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Endocrinology Survival Guide

1. Welcome

We trust that you will have a pleasant and productive 3- month rotation through the Division of Endocrinology.  Endocrine diseases are, with a few notable exceptions, relatively rare. Symptoms and signs of endocrine diseases are however non-specific and quite commonly encountered in general clinical practice. Use this opportunity therefore to familiarize yourself with endocrine patient evaluation and to improve your management skills in this discipline. Although endocrinology has largely evolved into an OPD discipline, we are extremely fortunate to still have at our disposal a 12-bed Endocrine Unit located in Ward A10 of the Tygerberg Academic Hospital. Outpatient facilities (C7C Tygerberg) and basic research laboratories (3rd Floor, Faculty of Health Sciences) are also available. A comprehensive patient care service in General Endocrinology, Diabetology and Metabolism is provided and the division also acts as a referral centre for patients with metabolic bone diseases like osteoporosis and those with complex endocrinopathies. 

2. Staff

Three consultants, Prof Brynne Ascott-Evans (Head), Prof Stephen Hough and Dr Magda Conradie share patient care, teaching, and administrative responsibilities and are available for advice and guidance. Dr Marli Conradie is the senior registrar doing her subspecialty training in endocrinology during 2010/11 and Dr Wilma Kruger is our career medical officer. 
Riana Eager (tel: x4062) is in charge of the bone lab (DXA densitometry to measure BMD, quantitative bone histology), Lee-Ann (x5125) is our ward secretary in A10, Pottie (x5432) the ward clerk, and Srs Pedro and Norman (x4583) the sisters in charge of A10. You will also meet Elizabeth Wanza (x5536/7) who is the secretary in our Endocrine OPD, Sr Eunice Beukes (x4024) the head diabetes educator, as well as Prof Jan Lochner, Dr Sue Honnibal and other part-timers during your stay.

3. Weekly Programme

The week’s programme is summarized in the table on page 2. 
Responsibilities are essentially shared between:
  • 4 OPD sessions (2 diabetes; 1 endocrinology; and 1 general medicine) / week
  • 2 Elective patient intakes/week (Mon. and Wed.) and 2 Consultant Ward Rounds / week (Tues. and Fri.)
  • Referrals 
  • 3-4 Academic Meetings/Teaching Ward Rounds in Endocrinology (Wed. Thurs. and Fri)/ week and 1 Endo Business Meeting / week, and
  • 1 Business (Mon.) and 2 Academic Meetings (Mon. and Thurs.) in General Medicine / week   

Monday
Tuesday
Wednesday
Thursday
Friday
08:00
Dept Medicine Business Meeting
08:00
Ward round of own patients
08:00
Ward round of own patients
08:30
Academic Meeting
08:00
Discharge Ward Round
08:30
Quick-scan of new A10 admissions and own old cases
 
 
 
09:30
Working ward round / assessment of next week’s admissions
09:30
Diabetes OPD
09:15
Diabetes OPD
09:15
General MOPD
10:00
Endo OPD
10:30
Academic Teaching Round
13:00
Clerking of new A10 patients
16:00
Pathology Meeting
14:00
Consultant Intake Ward Round
16:00
Ward work /summaries / references
14:00
Clerking of new admissions Ward work/summaries. Obstetric ward round (F2) with Dr Magda Conradie
16:00-18:00
Interdepartmental Pituitary Clinic (1st) Combined TBAH/GSH meeting (4th/last)
15:00
Ward work/summaries / references
16:00-17:30
Internal Medicine Academic Meeting
12:15
Endocrinology Business Meeting
13:00
Journal Club

 

 4. Endocrine / Diabetes OPD

Please note that for Endocrine OPD:

  • Outpatient clinics take priority over all other duties, except true emergencies in Ward A10
  • The clinic starts at 10:00 sharp and we aim to complete the clinic by 13:00 and no later than 13:30
  • On the Wednesday preceding the clinic, the senior registrar is in charge of assessing all booked endocrine patient folders and deciding on the necessary laboratory tests to be performed when the patient reaches the OPD clinic. However, at each OPD visit, the doctor who sees the patient should state in the notes which tests are to be done on the next visit, and the completed lab forms for these tests should be given to the OPD secretary (Mrs Wanza) when she books the follow-up date. 
  • Every month one of the 3 consultants functions as “Clinic Manager” (rotation will coincide with their rotation on the ward) to ensure appropriate allocation of endocrine patient folders to each of the 3 patient stations.
  • No new patients will be accepted after 12:00 unless discussed with the Clinic Manager
  • 5 Elective and 5 urgent new patients may be booked per clinic.
  • Always consider whether a particular patient should be followed up long term in a tertiary endocrine OPD – if not, discharge the patient  
  • Everyone shall inform the Clinic Manager if they have to leave before all patients have been seen 
  • Registrars are encouraged to see both follow-up and new patients – discuss the latter with one of the “free” consultants who are not on Clinic manager duty.
  • Use the Endo OPD as an active source of learning

5. Admissions of Patients to A10

5.1 General

Patients are admitted to A10 on a Monday (largely endocrine cases but also diabetics) and a Wednesday (predominantly diabetics). These patients are usually booked in from the Endo /Diabetes OPD (arrange with sister at x4583). Patients can also be admitted from other wards or from outside TBAH if needed, but this must first be discussed with the senior registrar or the consultant on call for the month

Allocation of newly admitted patients is solely determined by the senior registrar and depends on who booked the patient, how many patients each doctor has, appropriateness of the case as a teaching tool etc.

5.2 The Protocol Book

A protocol book is available in A10 and covers the laboratory tests necessary to evaluate most of the common endocrine diseases. Consult the protocol book and employ the suggested protocol on each patient unless a very good reason exists not to do so. Always consult the senior registrar / consultant when a provocative endocrine test is contemplated.

Each patient admitted to A10 must be fully examined clinically and the appropriate Endocrine / Diabetes booklet comprehensively completed. Please keep the Results section up to date. Daily follow-up clinical notes are mandatory.

5.3 Ward Rounds

The consultant intake ward round takes place on Tuesdays at 14:00. Often other commitments at 16:00 require that this round be completed within 2 hours or less. It is therefore essential to prepare well, to liaise with the senior registrar beforehand and to be absolutely clear on the problem list, differential diagnosis and plan / proposed way forward.

The consultant discharge round takes place on a Friday morning and comprises (i) a working ward round that precedes the (ii) teaching ward round at 10:30.

It is of course essential that all your own patients are seen twice per day.   

5.4 Ward Cover after hours

The monthly on-call roster is compiled by the senior registrar and supplied well ahead of time. There are no junior staff (interns, rotating MOs) in A10 and everyone participates in providing cover after hours and on week-ends – you must be available/contactable when on call since there is no one else to call upon when the staff in A10 need help.  When on call over the weekend you are responsible to do the ward round in A10 as well as see patients under our care in other wards. Call the consultant on call for help whenever required. 

5.5 Discharge Summaries  

Diabetic patients need the summary at the end of the diabetes booklet (“Kliniese toestand by ontslag” / “Clinical condition at discharge”) OR a formal summary (template on PC) can be typed. On the day of discharge they also need the usual “Verslag van hospitaalverblyf / Report of hospital stay” page to be completed in triplicate (one copy for the patient; one for the (yellow) hospital folder, and one for the in-house (blue)diabetes booklet).

