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SECTION 1: CURRICULUM OVERVIEW.doc.doc

  1. 1. SECTION 1: CURRICULUM OVERVIEW FACILITIES FOR TRAINING 1.1 Sponsoring Institution: Name: Duke University Hospital Program Address: Duke University Medical Center Box 3951 Durham, North Carolina 27710 JACHO Approved: X Program director located at this site: X Number of inpatient beds: 1225 Number of Internal Medicine faculty: 13 Number of Endocrinology faculty: 12 Chair, Department of Internal Medicine: Name: Harvey Cohen, MD Title: Chair, Department of Medicine Address: Duke University Medical Center 1102 Duke North Hospital Durham, North Carolina 27710 Telephone: (919) 668-1755 Fax: (919) 681-5400 Email: cohen015@mc.duke.edu Chief, Division of Endocrinology and Metabolism: Name: Mark N. Feinglos, MD Title: Professor of Medicine and Chief Address: Duke University Medical Center Box 3921 Durham, North Carolina 27710 Telephone: (919) 684-4005 Fax: (919) 681-8477 Email: feing002@.mc.duke.edu Participating Hospitals: Name: Veterans Affairs Medical Center (Durham) Address: 508 Fulton Street Durham, North Carolina 27705 Distance from primary hospital: Across the street, less than two minute walk Are these rotations required: Yes, each week for 12 months Number of months assigned to this site: 12 (four full months, ½ clinic) JACHO Approved: X Program director located at this site: X Number of inpatient beds: 502 Number of Internal Medicine faculty: 17 Number of Endocrinology faculty: 2 Chair, Department of Internal Medicine: Name: William Yarger, MD Title: Chair, Department of Internal Medicine Address: 508 Fulton Street 1
  2. 2. Durham, North Carolina 27705 Telephone: (919) 286-6941 Fax: (919) 286-6873 Email: yarge001@mc.duke.edu Chief, Division of Endocrinology and Metabolism: Name: Jennifer Green, MD Title: Chief, Division of Endocrinology and Metabolism Address: 508 Fulton Street Durham North Carolina 27705 Telephone: (919) 286-0411 ext 7196 Fax: (919) 286-6873 Email: green094@mc.duke.edu 1.2 Program Number: 1433621116 1.3 Program Director: Name: Mark Feinglos Title: Professor of Medicine, Chief Address: Duke University Medical Center Box 3921 Durham North Carolina 27705 Telephone: (919) 684-4005 Fax: (919) 681-8477 Email: feing002@mc.duke.edu 1.4 Other Key Faculty: Name: Ann Brown, MD Title: Assistant Professor of Medicine, Endocrinology Address: Duke University Medical Center Box 3611 Durham North Carolina 27710 Telephone: (919) 684-5002 Fax: (919) 681-7796 Email: brown006@mc.duke.edu Name: Thomas Weber, MD Title: Assistant Professor of Medicine, Endocrinology Address: Duke University Medical Center Box 3470 Durham, North Carolina 27710 Telephone: (919) 668-1367 Fax: (919) 668-1366 Email: weber004@mc.duke.edu Name: John Guyton, MD Title: Associate Professor of Medicine, Endocrinology Address: Duke University Medical Center Box 3510 Durham North Carolina 27710 Telephone: (919) 684-9036 Fax: (919) 681-7796 Email: john.guyton@duke.edu 2
  3. 3. 1.5 Introduction: This subspecialty training program in endocrinology, diabetes and metabolism is designed to provide advanced training and experience at a level for the trainee to acquire the knowledge, skills, attitudes and experience required for all of the competencies needed by a consultant in this field. This program is designed to fulfill the needs of those trainees who anticipate their future activities to be solely the clinical practice of this specialty, those who expect to function as clinician-educators and those who intend to pursue careers in clinical and/or basic endocrine research. The program recognizes that some trainees may evolve into specialists whose activities encompass more than one of the above career paths. The teaching environment and educational experiences for trainees, detailed below, will equip them to become strong clinicians, educators, and investigators. 1.6 Goals: 1. To learn basic and advanced endocrine biochemistry, physiology and pathophysiology, which provide the basis for understanding endocrine disease. 2. To accumulate a critical mass of fundamental information and practical approaches for the diagnosis, management and prevention of endocrine disorders. 3. To acquire the technical and practical skills that are required by a consultant in endocrinology, diabetes and metabolism. 4. To acquire clinical skills in a progressive fashion and with increasing responsibility appropriate for a consultant in endocrinology, diabetes and metabolism. 5. To acquire knowledge and skills necessary for providing cost-effective, ethical and humanistic care of patients with diabetes and disorders of endocrinology and metabolism. 6. To acquire knowledge and skills necessary for critical analysis of the laboratory testing and the endocrine literature. 7. To acquire skills in design and performance of hypothesis-driven endocrine research, and to participate in such research or equivalent scholarly activity. This may include gaining extensive experience in grant writing and scientific presentation. 1.7 Objectives: The program will provide training in: 1. Endocrine biochemistry, physiology and pathophysiology. 2. Hormone action and inter-relationships. 3. Diagnosis and management of endocrine diseases including: (3.1) History and physical examination with emphasis on examination of the fundi, thyroid, breasts, penis, testes and female reproductive organs. (3.2) Selection and interpretation of endocrine biochemical tests. (3.3) Selection and interpretation of imaging procedures such as sonography, radionuclide scans, computerized axial tomography, magnetic resonance imaging, positron emission tomography, etc. (3.4) Fine needle aspiration of the thyroid. (3.5) Understanding pharmacotherapy for endocrine disorders and appropriate use of surgery, radiation therapy, treatment with radioisotopes, etc. 4. Professionalism, including peer interactions, communication with patients, their families and other health care providers, confidentiality and avoidance of conflict of interest. 5. Endocrine clinical and basic research. 6. Understanding of existing and emerging endocrine literature. 7. Personal scholarship and self-instruction. A summary of how these specific learning objectives apply to the major learning experiences of this program is indicated below: 3
  4. 4. Objectives for the Major Learning Experiences Objectives 1 2 3 4 5 6 7 3.1 3.2 3.3 3.4 3.5 Ambulatory: Consultation X X X X X X X X X X Continuing Care X X X X X X X X X X Inpatient: Consultation X X X X X X X X X X Teaching: X X X X X X X X X X Conferences: Clinical X X X X X X X X X X X Basic Science X X X X X X Journal Club X X X X X X X X X Research X X X X X X ESAP X X X X X Procedures: X 1.8 Patient Care Experience Trainees are directly supervised and continually evaluated by attending physicians assigned to the inpatient and ambulatory settings. Inpatients are reviewed on a daily basis with the attending physician. Attending physicians who are physically in the ambulatory setting review the ambulatory care experience of the trainee on a case by case and real time basis. The continuing interaction between trainee and attending physician is the heart of the educational experience. The integration of endocrine disorders with other diseases of the patient is part of the interaction between attending physician and trainee. When relevant, health promotion and identification of risk factors for disease are emphasized. All patient interactions take into account cultural, socioeconomic, ethical occupational, environmental and behavioral issues. Our program provides a progressive learning experience. Trainees are given increasing responsibility as they progress through the program and demonstrate their expanding knowledge base and expertise in diagnosis and management of endocrine disease. They serve as leaders of the endocrine “team”, which is constituted by trainee, internal medicine residents and medical students, always under the supervision of the attending physician. Our program emphasizes a scholarly approach to diagnosis and management. Self-instruction is expected of the trainee along with critical analysis of the patient’s problems and appropriate decision analysis regarding further evaluation and/ or management. Professionalism and ethical behavior are hallmarks of this training program. Our faculty serves both as mentors and role model clinicians for the values of professionalism. These include placing the needs of the patient first, a commitment to scholarship, helping other colleagues, continuous quality improvement and humanistic behavior both in patient interactions and interactions with other health care providers. Issues concerning professional ethics and physician impairment are discussed as they relate to specific interactions with patients. When applicable, these issues will be discussed as part of the evaluation of specific patients. 1.8.1 General Duke University Medical Center and the Duke Medical School are nationally renowned institutions, being ranked consistently in the top ten according to US News and World Report. The division of Endocrinology, Metabolism and Nutrition at Duke is also ranked within the top 20 of all programs nationally. It is also home to a number of clinical, basic science and translational investigators who, through both NIH-sponsored and private research resources, direct studies in a variety of areas, including mechanisms of insulin action and insulin resistance, treatment of Type 2 diabetes mellitus, polycystic ovarian syndrome, osteoporosis and inherited and acquired hypophosphatemic bone disease. In addition to a strong research environment, clinical care in Endocrinology at Duke encompasses a wide spectrum of common and uncommon conditions. This is no doubt facilitated to 4
