Download Department of Medicine - University of Minnesota

UNIVERSITY OF MINNESOTA
GRADUATE MEDICAL
EDUCATION
2016-2017
FELLOWSHIP
POLICY AND PROCEDURE
ADDENDUM
Department of Medicine
Diabetes, Endocrinology and
Metabolism Fellowship
Program
Table of Contents
Introduction and Welcome to New Fellows ...............................................................................4
Department of Medicine Mission Statement .............................................................................4
Division of Diabetes, Endocrinology and Metabolism Mission Statement .................................4
SECTION 1 - STUDENT SERVICES........................................................................................5
Campus Mail and Copy Machine ..............................................................................................5
Computer Training ....................................................................................................................5
E-Mail Addresses......................................................................................................................5
HIPAA Training .........................................................................................................................5
Hospital EMR Passwords and Access ......................................................................................6
Internet and Intranet Access .....................................................................................................6
Pagers ......................................................................................................................................6
Research Resources ................................................................................................................7
Tuition and Fees .......................................................................................................................7
Useful Websites ........................................................................................................................7
Career-Related Websites ..........................................................................................................7
Debt Management ....................................................................................................................7
SECTION 2 - BENEFITS ..........................................................................................................8
Holidays ....................................................................................................................................8
Insurance - Dental ....................................................................................................................8
Insurance - Life .........................................................................................................................8
Insurance - Long-Term Disability ..............................................................................................8
Insurance - Medical ..................................................................................................................8
Insurance - Short-Term Disability ..............................................................................................8
Laundry Service ........................................................................................................................8
Leave – Illness and Vacation ....................................................................................................9
Leave – Parental and Personal ................................................................................................9
Leave - Professional and Academic (Includes Conferences and CME)..................................10
Leave - Unauthorized Leave...................................................................................................10
Leave - Other ..........................................................................................................................10
Leave - Policy on Effect of Leave for Satisfying Completion of Program.................................10
Meal Tickets ...........................................................................................................................10
Meetings .................................................................................................................................11
Parking ...................................................................................................................................11
Professional Liability Insurance ...............................................................................................11
Resident and Fellow Assistance Program (RAP) ...................................................................11
Stipends..................................................................................................................................12
U-Card ....................................................................................................................................12
White Coats ............................................................................................................................12
SECTION 3 - GENERAL POLICIES AND PROCEDURES ...................................................13
ACGME Competencies ...........................................................................................................13
Duty Hours and Call Schedules ..............................................................................................13
Evaluation Policy ....................................................................................................................13
Graded Responsibility .............................................................................................................15
In-Training Examination (ITE) .................................................................................................15
Laboratory/Pathology/Radiology Services ..............................................................................15
Life Support Certifications (BLS/ACLS/PALS) ........................................................................16
Medical Records .....................................................................................................................16
2
Monitoring of Fellow Well-Being / Adequate Rest...................................................................16
Moonlighting Policy .................................................................................................................16
On Call Activities.....................................................................................................................17
Procedure Logs ......................................................................................................................17
Professional Dress Code ........................................................................................................17
Residency Management Suite (RMS) .....................................................................................17
Security/Safety .......................................................................................................................18
Supervision .............................................................................................................................18
Support Services ....................................................................................................................18
Training/Graduation Requirements .........................................................................................18
Visa Sponsorship ....................................................................................................................18
Workers’ Compensation .........................................................................................................19
SECTION 4 – INSTITUTION RESPONSIBILITIES ................................................................20
SECTION 5 - DISCIPLINARY AND GRIEVANCE PROCEDURES .......................................21
SECTION 6 – ADMINISTRATION ..........................................................................................22
Program Contact Information ..................................................................................................22
Faculty Lists ............................................................................................................................22
SECTION 7 – FELLOWSHIP PROGRAM CURRICULUM ....................................................23
Program Requirements ...........................................................................................................23
Goals ......................................................................................................................................23
Objectives ...............................................................................................................................24
Conferences ...........................................................................................................................25
Clinical Training ......................................................................................................................28
Outpatient Clinical Training .....................................................................................................29
Inpatient Clinical Training .......................................................................................................31
Research Training ..................................................................................................................32
Core Curriculum......................................................................................................................32
3
Introduction and Welcome to New Fellows
On behalf of the faculty, staff, and fellows, welcome to the Division of Diabetes, Endocrinology
and Metabolism at the University of Minnesota. We hope the time you spend with us will be
both educational and enjoyable.
The policies and guidelines that pertain to endocrine fellows are laid out in three separate
documents:
(1) The Institution Manual is designed to be an umbrella policy manual. Some programs
may have policies that are more rigid than the Institution Manual in which case the
program policy would be followed. Should a policy in a Program Manual conflict with
the Institution Manual, the Institution Manual would take precedence.
(2) The Program Manual is specific to the Department of Medicine and policies are written
in accordance with the American Board of Internal Medicine (ABIM) and the
Accreditation Council for Graduate Medical Education (ACGME). Policies apply to all
educational experiences within the program and are subject to periodic review and
change by the faculty, Program Director, Fellowship Director and Department Chair.
(3) The Fellowship Policy and Procedure Addendum (this document) outlines policies and
procedures specific to your training program. Please refer to the Program Manual
(above) for further departmental policies and procedures.
Fellows are responsible for knowing and adhering to the policies and guidelines contained in
this handbook. If you have any questions about the policies or guidelines, please contact the
program director or coordinator for assistance.
Again, welcome to the program!
Department of Medicine Mission Statement
The mission of the Department of Medicine is to enhance the health of the people of
Minnesota, the nation and the world, through innovation and research, education and
patient care.
It is the mission of the Department of Medicine to provide excellent training in the practice
and science of Medicine by immersion in patient care with emphasis upon critical
reasoning, scholarship, and professional responsibility, and to promote personal and
professional satisfaction.
Division of Diabetes, Endocrinology and Metabolism Mission Statement
To develop academic endocrinologists who will become leaders in education, research, and
patient care.
4
SECTION 1 - STUDENT SERVICES
Campus Mail and Copy Machine
The fax machine (number 612-626-3133), outgoing campus mail, and US mail collection boxes
are located in 6-207 PWB. Check your mailbox frequently for various distributions and
telephone messages. There are also refill request forms and other documents that may need
your immediate attention. For those of you not at the University of Minnesota site, important
mail/information will be mailed to your home address or your site location.
The copy machine is also located in 6-207 PWB. You may be given the division account
number to use to pay for journal articles or book chapters that you copy in the Biomedical
Library. This account number is to be used sparingly. All fellows are encouraged to use
discretion in order to minimize copying charges outside of the division’s copy machine.
Computer Training
Computer literacy is essential to functioning effectively as a physician and within our program.
All of your medical charting is done through electronic medical record systems. Residency
Management Suite (RMS) is used to log duty hours weekly, collect evaluation feedback and log
procedures.
Computer training is available at the University of Minnesota Medical Center, Fairview
(UMMC-FV). The Biomedical Library staff present an overview of the services and resources
offered through the use of computers, and also demonstrate search strategies for medical
practice and research. Using online demonstrations of the Library's online Web forms to
request services (e.g., photocopying) and databases to search for health related information
(e.g., Medline and electronic journals), fellows can learn how to connect to these resources
from within the Library, their clinics, or from home. Information is updated monthly to give
fellows access to the most current health topics. The Bio-Medical Library will also assist fellows
in any other computer-related issues they might have.
RMS training will be conducted during your orientation in July. Should you feel you need
additional training, please speak with your program coordinator.
E-Mail Addresses
Fellows are assigned a University e-mail account at the beginning of their fellowship. If you are
coming from another program, you will need to initiate your new U of M account (if you haven’t
already). Go to https://www.umn.edu/initiate. You will choose a password. If you have
complications, contact UMN Tech Support at (612) 301-4357.
You are required to log-on to your U of M email at least twice a week as we regularly send
announcements about the program via e-mail. Additionally, the University exclusively uses
email as the official mode of communication.
HIPAA Training
All University of Minnesota Residents, Fellows, Faculty and Staff have to complete HIPAA
training sessions through the University of Minnesota, regardless of any other training
sessions you may have had elsewhere. HIPAA Training is federally mandated. You access
your training through ULearn. These training sessions will be assigned to you and must be
5
completed soon after your fellowship start date. To log on, sign in using your X500 and
password.
All Fellows will need to complete the following training sessions:
 Introduction to HIPAA Privacy and Security Video
 Privacy and Confidentiality in the Clinical Setting
 Privacy and Confidentiality in Clinical Research
 Data Security in Your Job
 Securing Your Computer Workstation
 Using University Data
 Managing Health Data Securely
If you have problems accessing the training sessions call the helpline: 612-301-4357
Hours:
Monday – Thursday:
Friday:
Saturday:
Sunday:
8:00 a.m. – 11:00 p.m.
8:00 a.m. – 5:00 p.m.
12:00 noon – 5:00 p.m.
5:00 p.m. – 11:00 p.m.
For more information about the University of Minnesota’s Privacy and Security Project and
Federal regulations, go to: privacysecurity.umn.edu.
Hospital EMR Passwords and Access
EMR passwords and access will be provided at all site locations. Initial login and password
information can be obtained through the Education Office at each site. If you are having
problems logging into these systems, please call the Information Center at 612-672-6805 (for
EPIC, PACS) or the UMPhysicians Help Desk at 612-884-0884 (for Allscripts).
Internet and Intranet Access
All residents and fellows have internet access through the University of Minnesota. Your login
and password are tied in with your email account at the University. To login, go to the
University of Minnesota, Twin Cities website at umn.edu/twincities/index.php.
Click on “One Stop”. At this level, you can search for names and check your email. Click on
“myU” located in the top, right corner of this page then enter your X500 (Internet ID) and
password. MyU is the location for many resources related to academics, human resources, etc.
Remember, it is very important to logout of the internet when you are done viewing this site
as your personal payroll information is listed here.
Pagers
Each fellow will be assigned a universal pager to be carried throughout their training. Fellows
will not have to switch beepers when they switch sites as the pagers have an 80-mile radius.
Batteries for pagers are available in the division office. If the pager needs repair, please
contact the program coordinator. Certain repairs are at no charge to the fellow; however, if the
repair is due to water damage or poor handling, the fellow may be responsible for the repair or
replacement of the pager. At the end of training, fellows must turn their pagers in to the
program coordinator.
6
Research Resources
Fellows have free access to Medline and other electronic library services. Fellows may gain
access from home computers via modem, DSL, etc., and from computers in the fellows’ room
at some of the hospital sites. Fellows also have access to workstations in the Reference Area
of the Bio-Medical Library in Diehl Hall. The University of Minnesota Biomedical Library has a
comprehensive collection of journals and textbooks in electronic format which can be readily
accessed via the internet.
Tuition and Fees
Tuition and fees are being waived at this time. Trainees who are enrolled in Graduate School
pay tuition and fees.
Useful Websites
Bio-Medical Library Website: https://hsl.lib.umn.edu/biomed
Extensive on-line biomedical information including over 100 medical journals available with full
text is available.
The University of Minnesota also has web sites (twincities.umn.edu/) on campus involvement
and events with ongoing information on campus. Residents/fellows can present their U Card at
many of these events for discounted or student rates.
Career-Related Websites
There are many web sites dedicated to physician recruitment. A sample of those includes:
American College of Physicians / American College of Internal Medicine:
acponline.org
The New England Journal of Medicine: content.nejm.org/
PracticeLink: practicelink.com
Physicians Employment: physemp.com/ Healthcare
Monster.Com: jobs.monster.com/v-healthcare.aspx
Association of American Medical Colleges: aamc.org/
Association of Program Directors in Internal Medicine (resources / job bank
section has job postings): im.org
Debt Management
The AAMC has a debt management free list serve for residents/fellows designed to help
residents/fellows manage their medical student loans. Residents/fellows can subscribe to it by
doing the following:
 Send an e-mail to: [email protected]
 In the subject field, provide information and identify your residency program
 In the text section of the e-mail, simply type: Subscribe-moneymatters-your email address
7
SECTION 2 - BENEFITS
Holidays
University holidays are posted on the Office of Human Resources website. Holidays may vary
by training site. Please check the call schedule at your site for holiday coverage assignments.
Insurance - Dental
Optional dental coverage is available for medical fellows only. Family dental coverage is not
available.
Please contact the Office of Student Health Benefits at 612-624-0627 or [email protected] if
you have dental enrollment questions. Questions regarding this dental policy, such as what is
and is not covered should be directed to the Delta Dental Customer Service Center at
651/406-5916 or 1-800/553-9536 Web site: deltadentalmn.org.
Insurance - Life
Forms to request a change of beneficiary may be obtained by contacting the Office of Student
Health Benefits at 612-624-0627 or [email protected].
Insurance - Long-Term Disability
(Please see the Institution Manual for complete long-term disability insurance information.)
Insurance - Medical
All medical fellows must be enrolled in one of two medical insurance plans offered through the
residency/fellowship training program unless the fellow provides documentation of other
comparable medical insurance coverage. Please refer to the departmental Medical
Resident/Medical Fellow Benefits Program Booklet for comparison information of premiums
and benefits available under each plan. Please contact the Office of Student Health Benefits at
612-624-0627 or [email protected] if you have enrollment questions or need to make
changes in your medical insurance coverage. Questions regarding your specific policy, such
as coverage should be directed to the insurance carrier (shb.umn.edu/residents-fellows-andinterns/health-benefits).
Insurance - Short-Term Disability
Short-term disability insurance is provided, at no cost, to all fellows in the Department of
Medicine through Guardian. Enrollment in the short-term disability plan is automatic with no
application form required.
Under this policy, a disability is defined as an injury, sickness or pregnancy for which you are
under the ongoing care of a physician or practitioner other than yourself. The plan pays for
both total and partial disability. This plan has a 15-day beginning date - you must be disabled
for 14 days before benefits begin. The plan pays 70% of your base stipend if disabled and
benefits can be paid up to 24 weeks. Maximum weekly benefit is $1,000.00.
Laundry Service
The first time you are having your coat laundered, you must be sure to request that your coat
is tagged and chipped for identification so that your coat will be routed back to you. Ask for
assistance with this from the division administrative assistant. After the initial identification, lab
8
coats are laundered on an as needed basis and are sent in on a Tuesday and returned within
two weeks.
Leave – Illness and Vacation
In accordance with the ABIM policy for board certification, all fellows will be given one month of
leave (four weeks), to be used for both vacation and sick leave. Any leave that exceeds one
month will be unpaid and must be made up at the end of the training. There is no carryover of
vacation or sick time from one year to the next. For details, please refer to the ABIM policy
located on the web at www.abim.org.Fellows are allotted five paid working days (one week) of
sick/personal time per fellowship year. Personal days may be used for personal or family
illness, personal or family emergency and practice search. When such a situation arises,
fellows are responsible for notifying the program coordinator, the coordinator of the site you
are rotating at, the appropriate faculty member, and/or your continuity clinic.
Fifteen (15) paid working days (three weeks) are granted for vacation each fellowship year.
Vacation days cannot be carried over to the next academic year. Regarding planned
vacations, fellows are responsible for notifying the fellowship coordinator at least 60
days in advance.
Fellows who are graduating from the fellowship program are allowed to take vacation during
one of the last two weeks of their fellowship. Please plan accordingly and save a week of
vacation if you wish to use it at the end of your academic year.
All fellows, regardless of rotation location, must complete a Fellow Time Off Request Form for
any absence due to vacation, meeting, or personal time away from work. This form is available
via the RMS homepage or from your program coordinator. Once the form is completed, it
should be returned to the coordinator for processing which includes notification of rotation sites
and continuity clinics.
Leave – Parental and Personal
Fellows are provided with six weeks of paid maternity leave and two weeks of paid paternity
leave. (Note that any leave that, when added to vacation time and any other personal time
away, results in more than one month away from the program in a PGY year will extend
training.) Fellows should notify the program director as far in advance as possible of the
request for maternity/paternity leave.
Other Personal Leave should be requested at least three months in advance of the planned
leave, except in the case of a personal crisis or emergency, for which appropriate notifications
should be made as soon as possible to the program director. Fellows are responsible for
arranging schedule changes for all other personal leave and should make arrangements as far
in advance as possible, in consideration of their colleagues and the program.
When requesting a Leave of Absence, please consider the following:
The ABIM allows any one year of training to be interrupted by only four weeks, including
vacation, sick leave, educational leave and Maternity/Paternity Leave. Any time off exceeding
four weeks will extend your training.
When taking maternity leave (6 weeks paid) or paternity leaves (2 weeks paid), consider the
9
following:
This leave time in addition to any vacation time could extend a resident’s training.
Maternity Leave (6 weeks paid):
4 weeks – If no vacation time was used in the year, no time needs to be made up. And
it is paid time.
2 weeks – This time will need to be made up, but it is paid time.
**Anything past this will not be paid and all time over four weeks will need to be made up.
Paternity Leave (2 weeks paid):
2 weeks – does not need to be made up, paid time.
**This will then shorten the allowed vacation time from 3 weeks to 1 week.
Leave - Professional and Academic (Includes Conferences and CME)
Time away for academic leave and conferences other than those that are part of the
curriculum may be granted in addition to regular vacation time. Requests must be received in
writing by the fellowship office and approved by the fellowship director following the same
guidelines as for vacation time. No more than 10 days per academic year will be allowed; time
beyond this limit must be taken as regular vacation time.
Leave - Unauthorized Leave
Unexcused, unsupportable, or unauthorized absences/leaves and/or significant tardiness from
any mandatory clinical or educational activity constitutes unprofessional conduct. Under your
signed employment contract, unprofessional conduct is behavior which will subject the fellow
to discipline for non-academic reasons. Such discipline may be in the form of a written
warning, probation, suspension or termination.
Leave - Other
See the Institution Manual for information on the following types of leave: bereavement,
medical, Family Medical Leave Act (FMLA), jury/witness duty and military.
Leave - Policy on Effect of Leave for Satisfying Completion of Program
All fellows must meet the twenty-four month training requirements established by the American
Board of Internal Medicine. Fellows may miss one month per year or two months per
fellowship, including vacations, sick leave, leaves of absence (LOAs), etc. Time in excess of
two months whether for vacations, sick leave, maternity or paternity leave must be made up to
meet this requirement. This requirement does not include the additional third year for research
that many fellows undertake.
A requested LOA must be discussed with the Fellowship Program Director. The Fellowship
Program Director must approve your request at least three months prior to the requested LOA
date. Exceptions may be made if the request falls under the definition of the Family Medical
Leave Act (FMLA). (Please see Part A of the Department of Medicine Policies and Procedure
manual for the Medical School policy on FMLA). Do not assume that a LOA will be granted
automatically. Obtain approval before making plans.
Meal Tickets
There is no allotment for meals to fellows in Diabetes, Endocrinology and Metabolism.
10
Meetings
The program will reimburse the cost, up to $1,200, for each fellow to attend one national
meeting of the Endocrine Society or American Diabetes Association once during the
fellowship. The program will also pay the cost, up to $1,200, for a fellow to attend additional
annual meetings of the Endocrine Society or American Diabetes Association if the fellow is
presenting his or her research work (poster or oral presentation).
Fellows will be responsible for expenses above $1200. Fellows will be expected to consume
the meals offered at the meetings and should share rooms whenever possible to defray costs.
Fellows will not be reimbursed for car rental or expenses for other individuals.
In addition, during the final year of fellowship, the program will cover the registration fee for
Endocrine University for those fellows accepted into the program. Fees associated with
submission of abstracts and poster printing will be reimbursed in addition to the allotted $1200.
All expense reimbursement requests should be submitted within 30 days following the
conference (or within 30 days of when the expense is incurred if not conference related).
Fellows may be given academic or vacation leave (as determined by the fellowship director) to
attend other meetings to present their research work. The funding for these meetings will be
determined on an individual basis.
Parking
University of Minnesota Medical Center: There are a number of parking lots available on
the East Back campus. Go to: http://www1.umn.edu/pts/ for maps and prices or for
information on contract parking.
After hours parking in the East Bank patient visitor ramp begins at 4:30 p.m. Monday
through Friday and is available all day/night on weekends and holidays. Residents/fellows
must go to the parking office (Mayo Building B-340) to activate their after hours parking.
(This also allows fellows to park in the Yellow ramp on the Riverside campus during
daytime hours and shuttle to the East Bank.) A $25 refundable deposit is required.
Fellows on their two month UMMC clinical rotation can obtain a parking card from the
fellowship coordinator.
VA Medical Center: Free parking is available at the VA Medical Center.
Hennepin County Medical Center: Fellows on the inpatient service pay a $50 deposit for
a parking card at the beginning of the month. At the end of the rotation when the card is
returned, the $50 is refunded.
Professional Liability Insurance
The Medical Resident and Medical Fellow Professional Liability Insurance policy is
administered through the University’s Office of Risk Management and Insurance.
Questions regarding this policy should be directed to Krista Cozine at 612-625-9995.
Resident and Fellow Assistance Program (RAP)
Training can be stressful for fellows and their families. While we try to foster a culture of
11
professionalism, warmth and support within the program, there are times when a fellow or
her/his family may wish to have additional counseling. The Resident and Fellow Assistance
Program (RAP) is a confidential assistance program designed specifically for residents and
fellows, and is available to all residents/fellows and their families free of charge.
Residents/fellows and their families are encouraged to take advantage of this benefit.
RAP offers support and assistance to residents/fellows with issues and problems such as
getting a handle on debt, dealing with stress, career choices, relationships, and adjusting to
training programs. RAP is strictly confidential, and is provided by an outside firm, Sand Creek
Group, Ltd. The RAP program will NOT notify the program or program director of a fellow’s use
of the program. Contact: Sand Creek Group, Ltd. at 651-430-3383 or 1-800- 632-7643. More
information can be found on the GME website.
