Endocrinology and Metabolism

Competency-Based Curriculum

Educational Rationale

Endocrine and metabolic disorders represent important chronic health problems. These disorders bring many patients to general physicians. In addition, endocrine disorders such as diabetes are increasing in prevalence. These disorders often involve multiple organ systems and their recognition requires broad-based familiarity with all of internal medicine and judgments. Those patients hospitalized with endocrinologic diseases are often seriously ill and demand sophisticated skills for optimal care. Endocrinologists cannot care for all of these patients at all times. Increasingly expectations are that primary care physicians/internists will manage patients with many of these disorders. It is the goal of this endocrinology curriculum that our internal medicine residents acquire sufficient knowledge, skills, and attitudes to care for these patients.

Goals

A. Knowledge:

Upon completion of training, we expect our residents to:

1. Acquire sufficient knowledge and experience to recognize, diagnose and manage endocrine disorders.

• know the pathogenesis and complications of type 1 and type 2 diabetes,
• diagnosis and management of metabolic syndrome
• management of hyperlipidemias
• know how to perform a correct thyroid exam, to interpret thyroid function tests, know when to order and how to interpret a thyroid scan, diagnose and treat hypo and hyperthyroidism
• know the work-up of hypercalcemia, diagnose hyperparathyroidism and manage the secondary one
• know how to diagnose hypercortisolism, how to diagnose and treat hypocortisolism (primary and secondary), know how to manage patients on supraphysiologic steroid doses no longer requiring corticosteroids; know when to suspect and how to screen for pheochromocytoma and hyperaldosteronism
• know the screening, diagnosis and management of osteoporosis and the diagnosis and management of osteopenia; know the secondary causes of osteoporosis
• MEN syndromes (types)

2. Provide satisfactory care for patients with common and uncomplicated endocrine disease
3. Identify those circumstances when consultation and/or referral are appropriate.
4. Learn to use diagnostic studies in a selective, efficient, and proper cost-effective manner.
5. Learn the indications and contraindications and benefits and risks of therapies used in treating endocrine diseases.
6. Learn to use effectively the services of other care workers involved in management of patients with endocrine disease.
7. Learn to direct or participate in a team effort to provide care for certain endocrine diseases

B. Skills

Upon completion of training we expect our residents to:

1. Know the endocrinologic evaluation.
2. Be able to function as part of a team providing care to endocrine patients.
3. Understand appropriate circumstances for cost-effective diagnostic studies and their interpretation.
4. Know the indications, contraindications, risks, and benefits of endocrine therapies.
5. Identify those circumstances when consultation or referral is appropriate.
6. Appreciate the value of functional evaluations and assessments.

C. Attitudes

Upon completion of training, we expect our residents to appreciate those attitudes valued and nurtured by endocrinologists, including:

1. Viewing medicine as humane science.
2. Balancing art with science
3. Recognizing the limitations of technology and the value of clinical insight
4. Making difficult judgments when certainty is elusive.
5. Understanding that testing, no matter how advanced or sophisticated, rarely substitutes for thorough, thoughtful evaluation by an informed clinician.
6. Balancing intervention with patience.
7. Recognizing limitations of our interventions.
8. Appreciating the unique circumstances of caring for patients with chronic, usually incurable diseases.
9. Learning the importance of functional considerations.

Educational Experience

1. The Inpatient Experience (IP)

Residents will see inpatient consults prior to the attending. Consultations are presented on rounds to the consulting hematologist, at times to be mutually arranged. Usual practice is for the resident to join the consulting physician for hospital rounds each morning and evening, as applicable. It is expected that at the time of presentation to the consulting physician, the residents are totally familiar with the patient's problem(s), have read and reviewed pertinent literature, and are prepared to knowledgeably discuss the problem at hand. Literature references are available to all students and residents rotating through the service. In each instance, the consultation is discussed with referring housestaff or attending physician, as applicable.

2. The Ambulatory Experience (AM)

Students and housestaff are expected to attend all sessions, outpatient activities, and practices. Patients are assigned in clinics and offices by the attending physicians. Every effort is made to select patients of "interest". Depending on numbers of individuals on the rotations and clinic/office loads attempts are made to permit students and residents to spend the first few experiences seeing patients together with attending physicians, so as to better introduce them to the endocrine evaluation. The goals of this experience will be for the residents to gain expertise in the outpatient evaluation management of endocrine problems.

Ambulatory experience is available at the endoricinlogists' offices. In addition residents have the opportunity to spend time at the Osteoporosis Center at the Ambulatory Care Center if they so desire.

3. Didactic Conferences (DC)

Numerous monthly conferences are held for the residents throughout the month. They cover a variety of topics in all the major medical subspecialties. Residents will be required to attend each of the conferences that do not conflict with their clinical duties.