  5. 5. a large extent by a rather large referral base and catchment area that includes a large portion of Southeastern United States. In addition, Duke also has an active International Medicine Program and provides consultation to patients from the Middle East as well as many other areas of the world. In addition to consultation on-site at Duke Hospital, Endocrine faculty members, in concert with Endocrine fellows, also provide consultation at a number of satellite outreach clinics, thereby facilitating a broader reach of endocrine expertise and care throughout North Carolina. In total, the Division of Endocrinology at Duke provided consultation to nearly 850 inpatients and 9,000 outpatients at Duke alone in 2003. 1.8.2 Ambulatory Care Since most endocrine care is delivered in an ambulatory setting, the ambulatory experience is emphasized throughout the entire duration of the program. We estimate that over 40% of the trainees time (based on an 80-hour work week) is spent in ambulatory care, averaged for the first and second years of the program. This includes 56% from the first year and 32% from the second year. Educational Purpose: To learn about a variety of diseases of endocrinology and metabolism, through consultation and provision of continuing care. Teaching Methods: Ambulatory care is both consultative and continuing. For each interaction, the trainee will spend sufficient time with the patient to carry out an appropriate history and physical examination and then to interact with and be directly supervised by the endocrine faculty assigned to that ambulatory activity. The learning experience surrounding a patient interaction evolves from review of history, physical examination and laboratory results with the faculty, taking direction from the faculty and being provided with references or other learning materials that can be used for self- instruction and subsequent review with the faculty. Disease Mix and Patient Characteristics: Patients are generally 18 years of age or older including adequate representation of geriatric patients. Trainees care for patients with a wide range of clinical problems in stages of illness appropriate to the ambulatory setting. In addition to clinics in which the trainee encounters the broad range of endocrine pathology, rotations through disease-specific clinics are an integral part of the training program. These clinical opportunities are required. They include pediatric endocrine, reproductive endocrine, thyroid/nuclear medicine and PCOS. Procedures and Services: Dynamic endocrine studies and fine needle aspiration biopsy of the thyroid is taught and performed by the trainees in the ambulatory setting. Appropriate laboratory testing, including imaging, is ordered and results reviewed as part of the doctor/patient/attending interaction. Cytological and pathological material is reviewed and analyzed when appropriate. Reading Lists and Educational Resources: These are listed below under the disease specific sections of the curriculum. There are also two binders containing core endocrine-related articles in addition to the reading list contained in the curriculum, located in the endocrine conference room. Evaluation: See section on evaluation below. Trainees are provided the opportunity to follow their ambulatory patients for the duration of the program. By means of the ambulatory experience provided in this program, the trainee has the opportunity to observe and learn the course of endocrine diseases and their treatments. 1.8.3 Inpatient Care Since endocrine specialists are frequently required to consult on and manage endocrine aspects of care in hospitalized patients, the training program also emphasizes training in the inpatient setting. 5
  6. 6. Educational Purpose: To learn about a variety of diseases of endocrinology and metabolism as they occur in the hospitalized patient. Teaching Methods: Hospital care is mainly consultative. For each interaction, the trainee will spend sufficient time with the patient to carry out an appropriate history and physical examination and then to interact with and be directly supervised by the endocrine faculty assigned to that activity. The learning experience surrounding a patient interaction evolves from review of history, physical examination and laboratory results with the faculty, taking direction from the faculty and being provided with references or other learning materials that can be used for self-instruction and subsequent review with the faculty. Consultation is frequently requested to determine the impact of endocrine disease on coexisting illnesses that necessitated hospitalization. The trainee will also learn, under supervision, how to interact not only with the patient and family, but also with other physicians caring for the patient. Practice Setting______________ Number of consults/week 20 Number of fellows/team 1 Number of residents/team 1-2 Number students/team 1-2 Average duration of rounds (hrs) 3-4 hours Disease Mix and Patient Characteristics: On request, trainees provide consultation to the Internal Medicine service and other departments such as surgery, vascular surgery, obstetrics and gynecology, psychiatry, ophthalmology, neurosurgery, orthopedic surgery, etc. Patients will have a variety of diseases that impact on the endocrine system, diseases of other systems with coexisting endocrine disease, or manifestations of primary endocrine disease such as diabetes mellitus, thyroid or parathyroid disease that warrant hospitalization. Patients will be adults of all ages, including the geriatric age group and both sexes. The severity of illness will be much greater than in the ambulatory setting. Procedures and Services: Trainees will coordinate the evaluation and management of the endocrine aspects of the patient’s illness. After interaction with the endocrine-attending physician, the trainee may order or request (depending on the patient’s location) appropriate laboratory tests, biopsies, imaging and infusion studies, as dictated by the patient’s problem. Data will be reviewed and treatment recommended. Reading Lists and Educations Resources: These are listed below under the disease specific sections of the curriculum. There are also two binders containing core endocrine- related articles in addition to the reading list contained in the curriculum, located in the endocrine conference room. Evaluation: See section on evaluation below Trainees evaluate patients by history, physical examination, and review of available laboratory and other data. The trainee is encouraged to formulate a differential diagnosis, plan for further evaluation and management. These are reviewed with faculty assigned to teaching rounds. Learning occurs by an iterative process through continuing interaction with faculty, review of pertinent literature and further discussion as new data emerge or change in the patient’s condition occur as a consequence of recommended treatment. Experience in the inpatient setting will include preparation of appropriate patients with endocrine disease for surgery as well as postoperative management, radiation therapy and/or treatment with iodine I-131. Interaction with professionals from other departments is reviewed and evaluated. Inpatients who have surgery or biopsy, pathology and cytology are reviewed with appropriate specialists in those departments. 6
  7. 7. 1.8.4 Patient Care Experiences (Year 1-2): Tabular Overview of Activities PATIENT CARE EXPERIENCE: YEAR 1 1) AMBULATORY CARE Clinical Patient Volume Location Duration Continuity Rotating Disease Mix Initial Visit F/U Visit Clinic 1 VA Clinic Half Day YES no *YES 3 per session 5 per session Durham, NC weekly during VA and ‘elective’ months Clinic 2 Outreach Clinic Whole day YES no *YES 3 per session 3 per session Various locations once a month Throughout NC for whole year Clinic 3 Specialty Clinics Full Day no YES **YES 2 per session 2 per session Duke Endocrine 4 days per week Clinics during ‘elective’ months Durham, NC See Appendix A Specialty Clinics: Lipid Clinic, Metabolic Bone Disease Clinic, Reproductive Endocrine Clinic, Polycystic Ovarian Disease Clinic, Thyroid Nodule Evaluation Clinic, Diabetes+General Endocrine Clinics, Pediatric Endocrine Clinic, Insulin Pump Education *Diabetes Mellitus, Bone, Thyroid, Pituitary Gland, Adrenal Glands, Lipids **Diabetes Mellitus, Bone, Thyroid, Pituitary Gland, Adrenal Glands, Lipids, PCOS, Pediatric Endocrinology, Reproductive Endocrinology 2) INPATIENT CARE The first-year endocrine fellow’s experience consists of a rotating set of inpatient and outpatient experiences which provides the fellow with exposure to a variety of disease states. The 12 months of the year are divided into 4 blocks of 3-month-cycling rotations: 1 month of the Duke Inpatient Consult Service, followed by 1 month of the VA Inpatient Consult Service, Outpatient Endocrine Clinic and 1 month of ‘elective’ Endocrine Specialty Clinics as described above. Duke Inpatient Consult Service During the Duke Inpatient Consult Service rotation, the fellow serves as the team leader and primary organizer for the Diabetes Management Service/Endocrine Consult Service and thus has the opportunity to manage complex inpatient diabetes cases as well as a broad array of general endocrine diseases. The fellow rounds with the Duke Endocrine Faculty on the entire service every day. The accessibility of the senior staff creates a fertile learning environment for the fellow on-service, who also gets additional training in mentoring and teaching the internal medicine residents and, occasionally, medical students who are an important component of the rounding team. Clinical Volume for the whole team generally consists of on average 4-5 new patient consults daily, in addition to follow-up of 10 to 15 patients of whom the service has previously been consulted and have ongoing endocrine issues. VA Inpatient Consult Service During the VA Inpatient Consult Service, the fellow also consults on inpatients with endocrine issues. Consults come from all departments of the hospital including post-surgical, medical, and psychiatric cases. The VA fellow has the opportunity to discuss cases with the VA Endocrine Chief and other VA Endocrine attendings. Clinical Volume is variable – it typically ranges from 4 to 8 consults weekly, for which the fellow is primarily responsible as this service does not include resident or student participation. 7
