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Endocrinology, Diabetes, & Metabolism

Curriculum


FIRST YEAR OF FELLOWSHIP
 
The first year of training focuses on obtaining a large amount of clinical experience in basic endocrinology. Most of this occurs in the outpatient setting, consistent with the mix seen by practicing endocrinologists.

AMC Outpatient Clinic

This rotation provides the bulk of the patient care learning experience for the fellow and is a continuity clinic, since patients encountered here will be followed into the second year.

Goals and Objectives:
The fellow will obtain the medical knowledge and skills necessary to become an endocrine consultant and provide optimal care to patients with endocrine disorders. The fellow will be exposed to practice based learning and improvement and system-based practice. Interpersonal communication skills and professionalism will be developed.


Description
:
The AMC outpatient endocrine clinic is a busy clinic with over 7,000 patient encounters yearly. Approximately two thirds of the patients have diabetes, a substantial minority with type 1. The remainder of patients seen comprise all forms of endocrine disorders, including thyroid, adrenal, pituitary, gonadal, metabolic bone disease, and other metabolic abnormalities. All ages from adolescence and older are represented. The clinic is a referral clinic for the Albany Medical College faculty practice and for a large area of northeastern NY. Nearly 40% are on Medicare, and approximately 15% are on public assistance or uninsured. All forms of insurance and health care systems are represented.

Fellows with patientThe fellow has patients scheduled in the endocrine outpatient clinic on all weekday mornings except Wednesday (when the patient attends continuity clinic in the morning at the VA medical center).  There is a combination of new patients and follow up visits. New visits are allocated one hour; follow up visits are 30 minutes. The clinic is scheduled for 4 hours except for Tuesdays and Thursdays (to allow for case conference and monthly Medicine Grand Rounds). This is a continuity clinic, meaning the trainee will follow individual patients throughout the course of the training period. All patients are seen and evaluated by the fellow prior to presentation to a faculty member. The fellow will be responsible for all medical record keeping for these patients (including dictation), laboratory follow up, and subsequent patient contact.

All aspects of patient care are managed in this setting. The fellow will learn and be expected to demonstrate skills in physical diagnosis, laboratory and diagnostic test interpretation, technology applications in diabetes care (i.e., insulin pumps and glucose sensors), and fine needle aspiration of the thyroid. The fellow will be exposed to practice based learning and system-based learning across a broad range of patients and health care systems. The fellow will learn to work as a team member with other health care professionals and will be expected to demonstrate professionalism throughout the experience.

VAMC Outpatient Clinic
This rotation augments the experience at the AMC outpatient clinic, providing a different learning environment.

Goals and objectives:
The fellow will obtain the medical knowledge and skills necessary to provide optimal care to patients with endocrine disorders. The fellow will be exposed to practice-based learning and improvement and system-based practice. Interpersonal communication skills and professionalism will be developed.

Description:
The VAMC outpatient endocrine clinic is a referral clinic for patients with endocrine disorders. This clinic meets once weekly, on Wednesday mornings. The VA patient population is predominantly male, similar to VA populations across the country. The majority of patients have diabetes, but this is not a diabetes continuity clinic, as the VA system is encouraging primary care treatment of diabetes. Patients in the VA system are sent to this clinic with specific issues regarding their diabetes care, or for general endocrine problems.

This clinic is staffed by Drs. Luidens and Davis. Patients are seen prior to being discussed with either of the attendings. As for the AMC clinic, the fellow is expected to be involved in all aspects of the management of these patients, with the expectations of everything from diagnosis to medical records and health care team communication.

Endocrine Inpatient Consult Service
Goals and objectives:
The fellow will obtain the medical knowledge and skills necessary to function as an endocrinology consultant and provide optimal care in the hospital setting to patients with endocrine disorders. The fellow will develop the skills to function as an effective member of a health care team, including management and interpersonal communication skills.  The fellow will also become an effective teacher of students and residents.

Description:
On weekdays, the fellow will be responsible for the hospital endocrine consult service.  New patients are evaluated by the fellow (as well as residents and students who may be rotating with the division) prior to presentation to the service attending later in the day. This consultation service comprises consultations from the OB/GYN service and patients with non-diabetes endocrine problems throughout the hospital, and averages about one consult per day. The fellow will be responsible for maintaining an up to date list of the patients, and be expected to manage rounds with the attending. These rounds will be a combination of work and teaching rounds. The fellow will be responsible for medical record keeping, including JCAHO compliance (which is monitored by the hospital). It is also expected that the fellow will comply with all hospital regulations involving patient safety (i.e. infection control) and help ensure compliance of consult team members.

Diabetes Consult Service
Goals and objectives:
The fellow will obtain the medical knowledge and skills necessary to provide optimal care in the hospital setting to patients with diabetes mellitus. The fellow will develop the skills to function as an effective member of a health care team. The fellow will learn methods of self-assessment.

