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  • 1. Program Curriculum for Fellow Education in Endocrinology, Diabetes and Metabolism (Internal Medicine) Program Director: Albert Jochen, MD Revised: March 2009 I. Endocrinology and Metabolism Fellowship Objectives A. The fellowship is structured to provide broad and in-depth clinical training in the areas of endocrinology, metabolism and clinical nutrition. These include diseases of the pituitary, thyroid and adrenal glands, diabetes mellitus, hypoglycemic syndromes, dyslipidemias, calcium disorders and metabolic bone disease, reproductive endocrinology, pediatric endocrinology, endocrine oncology, fundamentals of enteral and parental nutrition, eating disorders, disorders of vitamin and trace metal metabolism, endocrinology of aging, metabolic disorders in pregnancy and endocrine diagnostic testing. B. Each fellow is required to participate in a research project under the mentorship of a faculty member. It is expected that the fellow’s involvement will be of sufficient intensity to lead to abstract presentations and authorship of manuscripts. The fellowship will be sufficiently flexible to allow a more in-depth research experience for those planning a career in academic medicine. C. The program is designed to allow fellows to meet required competencies in patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism, and systems-based practice and allow for board eligibility in Endocrinology, Diabetes and Metabolism. Clinical competencies in the fellowship program are defined as follows: 1. Patient Care- acquisition of skills in data collection, including history- taking, physical examination, the appropriate ordering and interpretation of laboratory and imaging studies, and medical decision making. Fellows will demonstrate competence in fine needle aspiration of the thyroid. 2. Medical Knowledge- learning a basic core of knowledge of endocrine diseases; their clinical manifestations, pathophysiology, and management. This knowledge base will include both common and uncommon endocrine disorders and will also incorporate instruction in the genetics, biochemistry, pharmacology, and psycho-social aspects of endocrine diseases. The ability to analyze and critique the design, data, statistical analysis and conclusions of medical literature through study of past and current key journal papers will be developed through curriculum lectures, review of board-type questions, and journal club presentations.
  • 2. 3. Communication and Interpersonal Skills- adequate written documentation in charting, dictations, and computerized medical records. Development of oral communication skills and appropriate interpersonal interactions with patients, peers, and other health care professionals. 4. Professionalism- development of qualities of professionalism and humanistic skills including integrity, compassion, respect for patients, peers, and other health care professionals. To serve as a model for trainees at a more junior level. 5. Practice-Based Learning and Improvement- fellows are expected to review thyroid fine needle aspiration results with the cytopathologist to improve their procedural proficiencies. Fellows are the principal participants in the design and performance of Quality Improvement projects that collect data on endocrine clinical practices at MCW and provide recommendations for improvement. 6. Systems-Based Practice- appropriate consultation with, and utilization of, ancillary personnel such as diabetes educators and nutritionalists. The ability to serve as a consultant to internists and non-internists in the acute inpatient setting, the ambulatory clinic, the emergency department, and the intensive care setting. To serve as a systems-wide health-care team leader and resource for common diseases such as diabetes. II. Facilities and Resources The principal venues for fellowship education are three major teaching affiliates (for adult medicine) of the Medical College of Wisconsin-Froedtert Memorial Lutheran Hospital, North Hills Clinic, and the Zablocki Veterans Administration Medical Center. A one month rotation is also scheduled at MCW’s Pediatric Endocrine Clinic and the OBGYN Reproductive Endocrinology Clinic. A. Froedtert Memorial Lutheran Hospital (FMLH) is a private hospital. FMLH is the principal hospital for the Division of Endocrinology, Metabolism and Clinical Nutrition. The majority of the research labs are located here. Our Diabetes Management Service and Diabetes Care Center are affiliated with FMLH, which services outpatients, inpatients and organ transplant recipients. Outpatient clinical activities are conducted in the MCW Clinic at Froedtert East building. The Endocrine Diagnostic Unit, where our fellows learn to perform studies such as ACTH stimulation tests, glucose tolerance tests, etc. is located here. This is also the venue for the weekly fellow’s Continuity Clinic. B. North Hills Clinic Each fellow spends two months per year rotating through the out-patient