  8. 8. PATIENT CARE EXPERIENCE: YEAR 2 1) AMBULATORY CARE Clinical Patient Volume Location Duration Continuity Rotating Disease Mix Initial Visit F/U Visit Clinic 1 VA Clinic Half Day YES no *YES 3 per session 5 per session Durham, NC Weekly, for the whole year Clinic 2 Duke Endocrine Clinic ½ day bimonthly YES no *YES 3 per session 3 per session Underserved Locales 8/12 months Clinic 3 Duke Outpatient Weekly for YES no **YES 2-4 per session 5-8 per session Clinic 4/12 months continuous The typical patient encounter is quite similar to the experience in year one with the main difference being an increased level of independence in the fellow’s care of the patient. The fellow now conducts the history and physical and formulates the treatment plan independently, without direct observation by the attending. However, the attendings are always on site during clinic and available for consultation, and they can directly participate if the fellow wishes. Attendings review written notes of the encounter for quality control as well. At the Duke Outpatient Clinic, the second year fellow runs the clinic with the supervision of two endocrine attending physicians. The second year fellow typically oversees one first year fellow, one medicine intern and one medical student. The second year fellow also has primary responsibility for patient follow-up. *Diabetes Mellitus, Bone, Thyroid, Pituitary Gland, Adrenal Glands, Lipids **Diabetes Mellitus, Bone, Thyroid, Pituitary Gland, Adrenal Glands, Lipids, PCOS, Reproductive Endocrinology 2) INPATIENT CARE Unlike the first year of training, there are no inpatient care experiences required this year. 1.9 Facilities and Resources The program has secretarial support to facilitate scheduling and referrals. Fellows have office space with computer facilities for email and internet services, including literature searches: this is particularly beneficial to the fellows in that the Duke Medical Center Library has electronic access to many publications as well. The faculty regularly receives a number of journals and books, all of which are available to the trainee. Trainees are encouraged to participate in local and national endocrine meetings. In general, each trainee attends at least one national meeting per year. 1.9.1 Teaching Sites Site 1 (a) Duke Inpatient Consult Service During the Duke Inpatient Consult Service rotation, the fellow serves as the team leader and primary organizer for the Diabetes Management Service/Endocrine Consult Service and thus has the opportunity to manage complex inpatient diabetes cases as well as a broad array of general endocrine diseases. The fellow rounds with the Duke Endocrine Faculty on the entire service every day. The accessibility of the senior staff creates a fertile learning environment for the fellow on-service, who also receives additional training in mentoring and teaching the internal medicine residents and, occasionally, medical students who are an important component of the rounding team. Clinical Volume for the whole team generally consists of, on average 4-5 new patient consults daily, in addition to follow-up of 10 8
  9. 9. to 15 patients daily of whom the service has previously been consulted and have ongoing endocrine issues. (b) Duke PDC During four months of the initial fellowship year, fellows will attend a pre-specified block of Endocrine subspecialty clinics at Duke Clinic. These clinics are staffed by Adult Endocrine, Pediatric Endocrine and Reproductive Endocrine faculty members who have specific interests in a number of endocrine disease states, including but not limited to diabetes mellitus, lipid disorders, polycystic ovarian disease, thyroid disease, metabolic bone disease, pediatric endocrinology (including juvenile-onset diabetes mellitus and disorders of growth and development) and disorders of reproductive endocrinology, including infertility. In addition to the Duke site, fellows will also rotate through the Durham VA lipid and bone clinics while participating in this elective rotation. Fellows will also attend the Duke Outpatient Clinic on selected rotation blocks. In addition to direct patient interaction with faculty observation, the fellows will also be allotted one to two half-day sessions per week in order to facilitate self- directed education, well as initial identification and development of a mentored-research project, which will be pursued in earnest during the second year of fellowship training. Site 2 (a) Durham VA Inpatient Consult Service During the VA Inpatient Consult Service, the fellow consults on inpatients with endocrine issues. Consults come from all departments of the hospital including post-surgical, medical, and psychiatric cases. The VA fellow has the opportunity to discuss cases with the VA Endocrine Chief and other VA Endocrine attendings. Clinical Volume is variable – it typically ranges from 4 to 8 consults weekly, for which the fellow is primarily responsible as this service does not include resident or student participation. (b) Durham VA Endocrine Clinic The DVAMC Endocrine Clinic provides fellows with a wealth of general endocrine continuity experiences. Each fellow has a continuity clinic, which meets for half-a-day weekly, and the fellow is responsible not only for the patient encounter, which occurs during the visit, but also for all follow-up associated with that encounter. The VA Clinics include a General Endocrine clinic that takes place twice weekly, as well as a Bone/Calcium Disorder clinic and Lipid/Risk Reduction clinic that each occur weekly. These clinics provide exposure to a wide range of Endocrine disorders. These include, but are not limited to, conditions such as diabetes mellitus; a variety of thyroid conditions including thyroid cancer; adrenal and pituitary disorders; osteoporosis; hyperparathyroidism; and lipid disorders. As there are no other VA Endocrine clinics in North Carolina, a wide variety of patients are referred to the Durham Clinic for management. The consultation service provides experience in the management of these same conditions in the inpatient setting. Although the majority of patients seen at the VA are male, it is anticipated that the recent establishment of the Bone/Calcium disorder clinic will attract more female patients to the Endocrine service. In addition, the increasing presence of women in the armed forces will likely result in larger numbers of women seeking medical care through the VA system. Site 3 Duke Outpatient Clinic “DOC” Endocrine Clinic is a one-half day clinic per week. The clinic serves as an Endocrine continuity clinic for an Endocrine second-year fellow and is also attended by a first- year Endocrine fellow as well as an internal medicine intern. There is on-site supervision and teaching by faculty in the division of Endocrinology. The clinic serves as a referral site for the ambulatory clinics at DOC, Duke General Internal Medicine clinics, Lincoln clinics, and other clinics and hospitals in the area. Patients seen in this clinic have a variety of endocrine and other medical problems including, but not limited to, diabetes mellitus, hypertension, dyslipidemia, obesity, cardiovascular diseases, endocrine tumors, and diseases of the pituitary, thyroid, parathyroid, adrenals, reproductive system, electrolytes, and bone. In these clinics, trainees serve as the providers for a panel of patients and are fully responsible for the 9
  10. 10. coordination of their care. Additionally, trainees have the opportunity to work with a multidisciplinary team of health professionals including pharmacists, psychologists, social workers, and diabetic educators. Site 4 Outreach Endocrine Clinic Underserved Locales throughout North Carolina Roxboro, NC The Outreach Endocrine Clinic provides fellows with further exposure to continuity of care, but with a particular ‘real-world’ experience in underserved areas of the state. Although there are numerous outreach locations throughout NC, each fellow is assigned to one specific clinic and returns to that clinic one-day per month, ensuring continuity. Typically, the fellow will see about 3 new-patient consultations (initial visits) and 3 to 4 return-patient visits in a single clinic session. The disease mix is again excellent as the population presents with issues from all areas of general endocrine. 1.9.2 Additional Facilities and Resources Our hospital has modern facilities and services, including in-patient, ambulatory care and laboratory resources and these are readily available to all trainees. In addition, complete biochemistry laboratories and hormone assays are available 24 hours daily. The hospital has facilities for karyotyping. The Department of Radiology provides MRI, CT, ultrasound, DEXA, PET, and other radiologic imaging services that can conduct studies for all types of endocrine diseases including petrosal sinus and adrenal vein sampling. The hospital supports a dietary/nutritional service. There is a fully staffed surgical pathology laboratory for the interpretation of surgical and cytologic specimens, including immunohistologic studies. Cytologic interpretation of thyroid aspirations is available within a few hours and fellows can review these specimens with the Department of Pathology staff. Nuclear Medicine provides all routine radionuclide-imaging methods including radioiodine thyroid scanning and ablation, adrenal and parathyroid scanning as well as MIBG and technetium pyrophosphate bone scans. Podiatry is available as needed. 1.9.3 Core Conferences Clinical Conferences: Endocrine Fellows Case Conference Educational Purpose: To discuss a variety of diseases of endocrinology, metabolism, and nutrition in considerably greater depth than what can usually be accomplished in the ambulatory care clinics or bedside setting. Correlation with endocrine biochemistry, physiology, and pathophysiology is an integral part of the conference. Teaching Method: This is a fellow-conducted conference: fellows have the responsibility of selecting appropriate cases and preparing presentations. Typically, one fellow will present 1-2 cases per conference in depth, followed by discussion and a presentation of teaching points or relevant literature as well. Disease Mix: All endocrine diseases are discussed. Cases reflecting disorders that may be less commonly encountered in a typical ward or clinic experience are highlighted during this conference. Procedures and Services: Appropriate use of biochemical testing, imaging, and biopsy, as well as review of techniques for the above studies, cytopathology, and pathology are discussed as relevant during conference. Reading Lists and Educational Resources: An integral part of most conference sessions includes hand-out materials summarizing important points, with lists and resources on specific groups of endocrine diseases. Evaluation: Fellows who present at conferences are evaluated by attending physicians who are present at conference. Their performance in this venue is part of the overall evaluation by attendings and the program director. Also see section on evaluation. Specific aspects of the clinical conference-case conference experience: Fellows Case Conference represents a major teaching opportunity for both the individual fellow presenter as well as all those in attendance at these sessions. This allows teaching of 10