All endocrine patients need a comprehensive discharge summary (template on PC), clearly stating the:

  • Reason for / problem list on admission
  • Results of clinical and laboratory assessment – all the relevant lab data need to be listed with their interpretation
  • Outstanding lab results
  • Final diagnoses and the way forward

For new registrars it may be difficult if not impossible to put together a clear, cohesive summary of a complex endocrine problem. Please ask for advice from the senior registrar, the career MO or consultant on call. It may also be wise to consider, in consultation with the senior registrar, to hold back very complex cases for discussion at the “Folder Discussion” that takes place on a Friday afternoon every 4-6 weeks. Otherwise all summaries should be completed within 2 weeks after discharge so as to be available for OPD follow-up. Print your summary in triplicate (one for the patient; one for the yellow hospital folder and one for the blue in-house Endocrine folder) and give to Pottie for filing. Pottie should also be supplied by the appropriate ICD 10 codes.  Also save all your summaries on the PC in a folder under your name.

6. Referrals

All referrals should be seen on the same day. Diabetics referred from outside the Department of Medicine can be discussed with the senior registrar and finalized. All other referrals should be presented to the consultant on call as soon as possible. Please keep a record of all referrals (include telephone or electronic referrals) for the weekly stats of the Division which is ultimately the responsibility of Lee-Ann Cardoza.

7. Meetings

7.1 Academic Endocrine Meetings

The major academic meeting in the division takes place at 08:30 on Thursdays; a Journal Club is held every Friday at 13:00, a Teaching Ward Round at 10:30 on Fridays and a Combined TBAH-GSH meeting at 16:00 on the last Wednesday of every month with the exception of April (SEMDSA meeting), June(Vacation) and Nov/Dec(Festive Season). You will be requested to present at all our academic meetings.

Every 4-6 weeks a “Folder Discussion” is held instead of a Journal Club, where we discuss all the Endocrine patients admitted to the ward during the preceding month or two to ensure that all the laboratory results are up to date and a clear plan of action how to proceed is in place. The senior registrar is responsible to arrange this meeting and you will be warned in advance.     

7.2 Business Meeting

This is held at 12:15 on a Friday and provides the opportunity to discuss all issues involving patient care, administration as well as academia and research.

7.3 General Medicine Meeting

Registrars are expected to attend the Medicine Business Meeting at 08:00 on a Monday morning, the Pathology Meeting at 16:00 on a Monday and the Medicine Academic Meeting at 16:00 on Thursdays.

8.  Research

Clinical as well as basic research has been a top priority for the Endocrine Unit since its inception. Registrars are invited to make use of this unique opportunity to do their research project in Endocrinology.

9 The Bone Laboratory

The unit specializes in metabolic bone disease and is the only facility in the country that performs quantitative bone histology. You are invited to spend an hour or two during your rotation with Riana, to learn the principles about densitometric measurement of bone mass (BMD) and the use of bone histology.

10. Teaching

10.1 Outcomes for the Endocrine Rotation

Study methods and results are large determined by what is expected of the student i.e. study outcomes. The following list is not comprehensive, but should act as a guide to plan your study programme whilst in Endocrinology.

At the end of your 3-month rotation you will be expected to:

  • Understand the basic physiology of the endocrine system viz define the terms endocrine paracrine and autocrine; discuss the classification of hormones, their biosynthesis, secretion, plasma transport, biotransformation and mode of action; explain the different hormone receptors and intracellular signal transduction pathways and how defects in these can result in disease. More specifically, discuss the pathogenesis of endocrine disease with reference to (i) genetic defects (ii) environmental toxins (iii) auto-immune disorders (iv) endocrine tumours/hyperplasia (v) recepteropathies (vi) drug-induced endocrinopathies
  • Know the principles of the different radio-immunoassays/radiometric assays to quantitate hormone levels; understand the principles of stimulation and suppression tests in endocrine diagnosis, as well as the various radiological / radionuclear methods to localize endocrine pathology 
  • Have in-depth knowledge of the hormonal control of glucose homeostasis; the pathophysiology, classification, clinical manifestations and diagnosis of diabetes mellitus; the pharmacology of oral anti-diabetic drugs, insulin and insulin analogs; understand the step-wise treatment approach to the management of T2DM; the diabetic diet; management of adolescent / pregnant diabetics; goals of therapy; acute complications of diabetes including the different diabetic comas; microvascular and macrovascular complications; the metabolic syndrome.
  • Know the modern classification of hypoglycaemia and the appropriate laboratory work-up and management of patients with this disorder in diabetics and non-diabetics
  • Have in-depth knowledge of the hormonal control of calcium homeostasis and a working knowledge of the micro-structure of bone; know the causes and assessment of hyper- and hypocalcaemia, and parathyroid dysfunction. Have a thorough understanding of the causes, assessment and treatment of patients with osteoporosis. Have a working knowledge of other metabolic bone diseases like osteomalacia, as well as Paget’s disease of bone
  • Have in-depth knowledge of the physiology of thyroid hormone synthesis and secretion. Know hypo and hyperthyroidism, imaging and treatment of thyroid disease. Have a good working knowledge of goiter, thyroid nodules and thyroid malignancies.
  • Understand the hypothalamo-pituitary-end-organ structure and function, and the biochemical and radiological evaluation thereof. Understand pituitary tumours/hypopituitarism and central / renal diabetes insipidus. Have in-depth knowledge of hyperprolactinaemia, prolactinomas and gynaecomastia. Have in-depth knowledge of how to confirm a diagnosis of Cushings disease. Have a good working knowledge of the assessment and management of patients with Cushing’s syndrome and Acromegaly
  • Know the pathophysiology and secondary causes of obesity; the assessment of patients with obesity; the dietary management and pharmacotherapy of obesity; bariatric surgery.
  • Understand the physiology of growth and puberty. Have a good working knowledge of delayed growth and puberty.
  • Understand adrenal physiology. Know Addisons and Cushings. Have in-depth knowledge of the complications of glucocorticoid therapy. Know endocrine hypertension including the assessment of patients with suspected primary hyperaldosteronism and phaeochromocytoma. Have a working knowledge of hirsutism, virilisation and the menopause.
  • Have in-depth knowledge of endocrine emergencies* and the preoperative management of patients with endocrine diseases# Understand the principles of multiple endocrine gland dysfunction (including the MEA-1 / MEA-2 syndromes; polyglandular endocrinopathies), endocrine manifestations of malignancies (e.g. hypercalcaemia, SIADH etc), endocrine abnormalities in systemic diseases (e.g. liver, kidney etc), endocrine disorders with ageing.
  • Ensure that “metabolic” diseases like porphyria, dyslipidaemias etc which are not specifically covered in Endocrinology are included in your study programme 

*These include the diabetic comas, Addisonian crisis, thyroid storm, thyrotoxic heart failure or shock, myxedema coma, hypopituitarism, hyper-/hypocalcaemia, hypertensive crisis in patient with a phaeo, hypertriglyceridaemia with acute pancreatitis etc 

#These would include diabetes mellitus, phaeochromocytoma, thyroid disease, hyper- / hypocalcaemia, hypercortisolaemia

10.2 Suggested Reading

  • Greenspan’s Basic and Clinical Endocrinology  (8th or later editions) is an easy-to-read, well illustrated excellent textbook that covers just about everything you need to know
  • The endocrinology in Harrison’s Texbook of Medicine is generally very good but will need supplementation
  • Larger textbooks in endocrinology include William’s Texbook of Endocrinology and De Groot’s Endocrinology, but these should be used as reference books only
  • Journal articles from JCEM, JBMR, NEJM etc are of course invaluable for specific reviews

 10.3 Assessment

In addition to the informal feedback during case presentations / lectures, you will also receive formal feedback in the middle of (after 6 weeks) and upon completion of your rotation. Final evaluation will be based on the assessment of (i) a clinical case (ii) an objective written test, and (iii) a consensus mark of the 3 consultants of your performance during the 3 month rotation. It is your responsibility to keep your FCP log-book up to date at all times and to have it signed and returned at the end of your rotation.

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