic five 1/2 days a week at TCH, plus your Continuity Clinic every Wednesday afternoon at BTGH. iii) The fellow will keep a log of patients seen to assess a variety of cases and to assist with follow-up of these patients’ studies. The fellow will draft letters to patients of lab results/interpretations for attending approval. iv) Attend Pediatric Endocrine clinical conferences on Thursdays. v) 1-½ days per week for academic time. vi) Adult fellow will attend diabetic education class: carbohydrate counting (CHO) and advanced pump class (ADP). j) Inpatient Service i) Each adult medicine fellow shall be responsible for one month of inpatient service. The adult medicine fellow will always be on service with a pediatric endocrine fellow. ii) The adult fellow will never take night call while on the inpatient service. iii) The adult fellow will participate in one weekend of call without pager responsibilities. iv) The adult fellow will attend all rounds. The Pediatric Endocrine Consult Fellow will accompany the Adult Fellow for the initial assessment of the first few consults 12
  13. 13. Pediatric-Endocrinology Fellow Handbook July 2006 assigned to the Adult Fellow. Thereafter, the Adult Fellow will perform the initial assessments on his/hew own, but there will always be close backup from the Pediatric Endocrine Fellow and attending physician. v) The adult fellow will then follow the new consult as his/her primary patient, which entails prerounding, dictating, appending Logician documents upon discharge, and discussing plan with primary team. vi) The adult fellow will follow approximately half of the inpatient service. Adult Endocrine Conferences: while on the outpatient service, the Adult Fellow may attend all scheduled conferences unless clinical responsibilities intervene. While on the inpatient service, it will frequently be impossible for the Adult fellow to attend these conferences – attendance at these conferences will always be considered secondary to clinical responsibilities. For any problems or concerns regarding the TCH service, please contact Dr. Kathy Hwu (832-822-3756; pager 832-824-7243, ID 4509), Dr. Colleen Buggs (832-824-3702; pager 832-824-7243 ID 5614) or Dr. Morey Haymond (713-798-6776). 3) HOLIDAY SCHEDULE There are 9 Baylor Holidays (Total of 11 days)*. a) The Attending Physicians expect that there will be a fellow covering each holiday/holiday weekend. b) The senior fellow in consultation with the junior fellows will equitably distribute holiday coverage throughout the year and get approval from Drs. Hwu and Haymond. c) A fellow may coordinate the holiday coverage to fall on their month on call if this is possible. If the fellow has other holidays that he/she may wish to observe, it shall require approval of Dr. Haymond and the attending on the hospital service that month. d) Holidays will be equally distributed among first year fellows (meaning no one fellow can have all holidays off). Senior fellows will cover one holiday per year. 0 *New Year’s Day (observed), MLK, President’s Day, Good Friday, Memorial Day, Independence Day, Labor Day, Thanksgiving (Thursday and Friday - 2 days) and Christmas Eve (observed), and Christmas Day (observed). New Year’s Eve shall count as an additional holiday for call purposes only. 4) PHONE COVERAGE FOR OUTPATIENT CALLS a) Each of the first year fellows shall be responsible for outpatient calls from 6pm to 8am. i) The fellow on inpatient service will be responsible for call coverage on Monday, Tuesday, and Thursdays. ii) The fellow on consultation service will cover Wednesdays. b) The PNP's will cover 1 weekend each per month (Sat and Sunday, 8am-2pm). The 5th weekend will be covered by a 2nd or 3rd year fellow who is not rounding. c) If the upper level fellows cannot provide coverage the PNP may be asked to provide coverage with permission of the attending 5) HOSPITAL SERVICE SCHEDULE a) Attendings shall rotate monthly covering from 1st of the month to last day of the month. b) Fellows shall round in 4 week blocks, starting the first Monday in August. c) First year fellows shall cover from Aug. – July inclusive. 13
  14. 14. Pediatric-Endocrinology Fellow Handbook July 2006 d) Each 3rd year shall cover 1 month of junior attending (Feb. to May). The faculty will back-up the 3rd year junior attending (coverage to be determined by faculty). e) Sick days will be covered by available fellows, when possible. f) Fellow’s responsibility is to dictate in a timely fashion (prefer within 24-48 hours): (1) consultations (2) –history and physicals on primary patients (3) -discharge summaries on primary patients (4) –append consultations upon discharge or sign-off (5) -ER visits for patients for whom they have had responsibility. Guidelines for Junior Attending/3rd Year Fellow Attending Month There will be a first year fellow rotating with the Junior attending. A faculty member will also be on the team as the attending of record. The faculty member must see all patients and review the case and plans with the Junior Attending. The Junior Attending and Faculty member will meet daily at 4pm (Monday to Friday) for sign out rounds to review the cases and to see the patients together. Critically ill or emergent cases should be discussed with the faculty member immediately, rather than the usual sign-out time. The Junior Attending is primarily responsible for supervising the first year, writing the notes with the first year, teaching of the first year fellow and residents (including the 14th floor diabetes lecture), and functioning as the attending for the service. Service responsibilities will include all admissions, consults, and transfers. The junior attending will also be the attending on call (with the faculty attending as the back-up). Transfers: the junior attending will be responsible for speaking with the transferring hospital and the transferring physician. The admitting/attending physician will be the faculty member that is covering with the junior attending. The junior attending will contact the transfer center and have them page the faculty attending to officially accept the transfer. The junior attending is responsible for making sure that the faculty attending is notified of all transfers immediately. 14
  15. 15. Pediatric-Endocrinology Fellow Handbook July 2006 B. DICTATION/DISCHARGE SUMMARIES 1) Dictation Responsibilities a) Attending shall sign all medical records b) Fellows are to document phone calls in Logician c) Fellows shall maintain a log of patients seen and ICD-9 codes, using bar code stickers from the inpatient service. d) Section Administrator will be notified in writing of all patient deaths. 