Endocrinology, Metabolism and Clinical Nutrition

Program Curriculum for Fellow Education in
Endocrinology, Diabetes and Metabolism

Endocrinology and Metabolism Fellowship Objectives

• The fellowship is structured to provide broad and in-depth clinical training in the areas of endocrinology, metabolism, and clinical nutrition. These areas include diseases of the pituitary, thyroid and adrenal glands, diabetes mellitus, hypoglycemic syndromes, dyslipidemias, calcium disorders and metabolic bone disease, reproductive endocrinology, pediatric endocrinology, endocrine oncology, fundamentals of enteral and parental nutrition, eating disorders, disorders of vitamin and trace metal metabolism, endocrinology of aging, metabolic disorders in pregnancy, and endocrine diagnostic testing.
   
• Each fellow is required to participate in a research project under the mentorship of a faculty member. It is expected that the fellow's involvement will be of sufficient intensity to lead to abstract presentations and authorship of manuscripts. The fellowship will be sufficiently flexible to allow a more in-depth research experience for those planning a career in academic medicine.
   
• Fellows are expected to develop their oral and written communication skills through organizing and leading clinical conferences, housestaff and student teaching, succinct patient presentations, and manuscript preparation.

I. Facilities and Resources

• The principal venues for fellowship education are three major teaching affiliates (for adult medicine) of the Medical College of Wisconsin-Froedtert Memorial Lutheran Hospital, St. Luke's Medical Center and the Zablocki Veterans Administration Medical Center. A one month rotation is also scheduled at MCW's Pediatric Endocrine Clinic.

A. Froedtert Memorial Lutheran Hospital (FMLH)
FMLH is a private hospital. FMLH is the principal hospital for the Division of Endocrinology, Metabolism and Clinical Nutrition. The majority of the research labs are located here. Our Diabetes Consult Service and Diabetes Care Center are affiliated with FMLH, which services outpatients, inpatients, and organ transplant recipients. Outpatient clinical activities are conducted in the MCW Clinic at Froedtert East building. The Endocrine Diagnostic Unit, where our fellows learn to perform studies such as ACTH stimulation tests, glucose tolerance tests, etc. are also located here.

B. St. Luke's Medical Center
St. Luke's is a private hospital located in Milwaukee, 7 miles from FMLH and 3 miles from the VA Medical Center. Dr. James Findling is the local Program Director. Other participating faculties include Dr's. Joseph Shaker, Beth Lalande, and Steve Magill. A full-time Ph.D., Hershel Raff, is included in their section and is available, together with the M.D. faculty, to assist and mentor research projects. Each of the M.D. faculty has developed a specific area of special expertise in endocrinology.

C. Clement J. Zablocki Veterans Administration Medical Center (VAMC)
Each fellow spends three months per year of fellowship training on the inpatient consult service and participates in outpatient clinics at this institution. The fellows' continuity clinics are scheduled here. The inpatient consultation service and clinics are staffed by Dr. Albert Jochen, Dr. Diana Maas, and Dr. Irene O'Shaughnessy.

D. Children's Hospital of Wisconsin's Pediatric Endocrine Clinic (CHW)
The Pediatric Endocrine Clinic is the venue for a one month rotation during the second year of the fellowship that provides education and experience in Pediatric Endocrinology.

E. In-Patient Consult Experience
There is not a separate Inpatient Endocrine Service. All patients are admitted to the medicine ward teams or other services, with the endocrinology service acting as consults.

These are four separate rosters of inpatient consults; the Endocrine Consult Service at FMLH, the Diabetes Consult Service at FMLH, the Endocrine Consult Service at St. Luke's Medical Center, and the Endocrine Consult Service at the Zablocki VAMC. On any given month a fellow is assigned to either the two consult services at FMLH or the single services at either St. Luke's or the Zablocki VAMC.

Each fellow is responsible for approximately 5-10 consult inpatients at any given time. Each of the four inpatient consult service sees approximately 10-30 consults per month. While on the FMLH Diabetes Consult Service, which is separate from the FMLH Endocrine Consult Service, the fellows monitor fingerstick results and writes all insulin orders on the organ transplant patients. All consults are staffed by one of the Endocrinology/Diabetology faculty. Fellows oversee the residents and medical students on the consult service and give short lectures on different endocrine topics during consult rounds. The fellows are also responsible for presenting patients at the Endocrine/Surgical Case Conference and Endocrine Case Conferences.