Stipends
The base stipend levels are available in the Institution Manual as well as on the GME website.
For specific payroll-related questions, contact Human Resources at 612-626-0119.
U-Card
Your U Card identifies you as a student, staff or faculty member. Your first U Card is free and
can be obtained at the U Card Office located in room G22 in the Coffman Memorial Union
building, 300 Washington Avenue SE, Minneapolis / East Bank Campus, phone 612- 6269900. They are open weekdays: 8:30 a.m. to 4:00 p.m. Bring your driver’s license, state ID or
passport and be prepared to have your picture taken.
See the U Card website for more information.
White Coats
Each fellow is issued two white lab coats to last throughout the fellowship. If needed, please
contact the fellowship coordinator to order an additional coat.
12
SECTION 3 - GENERAL POLICIES AND
PROCEDURES
ACGME Competencies
An in-depth description of the General Competencies requirements can be found on the
ACGME website. Reference to these competencies is indicated throughout the Fellowship
Program Curriculum section of this manual.
Duty Hours and Call Schedules
Generally, duty hours are 8:00 to 5:00 Monday through Friday. Duty hours are defined as all
clinical and academic activities related to the training program, i.e., patient care (both
inpatient and outpatient), administrative duties related to patient care, the provision for transfer
of patient care, time spent in-house during call activities, and scheduled academic activities
such as conferences. Duty hours do not include reading and preparation time spent away from
the duty site.
Duty hours are limited to 80 hours per week averaged over a four week period inclusive of all
in-house call activities.
There is no overnight in-house call for the fellowship program. A fellow and faculty are
assigned for phone calls and emergency consults 24 hours a day, 7 days a week. Typically the
first year clinical fellow takes calls during daytime hours on weekdays. After hour/night time call
and weekend call rotates between the first year clinical fellow and the senior fellows or faculty,
depending on the site. The first year clinical fellow will be assigned after hour/night time call
and weekend call every other week. Fellows assigned weekend call at UMN will round on
weekends with faculty. Typically fellows assigned weekend call at the VAMC or HCMC do not
need to come in on weekends to round, but may be called in for new or follow-up consults.
Fellows have a minimum of 1 day per week free of all clinical responsibilities averaged over a
four week period. The training program provides adequate time for rest and personal
activities, which consists of a 10-hour time period provided between all daily duty periods.
Evaluation Policy
All evaluations are completed online using RMS. The following describes the evaluation
program and schedule for evaluations:
Clinical Year – Clinical Rotations
The fellow will be evaluated monthly and will evaluate the attending faculty and
rotation.
Research Years
The fellow will be evaluated every six months by the faculty research mentor and will
evaluate the mentor/research experience every six months.
Continuity Clinic
13
Supervising faculty will evaluate the fellow every three months and the fellow will
evaluate the supervisor every six months.
Year End
The fellow will evaluate the program and faculty yearly.
Other Evaluation Methods
Patient surveys, evaluations by clinic staff, medical students and residents rotating on the
endocrine service and fellow performance on the annual in service training exam will also
be part of a fellow’s ongoing evaluation toward meeting ACGME milestones and meeting
core competencies.
Faculty evaluations may be reviewed online at any time and faculty is available to review
individual evaluations with fellows.
ACGME Competencies
Fellows are provided with multiple opportunities for training in the six core competencies, as
outlined by the ACGME, and are evaluated in each of these, as described below.
1. Learning activity.
Experience
Patient
care
Consults and
clinic
Continuity
clinic
Core
curriculum
conf
Clinical conf
Journal club basic
Journal club clinical
City wide
research conf
Research
project
Medical
knowledge
Core Competency
Interpers.
Professionalismm Practice& comm.
based
skills
learning
+
+
+
Systembased
practice
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
2. Evaluation methods.
Context/modality
Direct
observation
Global
assessment
Patient survey
Multisource
assessment
Patient
care
Medical
knowledge
Core Competency
Interpers. Professionalism
& comm.
skills
+
+
Practicebased
learning
+
Systembased
practice
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
14
In-training exam
+
Graded Responsibility
Fellows are assigned incrementally increasing responsibility and independence during their
training appropriate for their demonstrated level of competency and professional development
(as assessed by the supervising physicians), according to a three-tiered format as shown
below.
Level of responsibility/ independence by proficiency level*
Beginning
Developing
Clinical data collection
independent, with
staff supplementation
independent, with staff
confirmation
independent, with selective staff
confirmation
Formulation of clinical
assessments/ plans
jointly with staff
independent, with staff
confirmation
independent, with selective staff
confirmation
after discussion with
staff
preliminary,
independent; final, after
discussion with staff
independent, with selective staff
confirmation
Procedures – thyroid
fine needle aspiration
jointly with staff
participation
Independent with
selective staff
participation
Independent with staff supervision
Case conference
preparation
jointly with staff
independent, with staff
confirmation
independent, with selective staff
confirmation
Supervision of
students/ residents
jointly with staff
independent, with staff
review
independent, with selective staff
review
directed background
reading, tutored skill
development
execution of existing
projects with staff
oversight
Function/ activity
Communication of
0
recommendations to 1
teams/ referring MDs
Research
Proficient
analysis and presentation of results,
new project development, independent
conduct of research with selective staff
review
*As assessed by supervising faculty based on observation of fellow’s performance.
Clinical proficiency levels correspond approximately with the first, second, and third 4month blocks of clinical experience, but individual fellows move through the levels at
different rates depending on their rate of developing the relevant competencies.
In-Training Examination (ITE)
Fellows who have not completed the Endocrine Boards are required to take the In-Training
Examination offered by the Endocrine Society. The Division pays for this exam. The results of
the test assist fellows as well as the fellowship program directors to identify strengths and
weaknesses of both the fellow and the training program. The exam is taken in the winter of
each year.
Laboratory/Pathology/Radiology Services
Inpatient clinical support services are available on a 24-hour basis at UMMC, HCMC and the
Minneapolis VAMC to meet reasonable and expected demands, including intravenous
15
services, phlebotomy services, messenger/transporter services, Inpatient Radiology services
including laboratory and radiologic information retrieval systems that allow prompt access to
results.
Life Support Certifications (BLS/ACLS/PALS)
Please refer to the Institution Manual for the Life Support Certification policy.
Medical Records
Clinical records that document both inpatient and ambulatory care are readily available at all
times. Each site provides electronic and/or paper-based medical records for patient care.
Passwords and access to these records are provided at each site’s orientation during the first
day of the rotation.
Monitoring of Fellow Well-Being / Adequate Rest
Each inpatient site is responsible for ensuring adequate rest and well-being for its fellows. This
may be accomplished by a schedule of uninterrupted sleep and carrying pagers for a team
member during agreed-upon hours.
The program directors and fellowship coordinator will monitor duty hours, days off, and
adequacy of rest at all sites by reviewing RMS duty hour reports. The program directors will
review duty hour issues with fellows should they arise. The program encourages fellows to
recognize their own levels of stress also, and to seek the advice of their program directors,
fellowship coordinator or attending physician if stress becomes too great.
Moonlighting Policy
In addition to the Moonlighting Policy set forth in Part A of the Department of Medicine Policies
and Procedure Manual, fellows must adhere to the following guidelines specific to the Internal
Medicine training program. Moonlighting is defined as any work performed as a physician
outside of the fellowship program that generates revenue.
In general, the Department of Medicine discourages moonlighting activities by fellows.
Moonlighting during the hours of 8:00 am to 5:30 pm on workdays or during any hours while on
call is strictly prohibited; the Department views moonlighting during these times as a breach
of trust and a violation of professionalism. Clinical responsibilities extended beyond these
hours have priority over any scheduled moonlighting activities. Moonlighting must not interfere
with the fellow’s performance of patient care or educational responsibilities on any rotation
during fellowship training. Fellows violating this policy may be subject to probation, suspension
without pay and/or disciplinary action including, but not limited to, termination.
Moonlighting is discouraged during any rotation in which the fellow has clinical responsibilities.
Any moonlighting that is done during clinical rotations must not interfere with the fellow's
clinical responsibilities, so is best limited to the fellow's days off or, if done on weekdays,
should not begin until the completion of daily rounds (the timing of which must be negotiated in
advance with the supervising faculty physician). All fellows who secure moonlighting positions
must obtain advance approval from the Fellowship Program Director. In order to be approved,
the fellow must provide the organization and site of the moonlighting activity, the nature of work
(i.e. urgent care, chart review, etc.), the name and telephone number of the immediate
supervisor, and the anticipated hours of work per month. This information should be provided
to the Fellowship Director by using a standardized moonlighting form that is available from the
16
Fellowship Coordinator.

Moonlighting requires a prospective written statement of permission from the
program director that will be made part of the fellow’s file.

Fellows are not required to engage in moonlighting.

Moonlighting activities will not be allowed to conflict with the scheduled and
unscheduled time demands of the educational program and its faculty.

The fellow’s performance will be monitored for the effect of these activities upon
performance and adverse effects may lead to withdrawal of permission.

Internal moonlighting must be counted toward the 80-hour weekly limit on duty
hours.

Moonlighting activities must not coincide with scheduled “on call” responsibilities.

Moonlighting is not permitted with a J1 visa.
Professional liability insurance coverage is the responsibility of the fellow and/or hiring
institution. The insurance coverage provided by the University of Minnesota does not cover
moonlighting activities, including that which occurs at the VA or Regions Hospitals.
On Call Activities
In-house call is defined as those duty hours beyond the normal work day when fellows are
required to be immediately available in the assigned institution. Continuous on-site duty,
including in-house call, must not exceed 24 consecutive hours. Fellows may remain on duty
for up to 6 additional hours to participate in didactic activities, transfer care of patients, conduct
outpatient clinics and maintain continuity of medical and surgical care. Endocrinology trainees
have no In-hospital call. As a result, information is not provided in this manual regarding inhospital call and on-call rooms.
Procedure Logs
As a requirement for board certification, fellows are required to perform at least six fine needle
aspiration biopsies of the thyroid before they can be considered proficient. Trainees will keep
track of these procedures online in the Residency Management Suite (RMS).
Professional Dress Code
Residents/Fellows are expected to be neat, clean, and orderly at all times during the
performance of training program activities. Jewelry, clothes, hairstyle and fragrances should be
appropriate for the performance of duties in the hospital or clinic. The fellows’ identification
badges are to be worn whenever the fellow is involved in clinical or administrative duties.
Fellows are expected to dress according to generally accepted professional standards
appropriate for their training program. Where safety is a factor, fellows should use common
sense in choosing clothing and shoes for training activities.
Residency Management Suite (RMS)
All fellows will receive RMS training during their first-year orientation, where the “painting”
17
system will be introduced. Fellows are responsible for painting in their hours worked. It is
expected that fellows log in to RMS at least every three days to enter in hours; however, daily
entering would be ideal. For questions related to RMS, please contact the program
coordinator. The coordinator will be checking compliance and will send reminders with
deadlines. Painting in duty hours is a program requirement. Failure to comply fully could result
in disciplinary action.
Security/Safety
Security and personal safety measures are provided to fellows at all locations, including but
not limited to parking facilities, on-call quarters, hospital and institutional grounds, and related
clinical facilities (e.g. medical office buildings).
Contact Information:
UMMC Security Office: 612-273-4544 / East Building / Riverside Campus
University of Minnesota Security Monitor Program: 612-624-WALK
VAMC Security Office: 612-467-2007 / located on the first floor, in room 1U-162
HCMC Security Office: 612-873-3232
ANWH Security Office: 612-863-5416 (internal phone, 3-5416)
Supervision
Fellows are supervised closely in all their activities by designated faculty members, i.e. the
assigned endocrinology consult service attending during consult months, the assigned clinic
attending during continuity clinic and the designated research mentor for research activities. All
patient care decisions and recommendations made by the fellow are discussed with the
relevant faculty member, and changes (if any) are communicated to the primary teams or
patient, as appropriate. Faculty members confirm relevant aspects of the history and physical
examination, as assessed by the fellow, to the extent necessary in order to ensure that clinical
decision making is appropriate and documentation is accurate. When fellows supervise
residents and students in providing patient care, the fellow is responsible for seeing that the
decisions and recommendations made by the trainees are appropriate, which then is verified
by the responsible faculty member. The program director has overall responsibility for ensuring
that fellows are performing and progressing satisfactorily, as ascertained from the
standardized evaluations submitted periodically by the supervising faculty members and from
direct discussions with these faculty members as needed to clarify any questions raised by the
standardized evaluations.
Support Services
Please see the Resident Inpatient Guides for specific information related to accessing and
utilizing these services and systems at all sites affiliated with the Internal Medicine Residency
Program. Each of these services must be provided at all sites affiliated with the Internal
Medicine Residency Program.
Training/Graduation Requirements
Please review the ABIM website for requirements for certification in subspecialties and added
qualifications.
Visa Sponsorship
The J-1 alien physician visa sponsored by ECFMG is the preferred visa status for foreign
national trainees in all UMN graduate medical education programs; therefore, the Diabetes,
18
Endocrinology and Metabolism Fellowship Program sponsors only J-1 visas. We do not
sponsor H-1B visas. More information can be found on the UMN-GME webpage.
Workers’ Compensation
Please see the Institution Manual for workers’ compensation benefit information as well as the
GME website under “Resident and Fellow Resources” for a detailed description of the
procedure for needle sticks.
19
SECTION 4 – INSTITUTION
RESPONSIBILITIES
Please refer to the Institution Manual.
20
SECTION 5 - DISCIPLINARY AND
GRIEVANCE PROCEDURES
Please refer to the Institution Manual for Medical School policies on the following:
Discipline/Dismissal/Nonrenewal; Conflict Resolution Process for Student Academic
Complaints; Academic Incivility Policy and Procedure; University Senate on Sexual
Harassment Policy; Sexual Harassment and Discrimination Reporting; Sexual Assault
Victim’s Rights Policy; and Dispute Resolution Policy.
21
SECTION 6 – ADMINISTRATION
Program Contact Information
J. Bruce Redmon, MD
Director
Diabetes, Endocrinology and Metabolism Fellowship Program
Department of Medicine, MMC 101
University of Minnesota
420 Delaware Street SE, 6-126 PWB
Minneapolis, MN 55455
Phone:
Fax:
E-mail:
612-625-2154
612-626-3133
[email protected]
Pam Coppa
Fellowship Coordinator
Diabetes, Endocrinology and Metabolism Fellowship Program
MMC 101
420 Delaware Street SE, 6-207 PWB
Minneapolis, MN 55455
Phone:
Fax:
E-mail:
612-626-9943
612-626-3133
[email protected]
Sommer Wappel
Administrative Assistant
Division of Diabetes, Endocrinology and Metabolism
MMC 101
420 Delaware Street SE, 6-124 PWB
Minneapolis, MN 55455
Phone:
Fax:
E-mail:
612-624-5150
612-626-3133
[email protected]
Faculty Lists
See fellowship website for faculty lists.
22
SECTION 7 – FELLOWSHIP PROGRAM
CURRICULUM
Overall Objectives of the Endocrinology and Diabetes Fellowship Program
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 needed by a consultant in this field. Our 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.
Program Requirements
Our training program is an important part of the academic mission of the division. We seek to
ensure that our fellows successfully complete their training goals, whether they are preparation
for a career as an endocrinologist working as a researcher, teacher or clinician at an academic
institution or as a clinical endocrinologist in private practice. Fellows spend at least 12 months
in clinical endocrinology training in the inpatient and outpatient settings. These 12 months are
usually done as the first year of fellowship. In special circumstances, fellows may have
research time during their first year of fellowship, in which case their clinical training time will
extend into their second year. This latter arrangement is made for fellows who wish to begin
their research activities during the first year of fellowship. The majority of year two of the
fellowship is devoted to a research project(s) with some clinical time including one-half day a week
of fellow continuity clinic. There is the option for a third fellowship year for additional research
training for fellows with a demonstrated interest and commitment to an academic endocrinology
career.
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 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.
23
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, peripheral vascular system, neurologic system, 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 and DEXA.
(3.4) Fine needle aspiration of the thyroid and interpretation of cytology and pathology.
(3.5) Understanding pharmacotherapy for endocrine disorders and appropriate use of
surgery, radiation therapy, treatment with radioisotopes, etc.
4. Procedural and technical skills required by the endocrine subspecialist.
5. Professionalism, including peer interactions, communication with patients, their families
and other health care providers, confidentiality and avoidance of conflict of interest.
6. Endocrine clinical and basic research.
7. Understanding of existing and emerging endocrine literature.
8. Personal scholarship and self-instruction.
How these specific learning objectives apply to the major learning experiences of this
program is indicated below.
Objectives for the Major Learning Experiences
Objectives
Ambulatory:
Consultation
Continuing Care
Inpatient:
Consultation
Continuing Care
Teaching:
Conferences:
Core curriculum
Clinical
Basic science JC
Clinical JC
City wide
Procedures:
Research:
1
2
3.
1
3.
2
3
3.
3
3.
4
3.
5
4
5
6
7
8
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
24
X
X
X
X
Educational Program
Formal fellowship educational activities primarily are held at the UMMC site and include a
weekly endocrine core curriculum conference; a weekly clinical case conference; clinical and
basic science journal clubs; and a weekly endocrine citywide conference. Additional
educational instruction occurs through weekly department of medicine conferences including
a weekly departmental research conference (UMMC), grand rounds and morbidity and
mortality conference. Individual research groups and laboratories hold additional research
meetings and conferences. Individual on line training is available through the Clinical and
Translational Research Institute in clinical and translational research including responsible
conduct of research, clinical trial design and statistical methods.
Core Conferences
Conferences (at UMMC site)
Monday
Tuesday
Wednesday
Medicine Research
Conf.
Thursday (All Fellows)
Friday
Medicine Grand Rounds
Morbidity
and
Mortality
conference
Basic Science Journal Club
Clinical Journal Club (4
Thursday)
th
Core curriculum conference
Clinical case conference
Thyroid cytology conference
st
(1 Thursday)
City-Wide
conference
Weekly Conferences (at HCMC site)
Monday
Tuesday
Wednesday
Noon
Conference
Noon Conference
Weekly Conferences (at VA site)
Monday
Tuesday
Endocrine
Thursday
Friday
Grand Rounds
Noon Conference
Wednesday
Thursday
Friday
Morbidity and
Mortality
Medicine Research
Medicine Grand
Rounds
Clinical Journal Club
Noon
Conference
QI conference
- monthly
25
Core Curriculum Conference
Educational Purpose: Formal instruction by faculty in the molecular and biochemical
physiology, pathophysiology, diagnosis and management of the range of endocrine diseases
that a trained endocrinologist will need to understand and master.
Teaching Method: Lectures by endocrine faculty and other faculty or experts in related
disciplines.
Disease Mix: The spectrum of endocrinology is covered over a two year cycle of lectures.
Procedures and Services: Appropriate use of biochemical testing, imaging and biopsy may
be the subject of the conference.
Reading Lists and Educational Resources: May be prepared for selected conferences.
More detailed lists and resources are provided below in the sections on specific groups of
endocrine diseases.
Evaluation: Fellows will evaluate the effectiveness of faculty as teachers and the overall
effectiveness of the conference through annual faculty and program evaluation. (See
Section 3 – Evaluation Policy).
Clinical Case Conference
Educational Purpose: To discuss a variety of diseases of endocrinology and metabolism in
greater depth than at the bedside or the ambulatory care setting. Correlation with endocrine
biochemistry, physiology and pathophysiology is expected.
Teaching Method: Case presentations by fellows and faculty. The first year fellow assigned
to the UMMC site is responsible for preparing and formally presenting a case and reviewing
the pertinent literature related to that case. Additional cases are brought for discussion by
other fellows and faulty. The conference also provides a forum for instruction and
participation in quality improvement as discussion of patient management and possible errors
in that management are also discussed. Once a month, the conference is held jointly with our
pathology department to review endocrine cases with their corresponding cytology and/or
pathology findings.
Disease Mix: All endocrine diseases are discussed. Those low frequency disorders that
might not be encountered by a trainee during the program are discussed.
Procedures and Services: Appropriate use of biochemical testing, imaging and biopsy as
well as review of above studies, cytology and pathology may be the subject of the
conference.
Reading Lists and Educational Resources: May be prepared for selected conferences.
More detailed lists and resources are provided below in the sections on specific groups of
endocrine diseases.
26
Evaluation: Trainees who give conferences will be evaluated by attending physicians. Their
performance in this venue is part of their overall evaluation by attending physicians and the
program director. (See Section 3 – Evaluation Policy).
Basic Science Journal Club
Educational Purpose: To instruct trainees in the basic biochemistry, physiology and
pathophysiology of the endocrine system. At a minimum, subject areas will include molecular
biology and immunology as they relate 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 and
feedback systems.
Teaching Method: Trainees will be given materials for self-instruction in the subject area of
the Basic Science Conference. Faculty will lead the conference, which will usually be a
seminar format with as much interaction between trainees and faculty as possible.
Disease Mix: Not relevant.
Procedures and Services: Not relevant.
Evaluation: The faculty will evaluate trainee preparedness and interaction. (See Section 3 –
Evaluation Policy).
Basic Science Conferences are held on a weekly basis. In addition, many other basic science
conferences take place within our institutions, almost on a daily basis both in basic science
and clinical departments. Their schedules are posted and trainees are encouraged to attend,
as their time allows.