2) Dictation Guidelines: Residents/Fellows/Medical Students a) Dictation phone numbers & codes 1-866-418-9375outside the hospital *9191 inpatient work type 10 H and P 20 consult 40 discharge summary 50 death summary Dictation ID number: the code of the attending who saw the consult with you. EACH ATTENDING HAS A CODE. The discharge summary is dictated with thefellows ID code or the ID code of the attending who discharges the patient. b) Dictation/Consultation All consults must be dictated to Logician. Dictations must be done within 24 hours of the consult. (You may photocopy the note and take it with you to dictate from the office or at home). The fellow who saw the patient for the consult is responsible for the dictation. Medical students and residents who rotate on the inpatient service and see consults with us are responsible for the dictations for the patients they see. Consult dictations should include Day of admission Admitting physician (ie, who consulted us) Day of consult Reason for consult (ie “Hypoglycemia” “Abnormal thyroid levels” ) History, including HPI, pertinent hospital course and PMH, pertinent Family and Social History, pertinent ROS, physical findings, our impression and work-up and rationale for work-up. CC: to PCP and to referring doctor c) Consultation Lab Follow-up The fellow who is on call/on service when the patient is discharged is responsible for appending the consult in Logician or making an update in Logician that will include lab results that are available at discharge, what needs to be followed, follow-up arrangements, and pertinent hospital course. This should be done 24-72 hours after discharge. d) Requirements of Discharge Summaries Discharge summaries are required on all patients that are admitted directly to our service, including diabetics from the PICU who were initially admitted to Critical Care and then transferred to us. The Discharge summary must be done the day of discharge (or within 1 week after). It cannot be done the day of admission. If you have dictated an H & P or consult on the pt, you cannot use that first note as 15
  16. 16. Pediatric-Endocrinology Fellow Handbook July 2006 the discharge summary (although you may refer to it ‘see consult note for initial exam’ or “cut and paste” it into your discharge summary). e) Who is Responsible for dictating the discharge summary? The fellow who is discharging the patient is responsible for the discharge summary. The ID code used should be that of the attending who is rounding the day of discharge or your own ID code. f) Content of Discharge Summaries Discharge summaries must include: 1. Date of admission and date of discharge 2. Attending physician 3. Admitting diagnosis 4. Discharge diagnosis 5. Hospital course summary 6. Discharge diet 7. Discharge activity restrictions 8. Discharge medications 9. Condition at discharge 10. Follow-up arrangements (with our clinic, with PCP, with UTHSC, etc) 11. CC: PCP and referring doctor g) Phone Notes Phone notes, especially for patients that you give phone advice about to our ER or outside ER’s, must be entered into Logician. They can be typed or dictated. They should be routed to the attending on call with you when this occurred to sign off your note. 16
  17. 17. Pediatric-Endocrinology Fellow Handbook July 2006 C. POLICY ON RESIDENT SUPERVISION This policy outlines the procedural requirements for the supervision of residents in the specialty of Pediatric Endocrinology and Metabolism and is applicable to all patient services within that specialty. This policy shall complement any existing policy within any of the teaching hospitals where the residents obtain their training. It is the intention of this policy to delineate the level of responsibility granted by the program at each level of postgraduate education and the process by which the program director determines that such level of responsibility is adequate. At the beginning of each rotation, the program director shall clearly communicate to the supervising attending physician the level of supervision required for each resident assigned to that rotation based on evaluations and communications obtained by the program director from previous rotations. The direct and ultimate responsibility for supervision of patient care rendered by residents shall be by the patient’s attending physician in each rotation at each hospital. Graduated Level of Responsibility The residents are always supervised by an M.D., who is a full-time member of the Section of Pediatric Endocrinology and Metabolism, and a faculty member at Baylor College of Medicine. This attending physician shall be available at all times to the endocrine fellow. It is the responsibility of the fellow to communicate effectively and in a timely fashion with the attending physician as well as other members of the Endocrine Faculty. GUIDELINES FOR CONTACTING ATTENDING* • All primary service (Pedi-Endo patients) admissions • Calls regarding hospital transfers**(see below) • ICU admissions and/or consultations (TCH and Ben Taub) • Critically ill or unstable patients • Children discharged from the ER, when appropriate *NOTE: These guidelines shall be modified as Fellow’s clinical experience increases and according to the preference of the individual attending. **Calls regarding hospital transfers: ii) The fellow on call will speak with the transferring facility to collect the clinical information. iii) The fellow will then contact the attending on call, who will notify the transfer center of the pending transfer. If the attending does not accept the transfer, the attending will notify the transfer center to contact the appropriate service for that patient. iv) The fellow will communicate with the transferring physician and our hospital (including the ER or ICU if needed) with the supervision of the attending on call. Postgraduate Level I Inpatient Service/Continuity Clinic 1. Fellows shall evaluate all consults and new endocrine patients before the patient is examined by the attending. After discussion with the attending the fellows shall dictate the history, physical and consult. 2. Fellows shall obtain and interpret the results of patient’s diagnostic laboratory procedures, recognizing the pitfalls and limitations of the tests. 3. Fellows shall effectively communicate the diagnosis and the treatment plan (and any changes in the plan) with the faculty, patient, patient’s family and other physicians involved in the care of the patient. 4. Fellows shall participate in the education of the patient and the family about the disease. 5. Fellows shall write organized consultations and communicate with Endocrinology faculty and 17
  18. 18. Pediatric-Endocrinology Fellow Handbook July 2006 staff and with the Primary Care Physician in consult cases. 6. Fellows shall supervise junior residents in any activity in which they shall act independently. 7. Evaluate and write notes on all admissions and each patient/consults before rounds each day. 8. Round on children in evening to evaluate progress before leaving in the evening. 9. Dictate all admission and discharge summaries. 10. Sign out to Attending and other fellows when appropriate before going off call. 11. The Pediatric Endocrinology faculty shall assess the performance of each fellow monthly and report it to the program director. 12. If labs are pending at the time of discharge, the fellow will arrange for follow-up of their labs by either the primary team or our clinic. Postgraduate Level II Inpatient Service/Continuity Clinic 1. Fellows shall provide continuity of patient care with the cooperation of the attending and primary care physician. 2. Fellows shall encourage and incorporate critical feed back from attending physician and others involved in patient care. 3. The Pediatric Endocrinology faculty shall assess the performance of each fellow monthly and report it to the program director. 4. Fellows shall organize and present lectures to medical students, residents, and endocrinology faculty. These presentations should involve problem based learning as well as the classical 45- minute lecture presentation. 5. Fellows shall present clinic data at local meetings of endocrinologists. 