  • 3. Endocrine Clinics at North Hills. These clinics are staffed by full-time MCW faculty with particular expertise in pituitary disorders, adrenal disorders, and metabolic bone diseases. C. Clement J. Zablocki Veterans Administration Medical Center (VAMC) Each fellow spends 3 months per year of fellowship training on the inpatient consult service and participates in outpatient clinics at this institution. The inpatient consultation service and clinics are staffed by Albert L. Jochen, MD, Denise Teves, MD and Irene O’Shaughnessy, MD. D. Children’s Hospital of Wisconsin’s Pediatric Endocrine Clinic The Pediatric Endocrine Clinic is the venue for a one month rotation during the second year of the fellowship that provides education and experience in Pediatric Endocrinology. This rotation is supervised by Dr. Patricia Donohoue D. OBGYN Reproductive Endocrinology Clinic This is a one month rotation in the second year of fellowship with emphasis on infertility and assisted reproductive technologies. III. Inpatient (consult) Experience There is not a separate inpatient endocrine service. All patients are admitted to the medicine ward teams or other services, with the endocrinology service acting as consults. These are four separate rosters of inpatient consults; the Endocrine Consult Service at FMLH, the Diabetes Management Service at FMLH, and the Endocrine Consult Service at the Zablocki VAMC. On any given month a fellow is assigned to either the two consult services at FMLH or the single service at Zablocki VAMC. Each fellow is responsible for approximately 5-10 consult inpatients at any given time. Each of the four inpatient consult service sees approximately 10-30 consults per month. While on the FMLH Diabetes Management Service, which is separate from the FMLH Endocrine Consult Service, the fellows monitor fingerstick results and write all insulin orders on the organ transplant patients. All consults are staffed by one of the endocrinology/diabetology faculty. Fellows oversee the residents and medical students on the consult service and give short lectures on different endocrine topics during consult rounds. The fellows are also responsible for presenting patients at the endocrine/surgical conference and endocrine case conferences.
  • 4. IV. Ambulatory (outpatient) Experience 1. Location 1. Outpatients are seen in the Froedtert-East Clinics, the North Hills Clinic, and at the 1A Multispecialty Clinic at the Zablocki VAMC. 2. The Froedtert-East Clinics contain 8 exam rooms plus office space and several patient care rooms and classrooms for the Diabetes Care Center. The Endocrine Diagnostic Unit is also contained within this space. 3. The clinic area at North Hills consists of 12 exam rooms plus office space. An Endocrine Diagnostic Unit is present along with thyroid ultrasonography and a bone mineral densitometer. 4. The Endocrine Clinic at the VA Medical Center is in an area shared with other medical subspecialties. Each clinic has 6 rooms and one or two attendings. 2. Number of Patients Seen - Each fellow sees approximately 1000 outpatients in a given year. Fellows typically evaluate two new patients per clinic and as many follow-up patients as possible (typically 4-6). Decisions regarding diagnostic testing and management are made in conjunction with the faculty member during each visit. Fellows are also responsible for dictating the initial letter of consultation to the referring physician and follow-up letters after test results come back. 3. Continuity Clinic - Fellows follow the same cache of patients for two years at one weekly half-day “Continuity Clinic” at the FMLH East Clinics. V. Technical Skills A. Diabetes Mellitus – Fellows attend practical workshops during their first year of fellowship on nutritional instruction of diabetes (including carbohydrate counting), glucose monitoring devices and continuous insulin infusion devices. As part of this experience, fellows participate in initiating insulin pump therapy on new patients. B. Laboratory tests and imaging studies - Fellows gain experience in these areas by reviewing imaging results with on-site radiologists. Available imaging studies include CT scanning, MRI, invasive radiology (including adrenal vein sampling), Nuclear Medicine (including thyroid, parathyroid imaging, imaging of endocrine tumors, interpretation of bone density studies). Fellows also attend joint Endocrine-Nuclear Medicine conferences.