These basic science conferences are held from 1 pm to 2 pm once a week under the
supervision of the faculty. One fellow is assigned each week to identify (in consultation with
supervising faculty) a relevant article from the basic science literature, prepare a review and
critique of the article and present it to the group. All trainees are expected to attend this
conference and participate in critical evaluation of the article presented. In addition, fellows
rotating at UMMC are expected to attend the Department of Medicine weekly research
conference which provides exposure to research in related disciplines.
Clinical Journal Club
Educational Purpose: To expose trainees, on a continuing basis, to critical reading of the
emerging endocrine literature. Participation in Journal Club also provides instruction in clinical
epidemiology, in biostatistics and in clinical decision theory.
Teaching Method: Trainees will be expected to present analyses of assigned papers in the
current literature or of papers of their own selection. Their presentation will include analysis of
experimental groups and design, methodology of measurements, and of statistical analysis.
For the monthly division wide clinical journal club, a faculty member will be assigned with the
trainee to select and present one or more clinical papers at the conference.
27
Disease Mix: Literature relating to all endocrine disease will be discussed during the training
program.
Procedures and Services: As research concerning endocrine procedures or services is
published, those papers may come under discussion in Journal Club.
Evaluation: The trainee’s performance in this venue will be part of their evaluation by the
faculty. In turn, trainees will evaluate faculty as facilitators of the Journal Club and as
participants. (See Section 3 – Evaluation Policy).
The division wide clinical journal club is held once a month on the fourth Thursday from 3 – 4
p.m. at the VAMC. Other training sites have journal club at biweekly or monthly intervals. All
trainees and faculty are expected to participate in the monthly divisional clinical journal club.
Endocrine City Wide Research Conference
Educational Purpose: To educate trainees in the status of current research carried out by
the faculty, other trainees, members of other Divisions within the Department of Medicine, or
other Departments in the institution and visiting clinicians and researchers. Trainees will
participate in the critique of the presentation and be exposed to the interactive discussions of
the participants.
Teaching Method: Interactive discussion of presented research among experts on topics of
basic and clinical science of endocrinology and metabolism, including experimental design,
methodology, statistical analysis and interpretation of data. In addition, those fellows actively
participating in either basic or clinical research will present their research project to the
division at least annually.
Disease Mix: Research may be presented that relates to any and all endocrine disease.
Procedures and Services: Not applicable.
The endocrine division city wide research conference is held weekly from 4 to 5 PM on
Thursdays, October through June.
Clinical Training
The University of Minnesota fellowship program provides a rich array of opportunities for
clinical training in endocrinology.
The three primary teaching sites are University of Minnesota Medical Center (UMMC), the
Minneapolis Veterans Administration Hospital (VAMC) and Hennepin County Medical Center
(HCMC). In addition to these sites, one fellow typically maintains a continuity clinic at the
Health Partners (HP) Specialty Center Endocrinology Clinic in St. Paul.
The University of Minnesota Medical Center has modern facilities and services, including inpatient, ambulatory care and laboratory resources readily available to all trainees. In addition,
complete biochemistry laboratories and hormone assays are available 24 hours per day. The
hospital has facilities for karyotyping. The Department of Radiology provides MRI, CT,
ultrasound, DEXA and radiologic imaging services that can conduct studies for all types of
28
endocrine diseases including inferior 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 thyroid aspirations and
immunohistologic studies. Nuclear Medicine provides all routine radionuclide imaging
methods including radio-iodine thyroid scanning and ablation, adrenal and parathyroid
scanning as well as MIBG and technicium pyrophosphate bone scans.
The UMMC site also has an ADA certified diabetes education and management program that
is staffed by CDE nurse educator and CDE dietician. Other professionals participate in this
program including psychologists, psychiatrists, orthopedic surgeons, neurologists, and
podiatrists. The trainee works closely with these educators throughout the training program.
This activity provides the trainee exposure to the multidisciplinary approach to the
management of patients with diabetes.
Similar resources are available at the other training sites for clinical care and fellow training.
Trainees are directly supervised and 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 of highest importance in our training program. Our
faculty serve 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.
Outpatient Clinical Training
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
29
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.
During the first year of fellowship, the ambulatory care experience includes 4 months at each
of the three teaching sites, UMMC, HCMC and VAMC (done in 2 month blocks) During this
time fellows attend daily outpatient endocrinology clinics according to each site’s schedule.
First year fellows also have a weekly half day continuity clinic which they will maintain
throughout their fellowship. Continuity clinics are held at each of the three training sites and
at the Health Partners (HP) Specialty Center Endocrinology Clinic in St Paul. Typically the
fellow will have two new patients and three to five follow-up patients during continuity clinic to
evaluate and discuss with the staff. Faculty at the continuity clinic sites precept the continuity
clinic on a rotating basis so that fellows have exposure to a number of different faculty during
the continuity clinic experience. As the fellow demonstrates his or her competence in
endocrine consultation, the supervising faculty member will allow the fellow to take increasing
responsibility for the management of the patient. The continuity clinic allows the trainee to
experience continuity of care by following the new patients for the duration of their treatment.
In the second year of training (and third year if applicable), the ambulatory care experience is
primarily the ongoing continuity clinic. Depending on the training site, senior fellows may also
spend an additional half day a week seeing patients in their sites outpatient clinic.
All fellow/patient interactions are under the supervision and ultimate responsibility of
designated faculty members. For beginning trainees, faculty will assume a more hands on
approach and typically repeat significant and key portions of the history and exam.
Beginning fellows will typically discuss the assessment and plan/recommendations with
faculty prior to communicating recommendations with referring physicians or hospital staff. As
the trainee develops knowledge and proficiency in the evaluation and management of
endocrine patients, trainees will be given more independence and allowed to take more
initiative in patient evaluation and management.
Trainees may make preliminary management recommendations to referring physicians
contingent upon final review and approval by responsible faculty. While trainees take
ownership of their continuity clinic patients, ultimately these patients are the responsibility of
faculty. Should situations arise requiring faculty involvement outside of the continuity clinic,
the faculty member most recently staffing the patient will be the responsible faculty physician.
Disease Mix and Patient Characteristics
Patients are 18 years of age or older. The distribution of ages and sex in our clinics
approximates their distribution among the general population with endocrine disease.
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 (e.g., weight management clinic, pituitary clinic,
renal stone/osteoporosis clinic) are an integral part of the training program. Fellows also
have the opportunity to attend pediatric endocrinology clinic during their second year of
training.
30
Procedures and Services
Dynamic endocrine studies and fine needle aspiration biopsy of the thyroid will be taught and
performed by the trainees in the ambulatory setting. Trainees initially receive instruction in
ultrasound imaging of the thyroid and fine needle aspirate of thyroid nodules using a thyroid
model. The fellow will then progress to performing this procedure under the direct
supervision of faculty. Initially trainees may observe and assist with the procedure. They will
progress to performance of the procedure with assistance of faculty until they are sufficiently
competent to carry out the procedure without assistance but under the supervision of faculty.
Appropriate laboratory testing, including imaging, will be ordered and results reviewed as
part of the doctor/patient/attending interaction. Cytological and pathological material will be
reviewed and analyzed when appropriate.
Methods of evaluation
Trainees will be evaluated monthly during their first year clinical rotations. Assessment
methods will include direct observation and global assessment by faculty through the RMS
system, multisource assessment by medical students, residents and clinic staff. All trainees
will be evaluated every three months with regard to their continuity clinic performance.
Assessment methods will include direct observation and global assessment by faculty
through the RMS system, multisource assessment by clinic staff and patient surveys. (See
Section 3 – Evaluation Policy).
In-patient Clinical Training
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.
Our fellowship program provides consultative services to all hospitalized patients at the
request of the attending physician, including patients which may be designated as “nonteaching” with respect to other services.
Hospital 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
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.
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, and orthopedic surgery. Patients will have a variety of diseases
that impact 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
31
the geriatric age group and both sexes. Sex and age of patients will parallel their distribution
among the variety of endocrine disease that occurs in hospitalized patients. 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 will order
appropriate laboratory tests, biopsies, imaging and infusion studies, as dictated by the
patient’s problem. Data will be reviewed and treatment recommended.
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 emerges or changes
in the patient’s condition occurs 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 iodineI-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.
Methods of evaluation
Trainees will be evaluated monthly during their first year clinical rotations. Assessment
methods will include direct observation and global assessment by faculty through the R M S
system and multisource assessment by medical students and residents. (See Section 3 –
Evaluation Policy).
During the second fellowship year (and third, if applicable), fellow training in the in-patient
setting continues as fellows participate in evening and weekend call rotation which provides
additional in-patient clinical experience. This experience consists of coverage of the
consultative service at times when the first year fellow is not available for this coverage or for
weekend coverage as part of the normal call rotation. This experience averages two to four
call days per month.
Research Training
Research is a key component of the endocrine fellowship experience. The Division offers
exciting research opportunities in basic, translational and clinical research. Facilities for research
at the University of Minnesota include the NIH funded Clinical and Translational Sciences
Institute which provides facilities and other support for clinical and translational research, the
Stem Cell Institute, the Center for Magnetic Resonance Research and the Masonic Cancer
Center. Basic science research opportunities are also available through the laboratories of
faculty in the basic science departments of the Medical School. Endocrine faculty at the VAMC
and HCMC are also actively involved in clinical, translational and basic research.
Endocrinology Fellowship Core Curriculum
Disorders of the Adrenal Cortex and Medulla Introduction
A complete understanding of the diseases affecting the adrenal gland is essential for the
32
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 rarer. 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.
Discussion
The training program must provide 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 must include opportunities to diagnose
and manage adult outpatients and inpatients of both sexes. The trainee must be 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.
Physiology
The endocrine trainee must have a basic understanding of the normal physiology of the
adrenal cortex and medulla. This knowledge base must 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 regulation 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.
33
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 this section (Disorders of
the Adrenal). For each disorder listed, the trainee must have a thorough knowledge of:
(1) clinical presentation
(2) pathophysiology
(3) physical examination findings
(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. It would be optimal for the training
program to provide and document a breadth of adrenal topics in 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 [15], suggested supplemental articles, and Medline searches.
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 renindependent (e.g., renovascular disease, coarctation of the aorta) to renin-independent (e.g.,
11--hydroxysteroid 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.
Adrenal Hyperplasia; 21-hydroxylase deficiency
The trainee must 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.
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 (e.g., diabetes mellitus).
Glucocorticoid Therapy
Although not required by the RRC, a thorough understanding of glucocorticoid therapy must
34
be achieved (see Form). This part of the curriculum must include:
(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 pituitaryadrenal axis function
(5) recognition of the manifestations of excessive and insufficient glucocorticoid therapy.
Adrenal Studies and Procedures
The endocrine trainee must understand the indications for and the interpretation of all of the
tests and procedures listed in the Tables below. In addition, the trainee should be able to
personally conduct cosyntropin stimulation tests and dexamethasone suppression tests.
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 g and 250 g
Corticotropin-releasing hormone (oCRH) stimulation test
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
123I-metaiodobenzylguanidine (MIBG) scintigraphy
Indium In-111-labeled pentetreotide (OctreoScan) scintigraphy
[6ß131I]iodomethyl-19-norcholesterol (NP-59) scintigraphy
Evaluation
Evaluation of competency should include discussions with faculty on a continuing basis and
clinical presentations. Written evaluations such as ASAP and ESAP should be encouraged,
but not required.
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.
35
Adrenal Cortex. In: DeGroot LJ, Besser M, Burger HG,. Jameson 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 Tyrrell
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 Tyrrell
The Adrenal Glands. In: Becker KL, Bilezikian JP, Bremner WJ, Hung W, Kahn CR, Loriaux
DL, Nylen ES, Rebar RW, Robertson 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/. Accessed June 5, 2000.
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 Clin 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 Clin 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 Clin Endocrinol Metab. 1997; 82:3923-5
Pheochromoyctoma and Mineralocorticoid Excess
36
Dluhy RG, Lifton RP: Glucocorticoid-remediable aldosteronism. J Clin 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; 331:250258
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.
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; 26:853891.
Fluid and Electrolytes
Gennari FJ. Hypokalemia. N Engl J Med. 1998; 339:451-458.
Disturbances 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.
37
Sibai BM. Treatment of hypertension in pregnant women. N Engl J Med. 1996; 335:257265.
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 Clin 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.
Self Assessment Tests
Endocrine Society’s Endocrine Self Assessment Program (ESAP). Available at
http://www.endoselfassessment.org.
American Association of Clinical Endocrinologists (AACE) Self-Assessment Program
(ASAP) for Endocrinology, Diabetes and Metabolism.
38
Adrenal Disorders
Method of Education
Formal
Direct Clinical
Instruction Experiences
In-patient
1. Cushings syndrome
a) Adrenal
b) Pituitary
c) Ectopic
d) Latrogenic
2. Adrenal Insufficiency
a) Primary (including
polyglandular)
b) Secondary
c) Adrenal crisis
d) Glucocorticoid therapy
3. Pheochromocytoma
4. Mineralocorticoid Excess
a) Aldosteronism
5. Nonfunctioning Adrenal Mass (Including Incidtaloma)
a) Benign
b) malignant
6. Hirsutism and Virilization
7. Congenital adrenal
hyperplasia
8. Fluid and electrolytes
a) Hypernatremia and
hyponatremia
b) Hypokalemia and
Hyperkalemia
c) Metabolic acidosis and
alkalosis
9. Hypertension
a) Primary (Essential)
b) Secondary (Endocrine)
Clinical Case
Discussions
Out-patient Attd. Rds Conference
39
Selfdirected
learning
Method of Evaluation
Direct
observations Discussions Clinical
Written
with patient with faculty Presentation Examination
Bone and Mineral Disorders 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 (i.e., 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 must
begin with a solid understanding of the anatomy and biology of bone matrix and cellular
elements. S/he must 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 must be 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 in the template and
discussed further later. Clinical experience must 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 educational program must have at least 30%
of the experience in this area in ambulatory care settings.
The overall training program must 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, 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 must be in place for the evaluation of the trainees and the
provision of positive and negative feedback. Evaluation can be in the form of faculty
40
critiques of the trainee’s performance, ABIM examinations, or In-Training examinations.
Two self-assessment examinations are also available (ESAP and AACE). Feedback should
be provided both orally at the end of a specific rotation as well as using written evaluation
sheets. In addition, trainees should have an opportunity and a mechanism for providing
feedback to the faculty regarding the quality of teaching and mentoring they receive.
In the attached Discussion of specific learning areas, the panel recognizes certain essential
areas, which each training program must cover. In addition, there are a number of areas
which, while desirable and should be covered by the program, are not mandatory,
particularly if the relevant patient population is not available or appropriate faculty expertise
is not present.
Discussion
The attached template summarizes the key learning areas for the clinical training program.
These are discussed below.
Biology of Bone
The necessary basic background in this area must include an understanding of the
fundamentals of bone biology. Specifically, the trainee must know the macroscopic and
microscopic structure of bone, as well as the fundamentals of bone remodeling and growth
(i.e., the processes of intramembranous and endochondral ossification). S/he must also
have 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 must be
familiar with the various systemic and local factors regulating bone development and
remodeling.
Physiology of Calcium, Magnesium, and Phosphorus Homeostasis
A basic understanding of mineral homeostasis must 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 must also have an
understanding of alterations in calcium and phosphorus homeostasis during physiological
states such as puberty, pregnancy, lactation, and aging.
Molecular Biology, Biochemistry, and Mechanism of Action of Calcitropic Hormones
The trainee must have an understanding of the synthesis and secretion of PTH, its
peripheral metabolism, and mechanism of action. S/he must have knowledge of the role of
the calcium-sensing receptor in normal physiology. The trainee must understand the role
of PTH-rP in malignancy. S/he must 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 must
have an understanding of the synthesis and secretion of calcitonin, as well as its action on
bone resorption.
41
Clinical Evaluation of Bone and Mineral Disorders
The trainee must learn to obtain a comprehensive but relevant history and perform the
appropriate physical examination. This must include a detailed musculoskeletal
examination, as well as other parts of a comprehensive examination (e.g., gonadal exam)
when appropriate.
Laboratory Methods
The trainee must understand the methods, strengths, and limitations of the various
measurements s/he will be requesting. S/he must understand issues of assay accuracy,
variability (assay and biologic) and detection limits. S/he must be able to integrate a
number of tests and recognize specific patterns of test abnormalities associated with
various disease states.
The trainee must 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 must understand issues regarding
the collection and interpretation of ionized calcium and urinary calcium measurements.
S/he must 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 must have knowledge of calcitonin assays, as
well as the role of stimulated calcitonin testing in the diagnosis of C-cell hyperplasia and
medullary thyroid carcinoma. More recently, assays for PTH-rP have become available,
and the trainee must have an understanding of when a PTH-rP level may be useful in the
evaluation of the patient. S/he must have a knowledge of assays for 25-OHD and
1,25(OH)2D, and understand the situations warranting either the 25-OHD measurement
(i.e., 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 must 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 must have a
working knowledge of markers of bone formation and resorption, and their indicated uses.
Finally, the trainee must have knowledge of molecular diagnostics, particularly as they
apply to disorders of bone and calcium metabolism. This includes understanding the
different techniques of molecular diagnostics (i.e., mutation identification using singlestrand 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.
Imaging Techniques/Other Procedures
The training program should have a close working relationship with a skeletal radiologist
42
who can provide expert interpretation of bone radiographs of adults and children. The
trainee must develop the fundamental skills to recognize the radiographic appearance of at
least common metabolic bone diseases (i.e., osteoporosis, hyperparathyroidism,
osteomalacia, Pagets, etc.). Similarly, s/he must 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 must 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 understand 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 should, 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 must 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 must also learn the appropriate use of CT and MR imaging
in the evaluation of patients with persistent or recurrent hyperparathyroidism.
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 must have a thorough
understanding of the epidemiology and current concepts of the pathogenesis of
postmenopausal and age-related osteoporosis. The trainee must 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 must be able to advise the patient on appropriate prevention
measures, and learn to manage the woman going through the menopausal transition. S/he
must 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 must be able to exclude secondary causes of osteoporosis, including multiple
myeloma, underlying malignancy, primary hyperparathyroidism, osteomalacia, and
osteogenesis imperfecta. S/he must be comfortable with the use of both nonpharmacologic (i.e., lifestyle changes, calcium supplementation, and, working with a
physiatrist, prescription of appropriate physiotherapy) and pharmacologic measures (HRT,
SERMs, bisphosphonates, calcitonin, and PTH, when available) for the treatment of
osteoporosis. S/he must be able to evaluate the patient who has sustained an osteoporotic
fracture and institute measures to reduce the risk of subsequent fractures. The trainee
must also be familiar with issues of pain management in patients with vertebral or other
fractures. Finally, s/he should be able to work with the orthopedist in the evaluation of
patients with delayed healing of fractures.
Other Forms of Osteoporosis
43
In addition to postmenopausal and age-related osteoporosis, the trainee must 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 (i.e.,
hyperglycemia, hyperlipidemia) in addition to the metabolic bone disorder. Where
appropriate, the trainee should advise on the management of all of the multiple
endocrine/metabolic derangements in these patients. The trainee must also be familiar with
other skeletal complications of glucocorticoid use, including avascular necrosis. In addition,
the trainee must know how to evaluate and manage other forms of osteoporosis, including
idiopathic (male and female) osteoporosis and various forms of secondary osteoporosis.
Rickets and Osteomalacia
While less common than the various forms of osteoporosis, the trainee must 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 must know the appropriate tests to order in this
setting (i.e., 25-hydroxyvitamin D level, PTH, urine calcium), 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. 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 must also be familiar
with the medical management of these patients.
Hypocalcemic Disorders
The trainee must know how to manage acute hypocalcemia as, for example, in the postoperative setting. This includes the use of intravenous calcium preparations and when they
are indicated. S/he must 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 must 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 must 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.
Renal Osteodystrophy
While primarily managed by the nephrologist, the endocrine trainee must have a clear
understanding of renal osteodystrophy in its various forms, including secondary and tertiary
44
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 should have appropriate training in these
techniques.
Paget’s Disease
The trainee must 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.
Hypercalcemic Disorders
The trainee must have a full understanding of the evaluation and management of
hypercalcemia. S/he must be able to use the PTH assay to make a diagnosis of primary
hyperparathyroidism versus non-parathyroid hypercalcemia (i.e., hypercalcemia of
malignancy, that due to granulomatous disorders, or other miscellaneous causes of
hypercalcemia). S/he must be comfortable differentiating primary hyperparathyroidism from
FHH, as well as pursuing, where appropriate, a diagnosis of familial 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 must know the
necessary evaluation of these patients leading to a decision regarding surgical or medical
management. If the patient goes for surgery, the trainee must work with the surgical team
i n the peri- and post-operative management of these patients, including post-operative
hypocalcemia. Specifically, the trainee must 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 must be familiar with the follow-up of
these patients and the endpoints that would result in a recommendation for surgery. Finally,
s/he must be familiar with evolving approaches to the management of patients with primary
hyperparathyroidism, both surgical (i.e., minimal access parathyroidectomy, alcohol
ablation) and medical (i.e., bisphosphonates, calcium receptor agonists).
In addition to primary hyperparathyroidism, the trainee must know the evaluation and
management of parathyroid cancer. S/he must be able to effectively evaluate and manage
the patient with hypercalcemia in the setting of a suppressed PTH (i.e., hypercalcemia of
malignancy, that due to granulomatous disorders).
Other Mineral Abnormalities
The trainee must be able to identify the possible causes of hypo- and hypermagnesemia in
45
a patient, and to institute appropriate therapy. S/he must be able to identify situations in
which hypomagnesemia is the cause or contributing to hypocalcemia. S/he must also be
able to identify the etiology of hyper- or hypophosphatemia in a patient, and to treat these
conditions.