6. Fellows shall supervise junior residents in any activity in which they shall act independently. Postgraduate Level III Inpatient Service/Continuity Clinic 1. Fellows shall serve as junior attending for 1 month of Inpatient service in the last half of the third year . 2. Fellows shall organize and present lectures to medical students, residents, and endocrinology faculty. These presentations should involve problem based learning as well as the classical 45- minute lecture presentation. 3. Fellows shall present clinic data at local meetings of endocrinologists. 4. Fellows shall supervise junior residents in any activity in which they shall act independently. 5. The Pediatric Endocrinology faculty shall assess the performance of each resident monthly and report it to the program director. D. FACULTY RESPONSIBILITIES 1. To TEACH first and foremost. 1. To train our fellows to become the best in the country. 2. To evaluate fellow performance and review evaluations with the fellow in a timely fashion. 3. To forward the results of such evaluations to the Program Director in a timely fashion. 4. To provide direct feedback to the fellow. It is not the Program Director’s responsibility to triangulate conversations between the fellow and the faculty. 5. Effectively and clearly communicate with the fellow and the Program Director regarding issues pertaining to the training program and/or a fellow. 6. Provide mentorship with projects such as posters and oral presentations presented at national meetings 7. Provide mentorship with case conferences presented when subject of conference was seen with a specific faculty. 18
  19. 19. Pediatric-Endocrinology Fellow Handbook July 2006 8. Provide mentorship with ideas about the initial research project for each first year fellow 9. Continue training the first year fellows in coding and billing E. DUTY HOURS 1. Fellows do not work more than 80 hours per week averaged over 4 weeks. 2. Fellows have a minimum of one 24-hour period completely free of patient care per week, or 4 days per month averaged over each 4-week period 3. Fellows do not take overnight call any more frequently that once in every three days when averaged over a four week period. F. TIME OFF (Appropriate Baylor or Department policies will be in effect) 1. VACATION LEAVE Each Clinical Postdoctoral Fellow is entitled to three weeks of paid vacation during each year. Vacation must be taken in the year earned and may not be carried over to subsequent years. The section shall make a good faith effort to meet the Clinical Postdoctoral Fellows request for vacations and shall not assign vacations arbitrarily. However, the section has the final say in assignment of vacations and the responsibility to assign vacations in such a way as not to impair patient care. All vacation time must be scheduled with the prior approval of the Program Director and Assistant Program Director. Vacation requests must be submitted to the fellowship coordinator via the Request for Authorized Absences. • Vacations shall be during the clinic/outpatient months. • Vacations shall be arranged with prior notice (minimum of 3 months) with appropriate arrangement for patients scheduled and approval from Drs. Haymond and Hwu. • Fellows may trade coverage with each other for special events with prior approval (i.e., trade a week in June with a week in July with one of the other fellows) • 1st Year fellows schedule vacation by September 1 st; 2nd & 3rd year fellows schedule vacation by June 1st of previous year. If vacation deadline is not met, vacation will be determined by program director. • No more than ½ of program fellows may be off at one time • Prefer no vacations during conferences in June or in July (due to new fellow training and diabetes camps) • If a fellow needs to be off in the inpatient or consult months, you must find coverage for your position (ie trade with each other). Trades must be approved by senior fellow and program director (or associate). • Vacations can be spread out throughout the first year (you do not have to be here for 6 months, so vacations do not have to start in January. If some of you want to take vacation in the fall, please complete paperwork ASAP as clinics are open through Dec. • 2nd and 3rd year fellows will get priority (usually this is not a problem) over 1st years..... 2. ILLNESS The fellow should notify the Chief of the Service and the appropriate colleague or supervisor as soon as possible whenever he/she is ill. If he/she is on call that day, the Chief will first attempt to rearrange the call schedule. If this is not possible, the Chief and his/her designee will take all service responsibility. 3. AMERICAN BOARD OF PEDIATRICS POLICY REGARDING MAXIMUM ALLOWED TIME OF ABSENCE 19
  20. 20. Pediatric-Endocrinology Fellow Handbook July 2006 The American Board of Pediatrics’ policy states that, “any absence from the training program such as sick leave, vacation, or maternity leave, that exceeds three months during the three years of required training should be made up by additional periods of training.” The Board will require fellows to spend additional time in training to compensate for any time beyond a total of three months spent on leave or vacation. There are nine weeks of vacation over the three years. That leaves four weeks for sick leave, maternity leave or leave of absence. 4. DEPARTMENTAL POLICY ON PERSONAL LEAVE, SICK LEAVE (INCLUDING MATERNITY), AND LEAVE OF ABSENCE a) Personal Leave Up to three calendar days per year are provided for personal or family problems with the prior approval of the section chief or his/her designee. Personal days may not be appended to vacation except in situations of urgent problems and with the approval of the department. Paid leave will also be provided for jury duty as required by law. Attendance at professional meetings as part of the educational activity of the house staff will not be considered leave. Such attendance will be allowed with the approval of the department chair or his/her designee. b) Sick Leave (including maternity): Clinical Postdoctoral Fellows are entitled to up to 14 calendar days paid sick leave per year. Unused sick days will be carried forward and be available to the Clinical Postdoctoral Fellow in each subsequent academic year. Sick leave may only be taken for the Clinical Postdoctoral Fellows 's own actual illness or bona fide health related issues such as a doctor's visit or a diagnostic or therapeutic procedure. Sick leave may not be used as personal leave or for non-illness or non-health related issues. In the event a Clinical Postdoctoral Fellow suffers from work-related illness or injury and uses all accumulated sick leave before he/she is able to return to work, additional pay will be granted to supplement any benefits available under workers' compensation to bring the house officer's gross pay up to his/her current stipend level until disability insurance payments begin. Injuries or illnesses will be considered work related only when a workers' compensation claim is filed and approved. Pay for non-work related illness or injury will be limited to the house officer's accrued but unused sick leave. A physician's statement is necessary if the illness or injury extends beyond seven consecutive calendar days. A Clinical Postdoctoral Fellow may be eligible to take sick leave under the federal Family and Medical Leave Act. c. Paternity Leave: A Clinical Postdoctoral Fellow may be eligible to take paternity leave under the federal Family and Medical Leave Act. d. Unpaid Leave of Absence A Clinical Postdoctoral Fellow may request and take unpaid leave of absence for up to 12 months for personal or family health problems with the approval of the Department Chair or his/her designee. Additionally enrollment with at least half-time status in a degree program at an institution of higher education that is related to the house officer's medical career is an acceptable reason for requesting and being approved for leave of absence. A letter stating the purpose of the leave, arrangements made for completing the training program, and the mechanism for payment of medical, dental, term life, accidental death and dismemberment, and long-term disability insurance premiums and Psychiatric Counseling Service benefit shall be signed by both the department and the house officer with a copy kept on file in the Office of Graduate Medical 20