  • 5. C. Endocrine Diagnostic Unit - Fellows rotate through the Endocrine Diagnostic Unit for one month during the second year of fellowship. During this rotation they assist in interpreting dynamic testing results as well as learning testing procedures. They are also asked to periodically help in performing these tests at other times when a physicians presence is required. Specific protocols to be learned include: 1. Two hour OGTT to assess for type 2 diabetes. 2. Five hour OGTT to evaluate for reactive hypoglycemia. 3. Three hour OGTT to evaluate for gestational diabetes. 4. Water deprivation test to rule out diabetes insipidus. 5. ACTH stimulation test to rule out adrenal insufficiency. 6. Thyrogen injections to assess for residual thyroid cancer. D. Performance and interpretation of fine needle aspiration of the thyroid - Fellows are required to demonstrate proficiency in performing fine needle aspiration of the thyroid. Fellows are expected to review their slides with the cyto-pathologist and to maintain a logbook of these results. VI. Conferences and Formal Instruction A. Scope of Curriculum - In addition to wide exposure in a clinical setting, training in endocrinology requires formal instruction and on-going independent study in the following areas designated by the RRC (Residency Review Committee): 1 1. Thyroid disorders including hyperthyroidism, hypothyroidism, thyroid cancer, benign thyroid nodules and goiters. 2. Hypothalamic and pituitary diseases including pituitary tumors, craniopharyngioma, hypopituitarism including growth hormone deficiency, SIADH and diabetes insipidus. 3. Type 1 and Type 2 diabetes including treatment of glucose levels, prevention and management of all types of microvascular and macrovascular complications (including retinopathy, nephrology, neuropathy, coronary artery disease, peripheral vascular disease and cerebro-vascular disease), gestational diabetes, diabetes in pregnancy, peri-operative management of diabetes, diabetes nutrition and education, genetics of diabetes and psychosocial issues related to diabetes. 4. Hypoglycemic disorders including insulinoma, fasting and non-fasting
  • 6. hypoglycemia. 5. The diagnosis and management of lipid disorders. 6. The diagnosis and management of primary and secondary hypertension. 7. Disorders of bone and mineral metabolism including hypercalcemia, hypocalcemia, metabolic bone disease, kidney stones, vitamin D disorders and Paget’s disease. 8. Disorders of the adrenal cortex and medulla including Cushing’s Syndrome, Addison’s disease, incidental adrenal tumors, pheochromocytoma and adrenogenital syndrome. 9. Disorders of fluid, electrolyte, and acid-base metabolism, including hypernatremia, hyponatremia, hyperkalemia, hypokalemia, metabolic acidosis, and metabolic alkalosis. 10. Disorders of magnesium and phosphorous metabolism. 11. Endocrine aspects of psychiatric disease. 12. Endocrine aspects of aging. 13. Autoimmune polyglandular failure syndromes. 14. Endocrine emergencies including hypercalcemia, hypocalcemia, thyroid storm, myxedema coma, adrenal crisis and pituitary apoplexy. 15. Parenteral and enteral nutritional support. 16. Nutritional and eating disorders including obesity, anorexia nervosa and bulimia. 17. Hormone-producing neoplasma, including carcinoid syndromes, ectopic hormone production, islet cell tumors and multiple endocrine neoplasia syndromes. 18. Female and male reproduction including primary and secondary amenorrhea, hirsutism, virilization, dysfunctional uterine bleeding, infertility, menopause, testicular tumors, erectile dysfunction, gynecomastia, and hypogonadism. 19. Endocrine abnormalities in systemic illness.