Nephrolithiasis
The trainee must be able to evaluate the patient with nephrolithiasis. Based on the type of
stone and the evaluation (i.e., identification of hypercalciuria, hyperoxaluria,
hyperuricosuria, or low urinary citrate), the trainee must be able to identify any underlying
disorders such as primary hyperparathyroidism or enteric hyperoxaluria. S/he must 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.
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 is a
great asset to the training program in the accurate diagnosis of these conditions based on
the radiographic findings. The 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.
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.
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 manage these relatively rare conditions, s/he should be familiar
with these disorders and their treatment.
Suggested Reading
Favus MJ, ed. Primer on Metabolic Bone Diseases and Disorders of Mineral Metabolism,
Fourth Edition, Lippincott-Raven, Philadelphia, 1999.
46
Disorders of Bone and Mineral
Formal
Direct Clinical
Instruction Experiences
Method of Education
Clinical Case
Discussions
In-patient Out-patient Attd. Rds Conference
1. Biology of Bone
a) Anatomy/ultrastructure
b)Osteoblasts/osteocytes/
osteoclasts
c) Bone matrix/mineralization
d) Regulation of bone remodeling
2. Physiology of calcium, magnesium, and phosphorous
homeostasis
a) Intestinal absorption
b) Renal handling
c) Calcium flux in/out of bone
d) Mineral balance and
homeostasis
3. Molecular biology, biochemistry, and mechanism of action of calcitropic
hormones
a) Synthesis and metabolism of
PTH
b) PTH – Mechanism of action
c) PTH - rP
d) Vitamin D and metabolites
e) Calcitonin
4. Clinical Evaluation of Bone and Mineral Disorders
a) Comprehensive, relevant
history
b) Physical examination
5.Laboratory Methods/ Understanding assays for:
a) Calcium, phosphorus, and
magnesium
b) Ionized calcium
c) PTH
d) Calcitonin
e) PTH-rP
f) Vitamin D metabolites
g) Urinary calcium
h) Biochemical markers for bone
turnover
i) Molecular diagnosis of bone
and mineral disorders
47
Selfdirected
learning
Method of Evaluation
Direct
Discussions Clinical
Written
observations with faculty Presentation Examination
with patient
Disorders of Bone and Mineral
Method of Education
Formal
Direct Clinical
Instruction Experiences
Clinical Case
Discussions
In-patient
6. Imaging techniques/ other procedures
a) Bone radiology in children and
adults
b) Bone scintigraphy
c) Bone density and
measurement
d) Bone biopsy
e) Bone histomorphometry
f) Parathyroid imaging
7. Postmenopausal and Age-related Osteoporosis
a) Epidemiology
b) Pathogenesis
c) Role of physical activity
d) Nutrition and osteoporosis
e) Prevention of osteoporosis
f) Evaluation and treatment of
osteoporosis
8. Other Forms of Osteoporosis
a) Juvenile osteoporosis
b) Idiopathic (male and female)
osteoporosis
c) Glucocorticoid osteoporosis
d) Transplant related
osteoporosis
e) Other forms of secondary of
osteoporosis
9. Rickets and Osteomalacia
a) Nutritional rickets and
osteomalacia
b) Bone disease secondary to
GI/liver d/o
c) Vitamin D dependent rickets
d) Hypophosphatemic rickets
e) Tumor induced osteomalacia
f) Hypophosphatasia
g) Fanconi syndrome and RTA
h) Drug induced osteomalacia
Out-patient Attd. Rds Conference
48
Selfdirected
learning
Method of Evaluation
Direct
observations Discussions Clinical
Written
with patient with faculty Presentation Examination
Disorders of Bone and Mineral
Method of Education
Formal
Direct Clinical
Instruction Experiences
Clinical Case
Discussions
In-patient
Out-patient Attd. Rds Conference
10. Hypocalcemic disorders
a) Hypoparathyroidism
b) Parathyroid resistance
c) Misc causes of hypocalcemia
11. Renal Osteodystrophy
12. Paget’s Disease
13. Hypercalcemic disorders
a) Primary hyperparathyroidism
b) Familial hpt syndromes/ MEN
c) Familial hypocalciuric
hypercalcemia
d) Hypercalcemia of Malignancy
e) Hypercalcemia due to
granulomatous d/o
f) Other, misc causes of
hypercalcemia
14. Other mineral abnormalities
a) Magnesium depletion and
hypermagnesemia
b) Hyper- and
hypophosphatemia
15. Nephrolithiasis
16. Genetic, developmental,
and dysplastic d/o
17. Skeletal neoplasms/
infiltrative d/o
18. Extraskeletal calcification/
ossification
49
Selfdirected
learning
Method of Evaluation
Direct
observations Discussions Clinical
Written
with patient with faculty Presentation Examination
Diabetes Introduction
Diabetes is an increasingly common, potentially devastating, extraordinarily expensive,
treatable, but incurable, chronic disease. It is by far the most common endocrine disorder that
seriously impacts health and limits longevity in those affected. An estimated 16 million
Americans, and 135 million people worldwide, have diabetes. The World Health Organization
projects the latter will grow to 300 million by the year 2025. Many more have impaired glucose
tolerance or impaired fasting glucose and are at high risk for atherosclerotic disease and
diabetes. People with diabetes are at 2- to 4-fold increased risk for a myocardial infarction or a
stroke. Diabetes is the leading cause of blindness with its onset in working age adults and of
non-traumatic amputations, and the most common single cause of end-stage renal disease
requiring dialysis and transplantation. Medical care for people with diabetes costs
approximately $100,000,000,000 per year in the United States. Much of this is for the care of
long-term microvascular and macrovascular complications of diabetes that are now known to
be in large part preventable.
Sequelae of Treatment
It is now well-established that treatment makes a long-term difference for people with diabetes.
Currently available treatments are far from ideal, but they are demonstrably effective. These
treatments involve an integrated care team (e.g., an endocrinologist, a diabetes educator, a
nutritionist). Among the specific objectives of our training program is to teach our trainees
(residents) in Endocrinology, Diabetes and Metabolism to know and understand the evidence
that in people with diabetes:
(1) glycemic control reduces the risk of microvascular events (retinopathy, nephropathy and
neuropathy) and may reduce macrovascular events;
(2) treatment of dyslipidemia reduces the risk of macrovascular events;
(3) treatment of hypertension and even early nephropathy reduces end-stage renal disease
and other microvascular as well as macrovascular events;
(4) aspirin reduces macrovascular events;
(5) treatment of early retinopathy reduces blindness;
(6) foot care reduces amputations; and
(7) implementation of Standards of Care results in better glycemic control and
reduces costs.
Treatment Goals and Minimum Outcome Measures
Additional objectives are to know, understand and pursue the recommended treatment goals
(updated by the ADA in each January issue of Diabetes Care) and minimum outcome
measures shown in the following tables.
Treatment Goals
Hemoglobin A1c (%)
Goal
<7
Action Required*
>8
50
80-120
<80, >140
Preprandial Glucose
(mg/dL)
Bedtime Glucose (mg/dL) 100-140
<100, >160
LDL Cholesterol (mg/dL) <100
>130
Triglycerides (mg/dL)
< 200
> 400
Blood Pressure (mm Hg) < 130/85
> 135/90
Urine Microalbumin
Normal
Elevated
*Actions might include additional self-management education, medical nutrition therapy, or
both; increased SMBG, patient contact, or both; adjustment of meal plan, exercise, or
pharmacological therapy; or co-management or referral to a diabetes specialist. In some
individual patients it may be appropriate not to act, but the rationale for that decision should
be made explicit. These goals need to be modified for children with diabetes.
Minimum Outcome Measures
Hemoglobin A1c
Annually*
Dilated Eye Exam
Annually
Foot Exam
Annually
Blood Pressure
Annually
Urine Microalbumin
Annually
Fasting Lipid Profile
Annually
Self-Management Education
Annually
Medical Nutrition Therapy
Annually
Serum TSH
Annually
Self Blood Glucose Monitoring
Yes
Tobacco Counseling
Yes
*ADA Recommendation: Quarterly until glycemic control is achieved, then semiannually or
annually.
Comprehensive Patient Evaluation
Given this knowledge it is our objective to teach trainees to evaluate patients with diabetes
comprehensively including assessments of:
(1) glycemic control (long-term with HbA1C, short-term with the history and the SMBG log
including identification of both hyper- and hypoglycemia);
(2) blood pressure control;
(3) lipid control (fasting lipid profile);
(4) the status of microvascular complications (history, dilated eye examination, detailed foot
examination including monofilament testing, urine albumin);
(5) macrovascular complications (history, cardiovascular examination);
(6) the need for additional self-management education, medical nutrition therapy, or both;
and
(7) smoking status.
These basic principles are emphasized throughout the trainee’s training experience in our
inpatient and outpatient care settings as well as in our didactic program and our clinical
conferences. It is our premise that, while complications of diabetes must be detected and
51
treated in their early stages, the prevention of complications through comprehensive diabetes
care is the new paradigm in the management of diabetes.
An additional objective of our program is to provide, through research experience and
didactic instruction, insights into the basic and clinical scientific advances that will lead to
improvements in the prevention and treatment of diabetes and its complications.
Clinical Experience
Our training program provides opportunities for the trainee in Endocrinology, Diabetes and
Metabolism to develop clinical competence and expertise in the management of diabetes.
Our educational program – including the mission of the Division of Endocrinology, Diabetes
and Metabolism, the educational goals and objectives and the anticipated educational
outcomes of our fellowship program, its methodologies for teaching, faculty, methods of
evaluation and its educational settings (inpatient consultations, outpatient clinics and
conferences including the formal didactic program) – was detailed in Section I. Our facilities
and resources were described in Section II. Its clinical experiences as they relate to diabetes
are described in the paragraphs that follow.
The clinical experiences of our trainees include opportunities to diagnose and manage
inpatients and outpatients, representing adolescent and adult patients of both sexes and
representing variable acuity, with both types 1 and type 2 diabetes as well as the uncommon
types of diabetes. It also includes opportunities for the trainee to function in the role of
consultant for patients and other physicians and services in both inpatient and outpatient
settings.
Training in comprehensive diabetes care occurs repetitively in the setting of the trainee's
supervised inpatient and outpatient care of people with diabetes in the context of our didactic
diabetes teaching program. The latter includes Lectures (e.g., Standards of Care for People
with Diabetes, Management of Type 1 Diabetes, Management of Type 2 Diabetes, Diabetic
Ketoacidosis and Nonketotic Hypersmolar Syndrome, Diabetic Macro- and Microvascular
Complications, Dyslipidemia, Hypertension, and Hypoglycemic Syndromes), as well as selfdirected and faulty-directed reading about diabetes, including both specific and generic
reading.
In this context trainees become competent and then expert in the comprehensive
management of diabetes through supervised, progressive responsibility for the care of people
with diabetes in their inpatient and outpatient activities throughout their fellowship training.
This allows them to observe the natural history of diabetes and its complications, as well as
the effectiveness of therapeutic interventions. Trainees have experience representing
variable acuity and the full spectrum of diabetes. To accomplish these goals, more than 30%
of the training in diabetes occurs in ambulatory care settings.
Patient Encounters, Trainee Supervision and Evaluation
Patient encounters are supervised by a member of the Endocrinology, Diabetes and
Metabolism faculty who reviews the historical, physical and other information gathered by the
trainee with that trainee at the bed side/examination table and provides immediate
confirmatory or corrective feedback. That faculty member then reviews the trainee’s
52
diagnostic and therapeutic plans, again providing immediate feedback. Learning is facilitated
further by self-directed reading of the literature, reading suggested by the
responsible faculty member, or both and by patient follow-up. The latter includes analysis of
subsequent laboratory findings and of the patient’s course with refinement of the
management plan over time, again in consultation with the responsible faculty member.
Thus, learning is evaluated by direct observation of the trainee by the faculty member and
discussions with that and other faculty and colleagues including presentations at rounds and
case conferences as well as by formal written self-assessment (e.g., ESAP, ASAP, or both).
Biochemisty and Physiology
Our curriculum emphasizes biochemistry and physiology, including cell and molecular
biology as they relate to diabetes and its complications. These are fundamental to the
management of diabetes. The appropriate utilization and interpretation of clinical laboratory,
radionuclide and radiologic studies for the treatment of diabetes is stressed throughout the
clinical and didactic program.
Preventive Care
Trainees have clinical experience in multidisciplinary diabetes education and treatment
programs. As detailed earlier, our program emphasizes the training of fellows in the
preventive aspects of diabetes care (i.e., glycemic control, lipid control, blood pressure
control, aspirin, smoking cessation etc. and the identification and treatment of early
microvascular and macrovascular complications) in the context of the Standards of Care and
Outcome Measures recommended by the American Diabetes Association (updated each
January in Diabetes Care) [or the Medical Guidelines for the Management of Diabetes
Mellitus recommended by the American Association of Clinical Endocrinologists (Endocrine
Practice 6:43, 2000).] Patient education – by the physician, the diabetes educator, the
nutritionist and other specialists – is a fundamental component of diabetes care. Because
diabetes is so common, patients with this disease are seen by trainees in virtually all of their
inpatient and outpatient encounters and the team approach is also utilized in all of those
settings. In addition, multidisciplinary diabetes education and treatment is the central focus of
our Diabetes Clinic (specify).
Accreditation Council for Graduate Medical Education Program Requirements
The ACGME Program Requirements for Residency Education in Endocrinology, Diabetes
and Metabolism include a heavy emphasis on diabetes. We include these guidelines for your
reference.
III.A.4.Residents must have clinical experience in a multidisciplinary diabetes and
education program.
III.A.5.Residents must have formal instruction, clinical experience, or opportunities to
acquire expertise in the evaluation and management of the following disorders…
c. Type 1 and 2 diabetes mellitus including
(1) Patient monitoring and treatment objectives in adolescents and adults
(2) Acute and chronic complications, including
53
(a) Diabetic ketoacidosis
(b)Hypersmolar non-ketotic syndromes
(c) Hypoglycemia
(d) Microvascular and macrovascular disease, including
(i) Diabetic Retinopathy
(ii) Diabetic nephropathy
(iii) Diabetic neuropathy
(iv) Dermatologic aspects of diabetes
(v) Coronary heart disease
(vi) Peripheral vascular disease
(vii) Cerebrovascular disease
(e) Infections in the diabetic patient
(3) Gestational diabetes
(4) Diabetes mellitus in the pregnant patient
(5) The surgical patient with diabetes mellitus
(6) Patient education
(7) Psychological issues
(8) Genetics and genetic counseling as it relates to patients with endocrine and metabolism
disorders
(9) Dietary principles
III.B.5. (Provision must be made for the residents to acquire experience and skill in the
following areas:) Management of adolescent and adult patients of all ages with diabetes
mellitus, including but not limited to the following aspects of the disease:
(a) The utilization and interpretation of autoimmune markers of type 1 diabetes in patient
management and counseling
(b) Prescription of exercise program
(c) Rationale for and calculation of diabetic diets
(d) Oral antidiabetic therapy
(e) The use of intravenous insulin in acute decompensated diabetes mellitus
(f) Chronic insulin administration, including use of all varieties of insulin delivery systems
(g) Glucose monitoring devices
(h) Funduscopic examination, recognition, and appropriate referral of patients with diabetic
retinopathy
(i) Foot care
(j) Psychosocial effects of diabetes mellitus on patients and their families
(k) Patient and community education
III.C.1. The formal curriculum of the program must, at a minimum, provide instruction in the
following:
(1) Pathogenesis and epidemiology of diabetes mellitus
(2) Genetics as it relates to endocrine diseases
(3) Developmental endocrinology, including growth and development and pubertal
maturation, as it relates to diabetes.
(4) Endocrine physiology and its pathophysiology in diabetes and principles of hormone
action.
(5) Biochemistry and physiology, including cell and molecular biology and immunology, as
they relate to diabetes.
54
(6) Signal transduction pathways and biology of hormone receptors.
Trainees in our program have formal instruction, clinical experience or opportunities to
acquire expertise in each of these areas. The methods of education/educational settings and
the methods of evaluation are detailed in the table.
Technical and Other Skills
Trainees also develop technical and other skills relevant to diabetes. The issues of the
performance of endocrine clinical laboratory and radionuclide studies and basic laboratory
techniques – including quality control, quality assurance and proficiency standards – are
addressed specifically in the trainee’s didactic program. In addition, trainees gain experience
in these areas in their clinical and research activities.
Provision is made for the trainees to acquire experience and skill in the interpretation of
laboratory tests, including those based on immunoassays, radionuclide, ultrasound,
radiologic and other imaging studies and the effects of a variety of non-endocrine disorders
on laboratory and imaging studies, and performance and interpretation of stimulation and
suppression tests. This occurs in their inpatient and outpatient activities and in their patientbased conferences including the didactic program.
Provision is also made for the trainees to acquire experience and skill in the management of
adolescent and adult patients of all ages with diabetes mellitus, including the utilization and
interpretation of autoimmune markers of type 1 diabetes in patient management and
counseling, prescription of exercise programs, the rationale for and calculation of diabetic
diets, oral antidiabetic therapy, the use of intravenous insulin administration in acute
decompensated diabetes, the use of all varieties of insulin delivery systems, glucose
monitoring devices, funduscopic examination and recognition and appropriate referral of
patients with diabetic retinopathy, foot care, psychosocial effects of diabetes on patients and
their families, and patient and community education. They acquire experience and skill in
each of these aspects of diabetes care through conferences and their inpatient and
outpatient activities. Among the latter, the Diabetes Clinic focuses specifically on diabetes
care including the team concept and approaches to the prevention of complications.
Formal Instruction
The curriculum of our training program provides formal instruction in the pathogenesis and
epidemiology of diabetes and genetics as it relates to diabetes. This occurs in lectures,
clinical conferences and research seminars as well as in patient care settings. Indeed,
discussions of issues such as the relative roles of insulin deficiency and insulin resistance in
the pathogenesis of type 2 diabetes, the possible reasons for the increasing incidence of
diabetes in developing as well as developed countries and the most recent insights into the
molecular genetics of diabetes are recurring topics in the trainees’ clinical and research
activities. Thus, there is considerable informal as well as formal instruction in these areas.
Finally, trainees also receive formal instruction in developmental endocrinology – particularly
growth, development and pubertal maturation – as it relates to diabetes, in endocrine
physiology and pathophysiology in diabetes and systemic diseases and principles of
hormone action, in biochemistry and physiology, including cell and molecular
55
biology and immunology, as they relate to endocrinology and metabolism in general and
diabetes in particular, and signal transduction pathways and biology of hormone receptors.
These are fundamental to the practice of modern endocrinology, diabetes and metabolism
including clinical diabetology.
Suggested Reading Journal Articles
The DCCT Research Group. The effect of intensive treatment of diabetes on the
development and progression of long-term complications in insulin-dependent diabetes
mellitus. N Engl J Med. 1993; 329:977-986.
The DCCT Research Group. Lifetime benefits and costs of intensive therapy as practiced in
the Diabetes Control and Complications Trial. J Am Med Assoc. 1996; 276:1409-1415.
The UKPDS Group. Intensive blood glucose control with sulphonylureas or insulin compared
with conventional treatment and risk of complications in patients with type 2 diabetes.
Lancet.1998; 352:837-853.
The UKPDS Group. Effect of intensive blood glucose control with metformin on complications
in overweight patients with type 2 diabetes. Lancet. 1998; 352:854-865.
The UKPDS Group. Tight blood pressure control and risk of macrovascular and
microvascular complications in type 2 diabetes. Brit Med J. 1998; 317:703-713.
The UKPDS Group. Efficacy of atenolol and captopril in reducing risk of macrovascular and
microvascular complications in type 2 diabetes. Brit Med J. 1998; 317:713-720.
The UKPDS Group. Cost effectiveness analysis of improved blood pressure control in
hypertensive patients with type 2 diabetes. Brit Med J. 1998; 317:720-726.
Pyörälä K, Pederson TR, Kjekshus J, Faergeman O, Olsson AG, Thorgeirson G. Cholesterol
lowering with simvastatin improves prognosis of diabetic patients with coronary heart
disease: a subgroup analysis of the Scandinavian Simvastatin Survival Study.
Diabetes Care. 1997; 20:614-620.
Haffner SM, Lehto S, Rönnemaa T, Pyörälä K, Laakso M. Mortality from coronary heart
disease in subjects with type 2 diabetes and in nondiabetic subjects with and without
myocardial infarction. N Engl J Med. 1998; 339:229-234.
Haffner SM, Alexander CM, Cook TJ, et al. Reduced coronary events in simvastatin-treated
patients with coronary heart disease and diabetes or impaired fasting glucose levels. Arch
Intern Med. 1999; 159:2661-2667.
Lewis EJ, Hunsicker LG, Bain RP, Rohde RD. The effect of angiotensin-converting-enzyme
inhibition on diabetic nephropathy. N Engl J Med. 1993; 329:1456-1462.
The Heart Outcomes Prevention Evaluation Study Investigators. Effects of an angiotensinconverting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J
56
Med. 2000; 342:145-153.
The Heart Outcomes Prevention Evaluation Study Investigators. Effects of ramipril on
cardiovascular and microvascular outcomes in people with diabetes mellitus: Results of the
HOPE study and MICRO-HOPE substudy. Lancet. 2000; 355:253-259.
American Diabetes Association. Clinical Practical Recommendations 2000. Diabetes Care.
2000; 23(Suppl 1):S1-S116.