  21. 21. Pediatric-Endocrinology Fellow Handbook July 2006 Education. If all or any part of this leave of absence is due to illness or injury, then the department shall require a physician's statement. Leave under the federal Family and Medical Leave Act may be granted if eligibility requirements are met. 6. EDUCATIONAL LEAVE OF ABSENCES Educational leave of absences must be approved and supported by the Program Director. Absence guidelines must be followed (not more than ½ staff gone at once). G. PROFESSIONAL TRIPS, MEETINGS, AND COURSES FOR FELLOWS 1. MEETINGS - All pediatric endocrine fellows will be granted one professional meeting for each complete academic year (12 months). Approval and assignments of meetings, maximal reimbursement and other aspects of travel and time off shall be in accordance with current policies of the Department of Pediatrics. All meetings must be approved as educationally appropriate by the Program Director. Additional meetings may be taken based on the discretion and approval of the program director. Funds for additional trips must be generated by the fellow through the use of travel grants and such. When abstracts are written on research with the fellows, all authors must approve abstracts before submission and are responsible for the content of the abstract/poster and the talk resulting from the abstract submission. It is the fellow’s responsibility with their attending to present their poster/oral presentation to the section at least 8 weeks before the meeting. Failure to do so may result in withdrawing of abstract and approval to attend the meeting. All abstracts must be approved by Dr. Haymond or designee. 2. REIMBURSABLE EXPENSES - Baylor pays only certain legitimate expenses incurred in attending the meeting. The school does not pay the individual to go to the meeting. Under no circumstances can an individual be reimbursed for more than actual expenses incurred. Reimbursable expenses are limited to registration fees, lodging, travel expenses, including ground transportation to and from the airport, and airport parking. Receipts are required for all items. Total reimbursement is limited to $1,000.00 (unless other arrangements have been made). 3. REGISTRATION FEES - For most trips, the fellow is responsible for completion of meeting/conference registration. The department will prepay, as much as possible, registration. The fellow is responsible for notifying and making arrangements for registration payment with the administrative staff. 5. TRAVEL ARRANGEMENTS - For most trips, the fellow his/her own travel reservations. The section will pre-pay flight costs for any trips funded by BCM. Upon trip approval, the administrative staff will provide the fellow with an SAP trip number (as appropriate). This trip number is required before flight arrangements can be made. All receipts are required for trip expense reimbursement. Cab fare or other transportation to and from airports will only be reimbursed with a receipt. Parking at airports in Houston will only be reimbursed with a receipt, and fellows are “required to use long term parking facilities”. If an individual obtains free transportation to a meeting, he or she cannot be reimbursed for travel expenses. 10. HOTEL ACCOMMODATIONS - If an individual stays with friends or relatives, rather than at a hotel, he or she cannot be reimbursed for lodging expenses. You must keep accurate receipts if you wish to be reimbursed. It is your responsibility to keep your itemized hotel receipt (not just a credit card voucher). If the individual stays at the hotel at a time other than that booked for the 21
  22. 22. Pediatric-Endocrinology Fellow Handbook July 2006 group, the individual will need to make his or her own hotel reservations. The fellow will be responsible for all deposits and charges and will then present appropriate receipts to the department after the meeting for reimbursement. Advance payments, when possible by the department will be limited to those individuals traveling with the group. In the case of any individual hotel arrangements which cost more than the group cost negotiated by the department, the fellow will be responsible for the difference in cost. Please be advised that bookings by the department are generally at least 60 days in advance of the meeting. All special requests should be received by the department at least prior to this time. 11. SPECIAL MEETING TIME FOR “PRESENTERS” Individuals who have been selected to present a paper (not a poster) at a recognized medical meeting may be granted time and financial support to attend the meeting providing he or she will actually be presenting the paper. This is contingent upon the availability of coverage for the fellow’s clinical responsibility. Time off will be limited to the day of the presentation and appropriate travel time as needed. Any additional time will be at the fellow’s expense and will count against vacation or holiday time. 12. PAYMENT OF OVERAGE FOR PROFESSIONAL MEETINGS When the cost of a professional meeting exceeds the designated limit for departmental reimbursement, the overage should be paid by the fellow in advance of, or immediately upon return from, the meeting. In cases of hardship, the overage may be returned to the department in a maximum of five equal payments at the times of five consecutive paychecks beginning with the second paycheck after the meeting. H. REPORTING CHANGE OF ADDRESS OR TELEPHONE It is the fellow’s responsibility to notify the Program Director (713-798-6776) immediately of any change in home address or telephone number! This includes, especially, an unlisted number. It is also the responsibility of the fellow to keep current with this office his or her listing of persons to notify in the event of an emergency. 22
  23. 23. Pediatric-Endocrinology Fellow Handbook July 2006 SECTION 3: OUTLINE OF THE PEDIATRIC ENDOCRINOLOGY FELLOWSHIP 23
  24. 24. Pediatric-Endocrinology Fellow Handbook July 2006 A. Outline of the Pediatric Endocrinology Fellowship Clinical Curriculum Year 1 80% Clinical and 20% Academic Time Coursework 1 month In patient service 4 months Consultation service 4 months Out patient service 3 months Weekend call 12 weekends/year Research/ Academic Time 2 days/week Vacation 3 weeks Year 2 80% Research and 20% Clinical Out patient service/Continuity Clinic one day/week Vacation 3 weeks Research 10 months Year 3 85% Research and 15% Clinical Vacation 3 weeks In Patient Services 1 month Research 9.5 months Out patient service/Continuity Clinic one day/week Significant amount of time is spent on research activities. Fellows are expected to complete the program with at least 1 peer-reviewed first author journal article. Throughout the three years of training, the fellows participate actively in discussion of case reports, a lecture series by the faculty, lectures given by the residents and a number of conferences (see attached schedule of conferences). 24