  • 7. B. Conferences The venues for structured fellowship instruction are described below. Most conferences are based on the FMLH/MCW grounds. Other required, and optional, conferences are provided through the Department of Medicine, the Medical College of Wisconsin, regional sub-specialty societies and national sub-specialty organizations. The core of required conferences provides 4 hours per week of formal instruction. These are Thursday’s from 9:00AM to 10:00AM. (Journal Club/Core Conference and Resident’s Noon Conference), Thursday’s from 12:00PM to 1:00PM (Curriculum/Endocrine Board Review/Fellow Seminar), Tuesday 12 p.m. – 1 p.m. (North Hills City-Wide Endocrine Case Conference), Thursday 4 p.m. – 5 p.m. (Combined Endocrine – Surgical Case Conference, Resident Case Conference, Research Conference) and Fridays 8 a.m. – 9 a.m. (Department of Medicine Grand Rounds). There is also an Endocrine Case Conference Thursday’s from 8:00AM-9:00AM which the Pediatric Endocrinology Faculty and Fellows also participate in. A departmental morbidity and mortality conference is scheduled twice a month. The venues for conferences and instruction contained in our program and their roles in the instruction of our fellows are described below. 1. Conferences based in the Division of Endocrinology, Metabolism and Clinical Nutrition a. Thursday Endocrine Case Conference (8:00AM – 9:00AM) – i. A weekly clinical case conference is held in which current cases of interest are discussed. Faculty and fellows are active presenters at this conference. b. Thursday Journal Club (12:00PM – 1:00PM) i. Journal club is held weekly in which a recent paper (or an older, but classic paper) is discussed by one of the fellows. The background to the articles as well as relevant historical literature are reviewed by an endocrine attending prior to presentation of the paper. These reviews provide relevant basic science background material as well as providing clinical perspective. c. Core Curriculum/Endocrine Board Review (Thursday’s from 9:00AM – 10:00 AM) i. The objective of the conference is to provide basic and clinical instruction in the wide range of endocrine disorders. The format of this conference is to present and discuss approximately 4 board-type questions per week over a two year period preceded by a 15 minute lecture on the relevant basic and clinical science background. The distribution of topics during these sessions is as follows:
  • 8. 1. Diabetes mellitus (4 months = 20 hours) 2. Lipid disorders (2 months = 8 hours) 3. Thyroid diseases (4 months = 12 hours) 4. Anterior pituitary and adrenal disorders (4 months = 16 hours) 5. Calcium and metabolic bone disease (4 months = 16 hours) 6. Pediatric and Reproductive Endocrinology (1 months = 4 hours) 7. Posterior Pituitary (1 month = 4 hours) 8. Hypoglycemia (1 month = 4 hours) 9. Obesity, eating disorders, and parenteral nutrition (2 months = 8 hours) 10. Endocrinology and pregnancy (1 month= 4 hours) d. North Hills City-Wide Endocrine Case Conference (Tuesday 12:00PM to 1:00 p.m.) i. This conference meets once a week at the North Hills Clinic to discuss challenging endocrine cases. Attendees at this conference include endocrine staff, other interested endocrinologists from around Milwaukee as well as some internists. e. Thursday 4 p.m. Conferences i. This is a rotating conference three or four Thursday’s each month from 4 p.m. to 5 p.m. at FMLH. These conferences are detailed below. i. Combined Medical – Surgical Endocrine Case Conference – The second Thursday of each month a joint conference is held by the Endocrine Division and the Surgical Service. Also attending are radiologists and pathologists. This conference is case – based. Cases are typically thyroid, adrenal or parathyroid. ii. Residents Case Conference – The third Thursday of each month the medicine housestaff and the fourth year students on FMLH/VA endocrine rotations each do a 15 minute presentation on an interesting case they saw during the first half of the month.
  • 9. Most of the presentation consists of a literature review of the topic. iii. Research Conference - These are held on the 2nd Thursday of each month from 4:00 p.m. to 5:00 p.m. 1. Combined Endocrine – Nuclear Medicine Conference – These are held an average of twice per year on a Tuesday, 8:30 a.m. to 9:30 a.m. in the Nuclear Medicine Conference Room, 2nd floor of FMLH. The objective of these conferences is to instruct our fellows on the role of nuclear medicine in; the diagnosis and treatment of thyroid disorders (in particular thyroid cancer and hyperthyroidism); parathyroid imaging; nuclear imaging of endocrine tumors, including carcinoid, adrenal and MEN syndromes; and methods and interpretation of bone density measurement. 