Case conferences, journal clubs and research seminars focused on diabetes and related
issues
57
Diabetes Mellitus
Method of Education
Formal
Direct Clinical
Instruction Experiences
In-patient
Clinical Case
Discussions
Out-patient Attd. Rds Conference
1. General
a) Patient monitoring
b) Treatment objectives in adults
c) Objectives in adolescents
2. Acute and chronic complications
a) Ketoacidosis
b) Hyperosmolar non-ketotic
coma
c) Hypoglycemia
d) Retinopathy
e) Nephropathy
f) Peripheral neuropathy
g) Autonomic neuropathy
h) Dermatologic
i) Coronary heart disease
j) Peripheral vascular disease
k) Cerebral vascular disease
3. Gestational diabetes mellitus
a) Screening
b) Treatment
4. Surgical management
a) Pre-operative preparation
b) Post-operative preparation
5. Patient education
a) Home glucose monitoring
b) Psychosocial issues
c) Genetics and counseling
d) Nutrition
e) Hypoglycemia
f) Exercise
g) Foot care
6. Therapy
a) Oral agents
b) Subcutaneous insulin
c) Insulin Pump
d) Intravenous Insulin and DKA
58
Selfdirected
learning
Method of Evaluation
Direct
observations Discussions Clinical
Written
with patient with faculty Presentation Examination
Diabetes Mellitus (page 2)
Formal
Direct Clinical
Instruction Experiences
In-patient
Method of Education
Clinical Case
Discussions
Out-patient Attd. Rds Conference
7. Other
a) Pathogenesis of diabetes
mellitus
b) Genetics as it relates to
diabetes
8. Disease specific studies/ procedures
a) Fundoscopic examination
b) Photocoagulation therapy
9. Hypoglycemic Syndromes and
Islet tumors
59
Selfdirected
learning
Method of Evaluation
Direct
observations Discussions Clinical
Written
with patient with faculty Presentation Examination
Gonadal Disorders Introduction
Endocrinology of the reproductive system encompasses normal pubertal development and
adult male and female reproductive function and the effects of excesses or deficiencies of
reproductive hormones on other body systems. Issues in reproductive endocrinology are
extremely prevalent in the population, highlighting the importance of this area in an endocrine
training program. Disorders of this system may arise at a hypothalamic, pituitary or gonadal
level as a result of a primary abnormality or secondary to abnormalities in other endocrine or
non-endocrine organs. These disorders may present as primary or acquired hypogonadism,
infertility, or erectile dysfunction or with evidence of hyperandrogenism or hyperestrogenism. In
addition, this area includes abnormalities of primary or secondary reproductive end organs
such as skin, penis and accessory sex organs such as prostate, uterus, or breast. This is an
extremely important area of endocrinology, not only due to the prevalence of primary
abnormalities of the reproductive system per se, but also because of the profound impact of
gonadal hormone abnormalities on other endocrine and non-endocrine systems including
bone, thyroid, adrenal, metabolic, dermatologic, cardiovascular, muscle, neurologic and
psychiatric. Disorders of non-reproductive systems may be hormone dependent and conversely
non-reproductive disorders often affect the reproductive axis.
Goals
It is our intention that the trainee develop the following:
1. An understanding of the physiology of: (1) normal male and female adrenarche and
puberty; (2) the normal menstrual cycle; (3) normal male reproductive physiology; (4) the
physiology of the menopause and the physiology of reproductive aging in men and women;
and (5) an understanding of the genetics of disorders of the reproductive system.
2. An understanding of the biochemistry, cell biology, and molecular biology of gonadotropinreleasing hormone, the gonadotropins, gonadal steroids and the inhibin/activin/follistatin family
of proteins; an understanding of factors involved in growth and differentiation of the gonads
(including germ cell development ), internal genitalia and accessory sex organs, and
autocrine/paracrine interactions in reproductive function; knowledge of the mechanism of
gonadotropin and steroid hormone action.
3. Familiarity with the types of assays available for the measurement of gonadotropins,
steroids, inhibins and insulin and the clinical utility of these assays in the diagnosis and
management of patients with reproductive disorders; familiarity with the evaluation and
interpretation of semen analysis.
4. An understanding of how to perform, evaluate and determine the utility of dynamic
provocative endocrine testing as it applies to the reproductive system.
5. An understanding of how to evaluate and determine the utility of pelvic ultrasonography and
hypothalamic/pituitary, adrenal, prostate and testicular imaging, and bone densitometry.
6. A comprehensive understanding of how to evaluate and manage disorders of sexual
differentiation, disorders arising in the pediatric age group including congenital adrenal
hyperplasias, chromosomal disorders such as Turner and Klinefelter syndromes, and
60
precocious or delayed puberty.
7. A comprehensive understanding of how to evaluate and manage female reproductive
disorders including: (1) primary amenorrhea; (2) secondary amenorrhea or oligomenorrhea;
(3) galactorrhea; (4) hyperandrogenism; (5) dysfunctional uterine bleeding; (6) ovarian lesions;
(7) premenstrual symptoms; (8) peri-menopausal and menopausal symptoms; and
(9) infertility. The trainee may also receive training in ovulation induction.
8. A comprehensive understanding of how to evaluate and manage male reproductive
disorders including: (1) primary and acquired male hypogonadism; (2) gynecomastia; (3)
erectile dysfunction; (4) testicular masses; (6) prostatic disorders; and (7) fertility disorders
including induction of spermatogenesis.
9. Due to their prevalence the following areas should receive special attention: (1) the
diagnosis, pathophysiology, and genetics of polycystic ovarian syndrome and its metabolic
consequences; (2) male subfertility, erectile dysfunction and prostate disorders; and (3)
perimenopausal and menopausal management, including decreased libido.
10. An understanding of the clinical presentation and prevalence of hormone producing
neoplasms of the testis and ovary and of tumors that affect hypothalamic and pituitary function;
familiarity with the treatment of hormone responsive tumors and disorders (breast, prostate,
endometrium, neurologic).
11. An understanding of the effects of age on the reproductive axis in men and women and
the subsequent effects of hypogonadism on other systems.
12. An understanding of the effects of acute and chronic disease on the reproductive system
in men and women.
13. An understanding of the interaction of psychosocial disorders with the reproductive system
including premenstrual dysphoric disorder, eating disorders, perimenopausal mood disorders,
sexual dysfunction, decreased libido and substance abuse and facility in basic counseling and
triage in these areas.
14. An understanding of the physiology and importance of the following drugs as they apply to
the reproductive system: (1) GnRH, GnRH agonists/ antagonists, gonadotropins; (2) hormonal
contraceptives; (3) selective androgen and estrogen receptor modulators (SARMS and
SERMS); (4) hormone replacement therapy in men women; (5) non-hormonal strategies for
menopause management; and (6) non-prescription and environmental compounds.
15. An understanding of the emerging technologies and treatment and how they impact on the
comprehensive management of reproductive endocrine disorders including assisted
reproductive technologies and genetic testing and facility in counseling patients regarding
these options.
Training
1. The training program must provide opportunities for the trainee to develop clinical
61
competence in reproductive endocrinology. The opportunity to diagnose and manage male and
female adolescent and adult patients with reproductive endocrine disorders will occur primarily
in an outpatient setting due to the generally non-acute nature of these problems, but must also
include attention to reproductive endocrine issues in inpatients with other endocrine and nonendocrine diagnoses. This training is likely to require interaction with pediatric endocrinology,
gynecology, urology, oncology, genetics, surgery, pathology, radiology and/or other
subspecialties.
2. The trainee must be given the opportunity to assume responsibility for and follow patients
with reproductive endocrine disorders throughout the training period. Due to the nature of these
disorders, the majority of follow-up will be in outpatient settings. Appropriate experience with
the spectrum of reproductive endocrine disorders in adolescents and in male and female
patients may require that trainees see patients with a number of different attendings or in
several different types of clinics.
3. In addition to mentored inpatient and outpatient diagnosis and management of patients with
endocrine abnormalities pertaining to the reproductive system, trainees must be given the
opportunity to gain experience with case presentation and critique in informal and formal
settings to develop their own skills as teachers and consultants.
4. Due to the rarity of certain conditions and the need to cover a broad spectrum of
reproductive endocrine disorders in males, females and adolescents, patient encounters must
be supplemented by an ordered series of sessions that may be either didactic or problemoriented in approach.
5. Formal instruction must be provided in the types of assays used for measurement of
gonadotropins, steroids and inhibins and the concepts of standards, sensitivity and specificity
as they pertain to these hormone assays. Individualized instruction must also be provided in
examination of the pelvis, breast, testis and prostate and in semen analysis. Formal instruction
and experience in induction of spermatogenesis must be provided. Other technologies, which
have an impact on diagnosis and management of disorders of the reproductive system, may be
included such as pelvic ultrasound and induction of ovulation.
6. Self-assessment tools should be available to assist the trainee in acquiring knowledge in
reproductive endocrine areas.
Evaluation
Trainees should be evaluated on their clinical skills in patient interactions, physical diagnosis,
differential diagnosis and formulation of evaluation and treatment plans throughout the training
period. Feedback must be given in an ongoing manner in the clinical setting and formal verbal
and written evaluation must be provided at year-end.
Procedures must be monitored in an ongoing way throughout the training period and ongoing
verbal feedback provided to the trainee.
Case presentations in formal and informal settings will provide an important means of
evaluating students and advantage should be taken of the available self-evaluation programs.
62
Suggested Reading
Textbooks
Sperling M. Pediatric Endocrinology. 1st ed. WB Saunders Co; 1996. Liftshitz F. Pediatric
Endocrinology. 3rd ed.. Dekker; 1996.
Tulchinsky B, Little AB, eds. Maternal-Fetal Endocrinology. 2nd ed. Philadelphia, Pa: WB
Saunders Co; 1994.
Martinez-Mora J. Textbook of Intersexual States. Doyma; 1994.
Yee Wm, Rosen G, Cassidenti D. Transvaginal Sonography in Infertility. Lippincott-Raven;
1995.
Azziz R, Nestler J, DeWailly D, eds. Androgen Excess Disorders in Women. Lippincott- Raven;
1997.
Yen SSC, Jaffe RB, Barbieri RL, eds. Reproductive Endocrinology. 4th ed. Philadelphia, Pa:
WB Saunders Co; 1999.
CD-ROM
Male and Female Reproductive Endocrinology Sections. Up-to-Date in Endocrinology &
Diabetes [serial on CD-ROM]. The Endocrine Society, 2000.
Internet sites
National Center for Biotechnology Information. Online Mendelian Inheritance in Man. Available
at http://www.ncbi.nlm.nih.gov/omim.
American Association for Clinical Endocrinologists. AACE Guidelines in Male Hypogonadism,
Menopause and Sexual Dysfunction. Available at
https://www.aace.com/publications/guidelines.
Journal Articles
Hulley S, Grady D, Bush T, et al for the Heart and Estrogen/progestin Replacement Study
(HERS) Research Group. Randomized Trial of Estrogen Plus Progestin for Secondary
Prevention of Coronary Heart Disease in Postmenopausal Women. JAMA. 1998;280:605- 613.
Collaborative Group on Hormonal Factors in Breast Cancer. 1997 Breast cancer and hormone
replacement therapy: collaborative reanalysis of data from 51 epidemiologic studies of 52,705
women with breast cancer and 108,411 women without breast cancer. Lancet.
350:1047-1059.
Hayes FJ, Seminara SB, Crowley WF, Jr. Hypogonadotropic Hypogonadism. Endocrinol Metab
Clin North Amer. 1998; 4:739-763.
63
Hayes FJ, Welt CK, Martin KA, Crowley WF, Jr. GnRH deficiency: Differential diagnosis and
treatment. Endocrinologist. 1999;9:36-44.
Adashi EY, Hennebold JD. Single-gene mutations resulting in reproductive dysfunction in
women. N Engl J Med. 1999;340(9):709-718.
Taylor AE. Polycystic ovary syndrome. Endocrinol Metab Clin North Am. 1998;27(4):877-902.
Endocrine Reviews, Vol 20, No. 3, June 1999.
Suggested Self-Evaluation Tools: Endocrine Self-Assessment Program
64
Gonadal Disorders
Method of Education
Formal
Direct Clinical
Instruction Experiences
In-patient
Clinical Case
Discussions
Out-patient Attd. Rds Conference
1. Female
a) Normal female reproductive
physiology including puberty
b) Primary/ secondary
amenorrhea
c) Dysfunctional uterine bleeding
d) Hirsutism/ virilization
e) Polycystic ovarian syndrome
f) Infertility
g) Menopause
2. Male
a) Normal male reproductive
physiology including puberty
b) Hypogonadism
c) Gynecomastia
d) Erectile dysfunction
e) Infertility
f) Prostatic disorders
3. Pediatric
a) Intersex disorders
b) Precocious puberty
c) Delayed puberty
d) Gonadal dysgenesis
4. Neoplasia
a) Testicular tumors
b) Ovarian tumors
5. Disease Specific Studies/ Procedures
a) GnRH/ GnRH analogues
b) Ovarian ultrasound
c) Pelvic examination
d) Semen analysis
e) Induction of spermatogenesis
f) Male/Female hormone
replacement
g) Ovulation induction
(suggestion)
65
Selfdirected
learning
Method of Evaluation
Direct
observations Discussions Clinical
Written
with patient with faculty Presentation Examination
Hypothalamic-Pituitary Disorders Introduction
Growth, development and reproduction are regulated by the interactions of the endocrine and
nervous systems. The pituitary regulates endocrine organs under the influence of the
hypothalamus. Disorders of the pituitary and hypothalamus may therefore cause isolated or
multisystem endocrine hypofunction and hyperfunction. Furthermore, expanding lesions of
the pituitary/hypothalamic area may cause neurologic dysfunction.
Goals: Trainees will acquire an understanding of (1) neuroendocrine physiology, specifically
hypothalamic/pituitary anatomy and morphology, regulation of hormone secretion, cellular
and molecular mechanisms of action (receptors, signal transduction pathways, gene
interaction); (2) the pathophysiology, clinical manifestations, diagnostic approaches, and
treatment of hypothalamic and pituitary dysfunction. By the end of their training, trainees will
be competent in the evaluation and management of patients with hypothalamic-pituitary
disorders (see below).
Training and Evaluation: These objectives will be accomplished through a combination of
interdisciplinary conferences, formal lectures, case discussions, direct clinical experience,
and self-directed learning. Clinical training will include close interactions with other related
disciplines, including neurosurgery, neuroradiology, neurology, neuro-ophthalmology,
pathology, and nuclear medicine. Trainees will receive regular evaluations through frequent
individual assessments from supervising faculty and semiannual evaluations by the Program
Director.
Diagnostic Testing
The trainee will be able to understand the indications, performance and interpretation of the
following tests.
Basal Hormone levels
(1) prolactin (PRL)
(2) insulin-like growth factor-1 (IGF-1)
(3) growth hormone (GH)
(4) Free thyroxine (T4)
(5) thyrotropin (TSH)
(6) Cortisol (plasma and urine, including metabolites)
(7) adrenocorticotropic hormone (ACTH)
(8) luteinizing hormone (LH)
(9) follicle stimulating hormone (FSH)
(10) testosterone/estradiol
(11) serum osmolality
(12) urine osmolality.
Dynamic Hormone Testing
(1) Insulin-hypoglycemia stimulation (insulin tolerance test)
(2) Thyrotropin Releasing Hormone (TRH) stimulation test
66
(3) Gonadotropin Releasing Hormone (GnRH) stimulation test
(4) Corticotropin Releasing Hormone (CRH) stimulation test
(5) GH stimulation tests (L-dopa, arginine, clonidine, exercise, glucagon, GH
Releasing Hormone [GHRH], insulin-hypoglycemia)
(6) ACTH (cosyntropin) stimulation test
(7) Metyrapone test
(8) Dexamethasone suppression test
(9) Oral glucose suppression test
(10) Water deprivation test.
Neuroradiology
The trainee will understand the indications for and interpretation of the following procedures.
Magnetic Resonance Imaging (MRI) Computed Tomography (CT) Inferior Petrosal Sinus
Sampling
Neuroophthalmology
The trainee will understand the indications for and interpretation of formal visual field
examinations
6.2.4 Other Tests (growth charts, radiologic bone age)
6.2.5 Treatment Modalities
The trainee will understand the indications, advantages and adverse effects of surgical,
medical and irradiation (conventional and stereotactic) therapies for hypothalamic-pituitary
disorders.
Specific Disorders
The trainee will receive formal instruction, and clinical experience in the evaluation and
management of the following disorders.
Pituitary Adenomas Prolactinomas
(1) Manifestations (galactorrhea, amenorrhea, infertility, erectile dysfunction, osteopenia,
neurologic mass effects)
(2) Diagnostic tests (basal PRL, assessment for hypopituitarism when indicated, exclusion of
other causes of hyperprolactinemia, MRI)
(3) Management options (dopamine agonists, surgery, irradiation)
(4) Special considerations for pregnancy and MEN1
GH-secreting adenomas
(1) Manifestations (acromegaly, gigantism, neurologic mass effects)
(2) Diagnostic tests (IGF-1, glucose suppression test of GH, assessment for hypopituitarism
when indicated, MRI)
(3) Management options (surgery, somatostatin analogs, GH antagonists, dopamine
agonists, irradiation)
(4) Special considerations - ectopic GHRH syndrome, assessment for co-secretion of PRL,
TSH, ACTH, association with MEN1
67
ACTH-secreting adenomas
(1) Clinical manifestations – Cushing’s syndrome
(2) Diagnostic tests (urinary free cortisol, ACTH, dexamethasone suppression testing, CRH
testing, MRI, Inferior Petrosal Sinus Sampling, assessment for hypopituitarism when
indicated)
(3) Management options (surgery, irradiation, medical [ketoconazole, mitotane,
metyrapone, and other agents])
(4) Special considerations - differential diagnosis from ectopic ACTH and ectopic CRH is
critical; Nelson’s syndrome
TSH-secreting adenomas
(1) Clinical manifestations - hyperthyroidism
(2) Diagnostic tests (Free T4, TSH, alpha-subunit, consideration for TRH testing, MRI,
assessment for hypopituitarism when indicated)
(3) Management options (surgery, irradiation, somatostatin analogs)
(4) Special consideration - differential diagnosis from thyroid hormone resistance is critical
Gonadotropin cell adenomas
(1) Clinical manifestations - mass effects (neurologic dysfunction, hypopituitarism)
(2) Diagnostic tests (LH, FSH, glycoprotein subunits, TRH test, assessment for
hypopituitarism, MRI, visual field assessment when indicated)
(3) Management options (surgery, irradiation)
Non-secreting tumors
(1) Clinical manifestations - mass effects (neurologic dysfunction, hypopituitarism)
(2) Diagnostic tests (assessment for hypopituitarism, MRI, visual field assessment when
indicated)
(3) Management options (surgery, irradiation)
Space-occupying and Infiltrative Disorders of the Pituitary and Hypothalamic Region
Space occupying lesions (Craniopharyngiomas, Rathke’s cleft cysts, meningiomas,
arachnoid cysts, chordomas, dysgerminomas, hamartomas, gangliocytomas, abscess,
metastases)
Infiltrative/inflammatory disorders (sarcoidosis, tuberculosis, Langerhans cell histiocytosis,
lymphoma, lymphocytic hypophysitis, hemochromatosis)
Hypopituitarism Panhypopituitarism
(1) Clinical manifestations (growth failure, fatigue, decreased strength, body hair loss, fine
facial skin wrinkling, infertility, amenorrhea, erectile dysfunction, constipation, cold
intolerance, bradycardia, orthostatic hypotension)
(2) Etiology
Congenital (gene, receptor, embryopathic)
Acquired (tumors, infiltrative, trauma, apoplexy and Sheehanís, irradiation, metabolic [weight
loss, anorexia nervosa, malnutrition, hemochromatosis, critical illness], drug (corticosteroids,
dopamine)
Selective hormone deficiencies
(1) Gonadotropins (Kallmann’s syndrome, weight loss, idiopathic)
(2) ACTH (iatrogenic from glucocorticoid suppression, idiopathic very rare)
(3) TSH (rare)
68
(4) Growth Hormone
Child onset (congenital or acquired)
(i) Manifested as growth failure
(ii) Differential diagnosis (hypothalamic vs pituitary, GH insensitivity syndrome, differentiate
from non GH deficiency causes of short stature [systemic disease, dyschondroplasias,
Turner’s syndrome, psychosocial, etc.])
Adult onset is usually associated with other hormone deficiencies in panhypopituitarism. See
above.