  25. 25. B. GOALS AND OBJECTIVES AT EACH LEVEL OF TRAINING A. CLINICAL EXPERIENCE YEAR 1 GOALS SPECIFIC OBJECTIVES EVALUATION OF GOALS FOR EACH GOAL 1. To develop skills in 1. To learn basic and The fellows should be able treating neonates, infants, advanced endocrine to : children, and adolescents biochemistry, 1. 1. Evaluate and consult new with disorders of physiology and patients and make “learners carbohydrate metabolism, pathophysiology which entries” in the electronic thyroid, pituitary, adrenal, provide the basis for database to be reviewed by the gonadal, mineral and understanding attending physician. growth. endocrine disease. 2. 2. Obtain and interpret the 2. Keep accurate and results of patient’s diagnostic concise hospital notes laboratory procedures, and to become recognizing the pitfalls and proficient in the use of limitations of the tests. logician. 3. 3. Effectively communicate 3. To acquire sufficient with the faculty, patient, fundamental information patient’s family and other and practical approaches physicians involved in the care for identification and of the patient, regarding treatment of endocrine treatment plan and any changes disorders. in it. 4. To accumulate 4. 4. Participate in the education knowledge and skills of the patient and the family necessary for providing about the disease. cost-effective, ethical and 5. humanistic care of patients with diabetes and disorders of endocrinology and metabolism. 2.To acquire special skills 1. To acquire clinical skills in 1. Write organized in managing children with a progressive fashion and consultations and insulin dependent diabetes with increasing responsibility communicate with mellitus as regards diabetic appropriate for a consultant Endocrinology faculty and ketoacidosis, insulin in endocrinology, diabetes staff and with the Primary adjustments, pattern and metabolism. Care Physician in consult management, intensified cases. insulin management programs, sick day management, and patient and professional educational issues. YEAR 2 and 3 GOALS 1. To acquire skills in 1. Develop professional and peer 1.Provide continuity of supervising interns, residents interaction skills. patient care with the and others in the care of 2. Recognize the roles and cooperation of the attending patients with endocrine values of nurses, nurse and primary care physician. disorders. practitioners and others involved 25
  26. 26. in patient care. 2.Encourage and incorporate crtical feed back from attending physician and others involved in patient care. 2. To develop skills in 1. Develop formal presentation 1. Organize and present organizing and delivering skills. lectures to medical students, lectures on disorders of the residents, and endocrinology endocrine system. faculty involving problem based learning as well as the classical 45-minute lecture presentation. 2. Present clinic data at local meetings of endocrinologists 3. To develop skills to critique 1. Understanding of existing 1. Perform review of published manuscripts. and emerging endocrine appropriate literature research. and protocols on their 2. Understand the rationale own. of current therapies and 2. Active involvement questions being asked in the scientific papers. in Journal Club and 3. Develop research ideas. critical review of clinical research reports. 4. To refine skills for 6) To develop an ability to 6. Participate in didactic designing hypothesis driven propose a scientific lecture series clinical research. question. 7. Attend local and 7) To design experiments to national meetings and answer that question. educational conferences. 8) To develop grant writing skills. 8. Solicit and appreciate 9) To publish a manuscript critical feedback from regarding the above. mentor. 5. To develop an interest in 1. Be cognizant of the issues 1. Attend multidisciplinary the health of children at the impacting the health of conferences focusing on local, national, and state children. patient care and levels. 2. Be aware of the current management issues. trends that may impact health care management issues such as cost- effective patient care, practice management, quality improvement and clinical outcomes. B. RESEARCH EXPERIENCE YEAR 1 GOALS SPECIFIC OBJECTIVES EVALUATION OF GOALS FOR EACH GOAL 1. Expose the trainee to 1. To introduce the fellow to 1. Identify a mentor academic research a possibility of a career in 2. Develop a project academic research in 3. Develop a protocol, IRB endocrinology approval 26
  27. 27. YEAR 2 & 3 1. Acquire skills in design 1. Learn scientific method 1. Design relevant and performance of and reasoning experiments hypothesis driven 2. Acquire knowledge of 2. Acquire understanding endocrine research appropriate laboratory or of laboratory techniques other research techniques 3. Interpret results 3. Develop skills in recognizing their pitfalls obtaining research and trouble shoot funding experiments 4. Develop grant writing skills 2. Publish at least 1 peer- 1. Develop skills in scientific • Prepare a well written, reviewed first author communication cohesive scientific paper journal article • Send to appropriate journal • Answer reviewers comments 27
  28. 28. C. ACGME CORE COMPETENCIES CORE COMPETENCY EXPECTATIONS/GOALS HOW WE PROVIDE TRAINING OUTCOME ASSESSMENT 1. Medical knowledge 1. Knowledge of current research (basic 1. Endocrine Grand Rounds 1. Completion of Global Rating form by and clinical) pertaining to endocrine 2. Journal Club Faculty disorders and diabetes. 3. New Fellows Lecture Series 2. Multiple Choice Questions for FCI 4. Fundamentals of Clinical Investigation 3. Evaluation of presentations at clinical 2. Ability to critically evaluate relevant course case conferences information in scientific literature and 5. Seminars for which they are 2. apply to patient care responsible 6. Conferences with adult Endocrine fellows 2. Patient Care 1. Gather essential and accurate 1. Clinic and hospital service with 1. Global rating form by faculty information about their patient attending and other subspecialty residents 2. 360 evaluation by faculty, RN, CDE, 2. Make informed decisions about 2. Fellows Clinic residents etc.* diagnostic and therapeutic interventions 3. Clinical Case Conference 3. Evaluation of presentations at clinical based on scientific evidence 4. Journal Club case conferences 3. Develop and carry out patient 5. Endocrine Grand Rounds management plans 6. Seminars for which they are responsible 7. Conferences with adult Endocrine fellows 3. Communication and Interpersonal 1. Create and sustain a therapeutic and 1. Clinic and hospital service experience 1. Global rating form by faculty Skills ethically sound relationship with patients, with attending 2. 360 evaluation by faculty, RN, CDE, their families and colleagues 2. FCI residents etc.* 2. Maintain comprehensive, timely and 3. Logician training and execution 3. Retreat legible medical records 4. Evaluation of performance at fellows 28