  11. 11. important points from clinical endocrinology, and, as appropriate, biochemistry and pathophysiology, in a format that also permits open discussion and assessment of appropriate clinical decision-making. Basic Science Conferences: Selected Endocrine Grand Round Sessions, Selected Endocrine Journal Club Sessions, Selected Fellows Didactic Course Sessions Educational Purpose: To instruct trainees in the basic biochemistry, physiology, and pathophysiology of the endocrine system. Subject areas have included molecular biology, immunology as related to endocrinology and metabolism, signal transduction pathways, biology of hormone receptors and principles of hormone action, biology of sexual development, reproductive endocrinology, endocrine aspects of sexual dysfunction, among other topics. [see topic lists below] Teaching Method: Faculty lead the conferences, which are usually in a seminar / open discussion format allowing interaction between the fellows and faculty speaker. Disease Mix: Not relevant Procedures and Services: Not relevant Evaluation: The faculty will evaluate fellows’ participation and interaction, while the fellows will also evaluate the effectiveness of the faculty in communicating the educational topics. Basic Science Conferences are held on a MINIMUM monthly basis, in that Grand Rounds Conferences generally includes at least one session monthly devoted to a basic science topic; this is also well-supplemented by journal clubs and fellows didactic course sessions which alternate basic science topics with clinical discussions. Additionally, many other basic science conferences take place within our institution on a daily basis in both basic science and clinical departments. Their schedules are posted throughout the medical center and its website and fellows are encouraged to attend as time allows. Aspects of the basic science conferences: Examples of recent topics: Fellows Course: Examples of Basic Science Topics: (As noted above, “Subject areas have included molecular biology, immunology as related to endocrinology and metabolism, signal transduction pathways, biology of hormone receptors and principles of hormone action, biology of sexual development, reproductive endocrinology, endocrine aspects of sexual dysfunction, among other topics.”)  -Hypogonadism / hormone receptors -Adrenal anatomy/physiology -Infertility and Contraception -Reproductive Physiology -Congenital Adrenal Hyperplasia and Intersex issues -Genetic Diabetes Syndromes (MODY) -G-Proteins, Receptors, and Endocrine Disease Journal Club Educational Purpose: To discuss a variety of both clinical and basic science aspects of endocrinology, metabolism, and nutrition in greater depth than at the bedside or ambulatory care setting, with an emphasis on emerging endocrine literature. Participation in the conference allows fellows additional training in critical appraisal of the literature, epidemiology, biostatistics, and clinical decision theory. Teaching Method: Fellows are expected to accurately summarize AND critically appraise a paper from the endocrine literature: they present analyses of experimental groups and design, methodology of measurements, and of statistical analysis. The topic is open for an interactive discussion between the presenting fellow, the other fellows who are all in attendance at this session, and attendings who attend as well. Disease Mix: Literature relating to all endocrine diseases are discussed. Procedures and Services: As research concerning endocrine procedures or services is published; those papers may come under discussion in Journal Club 11
  12. 12. Reading Lists and Educational Resources: Most sessions include a handout with not only the journal article but also a summary and appraisal sheet. Evaluation: Fellows who present at conferences are evaluated by attending physicians who are present at conference. Their performance in this venue is part of the overall evaluation by attendings and the program director. Also see section on evaluation. Additionally, fellows may evaluate faculty as facilitators of Journal Club and active participants. Journal Club occurs on Thursdays of every other week; (the alternate Thursdays serve as teaching sessions during which Endocrine Board Review Questions are discussed among the fellows and attending educators). Specific aspects of the journal club experience Journal Club is unique in that it allows Endocrine Fellows to continue to develop and hone skills which are initially taught to them during residency: that of accurate and critical appraisal of the literature including attention to study design, methodology, and analyses. Further development of these skills develops physicians who not only can critically interpret the new endocrine literature but who also will focus this type of attention to detail in designing studies of their own. Research Conferences: Discussions of Research occur during Endocrine Grand Rounds and the Stedman Nutrition and Metabolism Center Forums Educational Purpose: To acquaint fellows with the status of current research carried out by the faculty, other fellows, members of other Divisions within the Department of Medicine, or other Departments at Duke Medical Center. Fellows can participate in interactive discussions during these sessions as well. Teaching Method: Interactive discussion of presented research in the areas of clinical and basic science endocrinology and metabolism including design, analysis, and interpretation of the data. Those fellows actively participating in either basic or clinical research will present their research project to the division at least annually: all upper level fellows give Endocrine Grand Rounds at least once per year, and first-year fellows present topics of potential research interest twice yearly. Disease Mix: Research may be presented that relates to any and all endocrine disease. Procedures and Services: .Not applicable Specific aspects: Research Conferences are available to fellows in the Division of Endocrinology, Metabolism, and Nutrition through a variety of venues, resulting in the realistic expectation that fellows attend Endocrine Research discussion sessions at least once monthly, and likely more often. Endocrine Grand Rounds occurs on a weekly basis in the division, and approximately at least twice monthly, Grand Rounds will be a presentation by either a fellow or division faculty in which the presenter’s on- going research is discussed in-depth. Additionally, the Sarah W. Stedman Nutrition and Metabolism Center provides weekly 60-90 minute presentation/discussion sessions wherein members of the endocrine division and experts from throughout the country present their research in the areas of nutrition and metabolism. 1.9.4 Procedures Fellows will obtain a comprehensive understanding of indications, contraindications, limitations, techniques, methods of interpretation, and potential complications of procedures that are required for the diagnosis and management of patients with disorders of endocrinology and metabolism, specifically thyroid fine-needle aspiration. This understanding includes informing the patient about the above aspects of specific procedures and obtaining informed consent. Procedures are taught and supervised by faculty in various patient care settings [settings as described above]. Fellows maintain password protected electronic logbooks to list each procedure and copies are kept. Entries include the name of the patients, identifying numbers, clinical problem, procedure, indication of complications if applicable, and results. All procedures are carried out in accordance with universal precautions and protection of healthcare workers, as defined by Occupational Safety and Health Administration (OSHA). Trainees, along with all other health care personnel at the institution, must participate in annual training sessions on precautions for health-care workers, as detailed by OSHA. 12
  13. 13. Specific procedures will be detailed in the disease-specific sections of this curriculum. 1.9.5 Other Competencies Fellows who enter this program have universally been found to have sufficient computer skills to enable them to search the literature electronically and participate in computer-assisted instruction and use electronic information networks; however, there are multiple opportunities for fellows to further develop these skills through offerings at the Duke Medical Center Library and Office of Information Technology. Issues concerning quality assessment, quality improvement, risk management, and cost- effectiveness are discussed in all clinical and laboratory settings throughout the program. Similarly, ethics and professionalism are considered in all patient interactions and may be supplemented by materials provided by the American Board of Internal Medicine. Each fellow is provided materials on ethics and professional standards and is expected to carry out daily activities in accordance with the highest professional standards. Additionally, all fellows involved in clinical research at Duke are required to complete, and update yearly, on-line training modules on specific topics related to ethics in clinical research. Patient education, counseling, and end-of-life care are taught by example when appropriate in interactions with patients and their families. Other issues that concern palliative care for terminally ill patients are discussed when appropriate. Available supplementary teaching materials include publications as follows: 1) Care of the Dying and Promotion of Physician Competency-Educational Resource and Personal Narratives, published by the American Board of Internal Medicine (www.ABIM.org) and 2) EPEC (Education for Physicians on End-of-life Care), published jointly by the Robert Wood Johnson Foundation and the American Medical Association (www.ama- assn.org/ethic/epec). 1.9.6 Research and Other Scholarly Activities Trainees in this program are expected to carry out research and participate in other scholarly activity. During the first year, trainees are expected to learn about the research interests of the faculty members by attending Research Seminars, Journal clubs, or by direct interaction initiated by the faculty, trainee or program director. In general, trainees should reach an agreement to carry out research with a specific faculty member by the middle of the first year of the program. This allows the trainee to learn the literature concerning the research area and begin by repeated interaction with the faculty mentor, to formulate and design an experimental project. Thus, within 6-9 months, the trainee is ready to move into the research arena without delay. In our program, the allotment of time dedicated to research varies over the course of a training year as well as between years of training. In general, the annualized percentage effort for research is: Year 1 10% Year 2 80% The figure for year two is based, as per NIH Training Grant required, on a 60-hour workweek. The research experience in our training program is based on a mentor: trainee relationship that is meaningful, interactive at frequent intervals, and that leads to formulation of the research problem, determination of appropriate experimental design, use of appropriate research methodology, analysis of data, interpretation of results and, eventually, publication in peer-reviewed journals. This is supplemented by biannual research committee meetings with a research mentoring committee, comprised of the primary mentor and two additional faculty co-mentors. In our program, almost all trainees publish in peer-reviewed journals and present their work at national endocrine meetings. In addition to basic and clinical research, trainees will present at Clinical Conferences, Journal Club, and Research Seminars. They are encouraged to write up and publish interesting cases that they encounter during their training. Finally, faculty is encouraged to ask trainees to participate in the writing of invited Chapters or Reviews, with appropriate authorship designation. 13
