Medical Knowledge and Patient Care

Endocrinology

Rationale

Family physicians encounter a significant number of endocrinologic problems in the course of practice. Millions of work days are lost per year due to diabetes, metabolic-related and nutrition-related disorders. The morbidity of endocrinologic and metabolic disorders results in numerous hospitalizations annually.

Each family medicine resident should be aware of the impact of this group of diseases on the patient and the family and be capable of performing a history and physical examination with special attention to the endocrine system. The resident should be able to perform appropriate laboratory tests and basic diagnostic procedures and to initiate a management and therapeutic plan for patients who have these diseases.

Given the number of patients with medical complications related to these disorders, primary care physicians cannot rely on referral to endocrinologist or nutritionist to identify, diagnose and manage this growing health need. The family medicine physician is an integral part of the health care team that needs to recognize the importance of early diagnosis, treatment and holistic care of the patient with endocrinologic, metabolic, and nutritional disorders. As part of a comprehensive treatment plan, family medicine physicians need competency in assessing patient understanding of these diseases and how to participate in the treatment plan through self- management skills.

Family medicine physicians need to continually update their clinical knowledge given the new advances in endocrine, metabolic and nutrition-related diagnoses and treatments. These patients require full-spectrum care that emphasizes the use of appropriate medications and identifying when psychological, educational, and other therapies are necessary. Because family medicine physicians focus on comprehensive treatment, they have the unique skills to meet the demands of these patients.

Competencies

Medical Knowledge and Patient Care

Goal: Acquire skills in data collection, including history-taking, physical examination, the appropriate ordering and interpretation of laboratory and imaging studies, and medical decision making.Learn a basic core of knowledge of endocrine diseases; their clinical manifestations, pathophysiology, and management. This knowledge base will include both common and uncommon endocrine disorders and will also incorporate instruction in the genetics, biochemistry, pharmacology, and psycho-social aspects of endocrine diseases.

Objectives:

A. The resident will completely evaluate and manage common endocrine medical problems, including the following:

Cardiovascular Endocrinology

Causes of secondary hypertension

Primary aldosteronism

Primary Hyperparathyroidism

Cushing syndrome

Pheochromocytoma

Hyperlipidemias
The Metabolic Syndrome

Diabetes Type I and Type II

a. DKA

b. Hyperosmolar Hyperglycemic Non-Ketotic Syndrome

Growth Disorders

Acromegaly
Growth Hormone Deficiency in Children
Idiopathic Short Stature
Precocious (Early) Puberty
Turner Syndrome Growth Disorders

Hormone Abuse

Anabolic Steroids and Young Adults
Growth Hormone Use and Abuse
Supplements, Steroid Precursors and Adolescent Health

Menopause

Bioidentical Hormones and Menopause
Breast Cancer Prevention
Complementary and Alternative Medicine (CAM) for Menopausal Symptoms
Hormones, Women and Breast Cancer
Menopause and Bone Loss
Menopause Management: Hormone Therapy and Alternative Treatments
Menopause Management: Treatment Options for Early Menopause
Osteoporosis and Women's Health

i. Premature Ovarian Insufficiency

Osteoporosis

Bioidentical Hormones and Menopause
Bisphosphonates for Osteoporosis
Glucorticoid-Induced Osteoporosis
Vitamin D, Calcium and Bone Health
Hormone Therapy for Menopausal Symptoms
Menopause and Bone Loss
Osteoporosis in Men
Vitamin D, Calcium, and Bone Health

Pituitary Disorders

Acromegaly
Cushing’s Syndrome
Hyperprolactinemia
Diabetes insipidus
SIADH

Reproductive Endocrinology

Endometriosis
Erectile Dysfunction
Gynecomastia
Infertility and Men
Infertility and Women
Klinefelter Syndrome
Low Testosterone and Men’s Health
Polycystic Ovary Syndrome
Primary Ovarian Insufficiency
Vaginal Atrophy
Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD)

Thyroid Conditions/Disorders

Congenital Hypothyroidism
Goiter
Graves' Disease
Hashimoto's Disease
Hyperthyroidism
Hypothyroidism
Postpartum Thyroiditis
Thyroid Cancer
Thyroid Nodules