  29. 29. 3. Communicate effectively with patients clinic and counsel and educate patients and their families 4. Work effectively with other health care professionals, including those from other disciplines, to provide patient focused care 4. Professionalism 1. Demonstrate respect, compassion and 1. Role modeling in patient encounters 1. Global rating form by faculty integrity, responsiveness to patient needs, (clinic, emergency room, hospital setting, 2. 360 evaluation by faculty, RN, CDE, commitment to excellence and ongoing etc.) residents etc.* professional development 2. Role modeling in patient care with 2. Commitment to ethical principles, clinic and hospital staff and members of patient confidentiality and informed department of Pediatrics responsible for consent scheduling, billing collection etc. 3. Demonstrates sensitivity to patient’s 3. Didactic educational seminars (ethics culture, age and disability component of FCI) 5. Practice-based learning and 1. Analyze practice experience and 1. Fundamentals of Clinical Investigation 1. Global rating form by faculty Improvement perform practice-based improvement course 2. 360 evaluation by faculty, RN, CDE, activities using a systematic methodology 2. Computer courses residents etc.* 2. Locate, appraise and assimilate 3. Faculty interactions and mentoring evidence from scientific studies related to 4. Teaching junior residents and medical their patient’s health problems students 3. Apply knowledge of study designs and 5. Fellow journal clubs statistical methods to the appraisal of 6. Conference presentations clinical studies and other information on 7. Fellows Clinic diagnostic and therapeutic effectiveness 8. Fellow evaluations 29
  30. 30. 4. Use information technology to manage information, access on line medical information and support their own education 5. Facilitate the learning of students and other health care professionals 6. System based Practice 1. Know how types of medical practice 1. Fundamentals of Clinical Investigation 1. Global rating form by faculty and delivery systems differ from one course 2. 360 evaluation by faculty, RN, CDE, another, including methods of controlling 2. Faculty interactions residents etc.* health care costs and allocating resources 3. Logician 3. MCQ in FCI exam 2. Practice cost-effective health care and 4. Required CME credits annually resource allocation that does not compromise quality of care 3. Understand how patient care and other professional practices affect other health care professionals, health care organization, the larger society and how these elements of the system affect their practice 30
  31. 31. 4. Advocate quality patient care and assist patients in dealing with system complexities 5. Know how to partner with health care managers and providers to assess, coordinate and improve health care and know how these activities can affect system performance * Not currently required in sub-specialty fellowship programs. 31
  32. 32. D. Curriculum – coordinated by Dr. Colleen Buggs We have restructured our curriculum to include the following: • Faculty-driven discussions with fellows that will provide an overview of pathophysiology, clinical assessment/diagnosis, and management of general pediatric endocrine disorders as outlined in Pediatric Endocrinology by Fima Lifshitz (4th Edition). Topics will include disorders of growth, puberty, sexual differentitation, pituitary function, adrenal gland, thyroid/parathyroid glands, calcium homeostasis, glucose metabolism/diabetes, obesity and other endocrinopathies. • Reading file- important review articles will be identified of various topics in pediatric endocrinology and diabetes. These articles will complement the faculty-driven discussions as well as provide evidence-based guidelines/algorithims for management and treatment of pediatric endocrine disorders and diabetes. • Orientation lectures-during the first month of training (July), all new subspecialty residents are required to attend a month-long series of activities for orientation purposes in pediatric endocrinology and metabolism. These activities will include: lectures that will specifically provide the residents with an initial structure for approaching patients with pediatric endocrine disorders, emergency management of pediatric endocrinology disorders and diabetes, an overview of case presentations that residents will be expected to give throughout the year, and an introduction to the Clinical Diabetes Education courses for our patients. • Pediatric Endocrinology and Metabolism Fellows Handbook-an overview of specific goals and requirements of our fellowship program. • Lecture series-the residents will also participate in year-long lectures discussing the application of laboratory methods such as cytogenetics, radioimmunoassays, and immunoassays in the diagnosis, evaluation and management of particular diseases in pediatric endocrinology. • Teaching skills-during the course of their training, second and third year residents are expected to develop their teaching skills by participating in giving lectures to medical students, residents, and first year residents. • Preparation for inpatient attending responsibilities-third year residents will be given an opportunity to do a junior attending month along with an attending on inpatient/consult services. • Development of professional skills-residents will be instructed on how to prepare abstracts as well as papers for publication of interesting clinical cases as well as their research projects. Annual reviews of our curriculum will be conducted by program directors in order to implement modifications as needed to enhance the quality of teaching and training provided to the residents. 32
  33. 33. GOALS 1. Instruction in: a. Endocrine Physiology, Pathology and Biochemistry b. Embryology of Endocrine and Related Systems with Emphasis on Sexual Differentiation c. Genetics including Laboratory methods, cytogenetics and enzymology d. Immunology and immunoassays DESCRIPTION REFERENCES See attached file of articles. In addtion, we recommend Up To Date (available on all TCH computers) as a resource for background information. 1. Diabetes Mellitus 1.1 Introduction Diabetes Mellitus is a syndrome of disturbed energy metabolism caused by insulin deficiency and/or action of insulin at the cellular level, that results in altered fuel homeostasis affecting carbohydrate, lipid and protein metabolism. 1.2 Discussion Program Requirements 1.2.1 Physiology • Insulin biosynthesis, secretion and action 1.2.2 Classification of Diabetes • Type 1 • Type 2 • Other specific types • Gestational 1.2.3 Type 1 diabetes • Etiology, genetics and pathogenesis • Pathophysiology • Clinical Presentation –acute - Diabetic ketoacidosis - Treatment of diabetic ketoacidosis • Natural history of disease • Chronic treatment of Type 1 diabetes - Diabetes education - Insulin regimens - Nutrition - Monitoring - Exercise • Complications of diabetes - Acute - Chronic • Prevention of complications of diabetes - DCCT 33