  14. 14. 1.10 Evaluation Evaluation in this program is an ongoing process and occurs in a 360-degree manner. During clinical rotations, the attending is the principal evaluator of the trainee. Trainees are evaluated in all aspects of clinical activities and patient care, including attributes of professionalism. Evaluation forms developed by the American Board of Internal Medicine are employed for this evaluation and the attending and trainee are expected to discuss the evaluation. Trainees are required to keep their own record of procedures indicating who supervised the procedure, and copies of the password procedure logbook or equivalent documents are provided to the program director for the trainee’s file annually. At semiannual intervals, the program director will review the evaluations with each trainee. Trainees will be advanced to a position of greater responsibility after they have demonstrated satisfactory scholarship and professional growth as demonstrated by the six competencies listed in MyEvaluations.Com. A written policy to ensure due process has been developed by the Department of Medicine and is used by all subspecialty divisions in our institution. To future determine the trainees’ factual knowledge, the program director, with the assistance of other faculty members, review questions from the Endocrine Self Assessment Program (ESAP), published by the Endocrine Society and Up-To-Date in a one hour session every second week. To complete the circle of evaluation, trainees will evaluate the faculty members who serve as Attendings and report those evaluations, using forms developed by the American Board of Internal Medicine, to the program director. Trainees, at annual intervals, also evaluate the program as a whole, using American Board of Internal Medicine forms. One faculty meeting each year, during the month following the completion of training, will be devoted, in part, to a review of these evaluations of the faculty and the program. The focus of this meeting will be to review the educational effectiveness of the curriculum. Plans to improve those parts of the program that may not be optimal will be developed at these meetings. Counseling and Remediation: In the unlikely event that a trainee requires remediation in one or more areas that impact on clinical competence, the program director will appoint an ad hoc committee of faculty to develop a plan of remediation, implement the plan and evaluate the trainee’s response. If a faculty member receives poor evaluations as an attending physician, those evaluations and plans for improving performance will be discussed in a meeting with the program director. The research mentor, using forms, will evaluate the research performance of each trainee. Those evaluations will be discussed with the trainee and then forwarded to the program director for review and inclusion in the trainee’s file. 14
  15. 15. Section 2: Disorders of the Adrenal Cortex and Medulla 2.1 Introduction A complete understanding of the diseases affecting the adrenal gland is essential for the endocrinologist. Adrenal pathophysiology includes numerous life-threatening conditions ranging from electrolyte disturbances, alterations in blood pressure, and malignancy. Indeed, it is essential that the endocrinologist accurately recognize and promptly manage the patient with adrenal disease. An appropriate knowledge base for this area includes an understanding of the hormonal and neurological regulation of electrolytes and blood pressure, the biosynthesis of steroid hormones and their target tissues/actions, the genetic basis for inherited diseases of the adrenal gland, recognition of adrenal cortical hyper- and hypo-function as well as adrenal medullary hyperfunction, static and dynamic tests of adrenal gland function, adrenal imaging techniques and management of adrenal dysfunction. Many of these diseases affecting the adrenal gland are common, such as the incidental adrenal mass, and will be routinely encountered in most clinical training settings. In contrast, conditions such as a pheochromocytoma are more rare. As noted, however, the latter condition represents an extremely critical medical diagnosis. Thus, appropriate training in adrenal disease will likely reflect a combination of both hands-on clinical encounters and an array of additional learning experiences including both formal teaching and self-directed methods. 2.2 Discussion The training program provides opportunities for the endocrine trainee to develop competence in the clinical evaluation and management of patients with adrenal cortical and adrenal medullary disorders. This clinical experience includes opportunities to diagnose and manage adult outpatients and inpatients of both sexes. The Trainee is given opportunities throughout the training period to assume responsibility for and follow patients to observe the evolution and natural history of these disorders, as well as the efficacy of therapy. 2.2.1 Physiology The endocrine trainee should have a basic understanding of the normal physiology of the adrenal cortex and medulla. This knowledge base should include: (1) Adrenal Gland embryology, anatomy, and zonation (2) Adrenal steroid pathways of biosynthesis, specific enzymatic steps, and steroid hormone structures (3) Steroid metabolism (4) Hypothalamic-pituitary-adrenal axis and normal patterns of ACTH and cortisol secretion (5) Regulation of adrenal glucocorticoid, androgen, and estrogen secretion (6) Factors affecting measured levels of steroids in plasma and urine (7) Molecular and cellular mechanisms as well as physiologic effects of glucocorticoids, mineralocorticoids, androgens, and estrogens (8) Renin-angiotensin-aldosterone system and regular of mineralocorticoid secretion (9) Catecholamine biosynthetic pathway, physiological effects of catecholamines, excretion of catecholamines and catecholamine metabolites The method of education for adrenal physiology should include formal instruction and reading the chapters covering adrenal cortex and adrenal medulla from one of the major endocrine textbooks (1-5) and other resources. 2.2.2 Evaluation and Management of Adrenal Disorders Competency in the evaluation and management of the adrenal disorders required by the Residency Review Committee are listed in the Form at the end of the section (Disorders of the Adrenal). For each disorder listed, the trainee should have a thorough knowledge of: (1) Clinical Presentation (2) Pathophysiology (3) Physical examination findings 15
  16. 16. (4) Differential diagnosis (5) Laboratory findings (6) Typical imaging findings (7) Clinical management The primary methods of education for these disorders should be direct clinical experiences and clinical case discussions. These case discussions would usually take place on hospital rounds or in the outpatient endocrine clinic setting, as well as clinical case conferences. The knowledge base of all of the adrenal disorders listed in the Form (Disorders of the Adrenal) should be enhanced with reading appropriate sections of an endocrine textbook (1-5), suggested supplemental articles, and Medline searches. 2.2.3 Rare Causes of Adrenal Disorders The trainee should also be familiar with rare causes of the adrenal disorders listed in the Form. For example, for the category of “Mineralocorticoid Excess,” in addition to primary aldosteronism, the trainee should be familiar with the spectrum of causes from rinin- dependent (eg, renovascular disease, coarctation of the aorta) to renin-independent (eg, 11- B-hydroxysteoid dehydrogenase deficiency, Liddle’s syndrome, hypercortisolism, congenital adrenal hyperplasia). The trainee should be knowledgeable of the special features of Cushing’s syndrome, adrenal insufficiency, aldosteronism, and pheochromocytoma in the hospitalized patient. 2.2.4 Adrenal Hyperplasia; 21-hydroxylase deficiency The trainee should have a thorough knowledge of the clinical presentation, pathophysiology, differential diagnosis, laboratory findings, and clinical management of 21- hydroxylase deficiency and should be familiar with other forms of congenital adrenal hyperplasia. 2.2.5 Hypertension With regard to hypertension, the trainee should know when to consider secondary (endocrine) causes of hypertension and how to manage essential hypertension in patients with endocrine disease (eg, diabetes mellitus). 2.2.6 Glucocorticoid Therapy Although not required by the RRC, a thorough understanding of glucocorticoid therapy should be achieved (see Form). This part of the curriculum includes: (1) Knowledge of the different glucocorticoid preparations (oral and Parenteral) (2) Chronic maintenance glucocorticoid dosing (3) Inpatient and outpatient “stress” coverage dosing (4) Management of glucocorticoid withdrawal including evaluation of hypothalamic pituitary-adrenal axis function (5) Recognition of the manifestations of excessive and insufficient glucocorticoid therapy. 2.2.7 Adrenal Studies and Procedures The endocrine trainee should understand the indications for and the interpretation of all of the tests and procedures listed in the tables below. The trainee should be proficient in identifying normal and abnormal adrenal glands on computerized imaging. Methods of education should include formal instruction, direct clinical experiences, clinical case discussions, and self-directed learning. Dynamic Endocrine Tests Cosyntropin stimulation test – 1 ug and 250 ug Corticotropin-releasing hormone (oCRH) stimulation test 16