Other Conditions

Acromegaly
Adrenal Insufficiency
Ambiguous Genitalia
Bariatric Surgery and the Endocrine System
Congenital Adrenal Hyperplasia
Cushing's Syndrome
Enlarged Prostate (Benign Prostatic Hyperplasia)
Klinefelter Syndrome

B. The resident will articulate proper use of endocrinology consultations (inpatient and outpatient).

Learning Activities
Attending Rounds / Research Conference / X / Outpatient Clinics
Multidisciplinary Rounds / Ethics/Comm Conference / X / Direct Patient care
Grand Rounds / Specialty Conference / Resident Seminar
Sub-Specialty Conference / Noon Conference / Journal Club
Morning Report / X / Faculty Supervision / X / Readings
X / Didactics / X / Procedures
Other
Evaluation Methods
X / Attending Evaluation / X / Directly Supervised Procedures / Morning Report
X / Program Director
Review / X / In-Training Exam / X / Faculty Supervision and Feedback
360 ᵒ evaluation / Videotape Review / X / Quarterly Review
Other

Interpersonal and Communication Skills

Goal: Develop skills for adequate written documentation in charting, dictations, and computerized medical records. Develop oral communication skills and appropriate interpersonal interactions with patients, peers, and other health care professionals.

Objectives:

Develop skills for interviewing patients that allow accurate, complete collection of information regarding symptoms, and the community environment that affect the patient’smetabolic and nutritional health.
Develop skills in communicating results, educating patients and their families, and dealing with sensitive issues for patients and families, and negotiating a plan of treatment with the patient and family.
Residents will understand the need for a multidisciplinary, integrated approach to disease prevention and rehabilitation including: nutritionists, behavioral scientists, educators, endocrinologists, and family physicians.

D. Develop skills in educating patients and their families, in dealing with sensitive issues forpatientsand

families, and in negotiating a plan of investigation and treatment with the patient and family.

E. Develop professional relationships with co-workers, consultants, ancillary staff and other

Professionalsto enable assembling of health care teams and mobilization of community resources to

optimize care ofthe patient.

F. Use professional language and demeanor when communicating with other residents, with Family

Medicine attending physicians, with physicians from other services, with non-physician clinical staff,

withnon-physician non-clinical staff, and with patients and theirfamilies.

G. Create and sustain a therapeutic and ethically sound relationship with patients.

H. Use effective listening skills and elicit and provide information using effective nonverbal,explanatory,

questioning, and writing skills.

I. Work effectively with others as a member or leader of a health care team or other professional group.

J. Improve skills for providing patient education regarding prevention of endocrinologicaldiseases

associated with other medical conditions.

K. Learn how to effectively and efficiently communicate and coordinate with endocrinology consultants.

Learning Activities
Attending Rounds / Research Conference / X / Outpatient Clinics
Multidisciplinary Rounds / Ethics/Comm Conference / X / Direct Patient care
Grand Rounds / Specialty Conference / Resident Seminar
Sub-Specialty Conference / Noon Conference / Journal Club
Morning Report / X / Faculty Supervision / X / Readings
X / Didactics / X / Procedures
Other
Evaluation Methods
X / Attending Evaluation / X / Directly Supervised Procedures / Morning Report
X / Program Director
Review / X / In-Training Exam / X / Faculty Supervision and Feedback
X / 360 ᵒ evaluation / Videotape Review / X / Quarterly Review
Other

Systems-Based Practice

Goal:Demonstrate an awareness of and responsiveness to the larger context and system for health care and the ability to effectively call on system resources to provide care that is of optimal value.

Objectives:

Understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice.
Know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources.
Practice cost-effective health care and resource allocation that does not compromise quality of care.
Advocate for quality patient care and assist patients in dealing with system complexities.
Know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance.

Professionalism

Goal: Residents will demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.

Objectives:

Understand the need for continuing medical education to stay abreast of the constant changes in therapy for endocrinological diseases.
Become familiar with resources available in the community for patients with chronic illness and learn how to incorporate them into the treatment plan when needed.
Demonstrate integrity, honesty, respect and a commitment to excellence in all activities.
Demonstrate sensitivity, respect and adapt appropriately to the social and cultural issues of each patient.
Display initiative and resourcefulness in patient care and in solving problems.
Be timely in attendance of activities and completion of tasks.
Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supersedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development.
Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices.
Arrive at the rotation in a timely fashion.
Work effectively as a member of a team.
Respect patient privacy by guarding medical records and discussion of personal information
about patients.
Assist patients and their families in planning for future care needs and care decisions based

on prognosis for the disease.