  34. 34. 1.2.4 Type 2 diabetes • Etiology, genetics and pathogenesis • Pathophysiology • Clinical Presentation • Diagnosis - glucose tolerance testing • Chronic treatment of Type 2 diabetes - Life style modifications  Diet  Exercise - Diabetes education - Oral antidiabetic agents - Insulin regimens - Monitoring 1.2.5 Diabetes associated with other genetic disorders 1.2.6 Gestational diabetes 1.3 Suggested Reading [Tamborlane, 2001 #3583;Anonymous, 1993 #1473;Glaser, 2001 #3650;Felner, 2001 #3651;Shulman, 1999 #233;Dunaif, 1999 #338;Sinha, 2002 #3616] 2. Hypoglycemia associated with diabetes 2.1 Introduction Hypoglycemia is the limiting factor in the intensive management of diabetes. Due to imperfections in insulin regimens and/or defective counter-regulation results in iatrogenic hypoglycemia. 2.2 Discussion Program Requirements 2.2.1 Risk factors and Pathophysiology • Glucose counter-regulation • Hypoglycemia unawareness 2.2.2 Treatment and Prevention of hypoglycemia C. Suggested Reading [Haymond, 1999 #307;Cryer, 1999 #3522] 3. Hypoglycemia not associated with diabetes 34
  35. 35. 3.1 Introduction Most causes of hypoglycemia can be divided in to two general categories (1) overutilization, which results from excessive tissue uptake of glucose invariably due to exaggerated, or dysregulated insulin secretion. (2) underproduction which results from deficient precursor conversion. 3.2 Discussion Program Requirements 3.2.1 Glucose measurements and definition of hypoglycemia 3.2.2 Mechanisms of normal glucose homeostasis 3.2.3 Signs and symptoms and prognosis of hypoglycemia 3.2.4 Etiology and Treatment of hypoglycemia • Overutilization of glucose o Islet cell hyperplasia o Islet cell hypertrophy o Microadenoma o Adenomatosis o Normal histology • Underproduction of glucose o Defects in glycogenolysis  Glycogen storage disease  Galactosemia o Defects in gluconeogenesis  Fructose-1,6-diphosphatase deficiency  Hereditary fructose intolerance  Substrate disturbances  Counter-regulatory hormone deficiencies 3.2.5 Diagnosis of Childhood hypoglycemia 3.3 Suggested Reading [Service, 1995 #3653;Burton, 1998 #3617;Rinaldo, 2002 #3618;Seashore, 1993 #3619;Sperl, 1993 #3621][Stanley, 1997 #3711] Disorders of the Anterior Pituitary 4. Growth and Development 4.1 Introduction Growth and development are regulated by the interactions of the endocrine and nervous systems. The pituitary regulates endocrine organs under the influence of the hypothalamus. Disorders of the pituitary and hypothalamus may therefore cause isolated or multisystem endocrine dysfunction. 35
  36. 36. 4.2 Discussion Program Requirements 4.2.1 Normal growth • Correct ways to measure height and weight • Growth charts • Growth velocity • Genetic potential • Pubertal effects on growth • Skeletal Age • Growth hormone and the hypothalamic-pituitary axis • Action of growth hormone, growth hormone receptor, and insulin like-growth factor I 4.2.2 Normal Growth Issues • Constitutional delay of growth • Genetic-familial short stature • Constitutional delay and familial short stature 4.2.3 Abnormal 1. Endocrine causes of growth failure i. GH deficiency isolated • Screening tests to evaluate GH deficiency • When to refer a patient with suspected GH deficiency • Confirmation of GH deficiency • Treatment with GH • Follow up of patients on GH • Risks of GH therapy ii. Hypothyroidism iii. Hypopituitarism iv. Excess cortisol v. Precocious puberty 2. Chromosomal defects i. Turner syndrome ii. Down syndrome 3. Intrauterine growth retardation i. Sporadic ii. Associated syndromes o Russell-Silver o De Lange o Seckel o Dubowitz o Bloom o Johanson-Blizzard 4. Bone Development disorders i. Achondroplasia 36
  37. 37. ii. Chondrodystrophies iii. Other skeletal disorders 5. Metabolic i. Mucopolysaccharidosis ii. Other storage disorders 6. Chronic Illness i. Chronic renal disease ii. Chronic liver disease iii. Congenital heart disease iv. Poorly controlled diabetes v. Cystic fibrosis 7. Associated birth defects and mental retardation 8. Psychosocial 9. Chronic drug intake 4.3 Suggested Reading [De Luca, 2001 #3658;Blethen, 1995 #3640;Drake, 2001 #3643;Hopwood, 2000 #3659;Brauner, 1999 #3660;Guyda, 1998 #3664] 5. Hypopituitarism 5.1 Introduction The clinical presentation of pituitary dysfunction varies with age of the patient and the specific hormones that are deficient. Documentation of a deficiency in one pituitary hormone requires evaluation of the others. 5.2 Discussion Program Requirements 5.2.1 Presenting signs and symptoms o Hypopituitarism in newborns o Hypopituitarism in infancy and childhood 5.2.2 Diagnostic evaluation 5.2.3 Evaluation of hormone deficits 5.2.4 Neuroimaging 5.2.5 Specific syndromes associated with hypopituitarism • Hereditary growth hormone deficiency o Type 1A o Type 1B o Type 3 37
  38. 38. o Panhypopituitary short stature • Growth hormone insensitivity syndrome and growth hormone resistance o Laron syndrome o Pygmies o GH insensitivity with Alagille syndrome o Abnormalities of PIT-1 gene o Bioinactive growth hormone • Acquired forms of hypopituitarism o Tumors and their treatment o Cranial irradiation o Trauma o Infiltrative, autoimmune and metabolic 5.2.6 Treatment of hypopituitarism 5.2.7 Strategies of hormone replacement • Effects of glucocorticoids on growth • Replacement of L-thyroxine in patients with ACTH deficiency • Effect of ACTH and TSH deficiencies in patients with central diabetes insipidus • Treatment of ADH deficiency • Timing of sex hormone replacement in gonadotropin-deficient patients 5.2.8 Follow up of patients with hypopituitarism 5.3 Suggested Reading [Arafah, 2001 #3641;Legault, 1999 #3663] 6. Disorders of the Posterior Pituitary 6.1 Introduction Neuroendocrine function of the posterior pituitary was described 100 years ago, neuroendocrine tissue was found to cause vasoconstriction, uterine contraction, lactation and antidiuresis. 6.2 Discussion Program Requirements 6.2.1 Physiology of the posterior pituitary • Hormone biosynthesis • Hormone structure • Regulation of hormone secretion • Hormone distribution and metabolism • Mechanism of vasopressin action 38
  39. 39. • Inter-relationship of vasopressin and oxytocin and other hormones 6.2.2 Pathophysiology of the posterior pituitary 6.2.3 Central diabetes Insipidus o Etiology of deficiency o Clinical manifestation o Diagnosis  Water deprivation test  Other tests 6.2.4 Familial vasopressin sensitive diabetes Insipidus o Clinical manifestation o Diagnosis o Prognosis 6.2.5 Treatment of Diabetes Insipidus 6.2.6 Nephrogenic Diabetes Insipidus • Genetics • Clinical Presentation • Diagnosis • Treatment 6.2.7 Neurogenic hyponatremia 6.2.8 Excessive secretion of vasopressin or SIADH 7.2.9 Treatment of SIADH 6.3 Suggested Reading [Valiquette, 1987 #3642;Hammond, 1986 #3644;Richman, 1981 #3657] 7. Thyroid 7.1 Introduction Thyroid disorders are among the most common diseases encountered by the primary care physician; they occur in the population with prevalence greater than 10% in some studies. Furthermore, the incidence of thyroid disorders is rising, in part because our diagnostic tools are much more sensitive and sophisticated. Thyroid disorders account for a significant amount of morbidity in our society and the trainee should be competent in their diagnoses and treatment. In addition, prompt treatment to infants born with congenital hypothyroidism underscores the necessity to have a pediatric workforce well trained in the diagnosis and the early treatment of this disorder. 7.2 Discussion Program Requirements 39