  17. 17. Dexamethasone suppression tests (DST) oCRH/DST protocol Insulin tolerance test Saline suppression test for aldosterone Clonidine suppression test for norepinephrine Imaging and Radiology Procedures Adrenal venous sampling for aldosterone Inferior petrosal sinus sampling for ACTH with oCRH stimulation Computerized adrenal imaging (CT, MRI) CT-guided adrenal FNA biopsy 123 I-metaiodobenzylguanidine (MIGB) scintigraphy Indium IN-111-labeled pentetreotide (OctreoScan) scintigraphy (6B-131-I)iodomethyl-19-norcholesterol (NP-59) scintigraphy 2.2.8 Evaluation Evaluation of competency should include discussions with faculty on a continuing basis and clinical presentations. Divisional ESAP Review Conferences also include adrenal questions. 2.3 Suggested Reading One of the following general endocrine textbooks The Adrenal Cortex and The Adrenal Medulla. In: A Grossman, ed., Clinical Endocrinology, 2nd ed. London: Blackwell Science Ltd: 1998. Adrenal Cortex. In: DeGroot LJ, Besser M, Burger HG,. James JL, Loriaux DL, Marshall JC, Odell WD, Potts JT, Jr, Rubenstien AH, eds. Endocrinology. 3rd ed. Philadelphia, PA: W.B. Saunders Co; 1995. Felig P, Baxter JD, Frohman LA, eds. Endocrinology and Metabolism, 3rd ed. New York, NY: McGraw-Hill Inc: 1995. Chapter 12 – The Adrenal Cortex, WL Miller, JB Tyrell Chapter 13 – Diseases of the Sympathochromaffin System, PE Cryer Chapter 14 – The Endocrinology of Hypertension, JD Baxter, D Perloff, W Hsueh, EG Biglieri Chapter 15 – Glucocorticoid Therapy, JB Tyrell The Adrenal Glands. In: Becker KL, Bilezikian JP, Bremner WJ, Hung W, Kahn CR, Loriaux DL, Nylen ES, Rebar RW, Roberson GL, Wartofsky L, eds. Principles and Practice of Endocrinology and Metabolism, 2nd ed. Philadelphia, Pa: J.B. Lippincott Co; 1995. Wilson JD, Foster DW, Kronenberg HM, Reed Larson P, eds. Williams Textbook of Endocrinology. 9th ed. Philadelphia, PA: W.B. Saunders Co; 1998. Chapter 12 – The Adrenal Cortex, DN Orth, WJ Kovacs Chapter 13 – Catecholamines and the Adrenal Medulla, JB Young, L Landsberg Chapter 14 – Endocrine Hypertension, R.B. Dluhy, GH Williams CD-ROM UpToDate in Endocrinology and Diabetes (CD ROM Series) (ISSN:190-3496). Available at http://www.uptodate.com. 17
  18. 18. Journal Articles Cushing’s Syndrome Findling JW, Raff H. Newer diagnostic techniques and problems in Cushing’s disease. Endocrinol Metab Clin North Am. 1999; 28:191-210. Graham KE, Samuels MH, Nesbit GM, et al. Cavernous sinus sampling is highly accurate in distinguishing Cushing’s disease from ectopic adrenocorticotropin syndrome and in predicting intrapituitary tumor location. J Clinic Endocrinol Metab. 1999: 84:1602-1610. Newell-Price J, Trainer P, Besser M, Grossman A. The diagnosis and differential diagnosis of Cushing’s syndrome and pseudo-Cushing’s states. Endocr Rev. 1998: 19:647-672. Raff H. Raff JL, Findling JW. Late-night salivary cortisol as a screening test for Cushing’s syndrome. J Clinic Endocrinol Metab. 1998; 83:2681-2686. Adrenal Insufficiency Betterle C, Greggio NA, Volpato M. Clinical review 93: Autoimmune polyglandular syndrome type 1. J Clin Endocrinol Metab. 1998; 83:1049-55. Kleerekoper M, Schiebinger R, Gutai JP. Steroid therapy for adrenal disorders – getting the dose right. J Clni Endocrinol Metab. 1997; 82:3923-5. Pheochromocytoma and Mineralocorticoid Excess Dluhy RG, Lifton RP: Glucocorticoid-remediable aldosteronism. J Clinic Endocrinol Metab. 1999; 84:4341-4. Young, WF JR., Pheochromocytoma and primary aldosteronism: Diagnostic approaches. Endocrinol Metab Clin North Am. 1997; 26:801-827. White PC. Disorders of aldosterone biosynthesis and action. N. Engl J Med. 1994; 331:250-258. Nonfunctioning Adrenal Mass Angeli A, Osella G, Ali A, et al: Adrenal incidentaloma: An overview of clinical and epidemiological data from the National Italian Study Group. Horm Res. 1997; 47:279-283. Cook DM, Adrenal mass. Endocrinol Metab Clin North Am. 1997; 26:829-852. Kloos RT, Gross MD, Francis IR, Korobkin M, Shapiro B. Incidentally discovered adrenal masses. Endocr Rev. 1995: 16:460-484. Mantero F. Masini AM, Opocher G, et al. Adrenal incidentaloma: An overview of hormonal data from the National Italian Study Group. Horm Res. 1997; 47:284-289. Hirsutism, Virilization, and Congenital Adrenal Hyperplasia Derksen J. Nagesser SK, Meinders AE, Haak HR, van de Velde CJ. Identification of virilizing adrenal tumors in hirsute women. N Engl J Med. 1994; 331:968-973. Franks S. Polycystic ovary syndrome. N Engl J Med. 1995; 333:853-861. 18
  19. 19. Gabrilove JL, Sharma DC, Wotiz HH, Dorfman RI. Feminizing adrenocortical tumors in the male – A review of 52 cases. Medicine. 1965; 44:37-44. Gabrilove JL, Seman AT, Sabet R, Mitty HA, Nicolis GL. Virilizing adrenal adenoma with studies on the steroid content of the adrenal venous effluent and a review of the literature. Endocr Rev. 1981;2:462-470. Pang S. Congenital adrenal hyperplasia. Endocrinol Metab Clin North Am. 1997; 26:853-891. Fluid and Electrolytes Gennari FJ. Hypokalemia. N Engl J Med. 1998; 339:451-458. Distrubances in Control of Body Fluid Volume and Composition. In: BM Brenner, ed. Brenner and Rector’s The Kidney. 5th ed. Philadelphia, PA: W.B. Saunders; 1996. Hypertension August P. Hypertension in men. J Clin Endocrinol Metab. 1999; 84:3451-3454. August P. Oparil S. Hypertension in women. J Clin Endocrinol Metab. 1999; 84:1862-1866. JNC-VI: The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Rockville, MD: National Institutes of Health; November 1997. NIH Publication 98-4080. Sibai BM. Treatment of hypertension in pregnant women. N Engl J Med. 1996; 335:257-265. Setaro JF, Black HR. Refractory hypertension. N Engl J Med. 1992; 327:543-547. Adrenal Studies and Procedures Aron DC, Raff H, Findling JW. Effectiveness versus efficacy: the limited value in clinical practice of high dose dexamethasone suppression testing in the differential diagnosis of adrenocorticotropin-dependent Cushing’s syndrome. J Clin Endocrinol Metab. 1997; 82:1780-1785. Doppman JL, Gill JR Jr. Hyperaldosteronism: Sampling the adrenal veins. Radiology. 1996; 198:309. Oldfield EH, Doppman JL, Nieman LK, et al. Petrosal sinus sampling with and without corticotropin-releasing hormone for the differential diagnosis of Cushing’s syndrome. N Engl J Med. 1991; 325:897-905. Torpy DJ, Chenn CC, Mullen N, et al. Lack of utility of 111-In-pentetreotide scintigraphy in localizing ectopic ACTH producing tumors: follow-up of 18 patients. J Clinic Endocrinol Metab. 1999; 84:1186-1192. Yanovski JA, Cutler GB Jr, Chrousos GP, et al. The dexamethasone-suppressed corticotropin-releasing hormone stimulation test differentiates mild Cushing’s disease from normal physiology. J Clin Endocrinol Metab. 1998; 83:348-352. 19
  20. 20. Self-Assessment Tests Endocrine Society’s Endocrine Self-Assessment Program (ESAP). Available at http://www.sales.uptodate@bdrinc.com/. American Association of Clinical Endocrinologists (AACE). Self-Assessment Profile (ASAP) for Endocrinology, Diabetes and Metabolism. Available at http://aace.com/asapindex.htm. 20
  21. 21. Adrenal Disorders Method of Education Method of Evaluation Formal Direct Clinical Clinical Case Self- Direct Discussions Clinical Instructions Experience Discussions Directed Observations With Presentations Learning With Patients Faculty Inpatient Outpatient Attd. Rds. Conferences 1. Cushing’s syndrome a) Adrenal X X X X X X X X X b) Pituitary X X X X X X X X X c) Ectopic X X X X X X X X X d) Iatrogenic X X X X X X X X X 2. Adrenal Insufficiency a) Primary (including X X X X X X X X X polyglandular) b) Secondary X X X X X X X X X c) Adrenal crisis X X X X X X X X X d) Glucocorticoid therapy X X X X X X X X X 3. Pheochromocytoma X X X X X X X X X 4. Mineralocorticoid excess a) Aldosteronism X *X X X X X X X X 5. Nonfunctioning adrenal mass (including incidentaloma) a) Benign X *X X X X X X X X b) malignant X *X X X X X X X X 6. Hirsutism and virilization X *X X X X X X X X 7. Congenital adrenal hyperplasia X *X X X X X X X X 8. Fluid and electrolytes a) Hypernatremia and hyponatremia X X X X X X X X X b) Hypokalemia and hyperkalemia X X X X X X X X X c) Metabolic acidosis and alkalosis X X X X X X X X X 9. Hypertension a) Primary (essential) X X X X X X X X X b) Secondary (endocrine) X X X X X X X X X *Most often seen in outpatient setting 21
  22. 22. Section 3: Bone and Mineral Disorders 3.1 Introduction A clear understanding of disorders of bone and mineral metabolism is a critical component of the fellowship in Endocrinology, Diabetes, and Metabolism. Osteoporosis is the major public health problem in this area. It is responsible for at least 1.3 million fractures and costs $13.8 billion in direct health care costs in the United States each year. The lifetime risk of a fracture of the vertebrae, wrist, or hip due to osteoporosis is nearly 40% for white women and increases to about 50% when other age-related fractures are included. Although osteoporosis is more common in women, men also incur substantial bone loss with aging, and elderly men have age-specific hip fracture rates and a prevalence of vertebral fractures that are at least half those in women. Given the widespread prevalence of osteoporosis, the endocrinology trainee needs to learn to work with the patient’s primary care and other physicians in providing appropriate consultative and management advice in the care of patients with osteoporosis. In addition to osteoporosis, a number of other disorders of bone and mineral metabolism are commonly referred to the practicing endocrinologist for evaluation and management. There include primary hyperparathyroidism, hypercalcemia of malignancy, Paget’s disease and nephrolithiasis. The remainder of the disorders in this area, while less common, clearly require the knowledge and experience of an endocrinologist to accurately diagnose and manage. These include hypoparathyroidism, other forms of hyper- and hypocalcemia, as well as disorders of other minerals (ie, magnesium and phosphorus), osteomalacia in its various forms, and developmental bone disorders. The overall competencies that an endocrinology trainee needs to acquire in this area begins with a solid understanding of the anatomy and biology of bone matrix and cellular elements. It is implied that trainees will have undertaken previous coursework in skeletal anatomy and physiology in their medical school training, which will be further enhanced throughout the course of their fellowship training. S/he will also be well versed in the physiology of calcium, magnesium, and phosphorus homeostasis, and understand the biochemistry of the calcium-regulating hormones. With this as a background, the trainee will become competent in the clinical evaluation of bone and mineral disorders, including obtaining a relevant, comprehensive