Description:
For approximately 8 weeks per year, the fellow will participate in the endocrine hospitalist diabetes service. This service, staffed by Dr. Desemone (and covering faculty) and mid level care providers, is responsible for diabetes consults in the hospital. During these weeks, the fellow will participate in the evaluation and care of hospitalized patients under the supervision of the attending physician. There will be no outpatient clinic for the fellow during these weeks.

On Call Responsibilities
On call responsibilities consist of one weekend per month and one weeknight each week. Weekend call requires managing the inpatient diabetes and endocrine consult services under the direct supervision of a faculty member. Weeknight call involves covering phone calls to the endocrine division and managing emergency consults (all under the supervision of a faculty member).

SECOND YEAR OF FELLOWSHIP
This year is structured to provide research experience and continued clinical exposure in general and subspecialty endocrinology. Clinical duties include the fellow’s continuity clinics (AMC and the VA) and the weekly Lipid Clinic. The second year fellow also attends additional clinical experiences outside the endocrine division (e.g., pediatric endocrinology, reproductive endocrinology, endocrine surgery). Approximately 50% of time in the second year is devoted to research. On call responsibilities are the same as during the first year.

AMC Outpatient Clinic
This rotation continues in the second year, but for 2 half days per week (4 hours) and functions as the trainee’s continuity clinic.

Goals and Objectives:
The fellow will obtain the medical knowledge and skills necessary to provide optimal care to patients with endocrine disorders. The fellow will be exposed to practice based learning and improvement and system-based practice.  Interpersonal communication skills and professionalism will be developed.

Description:
The clinic is structured the same way in the second year as in the first.  However, there is less time devoted to new patients and more time devoted to continuing care of chronic diseases. The fellows are given greater responsibility at this level, with less strict supervision. All patient encounters are discussed with the faculty, but some patients may be seen without the attending directly verifying the physical exam and interview. There are greater expectations regarding diagnostic and therapeutic skills.

VAMC Outpatient Clinic
This rotation continues throughout the second year of training.

Goals and objectives:
The fellow will obtain the medical knowledge and skills necessary to provide optimal care to patients with endocrine disorders. The fellow will be exposed to practice based learning and improvement and system-based practice.  Interpersonal communication skills and professionalism will be developed.

Description:
The VAMC outpatient endocrine clinic is structured similarly to first year. There is an increased level of autonomy during the second year, along with greater expectations regarding diagnostic and therapeutic skills.

Subspecialty Clinical Experiences:
Over the course of the second year, exposure to subspecialty areas in and related to endocrinology is gained through the following clinical experiences: reproductive endocrinology, neurosurgery, endocrine surgery, ophthalmology, pediatric endocrinology, nuclear medicine, and transplant endocrinology. Additional experiences can be arranged. The scheduling of these blocks is flexible, as patient availability can be a factor.

Goals and objectives:
The fellow will increase the medical knowledge of the diagnosis and management of endocrine disorders that are encountered by other medical specialists. In addition, the fellow will further develop interpersonal communication skills necessary for optimal patient care.

Description:
The clinical rotations are designed to be primarily observational; responsibility for patient care lies with the service provider. The lengths of these rotations are variable and dependent in part upon the interests of the trainee. It is the responsibility of the trainee to contact the individual services to arrange the timing of these rotations (see Appendix for details and contact information).

Inpatient Duties
There are no inpatient responsibilities for the trainee in the second year, other than on call duties. 

Goals and objectives:
The fellow will obtain the medical knowledge and skills necessary to provide optimal care in the hospital setting to patients with endocrine disorders. The fellow will develop the skills to function as an effective member of a health care team, including management and interpersonal communication skills. The fellow will learn how to “pick up” and manage (“cover”) a busy consultative service.

Description:
Inpatient responsibilities involve weekend call where, similar to first year, the fellow will round with the faculty to cover the inpatient consult services. Since the fellow has no weekday inpatient responsibilities, the service will be essentially new to the fellow. The second year fellow is expected to be able to manage this weekend/evening coverage as if he/she were functioning as an independent endocrinologist (but is still supervised for medical/legal purposes).

Research 
Research is a significant part of the training of an endocrinologist. The exposure to research occurs throughout the fellowship, though the major part of the research experience occurs in the second year.

Goals and objectives:
The fellow will develop skills in design and performance of hypothesis-driven endocrine research, and participate in such research or equivalent scholarly activity.  The fellow will become grounded in the professional and ethical standards coincident with conducting such research.

Description:
The research experience is individualized.  During the first year, the fellow is exposed to the research being conducted at the medical center. The fellow is encouraged to seek out a mentor and, with guidance, develop a project. The fellow should discuss this in the late winter of the first year with the program director so that ample time is available to make preparations.

The research experience is expected to occupy 50% of the fellow’s time during the year. Specific goals and responsibilities are set by the mentor and the program director and discussed with the trainee. The experience comprises basic science, clinical, literature based research, in varied amounts. The expectation is that the experience will lead to co-authorship of a publication or presentation at a national meeting.