Treatment
(1) Growth hormone administration - dose adjusted by IGF-1 levels Special consideration IGF-1 treatment for GH insensitivity
(2) Thyroxine -dose adjusted clinically and by Free T4 levels
(3) Glucocorticoids - dose adjusted clinically
(4) Estrogen/Progestin - oral, transdermal
(5) Testosterone - injection, transdermal
(6) GnRH - possible utility with hypogonadotropic hypogonadism of hypothalamic etiology
(7) HCG and HMG/FSH - for fertility in men and women
Posterior Pituitary Disorders
Diabetes Insipidus
(1) Clinical Manifestations - polyuria, polydipsia, thirst, dehydration
(2) Differential diagnosis
Central vs. nephrogenic
Congenital (familial) vs. acquired (see causes of hypopituitarism plus drug induced [cisplatin,
carbamazepine, lithium, vincristine,etc.] plus metabolic [hypercalcemia, hypokalemia], sickle
cell anemia)
Psychogenic polydipsia Others
causes of polyuria
(3) Diagnostic testing
Overnight water deprivation test
Measurement of vasopressin
Diagnostic trial of desmopressin MRI
Assessment of anterior pituitary function
(4) Treatment
Desmopressin - nasal, oral, parenteral
Chlorpropamide
Thiazide diuretics (esp. nephrogenic)
(5) Special considerations
Coexistent thirst center damage
Pregnancy - DI may be transient, may be associated with acute fatty liver of pregnancy
Hyponatremia
(1) Clinical manifestations (nausea, vomiting, headache, confusion, seizures, coma, death)
- symptoms dependent upon degree and speed of onset
(2) Differential diagnosis
Hypovolemic - appropriate vasopressin (ADH) secretion
Euvolemic - inappropriate ADH secretion (SIADH) {need to exclude hypothyroidism,
hypoadrenalism}
69
Hypervolemic - (intravascular hypovolemia, e.g., cirrhosis, CHF)
(3) Diagnostic tests
Urine and serum osmolality and urine sodium
Exclude other causes of hyponatremia (high triglycerides, glucose)
(4) Treatment
Mild - water restriction
Severe - saline, hypertonic saline, furosemide, monitor closely to avoid central pontine
myelinolysis
Miscellaneous Hypothalamic Syndromes
(1) Laurence-Moon-Biedl Bardet
(2) Prader-Willi Syndrome
(3) Sotosí Syndrome (cerebral gigantism)
(4) Pineal region tumors
(5) Empty sella syndrome
Suggested Reading
DIAGNOSTIC TESTING
Abboud CF. Laboratory diagnosis of hypopituitarism. Mayo Clin Proc 1986; 61:35-48.
Camanni F, Ghigo E, Arvat E: Growth hormone-releasing peptides and their analogs. Front
Neuroendocrinol 19:47, 1998.
Streeten DHP, Anderson GH, Bonaventura MM. The potential for serious consequences from
misinterpreting normal responses to the rapid adrenocortiocotropin test. J Clin Endocrinol
Metab 1996; 81:285-290.
Cutler GB Jr. Corticotropin-releasing hormone (CRH): clinical studies and use. The
Endocrinologist 1997; 7:10S-16S.
Bevan JS, Burke CW, Esiri MM, Adams CBT. Misinterpretation of prolactin levels leading to
management errors in patients with sellar enlargement. Am J Med 1987; 82:29-32.
Barkan A, Chandler WF. Giant pituitary prolactinoma with falsely low serum prolactin: the
pitfall of the "high-dose hook effect": case report. Neurosurgery 1998; 9:13-15.
NEURORADIOLOGY
Elster A. Modern imaging of the pituitary. Radiology 1993; 187:1-14.
Donovan JL, Nesbit GM: Distinction of masses involving the sella and suprasellar space:
Specificity of imaging features. AJR 1996; 167:597-503.
Naidich MJ, Russell EJ. Current approaches to imaging of the sellar region and pituitary.
Endocrinol Metab Clin N Amer 1999; 28:45-79.
Hall WA, Luciano MG, Doppman JL et al. Pituitary magnetic resonance imaging in normal
70
human volunteers: occult adenomas in the general population. Ann Intern Med 1994; 120:817820.
NEUROOPHTHALMOLOGY
Melen O. Neuro-ophthalmologic features of pituitary tumors. Endocrinol Metab Clin N Amer
1987; 16:585-608.
OTHER TESTS
Greulich WW, Pyle SI: Radiographic Atlas of Skeletal Development of the Hand and Wrist, 2nd
ed. Stanford, CA, Stanford University Press, 1959.
Tanner JM, Whitehouse RH, Marshall WA et al. Assessment of Skeletal maturity and
Prediction of Adult Height (TW2 Method). New York, Academic Press, 1975.
Bayley N, Pinneau SR: Tables for predicting adult height from skeletal age: revised for use with
the Greulich-Pyle hand standards. J Pediatr 1952; 40:423-441.
Tanner JM, Whitehouse RH, Marshall WA et al. Prediction of adult height from height, bone
age, and occurrence of menarche at ages 4-16, with allowance for midparent height. Arch Dis
Child 1975; 50:14-26.
Rosenfield RL. Essentials of growth diagnosis. Endocrinol Metab Clin N Amer 1996; 25:743758.
TREATMENT MODALITIES
Laws ER Jr, Thapar K. Pituitary surgery. Endocrinol Metab Clin N Amer 1999; 28:119-131.
Webb SM, Rigla M, Wagner A, Oliver B, Bartumeus F. Recovery of hypopituitarism after
neurosurgical treatment of pituitary adenomas. J Clin Endocrinol Metab 1999; 84:3696-3700.
Ciric I, Ragin A, Baumgartner C, Pierce D. Complications of transsphenoidal surgery: results
of a national survery, review of the literature, and personal experience. Neurosurgery 1997;
40:225-237.
Halberg FE, Sheline GE. Radiotherapy of pituitary tumors. Endocrinol Metab Clin N Amer
1987; 16:667-684.
Brada M, Rajan B, Traish D et al. The long-term efficacy of conservative surgery and
radiotherapy in the control of pituitary adenomas. Clin Endocrinol 1993; 38:571-578.
Snyder PJ, Fowble BF, Schatz NJ, Savino PJ, Gennarelli TA. Hypopituitarism following
radiation therapy of pituitary adenomas. Am J Med 1986; 81:457-462.
Littley MD, Shalet SM, Beardwell CG et al. Hypopituitarism following external radiotherapy for
pituitary tumours in adults. Quart J Med 1989; 70:145-160.
Brada M, Ford D, Ashley S, Bliss JM, Crowley S, Mason M, Rajan B, Traish D: Risk of second
71
brain tumour after conservative surgery and radiotherapy for pituitary adenoma. Brit Med J
1992; 304:1343.
Jackson IMD, Noren G. Role of gamma knife therapy in the management of pituitary tumors.
Endocrinol Metab Clin N Amer 1999; 28:133-142.
SPECIFIC DISORDERS
Pituitary Adenomas
Melmed: Pathogenesis of pituitary tumors. Endocrinol Metab Clin N Amer 1999; 28:1-12.
Asa SL, Ezzat S: The cytogenesis and pathogenesis of pituitary adenomas. Endocr Rev 1998;
19:798-727.
Asa SL: The pathology of pituitary tumors. Endocrinol Metab Clin N Amer 1999; 28:13-43.
Pernicone PJ, Scheithauer BW, Sebo TJ et al: Pituitary carcinoma: a clinicopathological study
of 15 cases. Cancer 1997; 79:804-812.
Burgess JR, Shepherd JJ, Parameswaran V, Hoffman L, Greenaway TM: Spectrum of
pituitary disease in multiple endocrine neoplasia Type 1 (MEN 1): Clinical, biochemical, and
radiological features of pituitary disease in a large MEN 1 kindred. J Clin Endocrinol Metab
1996; 81:2642-2646.
Shimon I, Melmed S. Management of pituitary tumors. Ann Intern Med 1998; 129:472-483
Melmed S: The Pituitary. Cambridge, MA. Blackewell Science. 1995.
Molitch ME (ed,). Advances in the Management of Pituitary Tumors. Endocrinol Metab Clin N
Amer 1999 Vol. 28:1.
Prolactinomas
Molitch ME. Diagnosis and treatment of prolactinomas. Adv Intern Med 1999; 44:117-153.
Klibanski A, Biller BMK, Rosenthal DI, Schoenfeld DA, Saxe V. Effects of prolactin and
estrogen deficiency in amenorrheic bone loss. J Clin Endocrinol Metab 1988; 67:124-130.
Molitch ME, Elton RL, Blackwell RE, et al. Bromocriptine as primary therapy for prolactinsecreting macroadenomas: results of a prospective multicenter study. J Clin Endocrinol Metab
1985; 60: 698-705.
Webster J, Piscitelli G, Polli A, Ferrari CI, Ismail I, Scanlon MF for the Cabergoline
Comparative Study Group. A comparison of cabergoline and bromocriptine in the treatment of
hyperprolactinemic amenorrhea. N Engl J Med 1994; 331:904-909.
Colao A, DeSarno A, Landi ML et al. Long-term and low-dose treatment with cabergoline
induces macroprolactinoma shrinkage. J Clin Endocrinol Metab 1997; 82:3574-3579.
72
Freda PU, Andreadis CI, Khandji G et al. Long-term treatment of prolactin-secreting
macroadenomas with pergolide. J Clin Endocrinol Metab 2000; 85:8-13.
Massoud F, Serri O, Hardy J, Somma M, Beauregard H. Transsphenoidal adenomectomy for
microprolactinomas:10 to 20 years of follow-up. Surg Neurol 1996; 45:341-346.
Feigenbaum SL, Downey DE, Wilson CB, Jaffe RB. Transsphenoidal pituitary resection for
preoperative diagnosis of prolactin-secreting pituitary adenoma in women: long term follow- up.
J Clin Endocrinol Metab 1996; 81:1711-1719.
Molitch ME. Management of prolactinomas during pregnancy. J Reprod Med 1999;
44(Suppl):1121-1126.
GH-secreting adenomas
Melmed S: Acromegaly. N Engl J Med 1990; 322:966-972.
Leiberman SA, Hoffman AR: Sequelae to acromegaly: reversibility with treatment of the
primary disease. Horm Metab Res 1990; 22:313-318.
Molitch ME: Clinical manifestations of acromegaly. Endocrine Metab Clin N. Amer. 1992;
21:597-614.
Freda PU, Post KD, Powell JS, Wardlaw SL. Evaluation of disease status with sensitive
measures of growth hormone secretion in 60 postoperative patients with acromegaly. J Clin
Endocrinol Metab 1998; 83:3808-3816.
Barkan AL, Beitins IZ, Kelch RP. Plasma insulin-like growth factor-I/Somatomedin-C in
acromegaly: correlation with the degree of growth hormone hypersecretion. J Clin Endocrinol
Metab 1988; 67:69-73.
Dobrashian RD, O'Halloran DJ, Hunt A, Beardwell CG, Shalet SM. Relationships between
insulin-like growth factor-1 levels and growth hormone concentrations during diurnal profiles
and following oral glucose in acromegaly. Clin Endocrinol 1993; 38:589-593.
Faglia G, Aorsio M, Bazzonei N: Ectopic acromegaly. Endocrinol Metab Clin N Amer 1992;
21:575-596.
Melmed S, Jackson I, Kleinberg D, Klibanski A. Current treatment guidelines for acromegaly. J
Clin Endocrinol Metab 1998; 83:2646-2652.
Bates AS, van’t Hoff W, Jones JM, Clayton RN. An audit of outcome of treatment in
acromegaly. Quart J Med 1993; 86:293-299.
Abosch A, Tyrrell JB, Lamborn KR et al. Transsphenoidal microsurgery for growth hormonesecreting pituitary adenomas. Initial outcome and long-term results. J Clin Endocrinol Metab
1998; 83:3411-3416.
73
Swearingen B, Barker FG II, Katznelson L et al. Long-term mortality after transsphenoidal
surgery and adjunctive therapy for acromegaly. J Clin Endocrinol Metab 1998; 83:3419- 3426.
Newman CB. Medical therapy for acromegaly. Endocrinol Metab Clin N Amer 1999; 28:171190.
Abs R, Verhelst J, Maiter D et al. Cabergoline in the treatment of acromegaly. A study in 64
patients. J Clin Endocrinol Metab 1998; 83:374-378.
Newman CB, Melmed S, Snyder PJ et al. Safety and efficacy of long-term octreotide therapy
of acromegaly: results of a multicenter trial in 103 patients. J Clin Endocrinol Metab 1995;
80:2768-2775.
Flogstad Ak, Halse J, Barke S et al. Sandostatin LAR in acromegalic patients: long-term
treatment. J Clin Endocrinol Metab 1997; 81:23-28.
Turner HE, Vadivale A, Keenan J, Wass JAH: A comparison of lanreotide and octreotide LAR
for treatment of acromegaly. Clin Endocrinol 1999; 51:275-280.
Trainer PJ, Drake WM, Katnelson L et al: Treatment of acromegaly with the growth hormonereceptor antagonist pegvisomant. N Engl J Med 2000; 342:1171-1177.
Powell JS, Wardlaw SL, Post KD, Freda PU. Outcome of radiotherapy for acromegaly using
normalization of insulin-like growth factor I to define cure. J Clin Endocrinol Metab 2000;
85:2068-2071.
Landolt AM, Haller D, Lomax N et al. Stereotactic radiosurgery for recurrent surgically treated
acromegaly: comparison with fractionated radiotherapy. J Neurosurg 1998; 88:1002- 1008.
(9609294
ACTH-secreting adenomas
Orth DN: Cushing's syndrome. N Engl J Med 1995; 332:791-803.
Meier C, Biller BMK. Clinical and biochemical evaluation of Cushing’s syndrome. Endocrinol
Metab Clin N Amer 1997; 26:741-762.
Newell-Price J, Trainer P, Besser M et al. The diagnosis and differential diagnosis of
Cushing’s syndrome and pseudo-Cushing’s states. Endocrine Revs 1998; 19:647-672.
Findling JW, Raff H: Newer diagnostic techniques and problems in Cushing’s disease.
Endocrinol Metab Clin N Amer 1999; 28:191-210.
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; 325:896-905.
Invitti C et al: Diagnosis and management of Cushing’s syndrome: results of an Italian
74
Multicentre Study. J Clin Endocrinol Metab 1999; 84:440-448.
Mampalam TJ, Tyrrell JB, Wilson CB. Transsphenoidal microsurgery for Cushing’s disease. A
report of 216 cases. Ann Intern Med 1988; 109:487-493.
Swearingen B, Biller BMK, Barker FG et al. Long-term mortality after transsphenoidal surgery
for Cushing disease. Ann Intern Med 1999; 130:821-824.
Sonino N, Zielezny M, Fava GA et al: Risk factors and long-term outcome in pituitarydependent Cushing’s disease. J Clin Endocrinol Metab 1996;81:2647-2652.
Sonino N, Boscaro M. Medical therapy for Cushing’s disease. Endocrinol Metab Clin N Amer
1999; 28:211-222.
Estrada J, Boronat M, Mielgo M et al: The long-term outcome of pituitary irradiation after
unsuccessful surgery in Cushing’s diseaes. N Engl J Med 1997; 336:172-177.
TSH-secreting adenomas
Beck-Peccoz P, Brucker-Davis F, Persani L et al: Thyrotropin-secreting pituitary tumors.
Endocrine Rev 1996; 17:610-638. (8969971)
Brucker-Davis F, Oldfield EH, Skarulis MC, Doppman JL, Weintraub BD: Thyrotropinsecreting pituitary tumors: diagnostic criteria, thyroid hormone sensitivity, and treatment
outcome in 25 patients followed at the National Institutes of Health. J Clin Endocrinol Metab
1999; 84:476-486.
Shomali ME, Katznelson L. Medical therapy for gonadotroph and thyrotroph tumors.
Endocrinol Metab Clin N Amer 1999; 28:223-240.
Chanson P, Weintraub BD, Harris AG. Octreotide therapy for thyroid-stimulating hormonesecreting pituitary adenomas: a follow-up of 52 patients. Ann Intern Med 1993; 119:236-240.
Gonadotropin-cell adenomas
Young WF, Scheithauer BW, Kovacs KT, et al. Gonadotroph adenoma of the pituitary gland: a
clinicopathologic analysis of 100 cases. Mayo Clin Proc 1996; 71:649-656.
Jameson JL, Klibanski A, Black PM, et al. Glycoprotein hormone genes are expressed in
clinically nonfunctioning pituitary adenomas. J Clin Invest 1987; 80:1472-1478.
Daneshdoost L, Gennarelli TA, Bashey HM, et al.. Recognition of gonadotroph adenomas in
women. N Engl J Med 1991; 324:589-594.
Shomali ME, Katznelson L. Medical therapy for gonadotroph and thyrotroph tumors.
Endocrinol Metab Clin N Amer 1999; 28: 223-240.
De Bruin TWA, Kwekkeboom DJ, Van’t Verlaat JW, et al. Clinically nonfunctioning pituitary
75
adenoma and octreotide response to long term high dose treatment, and studies in vitro. J Clin
Endocrinol Metab 1992; 75:1310-1317.
Katznelson L, Oppenheim DS, Coughlin JF, et al. Chronic somatostatin analog administration
in patients with -subunit-secreting pituitary tumors. J Clin Endocrinol Metab 1992; 75:13181325.
Warnet A, Harris AG, Renard E, et al . A prospective multicenter trial of octreotide in 24
patients with visual defects caused by nonfunctioning and gonadotropin-secreting pituitary
adenomas. Neurosurgery 1997; 41:786-796.
Non-secreting tumors
Arafah BM. Reversible hypopituitarism in patients with large nonfunctioning pituitary
adenomas. J Clin Endocrinol Metab 1986; 62:1173-1179.
Ebersold MJ, Quast LM, Laws ER, Scheithauer B, Randall RV. Long-term results in
transsphenoidal removal of nonfunctioning pituitary adenomas. J Neurosurg 1986; 64:713719.
Comtois R, Beauregard H, Somma M, Serri O, Aris-Jilwan N, Hardy J. The clinical and
endocrine outcome to transsphenoidal microsurgery of nonsecreting pituitary adenomas.
Cancer 1991; 68:860-866.
Tominaga A, Uozumi T, Arita K et al. Anterior pituitary function in patients with nonfunctioning
pituitary adenoma: results of longitudinal follow-up. Endocrine J 1995; 42:421-427.
Bradley KM, Adams CBT, Potter CPS, Wheeler DW, Anslow PJ, Burke CW. An audit of
selected patients with non-functioning pituitary adenomas treated by transsphenoidal surgery
without irradiation. Clin Endocrinol 1994; 41:655-659, 1994.
Turner HE, Stratton IM, Byrne JV, Adams CBT, Wass JAH. Audit of selected patients with
nonfunctioning pituitary adenomas treated without irradiation - a follow-up study. Clin
Endocrinol 1999; 51:281-284.
Hansen LK, Molitch ME. Postoperative radiotherapy for clinically nonfunctioning pituitary
adenomas. The Endocrinologist 1998; 8:71-78.
Donovan LE, Corenblum B The natural history of the pituitary incidentaloma. Arch Intern Med
1995; 153:181-183.
Reincke M, Allolio B, Saeger W, et al, The 'incidentaloma' of the pituitary gland. Is
neurosurgery required? JAMA 263:2772-2776, 1990.
Molitch ME. Pituitary incidentalomas. Endocrinol Metab Clin N Amer 1997; 26:725-740.
Space-occupying and infiltrative disorders
76
Space-occupying lesions
Freda PU, Wardlaw SL, Post KD. Unusual causes of sellar/parasellar masses in a large
transsphenoidal surgical series. J Clin Endocrinol Metab 1996; 81:3455-3459.
Rivarola MA, Mendilaharzu H, Warman M et al. Endocrine disorders in 66 suprasellar and
pineal tumors of patients with prepubertal and pubertal ages. Horm Res 1992; 37:1-6.
Shin JL, Asa SL, Woodhouse LJ, Smyth HS, Ezzat S. Cystic lesions of the pituitary:
clinicopathological features distinguishing craniopharyngiomas, Rathke
cleft cyst, and
arachnoid cyst. J Clin Endocrinol Metab 1999; 84:3972-3982.
Mukerjee JJ, Islam N, Kaltsas G, Lowe DG, Charlseworth M, Afshar F et al: Clinical,
radiological and pathological features of patients with Rathke
cleft cysts: tumors that may
recur. J Clin Endocrinol Metab 82:2357, 1997.
El-Mahdy W, Powell M. Transsphenoidal management of 28 symptomatic Rathke
cleft
cysts, with special reference to visual and hormonal recovery. Neurosurgery 1998; 42:7-17.
DeVile CJ, Grant DB, Hayward RD, Stanhope R: Growth and endocrine sequelae of
craniopharyngioma. Arch Dis Child 1996; 75:108.
Morita A, Meyer FB, Laws ER Jr. Symptomatic pituitary metastases. J Neurosurg 1998;
89:69-73.
Sklar CA, Grumbach MM, Kaplan SL, Conte FA. Hormonal and metabolic abnormalities
associated with central nervous system germinoma in children and adolescents and the effect
of therapy: report of 10 patients. J Clin Endocrinol Metab 1981; 52:9-16.
Fernandez-Real JM, Fernancez-Castaner M, Villabona C et al: Giant intrasellar aneurysm
presenting with panhypopituitarism and subarachnoid hemorrhage: a case report and literature
review. Clin Investig 1994; 72:302-306.
Infiltrative/Inflammatory disorders
Stuart CA, Neelon FA, Lebovitz HE. Hypothalamic insufficiency: the cause of hypopituitarism
in sarcoidosis. Ann Intern Med 1978; 88:589-594.
Chapelon C, Ziza JM, Piette JC et al. Neurosarcoidosis: signs, course and treatment in 35
confirmed cases. Medicine 1990; 69:261-276.
Kaltsas GA, Powles TB, Evanson J et al. Hypothalamo-pituitary abnormalities in adult patients
with Langerhans cell histiocytosis: clinical, endocrinological, and radiological features, and
response to treatment. J Clin Endocrinol Metab 2000:85; 1370-1376.
Lam KSL, Sham MMK, Tam SCF, Ng MMT, Ma HTG. Hypopituitarism after tuberculous
meningitis in childhood. Ann Intern Med 1993; 118:701-706.
Wolansky LJ, Gallagher JD, Heary RF et al. MRI of pituitary abscess: two cases and review of
77
the literature. Neuroradiology 1997; 39:499-503.
Cosman F, Post KD, Holub DA, Wardlaw SL. Lymphocytic hypophysitis. Report of 3 cases
and review of the literature. Medicine 1989; 68:240-256.