history and performing the relevant physical examination, as well as ordering and interpreting the appropriate laboratory tests in a cost-effective manner. The specific disorders and the management skills needed for each are described below. Clinical experience will also include opportunities to diagnose and manage patients of both sexes in both the inpatient and outpatient setting. The trainee must also learn to function as a consultant for other physicians in these disorders. To truly understand the evolution and natural history of bone and calcium disorders, as well as the effectiveness of therapeutic interventions, the bone and mineral educational program will dedicate at least 30% of the experience in this area to the ambulatory care setting. Indeed, the majority of clinical training will occur in both bone and general endocrine outpatient clinics, complemented by inpatient consultation and management of acute and non-acute calcium and mineral disorders. The overall training program will facilitate the acquisition of these skills through a number of tools. These include, but are by no means limited to, didactic lectures, interactive computer programs and/or web based resources, oral case presentation and discussion, and most importantly, direct and close supervision by the faculty of trainee evaluation and management of patients with as wide a spectrum as possible of bone and calcium disorders. Evaluation. Clear mechanisms will be in place for the evaluation of the trainees and the provision of positive and negative feedback. Evaluation will occur in the form of faculty critiques of the trainee’s performance and informal Endocrine Self-Assessment Program (ESAP) question and answer sessions. Two self-assessment examinations are also available (ESAP and AACE). Feedback will be provided both orally on a biannual basis as well as using written evaluation sheets. In addition, trainees will have an opportunity and a mechanism for providing feedback to the faculty regarding the quality of teaching and mentoring they receive. 3.2 Discussion The section below summarizes the key learning areas for the clinical training program. 22
  23. 23. 3.2.1 Biology of Bone The necessary basic background in this area includes an understanding of the fundamentals of bone biology. Specifically, the trainee will understand the macroscopic and microscopic structure of bone, as well as the fundamentals of bone remodeling and growth (ie, the processes of intramembranous and endochondral ossification). S/he will also have a knowledge of the cells in bone, specifically osteoblasts, osteocytes, and osteoclasts, as well as the composition and mineralization of the bone matrix. Finally, s/he will become familiar with the various systemic and local factors regulating bone development and remodeling. 3.2.2 Physiology of Calcium, Magnesium, and Phosphorus Homeostasis A basic understanding of mineral homeostasis will include knowledge of the factors regulating intestinal absorption, renal handling, and flux in and out of bone of these compounds. Included in this is the role of systemic hormones (1,25(OH)2D, PTH, growth hormone, estrogen, glucocorticoids, and others) as well as dietary factors (intake of these minerals, other factors such as sodium intake). The trainee will also have an understanding of alterations in calcium and phosphorus homeostasis during physiological states such as puberty, pregnancy, lactation, and aging. 3.2.3 Molecular Biology, Biochemistry, and Mechanism of Action of Calcitropic Hormones The trainee will have an understanding of the synthesis and secretion of PTH, its peripheral metabolism, and mechanism of action. S/he will have an understanding of the role of the calcium- sensing receptor in normal physiology. The trainee will understand the role of PTH-rP in malignancy. S/he will understand the synthesis, metabolism, and action of vitamin D and its key metabolite, 1,25(OH)2D. S/he should be aware of the potential normal skeletal and non-skeletal actions of PTH-rP and 1,25(OH)2D. Finally, s/he will have an understanding of the synthesis and secretion of calcitonin, as well as its action on bone resorption. 3.2.4 Clinical Evaluation of Bone and Mineral Disorders The trainee will learn to obtain a comprehensive but relevant history and perform the appropriate physical examination. This will include a detailed musculoskeletal examination, as well as other parts of a comprehensive examination (eg, gonadal exam) when appropriate. 3.2.5 Laboratory Methods The trainee will acquire an understanding of the methods, strengths, and limitations of the various measurements s/he will be requesting. S/he will understand issues of assay accuracy, variability (assay and biologic) and detection limits. S/he will be able to integrate a number of tests and recognize specific patterns of test abnormalities associated with various disease states. The trainee will have knowledge of abnormalities in protein binding that might affect serum calcium measurements, as well as possible artifacts/physiological alterations in the serum phosphorus and magnesium determinations. S/he will understand issues regarding the collection and interpretation of ionized calcium and urinary calcium measurements. S/he will have a full understanding of PTH assays, including the effects on the assay of changes in renal function, and the correct interpretation of the assay in light of the ambient serum calcium concentration. Similarly, s/he will have a basic knowledge of calcitonin assays. More recently, assays for PTH-rP have become available, and the trainee will have an understanding of when a PTH-rP level may be useful in the evaluation of the patient. S/he will have a knowledge of assays for 25-OHD and 1,25(OH)2D, and understand the situations warranting either the 25-OHD measurement (ie, in the evaluation of vitamin D deficiency or intoxication) or the 1,25(OH)2D measurement (as, for example, in the evaluation of possible granulomatous hypercalcemia). The trainee will also understand gonadal steroid and other hormonal measurements as they apply to the evaluation of bone and calcium disorders. The recent availability of biochemical markers of bone turnover has added another tool for the evaluation of osteoporosis and other metabolic bone diseases. The trainee will develop a working knowledge of markers of bone formation and resorption, and their potential uses. Finally, the trainee will have basic knowledge of molecular diagnostics, particularly as they apply to disorders of bone and calcium metabolism. This includes a basic understanding of the different 23
  24. 24. techniques of molecular diagnostics (ie, mutation identification using single-strand conformational polymorphism, direct DNA sequencing, restriction endonuclease analysis, etc.). While general applicability of these techniques at this point is principally for the MEN syndromes, clearly they will be increasingly used in the future in the laboratory evaluation of bone and mineral disorders. 3.2.6 Imaging Techniques/Other Procedures The training program has a close working relationship with skeletal radiologists who can provide expert interpretation of bone radiographs of adults and children. The trainee will acquire the basic fundamental skills to recognize the radiographic appearance of at least common metabolic bone diseases (ie, osteoporosis, hyperparathyroidism, osteomalacia, Pagets, etc.). Similarly, s/he will have an understanding of bone scintigraphy and its appropriate use. Understanding bone mass measurements is a critical component in the evaluation of osteoporosis. The trainee will also have knowledge of the technical aspects of DEXA measurements, and understand issues of quality control, precision, and interpreting DEXA measurements, both in terms of diagnosing osteopenia and osteoporosis, as well as in interpreting longitudinal changes. S/he should also have a basic understanding of the use of DEXA for assessment of body composition. S/he should also be familiar with other available technologies, such as quantitative CT, ultrasound, and digital radiography. The trainee may, if possible, acquire the skills to perform and interpret bone biopsies. Bone histomorphometry is useful in the evaluation of difficult metabolic bone diseases, and still remains instrumental for the definitive diagnosis of osteomalacia and renal osteodystrophy. The trainee will learn the fundamentals of parathyroid imaging (scan and ultrasound), including the appropriate use of these tests in the cost-effective evaluation of the hyperparathyroid patient. S/he will also learn the appropriate use of CT and MR imaging in the evaluation of patients with persistent or recurrent hyperparathyroidism. 3.2.7 Postmenopausal and Age-Related Osteoporosis As noted in the introduction, osteoporosis is the major public health disorder in this area, and likely the most common referral diagnosis. As such, the trainee will develop a thorough understanding of the epidemiology and current concepts of the pathogenesis of postmenopausal and age-related osteoporosis. The trainee will also be familiar with the impact of physical activity and nutritional factors (in particular, calcium and vitamin D nutrition) on bone mass and of factors such as medications, impaired vision, and propensity to fall on fracture risk. S/he will be able to advise the patient on appropriate prevention measures, and learn to manage the woman going through the menopausal transition. S/he will be well versed in the diagnostic evaluation of osteoporosis, including the correct interpretation of BMD data within the context of the clinical setting of the particular patient. S/he will be able to exclude secondary causes of osteoporosis, including multiple myeloma, underlying malignancy, primary hyperparathyroidism, osteomalacia, and osteogenesis imperfecta. S/he will be comfortable with the use of both non-pharmacologic (ie, lifestyle changes, calcium supplementation, and, working with a physical therapist with a specific interest in exercise management of osteoporosis, prescription of appropriate physical therapy, exercise and alteration of body mechanics) and pharmacologic measures (HRT, SERMs, bisphosphonates, calcitonin, and PTH, when available) for the treatment of osteoporosis. S/he will be able to evaluate the patient who has sustained an osteoporotic fracture and institute measures to reduce the risk of subsequent fractures. The trainee will also be familiar with issues of pain management in patients with vertebral or other fractures. Finally, s/he should have the opportunity to work with the Orthopedist in the evaluation of patients with delayed healing of fractures. 3.2.8 Other Forms of Osteoporosis In addition to postmenopausal and age-related osteoporosis, the trainee will also be familiar with the evaluation and management of other forms of osteoporosis. Principal among these are glucocorticoid- and increasingly, transplant-associated osteoporosis. S/he should work closely with the primary physicians in the management of these difficult patients, since particularly the post- transplant patient often has multiple endocrine abnormalities (ie, hyperglycemia, hyperlipidemia) in addition to the metabolic bone disorder. Where appropriate, the trainee should advise on the 24
