Endocrinology & Metabolism

INTERNAL MEDICINE RESIDENCY PROGRAM

Faculty: Kingsley U. Onyemere, MD, Robert W. Kirby , MD, William P. Marshall , MD , John D. Stokes, MD, Sathya Subbiah, MD

Sites: Carle Clinic Association, Carle Foundation Hospital, Christie Clinic, Veterans Administration Illiana Health Care System (VAIHCS), Provena Covenant Medical Center (PCMC)

Duration: 4 week Block Rotation

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DESCRIPTION

This is a four week block rotation under the supervision of the Division of Endocrinology. Residents gain experience in the evaluation and care of common endocrine and metabolic disorders.

I. GOALS

Demonstrate competence in the ambulatory and hospital care of patients with common endocrine and metabolic disorders, including competency in the performance of an appropriately directed history and physical examination, selection and interpretation of laboratory studies, and determination of treatment.

Describe the pathophysiology, clinical manifestations, and natural history of the listed clinical syndromes.

II. OBJECTIVES

A. PATIENT CARE

Objective 1. Gather accurate, essential Medical History information

a. Obtain a thorough and pertinent history of the patient's endocrine-related problems and complaints in the ambulatory and hospital settings.

b.Determine family, social, and medication history relevant to the patient's endocrine problems.

Objective 2.  Perform a competent general Physical Examination with emphasis on the following skills:

a. Non-dilated fundoscopy

b. Use of an exophthalmometer.

c. Direct neck examination (thyroid palpation)

d. Male breast examination (gynecomastia)

e. Testicular examination

f. Diabetic foot examination

g. Identify necrobiosis lipoidica

h. Identify xanthalasmas and xanthomas

i. Determine body mass index.

Objective 3. Determine the indications for the following diagnostic procedures:

a. Thyroid fine needle biopsy

• Observe a ultrasound guided fine needle aspiration biopsy

b. Thyroid scintigraphy

c. Thyroid ultrasound

d. Cosyntropin or CRH stimulation tests

e. Dexamethasone suppression test

f. Pituitary computed tomography (CT) or magnetic resonance imaging (MRI)

g. Adrenal CT or MRI

h. Transvaginal ultrasound

i. Testicular ultrasound

j. Commonly used radioimmunoassays

B. MEDICAL KNOWLEDGE

Objective 1. Demonstrate understanding and application of key facets of the following endocrine and metabolic disorders:

a. Diabetes Mellitus

1. Classification and diagnosis  
2. Pathobiology  
3. Natural history and chronic complications  
4. Treatment 
   • Rationale for tight glycemic control
   • Appropriate interventions for different types of diabetes mellitus
   • Management of diabetic emergencies (ketoacidosis and hyperglycemic hyperosmolar syndrome)  
5. Diabetes and Pregnancy
6. Syndrome X (Metabolic Syndrome)

b. Lipid Disorders

1. Classification
2. Pathophysiology and clinical manifestations  
3. NCEP screening and management guidelines
4. Therapeutic interventions

b. Obesity

1. Etiology and natural history
2. Screening and clinical evaluation  
3. Comorbidities and evaluation
4. Medical and surgical management

c.  Interpretation of thyroid function tests

1. Pathophysiology and etiologies of thyroid dysfunction (hyperthyroidism, hypothyroidism)  
2. Evaluation and management of thyroid dysfunction
3. Evaluation and management of thyroid nodules 
4. Approach to the patient with thyroid cancer
   • Well-differentiated thyroid cancer (papillary and follicular)
   • Medullary thyroid cancer

d. Calcium and Bone Metabolism

1. Approach to the patient with osteoporosis
• Observe a DEXA scan
2. Evaluation and management of hypercalcemia  
3. Evaluation and management of hypocalcemia
4. Osteomalacia and disorders of vitamin D metabolism  
5. Paget's disease of bone

e. Hypothalamus and Pituitary

1. Differential diagnosis and evaluation of hypopituitarism
2. Pituitary mass lesions, e.g. non-functional adenomas, prolactinomas. acromegaly, Cushing's disease
3. Diabetes insipidus
4. Syndrome of Inappropriate ADH (hyponatremia)

f. Adrenal Disorders

1. Addison's disease
2. Cushing's syndrome
3. Pheochromocytoma and paraganglioma
4. Syndromes of mineralocorticoid excess, e.g. Conn 's syndrome
5. Approach to the incidentally discovered adrenal mass
6. Glucocorticoid withdrawal syndrome

g. Gonadal Disorders

1. Polycystic ovary syndrome  
2. Amenorrhea
3. Hirsutism
4. Menopause and hormone replacement therapy
5. Male hypogonadism
6. Gynecomastia

h. Endocrine Neoplasia Syndromes

1. Multiple Endocrine Neoplasia (MEN) I  
2. MEN II a and II b  
3. von Hippel Lindau syndrome
4. Hereditary paragangliomatosis 
5. Carcinoid syndrome

C.   PRACTICE-BASED LEARNING AND IMPROVEMENT

Objective 1: Analyze and evaluate practice experiences and implement strategies to improve the quality of patient care.

Objective 2: Use information technology and other available methodologies to access and manage information, support patient care decisions and enhance both patient and resident education.

D. INTERPERSONAL AND COMMUNICATION SKILLS

Objective 1: Consistently establish rapport with patients and staff.