  40. 40. 7.2.1 Physiology of thyroid hormone • Synthesis of thyroid hormone • Regulation of thyroid function • Thyroid hormone effects • Mechanism of thyroid hormone action on growth and development • Thyroid dysfunction syndrome in a premature infant 7.2.2 Congenital thyroid disorders o Thyroid dysgenesis o Hypothalamic pituitary defects o Inborn defects of thyroid hormone production o Decreased TSH responsiveness o Iodide organification defects o Iodotyrosine deiodinase defect o Defects in TG synthesis and transport o Transient neonatal hypothryroidism • Diagnosis and Management 7.2.3 Acquired Hypothyroidism o Causes of Acquired hypothyroidism o Exposure to goitrogenic agents o Thyroid dysgenesis o Hashimoto’s thyroiditis o Compensated defect in thyroid hormone biosynthesis o Acquired hypothalamic pituitary hypothyroidism o Endemic goiter and hypothyroidism o Misc causes o Diagnosis of hypothyroidism o Treatment of hypothyroidism 7.2.4 Thyroid dysfunction syndromes in the premature infant • Transient hypothyroxinemia • Transient primary hypothyroidism • Transient hyperthyrotropinemia • Low T3 in premature infants 7.2.5 Non-thyroidal illness (The low T3 syndrome) 7.2.6 Thyroiditis • Acute • Subacute 40
  41. 41. 7.2.7 Hyperthyroidism • Pathogenesis • Clinical features • Diagnosis and management • Misc Topics o Neonatal thyrotoxicosis o Thyrotropin dependent hyperthyroidism o Pituitary tumors o Selected Pituitary T3 Resistance o Nodular hyperthyroidism 7.2.8 Thyroid nodule and Goiter 7.2.9 Resistance to thyroid hormone 7.2.10 Disorders of thyroid hormone carrier protein 7.2.11 Thyroid cancer 7.3 Suggested Reading [Van Vliet, 2001 #3647] [Rivkees, 1998 #3645;Koch, 2001 #3646] 8. Puberty Disorders of Puberty 8.1 Introduction Puberty is a period during which sexual maturity is completed, resulting in the capacity for reproduction. It involves growth and maturation of the primary sexual characteristics and the appearance of secondary sexual characteristics. Disorders of puberty may arise if puberty occurs early (precocious) or is delayed. 8.2 Discussion Program Requirements Puberty in • Boys • Girls 41
  42. 42. 8.2.1 Precocious Puberty in Girls • Normal occurrence of puberty • Central • Partial Pubertal development 1. Premature thelarche 2. Premature pubarche • Peripheral 1. McCune Albright’s syndrome 2. Ovarian cysts 3. Chronic primary hypothyroidism • Contrasexual pubertal development 8.2.2 Precocious Puberty in Boys Normal occurrence of puberty • Central • Peripheral 1. Familial gonadotropin independent puberty 2. Hyperthyroidism • Contrasexual pubertal development 8.2.3 Diagnosis of Precocious Puberty 8.2.4 Treatment of Precocious Puberty 8.3 Suggested Reading [Girgis, 2000 #3652;Kaplowitz, 1999 #3656] 9. Delayed Puberty 9.1 Introduction If initial changes in physical changes of puberty are not present in boys by 14 and in girls by 15 years of age then an evaluation should be considered for delayed pubertal development. 9.2 Discussion Program Requirements • Delayed puberty in boys • Delayed puberty in girls 9.2.1 Delayed puberty in boys • Constitutional delay of growth • Hypogonadotropic hypogonadism • Isolated gonadotropin deficiency • CNS abnormalities associated with the hypothalamus or pituitary • Genetic syndromes • Hypergonadotropic hypogonadism 42
  43. 43. 9.2.2 Diagnosis of delayed puberty 9.2.3 Treatment of delayed puberty 9.2.4 Delayed puberty in girls Onset of delayed puberty is a less common complaint among girls than boys and is more likely to have an underlying pathologic cause. • Hypergonadotropic hypogonadism -Turner syndrome • Hypogonadotropic hypogonadism 9.2.5 Diagnosis of delayed puberty 9.2.6 Treatment of delayed puberty 9.3 Suggested Reading [Argente, 1999 #3661] 10. Adrenal Cortex 10.1 Introduction Steroid hormones in the plasma arise from the secretory activity of the adrenal cortex, male and female gonads and placenta during pregnancy. Enzymatic abnormalities in the pathways of the steroid production results in congenital adrenal hyperplasia. Increased secretion of cortisol by the adrenal cortex results in Cushing’s syndrome. 10.2 Discussion Program Requirements • Normal sex differentiation • Steroid pathways • Blocks in activity of steroidogenic activity 10.2.1 Congenital Adrenal Hyperplasia Deficiencies of the following enzymes and their associated manifestations result in congenital adrenal hyperplasia 1. 21-Hydroxylase 2. 3 β-ol dehyrogenase 3. 11β-hydroxylase 4. 17α-hydroxylase 5. Cholesterol desmolase 43
  44. 44. 10.2.2 Diagnosis • Pre-natal • Post-natal • 10.2.3 Treatment of congenital adrenal hyperplasia • Classical • Non-classical Classical o Replacement of hormone therapy o Sex assignment o Psychoendocrine • Non-classical 10.3 Suggested Reading [Anonymous #3588;Collett-Solberg #3589;Quintos #3590;Collett-Solberg #3591;Van Wyk #3592;Carlson #3594;Pang #3595;Pang #3596;New #3597;Cutler, 1990 #3654 11. Ambiguous Genitalia 11.1 Introduction Sex differentiation is a complex process by which the undifferentiated genitalia of the embryo evolve in to male or female reproductive organs. Abnormalities that may pose difficulty in sex determination are described in this component. 11.2 Discussion Program Requirements 11.2.1 Gonadal disorders • True Hermaphoditism • Klinefelter syndrome • XX Males • Turner Syndrome • Noonan syndrome • XX and XY Gonadal dysgenesis • The dysgenetic gonad and neoplasia 11.2.2 Female pseudohermaphroditism • CAH • Exposure to androgens • Teratologic conditions associated with ambiguous genitalia 112.3 Male pseudohermaphroditism • Testicular biosynthetic defect • 17-lyase deficiency 44
  45. 45. • 17 ketosteroid reductase deficiency • Syndromes of androgen resistance • Leydig cell unresponsiveness to HCG • 5 alpha reductase deficiency • Defects in synthesis of antimullerian factor 11.2.4 Unclassified forms of abnormal sexual development in males • Hypospadias • Cryptorchidism • Anorchia • Male pseudohermaphroditism with multiple congenital anomalies 11.2.5 Unclassified forms of abnormal sexual development in females • Absence of vagina • Vaginal atresia • Atresia of the Uterine cervix 11.2.6 Diagnosis of ambiguous genitalia 11.2.7 Treatment of ambiguous genitalia 11.3 Suggested Reading [Al-Agha, 2001 #3668;, 2000 #3669;Reiner, 1999 #3670;Carlson, 1999 #3671] 12. Cushing Syndrome 12.1 Introduction Cushing syndrome is a relatively rare childhood disorder occurring due to excess cortisol. It has to be distinguished form obesity, which is very commonly seen in childhood and associated consequences of glucocorticoid excess delineated. 12.2 Discussion Program Requirements o Signs and symptoms o Differential diagnosis o Diagnosis o Hormonal tests o Stimulation and suppression tests o Treatment 12.3 Suggested Reading [Older #3584;Jeffcoate #3585;Williams #3586;Leinung #3587] 45
  46. 46. 13. Adrenal Insufficiency 13.1 Introduction Inadequate secretion of the adrenal hormones can result from disease of the adrenal cortex or from deficient secretion of ACTH from the pituitary. 13.2 Discussion Program Requirements 13.2.1 Primary adrenal insufficiency or Addison disease 13.2.2 Secondary adrenal insufficiency (deficient secretion of ACTH) 13.2.3 Polyglandular autoimmune syndromes 13.2.4 ACTH unresponsiveness 13.2.5 Adrenoleukodystrophy 13.2.6 Congenital adrenal hypoplasia o Signs and symptoms o Diagnosis o Hormonal tests o Treatment 13.2.7 Adrenal Crisis • Treatment • Prevention 13.2.8 Endocrine Hypertension • High rennin hypertension • Primary Reninism • Bilateral endocrine dysfunction of the kidney • Aldosteronism • Dexamethasone suppressible hyperaldosteronism • 11 beta hydroxysteroid dehydrogenase deficiency • Bartter syndrome 13.2.9 Other Topics • Tumors of the adrenal cortex • Feminizing tumors 13.3 Suggested Reading [Ten, 2001 #3665;Oelkers, 2001 #3666;Betterle, 2001 #3667] 46