  25. 25. management of all of the multiple endocrine/metabolic derangements in these patients. The trainee will also be familiar with other skeletal complications of glucocorticoid use, including a vascular necrosis. In addition, the trainee will also know how to evaluate and manage other forms of osteoporosis, including idiopathic (male and female) osteoporosis and various forms of secondary osteoporosis. 3.2.9 Rickets and Osteomalacia While less common than the various forms of osteoporosis, the trainee will learn to evaluate and treat the osteomalacic disorders and to distinguish these from osteoporosis. Nutritional vitamin D deficiency is particularly a problem in the elderly, and increases significantly the risk of hip fracture. In addition, recognition of vitamin D deficiency often uncovers a previously unsuspected diagnosis, such as non-tropical sprue, in an otherwise minimally symptomatic patient. The trainee will know the appropriate tests to order in this setting (ie, 25-hydroxyvitamin D level, PTH, urine calcium, anti-gliadin and anti-endomyseal antibodies), including possibly a bone biopsy when needed. Inherited disorders of vitamin D action or phosphate handling can be difficult to manage, and the trainee should have appropriate exposure to these if available. The evaluation of patients with tumor-induced osteomalacia is often extremely difficult, as the underlying tumor may be impossible to identify. As such, the trainee will also be familiar with the medical management of these patients. 3.2.10 Hypocalcemic Disorders The trainee will know how to manage acute hypocalcemia as, for example, in the post-operative setting. This includes the use of intravenous calcium preparations and when they are indicated. S/he will also be able to manage chronic hypocalcemia with oral calcium and vitamin D preparations and, if indicated, a thiazide diuretic. Working with a dietician, s/he should be able to advise the patient with hypoparathyroidism regarding dietary phosphate restriction, and use phosphate binders when indicated. S/he will also be able to assess the patient with various forms of hypocalcemia, including that due to acute pancreatitis, acute illnesses, and associated with the use of various medications. The trainee will also know the various types of parathyroid resistance syndromes and the appropriate testing necessary to establish a diagnosis of pseudohypoparathyroidism. S/he should be familiar with possible resistance to other hormones as well as the non-endocrine disorders in these patients. 3.2.11 Renal Osteodystrophy While primarily managed by the nephrologist, the endocrine trainee will have a clear understanding of renal osteodystrophy in its various forms, including secondary and tertiary hyperparathyroidism. The role of the endocrinologist may be most important during and following parathyroid surgery in these patients, and the trainee must be familiar with the post-operative management of these patients, particularly hungry bone syndrome. Use of bone biopsy and bone histomorphometry is particularly useful in the evaluation of renal osteodystrophy and if possible, the trainee may acquire appropriate training in these techniques. 3.2.12 Paget’s Disease The trainee will be familiar with current concepts of the pathogenesis, natural history, and treatment of Paget’s disease. The evaluation and management of Paget’s disease involves an understanding of the appropriate laboratory studies to identify the extent and severity of the disease (bone markers, scintigraphy, and radiographs), as well as combining this data with the patient’s symptoms, leading to a decision about appropriate therapy. The latter may include observation or pharmacologic therapy with calcitonin, oral, or intravenous bisphosphonates. 3.2.13 Hypercalcemic Disorders The trainee will have a full understanding of the evaluation and management of hypercalcemia. S/ he will be able to use the PTH assay to make a diagnosis of primary hyperparathyroidism versus non- parathyroid hypercalcemia (ie, hypercalcemia of malignancy, that due to granulomatous disorders, or other miscellaneous causes of hypercalcemia). S/he will be comfortable differentiating primary hyperparathyroidism from FHH, as well as pursuing, where appropriate, a diagnosis of familial 25
  26. 26. hyperparathyroidism or an MEN syndrome. Included in this is an understanding of genetic testing for these syndromes. If a diagnosis of primary hyperparathyroidism is established, the trainee will know the necessary evaluation of these patients leading to a decision regarding surgical or medical management. If the patient goes for surgery, the trainee will be familiar with the peri- and post-operative management of these patients, including post-operative hypocalcemia. Specifically, the trainee will be able to distinguish hungry bone syndrome from post-operative hypoparathyroidism, and manage both appropriately. If a decision is made for medical therapy or observation, the trainee will be familiar with the follow-up of these patients and the endpoints that would result in a recommendation for surgery. Finally, s/he will be familiar with evolving approaches to the management of patients with primary hyperparathyroidism, both surgical (ie, minimal access parathyroidectomy, alcohol ablation) and medical (ie, bisphosphonates, calcium sensing receptor agonists). In addition to primary hyperparathyroidism, the trainee will know the evaluation and management of parathyroid cancer. S/he will be able to effectively evaluate and manage the patient with hypercalcemia in the setting of a suppressed PTH (ie, hypercalcemia of malignancy, that due to granulomatous disorders). 3.2.14 Other Mineral Abnormalities The trainee will be able to identify the possible causes of hypo- and hypermagnesemia in a patient, and to institute appropriate therapy. S/he will be able to identify situations in which hypomagnesemia is the cause or contributing to hypocalcemia. S/he will also be able to identify the etiology of hyper- or hypophosphatemia in a patient, and to treat these conditions. 3.2.15 Nephrolithiasis The trainee will be able to evaluate the patient with nephrolithiasis. Based on the type of stone and the evaluation (ie, identification of hypercalciuria, hyperoxaluria, hyperuricosuria, or low urinary citrate), the trainee will be able to identify any underlying disorders such as primary hyperparathyroidism or enteric hyperoxaluria. S/he will know the medical management of the patient based on this evaluation, and to work with a dietician in the appropriate dietary management of these patients. 3.2.16 Genetic, Developmental, and Dysplastic Skeletal Disorders The trainee should be familiar with these disorders, which can present both in children and in adults. These include various sclerosing bone disorders and skeletal dysplasias. The trainee should also be able to evaluate the patient referred because of an elevated bone density, in the absence of radiographic sclerosis. An experienced skeletal radiologist, which is available at Duke, is a great asset to the training program in the accurate diagnosis of these conditions based on the radiographic findingsThe trainee should have exposure to the evaluation and management of patients with osteogenesis imperfecta as well as appropriate medical management of both the skeletal aspects of fibrous dysplasia and, when present, the management of precocious puberty in these patients. 3.2.17 Skeletal Neoplasms/Infiltrative Disorders The trainee should be able to identify benign and malignant skeletal neoplasms on skeletal radiographs, and institute appropriate referrals to the orthopedic surgeon as well as the radiation and medical Oncologists. S/he should also be familiar with the various infiltrative disorders of bone, including mast cell disease and histiocytosis X. 3.2.18 Extraskeletal Calcification/Ossification These include relatively uncommon conditions such as tumoral calcinosis, dermatomyositis, and various ossification disorders. While the trainee may not necessarily have the opportunity to mange these relatively rare conditions, s/he should be familiar with these disorders and their treatment. 3.3 Suggested Reading Favus MJ, ed. Primer on Metabolic Bone Diseases and Disorders of Mineral Metabolism, Fourth Edition, Lippincott-Raven, Philadelphia, 1999. 26
  27. 27. Disorders of Bone and Mineral Method of Education Method of Evaluation Formal Direct Clinical Clinical Case Self- Direct Discussions Clinical Instructions Experience Discussions Directed Observations With Presentations Learning With Patients Faculty Inpatient Outpatient Attd. Rds. Conferences 1. Biology of Bone a) Anatomy/ultrastructure X X X b) Osteoblasts/osteocytes/ X X osteoclasts X c) Bone matrix/mineralization X X X X X X d) Regulation of bone remodeling X X X X X X 2. Physiology of calcium, magnesium and phosphorous homeostasis a) Intestinal absorption X X X X X X X X X b) Renal handling X X X X X X X X X c) Calcium flux in/out of bone X X X X X X X X X d) Mineral balance & homeostasis X X X X X X X X X 3. Molecular biology, biochemistry, and mechanism of action of calcitropic hormones a) Synthesis & Metabolism of PTH X X X X X X X X X b) PTH – Mechanism of action X X X X X X X X X c) PTH – rP X X X X X X X X X d) Vitamin D and metabolites X X X X X X X X X e) Calcitonin X X X X X X X X X 4. Clinical Evaluation of Bone and Mineral Disorders a) Comprehensive, relevant history X X X X X X X X b) Physical examination X X X X X X X X 5. Laboratory Methods/Understanding assays for: a) Calcium, phosphorus, and X X X X X X X X X magnesium b) Ionized calcium X X X X X X X X X c) PTH X X X X X X X X X d) Calcitonin X X X X X X X X X e) PTH-rP X X X X X X X X X f) Vitamin D metabolites X X X X X X X X X g) Urinary calcium X X X X X X X X X h) Biochemical markers for bone X X X X X X X X X turnover i) Molecular diagnosis of bone and X X X X X X X X mineral disorders 27

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