F. Ambulatory Out-Patient Experience

1. Outpatients are seen in the Froedtert-East Clinics, the outpatient clinics at St. Luke's, and at the 4B Multi-Specialty Clinic at the VA Medical Center.
2. The Froedtert-East Clinics contain eight exam rooms, plus office space, several patient care rooms, and classrooms for the Diabetes Care Center. The Endocrine Diagnostic Unit is also contained within this space.
3. The clinic area at St. Luke's contains 16 exam rooms.
4. The Endocrine Clinic at the VA Medical Center is in an area shared with other medical subspecialties. Each clinic has four rooms and one or two attendings.
5. Number of Patients Seen-Each fellow sees approximately 1000 outpatients in a given year. Fellows typically evaluate two new patients per clinic and as many follow-up patients as possible (typically four to six). Decisions regarding diagnostic testing and management are made in conjunction with the faculty member during each visit. Fellows are also responsible for dictating the initial letter of consultation to the referring physician and follow-up letters after test results come back.
6. Continuity Clinic-Fellows follow the same cache of patients for two years at one weekly half-day "Continuity Clinic" at the VA Medical Center.

G. Technical Skills

1. Diabetes Mellitus – Fellows attend practical workshops during their first year of fellowship on nutritional instruction of diabetes (including carbohydrate counting), glucose monitoring devices, and continuous insulin infusion devices. As part of this experience, fellows participate in initiating insulin pump therapy on new patients.
2. Laboratory tests and imaging studies - Fellows gain experience in these areas by reviewing imaging results with on-site radiologists. Available imaging studies include CT scanning, MRI, invasive radiology (including adrenal vein sampling ), Nuclear Medicine (including thyroid, parathyroid imaging, imaging of endocrine tumors, and interpretation of bone density studies). Fellows also attend joint Endocrine-Nuclear Medicine conferences.
3. Performance and interpretation of fine needle aspiration of the thyroid - Fellows are required to demonstrate proficiency in performing fine needle aspiration of the thyroid. Fellows are expected to review their slides with the cyto-pathologist and to maintain a logbook of these results.
4. Endocrine Diagnostic Unit - Fellows rotate through the Endocrine Diagnostic Unit for one month during the second year of fellowship. During this rotation they assist in interpreting dynamic testing results as well as learning testing procedures. They are also asked to periodically help in performing these tests at other times when a physicians presence is required. Specific protocols to be learned include:

• Two hour OGTT to assess for type 2 diabetes.
• Five hour OGTT to evaluate for reactive hypoglycemia.
• Three hour OGTT to evaluate for gestational diabetes.
• Water deprivation test to rule out diabetes insipidus.
• ACTH stimulation test to rule out adrenal insufficiency.
• Thyrogen injections to assess for residual thyroid cancer.

II. Conferences and Formal Instruction

A. Scope of Curriculum
In addition to wide exposure in a clinical setting, training in endocrinology requires formal instruction and on-going independent study in the following areas designated by the RRC (Residency Review Committee):

1. Thyroid disorders including hyperthyroidism, hypothyroidism, thyroid cancer, benign thyroid nodules, and goiters.
2. Hypothalamic and pituitary diseases including pituitary tumors, craniopharyngioma, hypopituitarism including growth hormone deficiency, SIADH, and diabetes insipidus.
3. Type 1 and Type 2 diabetes including treatment of glucose levels, prevention and management of all types of microvascular and macrovascular complications (including retinopathy, nephrology, neuropathy, coronary artery disease, peripheral vascular disease and cerebro-vascular disease), gestational diabetes, diabetes in pregnancy, peri-operative management of diabetes, diabetes nutrition and education, genetics of diabetes, and psychosocial issues related to diabetes.
4. Hypoglycemic disorders including insulinoma, fasting, and non-fasting hypoglycemia.
5. The diagnosis and management of lipid disorders.
6. The diagnosis and management of primary and secondary hypertension.
7. Disorders of bone and mineral metabolism including hypercalcemia, hypocalcemia, metabolic bone disease, kidney stones, vitamin D disorders, and Paget's disease.
8. Disorders of the adrenal cortex and medulla including Cushing's Syndrome, Addison's disease, incidental adrenal tumors, pheochromocytoma, and adrenogenital syndrome.
9. Disorders of fluid, electrolyte, and acid-base metabolism, including hypernatremia, hyponatremia, hyperkalemia, hypokalemia, metabolic acidosis, and metabolic alkalosis.
10. Disorders of magnesium and phosphorous metabolism.
11. Endocrine aspects of psychiatric disease.
12. Endocrine aspects of aging.
13. Autoimmune polyglandular failure syndromes.
14. Endocrine emergencies including hypercalcemia, hypocalcemia, thyroid storm, myxedema coma, adrenal crisis, and pituitary apoplexy.
15. Parenteral and enteral nutritional support.
16. Nutritional and eating disorders including obesity, anorexia nervosa, and bulimia.
17. Hormone-producing neoplasma, including carcinoid syndromes, ectopic hormone production, islet cell tumors and multiple endocrine neoplasia syndromes.
18. Female and male reproduction including primary and secondary amenorrhea, hirsutism, virilization, dysfunctional uterine bleeding, infertility, menopause, testicular tumors, erectile dysfunction, gynecomastia, and hypogonadism.
19. Endocrine abnormalities in systemic illness.