Objective 2: Present cases in a logical, focused manner and outline impressions that can be justified based on the clinical data.

Objective 3: Work as an effective team member with staff, dietitians, nurses, diabetes educators, and attending physicians.

Objective 4: Write or dictate an appropriately thorough clinical record entry in standard form.

E. PROFESSIONALISM

Objective 1: Arrive at the office or hospital promptly, well-prepared with identified learning issues.

Objective 2: Assume responsibility for patient welfare.

Objective 3: Demonstrate the effective utilization of case related clinical learning through availability and appropriate follow-up

Objective 4: Demonstrate independent initiative in commitment to identify and follow through with learning issues.

Objective 5: Seek feedback from attending physicians.

Objective 6: Model effective teaching skills to students and peers.

Objective 7: Comply with Residency dress code.

F. SYSTEMS-BASED PRACTICE

Objective 1: Describe role of health educator, social services, and behaviorists in the care of endocrine patients.

Objective 2: Apply evidence-based, cost-conscious strategies to prevention, diagnosis, and disease management.

III. METHODS

The endocrinology rotation is a four-week experience supervised by endocrinologists, faculty members of the University Of Illinois College Of Medicine at Urbana-Champaign, Department of Internal Medicine. All endocrinology faculty members are certified by the American Board of Internal Medicine.

The rotation includes four weeks of meaningful patient responsibility in ambulatory and hospital settings. Residents train in Carle Clinic Association, Carle Foundation Hospital, Christie Clinic, Veterans Administration Illiana Health Care System (VAIHCS), and Provena Covenant Medical Center (PCMC).

Patient care responsibilities extend from Monday through Friday, 0730 to 1700. A sample ambulatory schedule is attached. Hospital consults are assigned, when appropriate, when requests are received in the ambulatory offices. Weekend, holiday, and on-call responsibilities are not scheduled.

Residents work under the direct supervision of an assigned attending endocrinologist. The residents perform the initial history and physical examination, and present findings and available laboratory data to the attending endocrinologist. After reviewing patient data and pertinent teaching points, the resident and attending endocrinologist complete the patient encounter together. Selected components of the examination may be repeated and demonstrated to the resident. Residents are responsible for documenting the patient encounter with a written or dictated note.

Residents are responsible for two clinical conferences each month. The resident presents a case-based endocrine presentation to peers on other assigned subspecialty rotations. The resident is responsible for identifying the key educational points of each case. Conferences are supervised by assigned endocrinology faculty. Residents are also required to attend Endocrinology Grand Rounds, held once a month. The residents are directed to learning resources during the rotation, e.g. The Washington Manual Endocrinology Subspecialty Consult, Medical Knowledge Self-Assessment Program-Endocrinology, and patient care guidelines (e.g. National Cholesterol Education Program lipid guidelines, American Diabetic Association diabetes guidelines).

IV. EVALUATION

ACGME Competencies

According to Accreditation Council of Graduate Medical Education (ACGME), training and evaluation must include the following competencies: Patient Care, Medical Knowledge, Practice – Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and System-Based Practice.

Patient Care will be evaluated by assessment of the attending physician. Procedures performed will be documented.

Medical Knowledge will be evaluated by assessment of the attending physician. A rotation pretest and post test is completed on line and results reviewed with the supervising physician.

Practice-Based Learning and Improvement will be evaluated by assessment of the attending physician.

Interpersonal and Communication Skills will be evaluated by assessment of attending physician and additional information from nursing staff, patients and families.

Professionalism will be evaluated by assessment of attending physician and additional information from nursing staff, patients and families.

System-Based Practice will be evaluated by assessment of the attending physician.

The evaluation method is primarily accomplished electronically. Residents' performance is evaluated by the attending physician. Evaluations are reviewed with the residents for formal feedback. Face to face interaction between the attending physician and the resident is the required method. At the midway point of the rotation, the resident is encouraged to approach the attending to assess and discuss performance. In addition, ongoing feedback is provided related to residents' patient care responsibilities and activities.

Residents will document the Endocrinology and Metabolism rotation in portfolios, e.g. patient care responsibilities. This tool will provide individual learning, reflection and assessment. Additionally, residents will evaluate the rotation experience.

Residents provide input on the Endocrinology & Metabolism Medicine core lecture series, which is used in scheduling future topics and speakers. Conference lectures include: Addison's disease, Anterior Pituitary Disorders (non-functional adenomas, hyperprolactinemia, acromegaly), Cushing's syndrome, Disorders of Calcium, Dyslipidemias, Endocrine Hypertension, Hyperglycemic Emergencies, Male Hypogonadism, Type 1 Diabetes Mellitus, Type 2 Diabetes Mellitus, Osteoporosis, Thyroid Nodules, and Thyrotoxicosis. Periodically, residents are surveyed to evaluate the curriculum and teaching faculty.

V. REFERENCES

American Diabetic Association Diabetes Guidelines

American Thyroid Association Guidelines for Thyroid Nodules and Thyroid Cancer

The Washington Manual Endocrinology Subspecialty Consult

Medical Knowledge Self-Assessment Program, Endocrinology

National Cholesterol Education Program Lipid Guidelines

SAMPLE ENDOCRINE SCHEDULE

2008-2009

Rev 7/1/06, 7/1/07, 8/25/08