Pressman EK, Zeidman SM, Reddy UM, Epstein JI, Brem H. Differentiating lymphocytic
adenohypophysitis from pituitary adenoma in the peripartum patient. J Reprod Med 1995;
40:251-259.
Hypopituitarism Panhypopituitarism
Vance ML. Hypopituitarism. N Engl J Med 1994; 330:1651-1662.
Lamberts SWJ, deHerder WW, van der Lely AJ. Pituitary insufficiency. Lancet 1998; 352:127134.
Treier M, Rosenfeld MG: The hypothalamic-pituitary axis: co-development of two organs. Curr
Opin Cell Biol 8:833, 1996.
Treier M, Gleiberman AS, O’Connell SM, et al: Multistep signaling requirements for pituitary
organogenesis in vivo. Genes & Dev 12:1691, 1998.
Radovick S, Nations M, Du Y, Berg LA, Weintraub BD, Wondisford FE: A mutation in the POUhomeodomain of Pit-1 responsible for combined pituitary hormone deficiency. Science
257:1116, 1992.
Pfäffle RW, DiMattia GE, Parks JS, Brown MR, Wit JM, Jansen M et al: Mutation of the POUspecific domain of Pit-1 and hypopituitarism without pituitary hypoplasia. Science 257:1118,
1992.
Sornson MW, Wu W, Dasen JS, Flynn SE, Norman DJ, O’Connell SM et al: Pituitary lineage
determination by the Prophet of Pit-1 homeodomain factor defective in Ames dwarfism.
Nature 384:327, 1996.
Wu W, Cogan JD, Pfäffle RW, Dasen J, Frisch H, O’Connell SM, Flynn SE et al: Mutations in
PROP1 cause familial combined pituitary hormone deficiency. Nature Genetics 18:147, 1998.
Cogan JD, Wu W, Phillips JA III, Arnhold IJP, Agapito A, Fofanova OV et al: The PROP1 2base pair deletion is a common cause of combined pituitary hormone deficiency. J Clin
Endocrinol Metab 83:3346, 1998.
Achermann JC, Jameson JL: Fertility and infertility: genetic contributions from the
hypothalamic-pituitary-gonadal axis. Mol Endocrinol 1999; 13:812-818.
Netchine I, Sobrier M-L, Krude H et al: Mutations in LHX3 result in a new syndrome revealed
by combined pituitary hormone deficiency. Nature Genetics 2000; 25:182-186.
Triulzi F, Scotti G, diNatale B, Pellini C, Lukezic M, Scognamiglio M et al: Evidence of a
congenital midline brain anomaly in pituitary dwarfs: a magnetic resonance imaging study in
78
101 patients. Pediatrics 93:409, 1994.
Bates AS, Van't Hoff W, Jones PJ et al: The effect of hypopituitarism on life expectancy. J
Clin Endocrinol Metab 1996; 81:1169-1172.
Edwards OM, Clark JDA. Post-traumatic hypopituitarism . Six cases and a review of the
literature. Medicine 1986; 65:281-290.
Benvenga S, Campenni A, Ruggeri RM, Trimarchi F. Hypopituitarism secondary to head
trauma. J Clin Endocrinol Metab 2000; 85:1353-1361.
Randeva HS, Schoebel J, Byrne J et al. Classical pituitary apoplexy: clinical featues,
management and outcome. Clin Endocrinol 1999; 51:181-188.
Sheehan HL. The recognition of chronic hypopituitarism resulting from postpartum pituitary
necrosis. Am J Obstet Gynecol 1971; 111:852-854.
Jialal I, Naidoo C, Norman RJ et al. Pituitary function in Sheehans’ syndrome. Obstet Gynecol
1984; 63:15-19.
Snyder PJ, Fowble BF, Schatz NJ, Savino PJ, Gennarelli TA. Hypopituitarism following
radiation therapy of pituitary adenomas. Am J Med 1986; 81:457-462.
Littley MD, Shalet SM, Beardwell CG et al. Hypopituitarism following external radiotherapy for
pituitary tumours in adults. Quart J Med 1989; 70:145-160.
Constine LS, Woolf PD, Cann D, et al. Hypothalamic-pituitary dysfunction after radiation for
brain tumors. N Engl J Med 1993; 328:87-94.
Schwartz MW, Seeley RJ: Neuroendocrine responses to starvation and weight loss. N Engl J
Med 336:1802, 1997.
Björntorp P: Endocrine abnormalities in obesity. Diabetes Revs 5:52, 1997.
Gama R, Smith MJ, Wright J, Marks V. Hypopituitarism in primary haemochromatosis:
recovery after iron depletion. Postgrad Med J 1995; 71:297-298
Van den BergheG, de Zegher F, Bouillon R: Acute and prolonged critical illness as different
neuroendocrine paradigms. J Clin Endocrinol Metab 83:1827, 1998.
Molitch ME: Pituitary response to stress: Growth hormone and prolactin. In Endocrinology of
Critical Disease. K.P. Ober (ed.), Humana Press, Totowa, NJ. 67-86, 1997.
Turner HE, Wass JAH: Gonadal function in men with chronic illness. Clin Endocrinol 47:379,
1997.
Bayraktar M, Van Thiel DH: Endocrine changes in liver disease. The Endocrinologist 5:403,
1995.
79
Hou S: What are the clinically important consequences of ESRD-associated endocrine
dysfunction? Sem Dialysis 1997; 10:11-13.
Chrousos GP, Torpy DJ, Gold PW: Interactions between the hypothalamic-pituitary-adrenal
axis and the female reproductive system: clinical implications. Ann Intern Med 129:229, 1998.
Selective Hormone Deficiencies
Yen SSC. Female hypogonadotropic hypogonadism. Endocrinol Metab Clin N Amer
1993;22;29-58.
Whitcomb RW, Crowley WF Jr. Male hypogonadotropic hypogonadism. Endocrinol Metab
Clin N Amer 1993;22:125-143.
Waldstreicher J, Seminara SB, Jameson JL, Geyer A, Nachtigall LB, Boepple PA et al: The
genetic and clinical heterogeneity of gonadotropin-releasing hormone deficiency in the human.
J Clin Endocrinol Metab 81:4388, 1996.
Conway GS: Clinical manifestations of genetic defects affecting gonadotrophins and their
receptors. Clin Endocrinol 45:657, 1996.
Nachtigall LB, Boepple PA, Pralong FP, Crowley WF Jr: Adult-onset idiopathic
hypogonadotropic hypogonadism - a treatable form of male infertility. N Engl J Med
1996;336:410-415.
Seminara SB, Hayes FJ, Crowley WF Jr: Gonadotropin-releasing hormone deficiency in the
human (idiopathic hypogonadotropic hypogonadism and Kallmann
syndrome):
pathophysiological and genetic considerations. Endocrine Revs 19:521, 1998. Orme SM,
Belchetz PE: Isolated ACTH deficiency. Clin Endocrinol 35:213, 1991.
Yamamoto T, Fukuyama J, Hasegawa K, Sugiara M: Isolated corticotropin deficiency in adults.
Report of 10 cases and review of literature. Arch Intern Med 1992; 152:1705-1712.
Samuels MH, Ridgway EC. Central hypothyroidism. Endocrinol Metab Clin N Amer 1992;
21:903-919.
Faglia G, Bitenski L, Pinchera A et al. Thyrotropin secretion in patients with central
hypothyroidism: evidence for reduced biological activity of immunoreactive thyrotropin. J Clin
Endocrinol Metab 1979; 48:989-998.
Collu R, Tang J, Castagne J, Lagace G, Masson N, Hout C, Deal C, Delvin E, Faccenda E,
Eidne KA, van Vliet G: A novel mechanism for isolated central hypothyroidism: inactivating
mutations in the thyrotropin-releasing hormone receptor gene. J Clin Endocrinol Metab 1997;
82:1361-1365.
Rosenfield RL. Essentials of growth diagnosis. Endocrinol Metab Clin N Amer 1996; 25:743758.
80
Phillips JA, Cogan JD: Genetic basis of endocrine disease. 6. Molecular basis of familial
human growth hormone deficiency. J Clin Endocrinol Metab 78:11-6, 1994.
Maheshwari HG, Silverman BL, DuPuis J, Baumann G: Phenotype and genetic analysis of a
syndrome caused by an inactivating mutation in the growth hormone-releasing hormone
receptor: Dwarfism of Sindh. J Clin Endocrinol Metab 83:4065, 1998.
Rosenfeld RG, Rosenbloom AL, Guevara-Aguirre J: Growth hormone (GH) insensitivity due to
primary GH receptor deficiency. Endocr Rev 1994; 15:369-390.
Carroll PV, Christ ER, Bengtsson BA et al: Growth hormone deficiency in adulthood and the
effects of growth hormone replacement: a review. J Clin Endocrinol Metab 1998; 83:382- 395.
Hoffman DM, O
AJ, Baxter RC, Ho KKY. Diagnosis of growth hormone deficiency
in adults. Lancet 1994; 343:1065-1068.
Anon: Consensus guidelines for the diagnosis and treatment of adults with growth hormone
deficiency: summary statement of the Growth Hormone research Society Workshop on Adult
Growth Hormone Deficiency. J Clin Endocrinol Metab 1998; 83:379-381.
Vance ML, Mauras N: Growth hormone therapy in adults and children. N Engl J Med
1999;341:1206-1216.
Tritos NA, Mantzoros CS. Recombinant human growth hormone: old and novel uses. Am J
Med 1998;105:44-57.
Bhasin S, Bremner WJ. Clinical Review 85: emerging issues in androgen replacement therapy
therapy. J Clin Endocrinol Metab 1997;82:3-8.
Bagatell CG, Bremner WJ: Androgens in men - uses and abuses. N Engl J Med
1996;334:707-714.
Wang C, Berman N, Longstreth JA et al: Pharmacokinetics of transdermal testosterone gel in
hypogonadal men: application of gel at one site versus four sites: a General Clinical Research
Center Study. J Clin Endocrinol Metab 2000; 85:964-969.
Snyder PJ, Peachey H, Berlin JA et al: Effects of testosterone replacement in hypogonadal
men. J Clin Endocrinol Metab 2000; 85:2670-2677.
Posterior Pituitary Disorders Diabetes Insipidus
Robertson GL: Diabetes insipidus. Endocrinol Metab Clin N Amer 1995; 24:549-572
Fujiwara TM, Morgan K, Bichet DG: Molecular biology of diabetes insipidus. Annu Rev Med
1995;46:331-343.
Adrogue HJ, Madias NE: Hypernatremia. N Engl J Med 2000: 342:1493-1499.
81
Ritting S, Robertson GL, Siggaard C et al: Identification of 13 new mutations in the
vasopressin-neurophysin II gene in 17 kindred with familial autosomal dominant
neurohypophyseal diabetes insipidus. Am J Hum Genet 1996; 48:107-117.
Imura H, Nako K, Shimatsu A, Ogawa Y, Sando T, Fujisawa I et al: Lymphocytic
infundibuloneurohypophysitis as a cause of central diabetes insipidus. N Engl J Med 329: 683,
1993.
Barrett TG, Bundy SE, Macleod AF: Neurodegeneration and diabetes: UK Nationwide Study of
Wolfram (DIDMOAD) syndrome. Lancet 1995; 346:1458-1463.
Strom TM, Hortnagel K, Hofmann S, et al: Diabetes insipidus, diabetes mellitus, optic atrophy
and deafness (DIDMOAD) caused by mutations in a novel gene (wolframin) coding for a
predicted transmembrane protein. Hum Mol Genet 1998; 7:2021-2028.
Bayliss PH: Investigation of suspected hypothalamic diabetes insipidus. Clin Endocrinol 1995;
43:507-510.
Hensen J, Henig A, Fahlbusch R et al. Prevalence, predictors, and patterns of postoperative
polyuria and hyponatremia in the immediate course after transsphenoidal surgery for pituitary
adnoema. Clin Endocrinol 1999; 50:431-439.
Richardson DW, Robinson AG. Desmopressin. Ann Intern Med 1985; 103:228-239
Lam KS, Wat MS, Choi KL et al: Pharmacokinetics, pharmacodynamics, long-term efficacy
and safety of oral 1-deamino-8-D-arginine vasopressin in adult patients with central diabetes
insipidus. Br J Clin Pharmacol 1996; 42:379-385.
Durr JA: Diabetes insipidus in pregnancy. Am J Kidney Dis 1987; 9:276-283. Hyponatremia
Bartter FC, Schwartz WB: The syndrome of inappropriate secretion of antidiuretic hormone.
Am J Med 1967; 42:790-806.
Adrogue HJ, Madias NE: Hyponatremia. N Engl J Med 2000;342:1581-1589.
Verbalis JG: Hyponatremia: epidemiology, pathophysiology, and therapy. Curr Opin Nephrol
Hyperten 1993; 2:635-652.
DeVita MV, Gardenswartz MH, Konecky A, Zabetakis PM: Incidence and etiology of
hyponatremia in an intensive care unit. Clin Nephrol 1990; 34:163-166.
Ayus JC, Wheeler JM, Arieff AI: Postoperative hyponatremia encephalopathy in menstruant
women. Ann Intern Med 1992; 117:891-897.
Taylor SL, Tyrrell JB, Wilson CB: Delayed onset of hyponatremia after transsphenoidal surgery
for pituitary adenomas. Neurosurgery 1995; 37:649-654.
Harrigan MR. Cerebral salt wasting syndrome. A review. Neurosurgery 1996; 38:152-160.
82
Sterns RH: Severe symptomatic hyponatremia: treatment and outcome. A study of 64 cases.
Ann Intern Med 1987; 107:656-664.
Sterns RH, Cappuccio JD, Silver SM, Cohen EP: Neurologic sequelae after treatment of
severe hyponatremia: a multicenter perspective. J Am Soc Nephrol 1994; 4:1522-1530.
Berl T: Treating hyponatremia: damned if we do and damned if we don’t. Kidney Int
1990;37:1006-1018.
Ellis SJ. Severe hyponatremia. Complications and treatment. QJM 1995; 88:905-9.
Gowrishankar M, Lin SH, Mallie JP et al. Acute hyponatremia in the perioperative period:
insights into its pathophysiology and recommendations for management. Clinical Nephrol
1998; 50:352-359.
Palm C, Gross P. V2-vasopressin receptor antagonists - Mechanism of effect and clinical
implications in hyponatremia. Nephrol Dial Tranplant 1999; 14:2559-2563.
Miscellaneous Hypothalamic Syndromes
Cassidy SB, Schwartz S: Prader-Willi and Angelman syndromes. Disorders of genetic
imprinting. Medicine 1998; 77:140-151.
Couper RT, Couper JJ. Prader-Willi Syndrome. Lancet 2000; 356:673-675.
Ruse R. Laurence-Moon-Biedl-Bardet Syndrome. Clinical, electrophysiological and genetic
aspects. Acta Ophthalmol Scan Suppl 1998; 226:1-28.
Poussaint TY, Barnes PD, Nichols K, Anthony DC, Cohen L, Tarbell NJ et al: Diencephalic
syndrome: clinical features and imaging findings. Am J Neuroradiol 18:1499, 1997.
Sotos JF, Dodge PR, Muirhead D, Crawford JD, Talbot NB: Cerebral gigantism in childhood: A
syndrome of excessively rapid growth with acromegalic features and a nonprogressive
neurologic disorder. N Engl J Med 271:109, 1964.
Aoki N, Oikawa Akihiro, Sakai T: Serial neuroimaging studies in Sotos’ syndrome (cerebral
gigantism syndrome). Neurol Res 20:149, 1998.
Jennings MT, Gelman R, Hochberg F: Intracranial germ-cell tumors: Natural history and
pathogenesis. J Neurosurg 63:155, 1985.
Bruce JN, Stein BM: Surgical management of pineal region tumors. Acta Neurochir 134:130,
1995.
Fauchon I, Jouvet A, Paquis P et al. Parenchymal pineal tumos: a clinicopathological study of
76 cases. Int J Radiat Oncol Biol Phys 2000; 46:959-968.
Masera N, Grant DB, Stanhope R, Preece MA: Diabetes insipidus with impaired osmotic
83
regulation in septo-optic dysplasia and agenesis of the corpus callosum. Arch Dis Child 70:51,
1994.
Dattani MT, Martinez-Barbera J-P, Thomas PQ, Brickman JM, Gupta R, Mårtensson I-L et al:
Mutations in the homeobox gene HESX1/Hesx1 associated with septo-optic dysplasia in
human and mouse. Nature Genetics 19:125, 1998.
Jordan RM, Kendall JW, Kerber CW. The primary empty sella syndrome. Analysis of the
clinical characteristics, radiographic features, pituitary function and cerebrospinal fluid
adenohypophysial hormone concentrations. Am J Med 1977; 62:569-580.
Brismar K, Efendic S. Pituitary function in the empty sella syndrome. Neuroendocrinology
1981;32:70-77.
84
Disorders of the Hypothalamus and Pituitary Method of Education
Formal
Direct Clinical
Instruction Experiences
In-patient
Clinical Case
Discussions
Out-patient Attd. Rds Conference
1. Pituitary Tumors
a) Cushing’s Disease
b) Acromegaly
c) Prolactinoma
d) Non-functioning adenomas
2. Space-Occupying/ Infiltrative Disease
a) Cranipharyngloma
b) Hemochromatosis
c) Histiocytosis X
d) Sacroid
3. Hypopituitarism
a) Adrenal
b) Thyroid
c) Growth hormone
d) Gonadotropins
4. Water Balance
a) Diabetes insipidus
b) SIADH
5. Disease Specific Studies/ Procedures
a) GnRH stimulation
b) Insulin induced hypoglycemia
c) CRH stimulation
d) IPSS
e) Pituitary imaging MRI/CT
f) Dexamethasone suppression
85
Selfdirected
learning
Method of Evaluation
Direct
observations Discussions Clinical
Written
with patient with faculty Presentation Examination
Lipid Metabolism Disorders Disease Area
Hyperlipidemia refers to elevations in plasma cholesterol, triglycerides or both. These are
usually due to an increase in the concentration of very low density lipoprotein (VLDL) and/or
low density lipoprotein (LDL) in plasma and result from disturbances in lipoprotein metabolism.
The term dyslipidemia is generally used to describe abnormalities in plasma lipoproteins that
include low levels of high density lipoprotein (HDL), and/or abnormalities of lipoprotein
composition or distribution. The lipid section requires an understanding of the physiology and
pathophysiology of lipoprotein metabolism, the clinical impact of disorders of lipoprotein
metabolism, and their treatment. An understanding of the pathobiology of the dyslipidemias
requires a fundamental understanding of lipoprotein physiology, and the various sites at which
defects can occur in these metabolic pathways. This includes an appreciation of the
pathogenesis and diagnosis of both genetic disorders and secondary forms of dyslipidemia
that result from the presence of several endocrine and other diseases, lifestyle variations,
and/or the use of a variety of drugs. The area of lipids also requires training in the therapy of
these disorders. Therapeutic options include both lifestyle (diet and physical activity) and
pharmacological therapy.
Importance of Lipids
Many forms of dyslipidemia are associated with an increased risk of cardiovascular disease
(CVD), especially coronary artery disease. These include those that have high levels of LDL,
and some forms of hypertriglyceridemia, which can be a marker of other abnormalities
associated with increased cardiovascular risk. Low levels of HDL in plasma also can be
associated with increased CVD risk. Epidemiological studies have demonstrated that the major
importance of dyslipidemia is that they are associated with an increased risk of developing
accelerated or premature CVD. Clinical trials have shown that CVD symptoms and
cardiovascular events can be markedly attenuated by appropriate therapy of these disorders.
However, not all forms of dyslipidemia are associated with increased CVD risk. An
understanding of the relationship between various forms of dyslipidemia and other
cardiovascular risk factors in determining overall cardiovascular risk is important in the
prevention and treatment of accelerated or premature CVD.
Marked elevations of plasma triglycerides also can result in pancreatitis and other features of
the chylomicronemia syndrome. An understanding of the multiple factors that may contribute to
marked hypertriglyceridemia and the appropriate management, which dramatically reduce the
risk of pancreatitis in these patients.
Goals
By the completion of their fellowship, trainees should be competent in the diagnosis of the
various common genetic and acquired forms of dyslipidemia. They should have a good
understanding of the various laboratory tests that are available to aid in their diagnosis, and
should be aware of the strengths and limitations of these diagnostic tests. Trainees also should
be competent in the management of these disorders. This includes an understanding
86
of the dietary principles and other life style modifications involved in the treatment of
dyslipidemia and in atherosclerosis prevention. The trainee also should be competent to
prescribe the major classes of drugs used to treat dyslipidemia, singly and in combination, and
be aware of their major side effects.
Training
These skills should be acquired through a variety of means, which may vary between different
programs, depending on the size and specific interest of the faculty, and whether or not the
program includes a clinic dedicated to the diagnosis and treatment of lipid disorders.
Suggested training to acquire these skills might include:
(1) Formal training such a didactic lectures and/or self-directed learning through reading
material concerning physiology and pathophysiology
(2) Familiarity with the latest guidelines for the diagnosis and management of hyperlipidemic
patients that are issued by the National Cholesterol Education Program. These are updated
periodically
(3) Hands on evaluation and follow-up of outpatients with various genetic and acquired
forms of dyslipidemia in either general endocrine continuity clinic or in rotations through
specialized lipid disorders clinic
(4) Lectures and/or reading materials regarding the application of diet therapy and lifestyle
changes
(5) Formal lectures and/or reading material on the pharmacological management of the
hyperlipidemic/dyslipidemic patient
Where no formal lectures are given, a specific list of articles on these topics, common to all
programs, should be provided to trainees at the beginning of their fellowship experience.