Evaluations

Assessment Methods (of Resident)

The evaluation methods that apply to these rotations include some or all of the following:

• Evaluation of resident competence by faculty attendings (AE)- Formal formative evaluations should occur at the completion of the specific rotation. It is to be based on direct observation on rounds, at conferences, and at the bedside. All faculty members are encouraged to complete the form prior to the completion of the rotation and review their impressions directly with the resident. All completed evaluation forms are returned to the Program Director for review and placed in the resident's permanent file.
• Mini CEXs may be used when warranted, particularly in the beginning of the academic year.
• Self-evaluation by In-service training examination scores
• MKSAP study plan (MKSAP)
• Participation and presentations at didactic conferences (DC)
• Multi Source evaluations by patients and staff (MS)

Assessment Method (of Program)

Residents have the ability to evaluate teaching faculty and experience at the end of each rotation. They are encouraged to use this opportunity to give constructive feedback.

Residents are encouraged to maintain a high level of communication with the Program Director and faculty. These informal meetings can be used to disseminate information, receive timely feedback, and for other purposes.

Annually, all residents are required to complete and return an evaluation form of the faculty and the program. Evaluations are collected in a fashion to assure the anonymity of the resident. The feedback received during informal meetings, formal meetings, and the semi-annual evaluation form will be used to make programmatic change.

Competency Based Goals & Objectives:

1) Medical Knowledge

Goals and Objectives-PGY1	Learning Activities*	Assessment
Describe the epidemiology, genetics, natural history, clinical expression of diabetes, thyroid, pituitary, adrenal, and relate hormonal disorders encountered in the inpatient and outpatient setting.	IP, AM, DC	AE, DC, MKSAP
Describe function of the endocrine systems-particularly the hypothalamic-pituitary axis, calcium metabolism, and diabetes	IP, AM, DC	AE, DC, MKSAP
Describe the epidemiology, genetics, natural history, clinical expression of related disorders encountered in the inpatient and outpatient setting.	IP, AM, DC	AE, DC, MKSAP

Goals AND Objectives-PGY2/3 (In addition to above)	Learning Activities*	Assessment
Summarize an approach to the evaluation of common endocrine presentations	IP, AM, DC	AE, DC, MKSAP
Interpret diagnostic tests used in the evaluation of in and outpatients with suspected endocrine disease	IP, AM, DC	AE, DC, MKSAP
Demonstrate ability to critically appraise and cite literature pertinent to the evaluation of inpatients with endocrine disorders.	IP, AM, DC	AE, DC, MKSAP

2) Patient Care

Goals and Objectives-PGY1	Learning Activities*	Assessment
Effectively perform a comprehensive history and complete physical examination in patients with symptoms affecting this system	IP, AM, DC	AE, DC, MKSAP
Appropriately select and interpret laboratory, imaging, and pathologic studies used in the evaluation of disorders affecting this system	IP, AM, DC	AE, DC, MKSAP

Goals AND Objectives-PGY2/3 (In addition to above)	Learning Activities*	Assessment
Construct a comprehensive treatment plan and assess response to therapy.	IP, AM, DC	AE, DC, MKSAP
Counsel patients concerning their diagnosis, planned diagnostic testing and recommended therapies.	IP, AM, DC	AE, DC, MKSAP
Utilize validated instruments in the assessment of function and quality of life to monitor and adjust therapy.	IP, AM, DC	AE, DC, MKSAP

3) Practice-Based Learning and Improvement

Goals and Objectives-PGY1	Learning Activities*	Assessment
Identify and acknowledge gaps in personal knowledge and skills in the care of hospitalized and ambulatory patients with related diseases	IP, AM, DC	AE, DC, MKSAP
Develop and implement strategies for filling gaps in knowledge and skills of patients related diseases	IP, AM, DC	AE, DC, MKSAP
Integrate and apply knowledge obtained from multiple sources to the care of inpatients and outpatients	IP, AM, DC	AE, DC, MKSAP
Demonstrate ability to critically assess the scientific literature	IP, AM, DC	AE, DC, MKSAP

Goals AND Objectives-PGY2/3 (In addition to above)	Learning Activities*	Assessment
Effectively use technology to manage information, support patient care decisions, and enhance both patient and physician education.	IP, AM, DC	AE, DC, MKSAP
Demonstrate ability to critically assess the scientific literature	IP, AM, DC	AE, DC, MKSAP
Set and assess individualized learning goals	IP, AM, DC	AE, DC, MKSAP
Analyze clinical experience and employ a systematic methodology for improvement	IP, AM, DC	AE, DC, MKSAP
Develop and maintain a willingness to learn from errors, and use errors to improve the system or processes of care	IP, AM, DC	AE, DC, MKSAP