2. Conferences based in the Department of Medicine – i. Department of Medicine Grand Rounds - Fellows clinic schedules are cleared 8 a.m. to 9 a.m. on Friday to allow them to attend Medicine Grand Rounds at FMLH. ii. Medical Mortality and Morbidity Conference (“CPC”) – This is a twice monthly conference held at the VA on Thursdays 12:00 p.m. to 1:00 p.m. iii. Research Conference – a monthly research conference targeting fellows is sponsored by the Department of Medicine. Attendance by endocrine fellows is required. This conference is held one Friday morning each month from 7:00 a.m. to 8:00 a.m. 3. Seminars and Courses based at The Medical College of Wisconsin – Courses on Research Methods and Design, Epidemiology, Genetics, etc are offered to MCW housetaff, fellows, and junior faculty. Other lectures are given on bioethics and palliative care. Our fellows are made aware of these opportunities and encouraged to attend. 4. Regional Endocrine Societies and Conferences – i. Wisconsin Endocrine Society – This society meets an average of twice per year. The format varies from a dinner with a one hour lecture to a full day program. ii. Wisconsin Lipid Club – The Lipid Club meets once or more a year at the University Club in Milwaukee and features a national authority on lipid disorders. iii. Wisconsin Bone Club – This is an annual two day meeting held at a
  • 10. resort in Green Lake, Wisconsin. The speakers and attendees include endocrinologists, rheumatologists and orthopedic surgeons. 5. National Meetings – Fellows are provided time to attend one 1 week national conference per year (e.g. Endocrine Society, American Diabetes Association). C. Independent Study A list of book chapters relevant to our core curriculum is listed below. These books can be found in the MCW and VA libraries. A copy of each book is also found in the fellow’s office at the Zablocki VA Medical Center. 1. Werner and Ingbar’s The Thyroid – A Fundamental and Clinical Text 8th Edition, 2000. Part II – “Laboratory Assessment of Thyroid Function,” pages 333-454. Part IV – “Thyroid Disease: Thyrotoxicosis,” pages 515-718. Part V – “Thyroid Disease: Hypothyroidism,” pages 719-860. 2. Speroff’s, Clinical Gynecological Endocrinology and Infertility, 7th Edition, 2005. Chapter 11 – “Amenorrhea,” pages 401-464. Chapter 12 – “Anovulation and the Polycystic Ovary,” pages 465-498. Chapter 13 – “Hirsutism,” pages 499-530. Chapter 18 – “Post-Menopausal Hormone Therapy,” pages 689-778. Chapter 30 – “Male Infertility,” pages 1135-1174. Chapter 32 – “Assisted Reproduction,” pages 1215-1274. 3. Degroot and Jameson’s Endocrinology, 4th Edition, 2001. Part I- “Principles of Hormone Action,” pages 1-166. VII. Research The NIH, VA, private grants and industry support research programs of our full time faculty and also provide support for the fellow’s research experience. Fully equipped
  • 11. laboratory suites at both FMLH and VAMC allow space and technical assistance during this endeavor. The General Clinical Research Center, funded by the NIH, provides a centralized unit for clinical investigations carried out by the fellow under faculty supervision. Participation of all fellow in some form of research, clinical or basic, is mandatory. Approximately 15% of their time is spent in this activity during the first year of fellowship and 30% in the second year of fellowship. These percentages are flexible depending upon the interest and research aptitude of the fellow. Each fellow chooses a research project and mentor during the first year of his/her fellowship. This research experience should be a project which can be initiated and completed during the two or three year fellowship. Mentors may be chosen from among faculty at FMLH, North Hills or the VA Hospital. This research may involve either clinical or basic research. Our fellows are encouraged to publish completed projects. VIII. The Evaluation Process A. Evaluation of Fellows Each fellow receives an evaluation from a faculty member with whom he or she worked every month. Summary evaluations are prepared every six months. These evaluations use the following tools; 1) written monthly evaluations by the faculty, 2) chart-stimulated review of two patient cases, 3) review of procedure log book of fine needle thyroid aspirations, 4) review of fellow’s joint quality improvement projects, 5) review of the fellow’s portfolio. In addition, a separate evaluation is prepared every six months on the fellow’s Continuity Clinic performance. All evaluations are maintained/retained as a part of the fellow’s permanent record. Finally, verbal feedback is provided by faculty at the completion of each month. B. Evaluations of Faculty The fellow complete evaluation forms on the faculty with whom they have had interacted on a monthly basis. Fellows may discuss issues orally and confidentially if need be. Fellows evaluate rotations, conferences and the program as a whole on an annual basis. These provide important feedback in modifying and improving our rotations, conferences, and teaching efforts. IX. Policies Policies regarding duty hours, moonlighting, promotion, dismissal, etc. are based upon the MCW housestaff manual. A copy of these policies are provided for the fellow’s portfolios.