Specific Disorders of Lipid Metabolism
Triglyceride
chylomicrons (risk for pancreatitis)
LPL deficiency
Mix of two common disorders: chylomicronemia syndrome
VLDL (with low HDL)
familial hypertriglyceridemia (FHTG)
familial combined dyslipidemia (FCHL)
diabetic dyslipidemia
Type III, remnant removal disease
Cholesterol
With increased triglyceride: FHTG, FCHL, diabetes
LDL: defective LDL receptor or ligand
Lp(a)
Other Endocrine Dyslipidemia
Hypothyroidism
Cortisol excess
87
Acromegaly
Estrogen, testosterone
(Other) drugs, alcohol
Management
Severe hypertriglyceridemia and pancreatitis
Atherosclerosis risk: LDL level and heterogeneity, Lp(a), low HDL with and without high
triglyceride
Special considerations
One area that requires special emphasis is the approach to the diagnosis and management of
diabetic dyslipidemia and the dyslipidemia that frequently accompanies insulin resistance. The
focus in many diabetic clinics is on management of hyperglycemia, which has been
convincingly shown to be of benefit to the prevention of microvascular complications of
diabetes. However, the major cause of morbidity and mortality in this disease is due to
complications of macrovascular disease. An approach to the prevention and treatment of the
macrovascular complications of diabetes is often inadequately emphasized in the management
of the diabetic patient. With the increasing awareness of the importance of treatment of
dyslipidemia and other modifiable risk factors in addition to hyperglycemia, special emphasis
on the management of diabetic dyslipidemia, and the dyslipidemia that accompanies the
insulin resistant syndrome, should be included as part of the lipid curriculum. This includes
knowledge of the specific changes in lipids and lipoproteins that occurs in diabetes and the
insulin resistance syndrome, how these changes are affected by the management of
hyperglycemia, specific approaches to the management of these lipid abnormalities in
diabetes, and a global approach to CVD risk factor management in diabetes and the insulin
resistance syndrome.
Another area that requires emphasis is the management of the patient with marked
hypertriglyceridemia. Elevation of plasma triglycerides to levels that put a patient at risk of
pancreatitis usually results from a combination of a common genetic form of
hypertriglyceridemia with one or more acquired forms of hypertriglyceridemia, and/or the use of
lipid raising drugs. Marked hypertriglyceridemia is one of the most common causes of recurrent
pancreatitis, but frequently is not diagnosed and treated appropriately. It is important that
trainees understand the interaction of genetic and secondary forms of hypertriglyceridemia in
the etiology of marked hypertriglyceridemia. At the completion of their fellowship, trainees
should be able to identify the major genetic and acquired conditions that are involved in the
causation of marked hypertriglyceridemia. They also should be competent in the management
of this condition, with a view to the prevention of recurrent pancreatitis.
An uncommon condition that trainees should be competent with the diagnosis and treatment of
is remnant removal disease (type III hyperlipoproteinemia), or remnant removal disease.
General internists or primary care physicians usually do not correctly diagnose this genetic
form of dyslipidemia. The clinical and laboratory features that lead to the diagnosis of this
relatively uncommon condition should be part of the lipid curriculum for endocrinology trainees.
Trainees also should be aware of the different therapeutic options in this condition. With the
advent of newer and improved lipid-lowering agents, combinations of drugs that affect lipid
metabolism are being used more frequently. Some of these combinations are rational,
effective, safe and cost effective. Others are associated with potentially dangerous
88
side effects. It is important that trainees understand the relative risks and benefits of
combination therapy for the treatment of dyslipidemia. In rare instances with high LDL that is
resistant to therapy, apheresis may be indicated.
There are a number of rare disorders of lipid and lipoprotein metabolism, which have provided
considerable insight into our understanding of lipid and lipoprotein metabolism. These include
lecithin cholesteryl acyl transferase deficiency, hepatic lipase deficiency, cholesterol ester
transport protein deficiency, apolipoprotein CII deficiency, abetalipoproteinemia and Tangier
disease. For example, the recent identification of the molecular defect in Tangier disease has
provided important insight into the understanding of reverse cholesterol transport. However,
most practicing endocrinologists and even lipid specialists are unlikely to see any of these
conditions in their lifetime. Therefore, a detailed working knowledge of these conditions should
not be a requirement for the lipid curriculum. A less rare condition is hypobetalipoproteinemia.
Trainees should be familiar with this condition, its diagnosis and implications.
Evaluation
The attending physicians with whom they work in their continuity and subspecialty clinics
should evaluate trainees at least annually. Evaluations must include comments regarding
clinical judgment, medical knowledge, clinical skills, humanistic qualities, professionalism,
medical care and continuing scholarship (ABIM).
Suggested Reading
Chapters 56-64. In: Scriver et al, eds. The Metabolic Basis of Inherited Disease. 7th ed.
McGraw-Hill; 1995.
Current Opinion in Lipidology: Journal published six times per year with extensive reviews.
Summary of the Second Report of the National Cholesterol Education Program (NCEP) Expert
panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult
Treatment Panel II). JAMA. 1993; 269(23):3015-3023.
AACE Medical Guidelines for Clinical Practice: Diagnosis and Treatment of Dyslipidemia and
Prevention of Atherogenesis. Endocrine Practice. 2000; 6:162-213.
89
Disorders of Lipid Metabolism
Method of Education
Formal
Direct Clinical
Instruction Experiences
Clinical Case
Discussions
In-patient
Out-patient Attd. Rds Conference
s
1. Cholesterol
a) LDL defect
b) LDL receptor defect
c) Management
2. Triglycerides
a) Chylomicrom
b) Lipoprotein lipase defect
c) Apoprotein CII deficiency
d) VLDL
e) Management
3. Mixed defects
a) Management
4. Secondary Dyslipidemias
a) Diabetes mellitus
b) Hypothyroidism
c) Medication
5. Other
a) Tangier’s disease
b) Lpa
c) Apoprotein physiology
90
Selfdirected
learning
Method of Evaluation
Direct
observations Discussions Clinical
Written
with patient with faculty Presentation Examination
s
s
Nutrition and Obesity Introduction
Endocrinology is concerned with the actions of hormones and the organs and tissues in
which the hormones are formed. A number of hormones are particularly involved with fuel,
vitamin, and mineral metabolism. They are profoundly involved in substrate flux and the
utilization of food for energy production and storage. Their importance in nutrition is
therefore great. A practicing endocrinologist must have a basic knowledge of nutrition to
understand the endocrine interactions that occur. At a minimum, there must be in an
endocrinology subspecialty training curriculum a core knowledge in nutrition (including
nutrition support), and an understanding of eating disorders (including obesity, anorexia
nervosa and bulimia).
The goals for the training of Endocrine Trainees in Nutrition are to have a working
knowledge of the above conditions, both basic pathophysiology and treatment modalities.
Core Knowledge in Nutrition
Fuel Metabolism
Role of hormones and peptides in the regulation of fuel metabolism Central Nervous System
Regulation
Micronutrient Requirements
Vitamins: A, D, E, K folate, ascorbate, thiamine, riboflavin, niacin, B12, biotin, pantothenic
acid, pyridoxine
Antioxidants
Inositol, choline, carnitine
Minerals: Ca, P, Mg, Mn, Fe, Zn, Cu, Se, iodine Vitamins and Minerals
(1) Sources in the diet: bioavailability and absorption
(2) Parenteral preparations
(3) Metabolism
(4) Antagonists
(5) Drug/nutrient interactions
(6) Deficiency syndromes
(7) Excess syndrome
(8) DRIs (normal requirements)
(9) Dietary supplements
Macronutrient Utilization: carbohydrates, proteins and fats
Modulation of Disease Processes by nutrients in food and by dietary supplements
(carcinogenesis, diabetes mellitus, cardiovascular disease, pregnancy, metabolic bone
disease)
Eating Disorders
Obesity
Who Are the Obese?
(1) body composition
(2) prevalence
What Causes Overweight?
91
(1) gene/environment interactions
(2) energy balance
(3) neuro-endocrine causes: rare hypothalamic obesity syndromes, pituitary, adrenal,
thyroid, PCO, insulin resistance, leptin deficiency
(4) drug induced
(5) primary psychiatric
Health Hazards
(1) insulin resistance leading to the metabolic syndrome
(2) mechanical complications
Clinical Classification and Natural History
Clinical Evaluation
Treatment
(1) behavior modification
(2) diet treatments including:
high protein, high fat, low carbohydrates, proteinsupplemented modified fast, liquid diets low fat,
high carbohydrate diets
traditional diet (ADA, AHA)
non-traditional diets
(3) physical activity
(4) pharmacological treatment
(5) surgery
(6) setting up a weight management practice
(7) complications of treatment (e.g., gallstones, electrolyte abnormalities, arrhythmias,
vitamin deficiency)
Obesity Clinical Trials – evaluation and interpretation
Anorexia/Bulemia
The Clinical Syndromes
(1) anorexia: diagnosis, full blown syndrome, pre"syndrome"
(2) bulimia: purging, exercise, laxative, exercise as purging
Neuro-Endocrine Metabolic Abnormalities
(1) gonadotropin abnormalities
(2) hypo metabolic manifestations
(3) HPA axis interrelations
(4) other pituitary abnormalities: GH, prolactin
(5) estrogen abnormalities
Clinical Sequelae
(1) osteoporosis
(2) amenorrhea
(3) dentition
(4) CVD
Psychological Characteristics
Treatment
Nutrition Support
92
Protein Calories Malnutrition (Marasmus)
head and neck cancer, malabsorption, CNS disease, anorexia and bulimia, GI obstruction,
iatrogenic, drug induced, senescence
Protein Malnutrition (Adult Kwashiorkor-Like Syndrome)
critical illness acute vs sustained/chronic, trauma, burn, protein-losing enteropathy, HIV,
cancer, nephrotic syndrome
Nutritional Assessment
history, physical exams, including anthropometrics, laboratory assessment, body
composition: bia dexa, metabolic cart
Treatment
(1) enteral: oral and tube feeding
(2) parenteral
(3) pharmacological (anabolics)
(4) combined modalities
(5) monitoring treatment
Interpretation of Clinical Trials in Nutrition Support
Specific Technical Procedures
Metabolic Cart - Energy Expenditure Dexa for Body Composition Bioelectrical Impedance
Analysis
Total Parenteral Nutrition Formulation/Management
Emergencies
Extreme Obesity
(1) decompensated respiratory failure
(2) decompensated cardiovascular failure
(3) cellulitis and other skin disorders
(4) complications of treatment (acute cholecystitis, arrhythmias)
Anorexia/Bulimia
(1) cardiac arrhythmia
(2) sepsis
(3) hypotension
(4) hypoglycemia
(5) psychosis
(6) electrolyte
abnormalities Parenteral
Nutrition
(1) catheter related sepsis
(2) thrombus or emboli
(3) bleeding
(4) hypo and
hyperglycemia Re-feeding
Syndrome
(1) volume overload and heart failure
(2) electrolyte abnormalities and arrhythmia
93
Suggested Reading
Texts
Biochemical and Physiological Aspects of Human Nutrition. Martha Stipanuk, editor. W.B.
Saunders Company.
A comprehensive textbook focusing on biochemistry and metabolism. It is appropriate for
the human nutrition curriculum in an endocrine training program setting.
George Bray. Contemporary Diagnosis and Management of Obesity. Newtown, Pa:
Handbooks in Health Care Co.
An excellent introduction to obesity.
Jeffrey S. Flier, Daniel W. Foster. Eating Disorders: Obesity, Anorexia Nervosa, and Bulimia
Nervosa. In: Williams Textbook of Endocrinology.
Disorders of Fuel Metabolism. In: Kenneth L Becker, ed. Principles and Practice of
Endocrinology. 2nd ed. Philadelphia, Pa: J.B. Lippincott Company.
Physicians Desk Reference: Dietary Supplements. Aspen Guidelines For Enteral and
Parenteral Nutrition
Nutrition in Medicine (NIM) Series
nutritioninmedicine.org/
Additional Reading
Shils ME, Olson JA, Shike M, Ross AC, eds. Modern Nutrition in Health and Disease. 9th
edition, Williams and Wilkins.
Carolyn D. Berdanier. Advanced Nutrition. Micronutrients. CRC Press.
For an introduction to alternative medicine products that an endocrinologist will be faced with
in practice:
Jeffrey I. Mechanick. Report of the AACE Nutrition Guidelines Task Force: The Use of
Nutraceuticals in Clinical Medicine.
Shultz. Rational Phytotherapy
US Food and Drug Administration website
Dr. Zeisel, SCIENCE, 1998 for understanding safety
US Office of Dietary Supplements website
Tufts website for dietary supplements
94
Nutrition and Obesity
Method of Education
Formal
Direct Clinical
Instruction Experiences
In-patient
Clinical Case
Discussions
Out-patient Attd. Rds Conference
s
1. Obesity
a) Pathophysiology
b) Diagnosis
c) Management
2. Starvation
a) Anorexia nervosa
b) Bulemia
3. Vitamin Deficiency
a) Water soluble
b) Fat soluble
4. Total Parenteral Nutrition
a) Management
5. Disease Specific Studies/ Procedures
a) Other
95
Selfdirected
learning
Method of Evaluation
Direct
observations Discussions Clinical
Written
with patient with faculty Presentation Examination
s
s
Thyroid Disorders Introduction
Thyroid specific disorders include both anatomical defects of the thyroid gland as well as
disorders due to the effects of thyroid hormones on extrathyroidal tissues. Thyroid disorders
are among the most common diseases encountered by the endocrine consultant; they
occur in the population with a prevalence greater than 10% in some studies.
Furthermore, the incidence of thyroid disorders is rising, in part because our diagnostic
tools are much more sensitive and sophisticated. Thyroid disorders account for a significant
amount of morbidity in our society and the trainee should be competent in their diagnoses
and treatment.
Program Requirements
1. The training program must provide opportunities for the trainee to develop clinical
competence in the area of thyroid disease. Clinical experience must include opportunities to
diagnose and manage (1) adolescent and adult inpatients and outpatients of both sexes
with (2) a variety of thyroid diseases of (3) varying acuity. The program also must include
opportunities to function in the role of an endocrinology consultant for patients and other
physicians and services in both inpatient and outpatient settings.
2. The trainees must be given opportunities to assume responsibility for and follow patients
throughout the training period in both inpatient and outpatient settings to observe the
evolution and natural history of thyroid disorders, as well as the effectiveness of therapeutic
interventions. To accomplish these goals, the educational program must have at least 30
percent of the training in endocrine subspecialty related ambulatory care settings.
Residents must have experience representing variable acuity and a wide spectrum of
thyroid related diseases.
3. The curriculum must emphasize biochemistry and physiology, including cell and
molecular biology, as they relate to thyroid disease. The appropriate utilization and
interpretation of clinical laboratory, radionuclide, and radiologic studies for the diagnosis
and treatment of thyroid diseases must be stressed.
4. Residents must have formal instruction, clinical experience, or opportunities to acquire
expertise in the evaluation and management of the disorders listed below as well as
aspects of those disorders that relate to: (1) psychiatric disease, (2) aging, with particular
emphasis on the care of geriatric patients and thyroid related changes associated with
aging, and (3) adaptations and maladaptations to systemic diseases with respect to effects
on the hypothalamic-pituitary-thyroid axis.
5. In relation to the diseases listed below, there should be formal instruction in: (1) thyroid
physiology and pathophysiology in systemic diseases and principals of hormone action, (2)
biochemistry and physiology, including cell and molecular biology and immunology, as they
relate to thyroid disease, and (3) signal transduction pathways and biology of thyroid
hormone receptors and their interaction with other hormone receptor pathways.
6. In relation to the diseases listed below, residents should have experience in the
performance of endocrine clinical laboratory and radionuclide studies and basic laboratory
96
techniques, including quality control, quality assurance, and proficiency standards.
Provision must be made for the trainee to acquire experience and skill in the following
areas:
(1) the interpretation of laboratory tests; immunoassays; and radionuclide, ultrasound,
radiologic, and other imaging studies for the diagnosis and treatment of thyroid
diseases;
(2) the effects of a variety of non-endocrine disorders on laboratory and imaging
studies and performance and interpretation of stimulation and suppression tests as
related to thyroid disease; and
(3) thyroid related emergencies, including:
(a) severe hypo- and hyperthyroidism (thyroid storm and myxedema coma);
(b) severe thyroid dysfunction during and after pregnancy;
(c) tracheal compression from a goiter or from the treatment of thyroid disease;
(d) agranulocytosis secondary to anti-thyroid drug therapy.
Specific Disease Disorders
The methods of education and methods of evaluation for the disorders of the thyroid are
provided in the subsequent table and listed in 6 broad areas.
1. The trainee must have a comprehensive understanding of all causes of thyrotoxicosis.
The major method of education will be by direct clinical experiences in the out-patient clinic,
by clinical case discussions on attending rounds and in conferences, and by self-directed
learning for Graves' Disease, thyroiditis, and toxic nodular goiters. For these disorders the
trainee will be evaluated by direct observations and discussions with the faculty, as well as
by clinical presentations. For other causes of thyrotoxicosis, the trainee may use selfdirected learning, clinical case discussions, or obtain formal instruction to assure adequate
understanding of the other causes of thyrotoxicosis.
2. The trainee must have a comprehensive understanding of all causes of hypothyroidism.
Auto-immune and post-ablative hypothyroidism should be learned by direct clinical
experience in the out-patient setting, as well as by clinical case discussions and selfdirected learning. Teaching of the other causes of hypothyroidism may also utilize formal
instruction, clinical case discussions, or self-directed learning to meet this objective.
3. The trainee must have a comprehensive understanding of thyroid cancer. Differentiated
epithelial thyroid cancer should be learned by direct clinical experience in the out-patient
setting and supplemented by experience in the inpatient setting. Further teaching by clinical
case discussion and self-directed learning is encouraged. Medullary thyroid cancer should
also be learned by direct clinical experience in either the out-patient or inpatient setting with
supplementation by formal instruction, clinical case discussion, and self-directed learning.
Other causes of thyroid cancer may be taught by clinical case discussions or self-directed
learning.
4. The trainee must have a comprehensive understanding of the causes of nodules and
goiters. The single nodule, multinodular goiter, and a diffuse goiter should be learned by
direct clinical experience in the out-patient setting with supplementation by clinical case
97
discussions and self-directed learning. Other causes of nodules and goiters may be taught
by self-directed learning in addition to direct clinical experience and clinical case discussion.
5. The trainee must be familiar with other causes of thyroid dysfunction. These include
pregnancy related thyroid dysfunction, polyglandular autoimmune syndrome, and thyroid
dysfunction in non-thyroidal disease. These diseases should be learned by direct clinical
experience in the in-patient or out-patient setting. They may be supplemented by clinical
case discussions and self-directed learning. Other causes of thyroid dysfunction may be
taught by self-directed learning in addition to clinical case discussions and direct clinical
experience.
6. The trainee must have sufficient experience to become competent in the following
procedures. (1) The trainee must perform at least 10 fine needle aspiration biopsies of a
thyroid nodule. The trainee is expected to review the cytology with a pathologist who has
expertise in interpretation of thyroid cytopathology. (2) The trainee is expected to review
imaging studies with individuals who have expertise in interpreting these images. Such
studies include thyroid ultrasound and nuclear imaging studies.
The curriculum committee recognizes that proficiency in fine needle aspiration biopsy,
which includes indications, interpretation and complication, often requires more than 10
procedures, and encourages the trainee to perform as many as practical during their
training.
Additional Training
Experience in the two following areas is encouraged. (1) The opportunity to become
proficient in the performance of thyroid ultrasound, including ultrasound-guided fine needle
aspiration biopsy of the thyroid and lymph node tissue. This opportunity may occur at the
trainee’s training site or through a sponsored course. (2) The opportunity to fulfill the
Nuclear Regulatory Commission and state requirements for administration of radio-iodine
for hyperthyroidism and thyroid cancer. This opportunity may occur at the trainee’s training
site or through a sponsored course.
Evaluation
The evaluation of the trainees in all areas should include direct observations with the patient
and discussions with the faculty. Additional evaluations can occur following clinical
presentations by the trainee.
Suggested Reading
The curriculum committee recognizes there are many appropriate textbooks that can be
used for directed self-learning. These include the textbooks on thyroid disease as well as
the textbooks in general endocrinology. The curriculum committee encourages the trainee
to utilize any of these sources for self-directed learning.
98
Disorders of the Thyroid
Formal
Direct Clinical
Instruction Experiences
Method of Education
Clinical Case
Discussions
In-patient Out-patient Attd. Rds Conferences
1. Hyperthyroidism
a) Grave’s Disease
b) Thyroiditis
c) Toxic nodule
d) Toxic multinodular goiter
e) Struma Ovaril
f) Thyrotoxicosis factitia
g) Other
2. Hypothyroidism
a) Thyroiditis
b) Post-ablative
c) Other
3. Thyroid Cancer
a) Pappillary thyroid cancer
b) Follicular thyroid cancer
c) Medullary thyroid cancer
d) Anaplastic thyroid cancer
e) Other
4. Nodules
a) Simple nodule
b) Multinodular goiter
c) Diffuse goiter
d) Other
5. Other
a) Polyglandular autoimmune
syndrome
b) Pregnancy-related thyroid
disease
c) Non-thyroidal illness
6. Disease Specific Studies/ Procedures
a) Fine needle aspiration
b) Thyroid ultrasound
c) Thyroid scan-iodine
d) Thyroid scan-Tcm
99
Selfdirected
learning
Method of Evaluation
Direct
observations Discussions Clinical
Written
with patient with faculty Presentations Examinations