4) Interpersonal Skills and Communication

Goals and Objectives-PGY1	Learning Activities*	Assessment
Apply empathy in all patient encounters	IP, AM, DC	AE, DC, MKSAP
Demonstrate effective skills of listening and speaking with patients, families and other members of the health care team	IP, AM, DC	AE, DC, MKSAP
Present patient information concisely and clearly, verbally and in writing	IP, AM, DC	AE, DC, MKSAP

Goals AND Objectives-PGY2/3 (In addition to above)	Learning Activities*	Assessment
Reliably and accurately communicate the patient's and his/her family's views and concerns to the attending	IP, AM, DC	AE, DC, MKSAP
Compose clear and timely admission and progress notes and consultations	IP, AM, DC	AE, DC, MKSAP
Counsel patients, families and colleagues regarding side effects and appropriate use of specific medications, providing written documentation when appropriate	IP, AM, DC	AE, DC, MKSAP
Teach colleagues effectively	IP, AM, DC	AE, DC, MKSAP

5) Professionalism

Goals and Objectives-PGY1	Learning Activities*	Assessment
Be prompt and prepared for all clinical duties	IP, AM, DC	AE, DC, MKSAP
Recognize the importance of patient primacy, patient privacy, patient autonomy, informed consent, and equitable respect and care to all	IP, AM, DC	AE, DC, MKSAP
Respect patients and their families, staff and colleagues	IP, AM, DC	AE, DC, MKSAP

Goals AND Objectives-PGY2/3 (In addition to above)	Learning Activities*	Assessment
Model ethical behavior by reporting back to the attending and referring providers any key clinical findings	IP, AM, DC	AE, DC, MKSAP
Demonstrate integrity	IP, AM, DC	AE, DC, MKSAP
Respond to phone calls and pages promptly	IP, AM, DC	AE, DC, MKSAP

6) Systems-Based Practice

Goals and Objectives-PGY1	Learning Activities*	Assessment
Demonstrate effective collaboration with other health care providers, including nursing staff, ancillary staff, therapists, primary care physicians, and consultants in the care of patients with related diseases	IP, AM, DC	AE, DC, MKSAP
Develop an understanding of the hospital resources available to the evaluation and management of patients with problems encountered by the subspecialty.	IP, AM, DC	AE, DC, MKSAP
Demonstrate a knowledge of and commitment to the rules governing confidentiality of patient information.	IP, AM, DC	AE, DC, MKSAP

Goals AND Objectives-PGY2/3 (In addition to above)	Learning Activities*	Assessment
Discuss how the health care system affects the management of inpatients with related diseases.	IP, AM, DC	AE, DC, MKSAP
Determine cost-effectiveness of alternative proposed interventions.	IP, AM, DC	AE, DC, MKSAP
Design cost-effective plans based on knowledge of best practices	IP, AM, DC	AE, DC, MKSAP
Demonstrate awareness of the impact of diagnostic and therapeutic recommendations on the health care system, cost of the procedure, insurance coverage, and resources utilized	IP, AM, DC	AE, DC, MKSAP

Teaching Methods

All residents participate in patient care duties, didactic conferences and independent reading. They will learn at the bedside from attendings, nurses and physician extenders, pharmacists, social workers, case managers, peers, and patients.

Level of Supervision

Interns are supervised in their care of patients by more senior medical house staff (PGY- 2/3 and Chief Residents) and faculty.

PGY2/3 residents have direct and indirect supervision by Chief Resident and Faculty

Educational Resources

a. Supervising clinicians-didactic and bedside rounds and concurrent patient care
b. Medical literature including assessment of knowledge using the MKSAP
c. Bedside rounds with team and faculty.
d. Medical Grand Rounds weekly.
e. Scheduled didactic conferences including: medicine morning report, journal club, ambulatory care conference, EBM conference
f. Cooperman Barnabas Medical Center library, librarians, and online references/resources.

References

• Endocrinology and Metabolism Clinics of North America (for selected review articles)
• Endocrinology and Metabolism. In American College of Physicians. Medical Knowledge Self-Assessment Program
• Endocrinology and Metabolism. In Isselbacher KJ et al. ed. Harrison's Principles of internal Medicine. McGraw-Hill, Inc.
• Greenspan F. Basic and Clinical Endocrinology. Appleton and Lange.
• Holmes EW, ed. Endocrinology, Metabolism and Genetics. In Kelley WN editor-in-chief. Textbook of Internal Medicine. Lippincott Co.,
• Lavin N. Manual of Endocrinology and Metabolism. Little, Brown and Co.
• McDermott MT. Endocrine Secrets. Hanley & Belfus, Inc.
• Porterfield S. Endocrine Physiology. Mosby
• Up-To-Date Clinical Reference Library
• Van Way III CW. Nutrition Secrets. Hanley & Belfus, Inc.

Faculty

• Sridhar S. Nambi, M.D., Education Coordinator
• Boradia, Chirag, M.D.
• Luckey, Marjorie, M.D.
• Patel, Parini, M.D.
• Luigina D. Vlad, M.D.