All endocrinology fellows are required to take a course required by all AMC principal investigators involved in research with human subjects. There are two options available for satisfying this requirement. Option A is to take the online University of Miami course in Protection of Human Research Subjects (free registration at www.citiprogram.org). Upon successful completion of the modules, the University of Miami contacts our Institutional Review Board and the fellow informs the program director. Option B is to access our copy of Protecting Human Subjects in Research.  At the end of the book is an exam, which is sent to the University of Rochester.  Passing the test generates a certificate which is sent to the examinee (the trainee) and then passed on to the program director.

THIRD YEAR OF FELLOWSHIP (optional) 
The fellow may choose to continue fellowship training for a third year. This is strongly encouraged for those wishing to pursue an academic career. This may be contingent upon the ability to obtain outside funding. The year is dedicated to research, with continued participation in conferences, teaching responsibilities, and on call coverage.  Clinical electives are encouraged.

WEEKLY CONFERENCES
Goals and objectives
:
The fellow will gain sufficient medical knowledge to become an effective and proficient endocrinologist. The fellow will learn the scientific method of problem solving, evidence-based decision making, and interpretation of research as it applies to patient care. The fellow will also learn how to utilize components of the health care system to provide and advocate for optimal patient care. In addition, the fellow will develop the ability to appraise and assimilate scientific evidence, and to continuously improve patient care based upon self-evaluation and life-long learning.

Schedule 
During both years, the fellows participate actively in the regularly scheduled conferences of the division. This includes monthly Grand Rounds of the Department of Medicine.

  • Tuesday Morning Conference: weekly case presentations
  • Tuesday Noon Conference:  One of the following each week: 
    • Journal Club (presentation and discussion of published research)
    • Research conference (faculty or invited research)
    • Didactic lecture or Resident Lecture (presentation of endocrine topics to internal medicine house staff)
  • Thursday Noon conference:
    • first week, hypertension conference with Nephrology
    • second and fourth weeks, pathology (with the Department of Pathology)
  • Department of Medicine Grand Rounds: the second Thursday of each month

Case Conferences
Every Tuesday morning, cases are presented to the faculty and private endocrine attendings. Generally, cases are presented by the fellows, though at times attendings will do so. The selection of cases will be discussed with faculty ahead of time.  Preparation for the case will include use of available source material to become familiar with pathophysiology, diagnosis, and management of the disease being discussed. This is done with the guidance and assistance of the faculty.  Literature searches are also expected as part of the preparation. Issues of diagnosis and management are discussed at the conference. Literature review by the trainee and personal experience of faculty and private endocrinologists are standard components of these presentations. Frequently, ethical issues, professionalism, access to care, and the broader context of systems of health care delivery are encountered.

Research Conferences
Once per month, faculty (and occasionally invited speakers) present current research to the division. During their second year, the fellows are expected to give a presentation regarding their research experience.  Research methodology is an integral part of this conference.

Didactic Lectures
These lectures are part of the Tuesday noon conference series. The following topics are discussed over the course of two years. Lectures are given by endocrine faculty and invited speakers (generally faculty at Albany Medical College). Additional lecture topics will be added over the two year period as deemed appropriate by the faculty.

  • Insulin: synthesis, regulation, and molecular mechanism of action
  • Developmental  endocrinology (growth and development, sexual differentiation, pubertal maturation)
  • Genetics (selected endocrine disorders) 
  • Principles of hormone action and signal transduction pathways
  • Creation, validation, and use of laboratory assays
  • Immunology of Endocrine Disorders
  • Pathogenesis of diabetes mellitus and insulin resistance
  • Pancreas transplantation
  • Non-genomic actions of steroid hormones
  • Radionuclide scanning

Pathology Conference
Twice monthly, pathologic specimens are reviewed with the pathology department.  The majority of these are cytologic specimens from fine needle aspiration (FNA) of the thyroid. FNAs from the previous months are reviewed, and the cases are discussed.  Additionally, pathology specimens of endocrine surgery are reviewed when available.

Nephrology Conference
On the first Thursday of each month, the divisions of endocrinology and nephrology hold a combined conference. The format is usually case presentation with discussion of management issues.

Core Competency Sessions
These didactic lectures are scheduled by the Department of Medicine for all medicine trainees. Topics include medical ethics, evidence based medicine, professionalism, and quality management (see Appendix).

Endocrine University
Each year the American College of Endocrinology sponsors a week long course for fellows in training. This course includes didactic lectures in multiple topics in endocrinology and provides hands on training, including certification, in bone densitometry and ultrasound. There are also lectures related to running a clinical practice. The senior fellow is sent to this course (see Appendix).

Required Reading
During the course of the two years of training, the fellow is expected to read one of the major endocrine texts (e.g., Williams Textbook of Endocrinology Wilson et al eds., Textbook of Endocrinology Felig et al, eds.). This will be provided to the fellow. The fellow can discuss with the faculty which textbook might be best matched to the fellow’s style of learning. It is expected that the fellow will become intimately familiar with the text and how to use it as a resource beyond fellowship training.

NATIONAL MEETINGS
During the course of the fellowship, each fellow is sent to at least one national meeting. Sponsored attendance at additional meetings is possible and supported whenever the fellow is involved in presenting research.