Support the patient in their healthcare decisions.
Demonstrate professional, respectful demeanor when addressing team members, patients,

ancillary staff, and consultants.

Appear professionally dressed and well groomed.
Attends required conferences.

Practice-based Learning and Improvement

Goal: The resident should develop skills in evaluating their own patient care, appraising and assimilation of scientific evidence to improve patientcare.

Objectives:

Analyze practice experience and perform practice-based improvement activities using a systematic methodology.
Locate, appraise, and assimilate evidence from scientific studies related to their patients' health problems.
Obtain and use information about their own population of patients and the larger population from which their patients are drawn.
Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness.
Use information technology to manage information, access on-line medical information; and support theirown education.
Learn to incorporate health promotion and disease prevention into patient care.
Use evidence-based medicine, evaluation of available evidence, and use of best-available evidence at morning report meetings and during routine clinical care.

Learning Activities
Attending Rounds / Research Conference / X / Outpatient Clinics
Multidisciplinary Rounds / Ethics/Comm Conference / X / Direct Patient care
Grand Rounds / Specialty Conference / Resident Seminar
Sub-Specialty Conference / Noon Conference / Journal Club
Morning Report / X / Faculty Supervision / X / Readings
X / Didactics / Procedures
Other
Evaluation Methods
X / Attending Evaluation / X / Directly Supervised Procedures / Morning Report
X / Program Director
Review / X / In-Training Exam / X / Faculty Supervision and Feedback
360 ᵒ evaluation / Videotape Review / X / Quarterly Review
Other

III.Instructional Strategies (see above)

The primary strategy will be precepted patient care and procedures on the endocrinology rotation and in the Family Medicine Clinic. This will be complemented by didactic presentations and supplemental reading materials.

IV.Evaluation Strategies (see above)

Direct observation by Endocrinology and Family Practice preceptors
Chart review
End of rotation summative evaluation by Endocrinology preceptor

E. Resident evaluation of rotation by evaluation form.

F. Resident-advisor meetings (before and after rotation). At the midpoint of each rotation (as

a minimum) and as frequently as possible throughout, the resident should be given specific

and constructive feedback by the Endocrinology preceptor on his/her progress, to include

recommendations for improvement and personal growth.

G. If the resident does not receive this midpoint 2 week evaluation, he/she should request it

from his/her staff preceptor.

ABFP in-training exam

I. Resident self-evaluation

V.Implementation Strategies

A. This is a PGY II/PGY III elective rotation. The rotation will be done in the clinics of Dr.

Victoria Musey
B. PGY II residents will spend 6 half days/week for 1 four week block in the Endocrinology

clinic and 4 half days/week in the Family Medicine Clinic. PGY III residents will spend 5

half days/week in the Endocrine clinic and 5 half days/week in the Family Medicine Clinic.

The resident will attend didactics 1 half day/week on Thursday mornings.
1 week of vacation is allowed during the Endocrinology rotation.
Location: Emory University Hospital Midtown, Suite 1010.
Resident responsibilities:
Meet with endocrine advisor and know the endocrinology rotation expectations.
Examine patients, formulate an initial plan for work-up, diagnosis and management, and then present the patients to the preceptor.
Call will take place on the Family Medicine Service at Emory University Hospital Midtown.
Spend 4-5 half-days per week in FPC.
Document all procedures and diagnoses of patients managed.
Actively seek feedback from preceptors.
Complete rotation evaluation at the end of rotation.

VI.Selected Resources/Readings

1.AFP Monographs

Fluids and Electrolytes (320) January 2006

Obesity (349) June 2008

Type 2 Diabetes (358) March 2009

Endocrine Disorders (310) March 2005

2.Web Sites

Healthy People 2010: US Department of Health and Human Services

American Dietetic Association (ADA)

Arbor Nutrition Guide

Last Updated April 19, 2013