B. Conferences
The venues for structured fellowship instruction are described below. Most conferences are based within the endocrine division. Other required and optional conferences are provided through the Department of Medicine, the Medical College of Wisconsin, regional sub-specialty societies, and national sub-specialty organizations. The core of required conferences provide four hours per week of formal instruction. These are Mondays 12:15 P.M. to 1:15 P.M. (Post-Clinic Care Conference, Resident), Tuesday 12:00 P.M.–1:00 P.M. (St. Luke's Endocrine Case Conference), Thursday 4:00 P.M.–5:00 P.M. (Combined Endocrine Surgical Case Conference, Resident Case Conference, Journal Club, Research Conference) and Fridays 8:00 A.M.–9:00 A.M. (Department of Medicine Grand Rounds). A departmental morbidity and mortality conference is scheduled once a month. The venues for conferences and instruction contained in our program and their roles in the instruction of our fellows are described below.

a. Conferences based in the Division of Endocrinology, Metabolism, and Clinical Nutrition.

• Monday Noon Conference (12:15 P.M. to 1:15 P.M.)
• Post-Clinic Care Conference – Three weeks of the month cases are presented and discussed by faculty, fellows, and residents. Cases are selected by their interest and teaching potential.
• Resident Noon Conference - Once every two months an endocrine faculty member presents a lecture to the Department of Medicine housestaff and students on a general endocrine topic. Fellows attend this conference in lieu of the Journal Club once every two months. Each fellow assists in preparing and presenting one of the conferences each year.
• Core Conferences - Approximately once every two months an endocrine "Core Conference" is prepared by the faculty and fellows on a basic science topic required in the endocrine core curriculum.

b. St. Luke's City-Wide Endocrine Case Conference (Tuesday 12:00 P.M. to 1:00 P.M.)

• This conference meets once a week at St. Luke's Medical Center to discuss challenging endocrine cases. Attendees at this conference include St. Luke's endocrine staff, other interested endocrinologists from around Milwaukee as well as some internists.

c. Thursday 4:00 P.M. Conferences

• This is a rotating conference three or four Thursday's each month from 4:00 P.M. to 5:00 P.M. at FMLH. These conferences are detailed below.

i. Journal Club – The first Thursday of each month a journal club is held in which a recent paper is presented and discussed by one of the fellows.

ii. Combined Medical – Surgical Endocrine Case Conference – The second Thursday of each month a joint conference is held by the Endocrine Division and the Surgical Service. This conference is case–based. Cases are typically thyroid, adrenal, or parathyroid.

iii. Residents Case Conference – The third Thursday of each month the medicine housestaff and the fourth year students on FMLH/VA endocrine rotations each do a 15 minute presentation on an interesting case they saw during the first half of the month. Most of the presentation consists of a literature review of the topic.

iv. Research Conference - These are held periodically on Thursday 4:00 P.M. to 5:00 P.M.

d. Combined Endocrine – Nuclear Medicine Conferences

• These are held an average of twice per year on a Tuesday, 8:30 A.M. to 9:30 A.M. in the Nuclear Medicine Conference Room, 2nd floor of FMLH. The objective of these conferences is to instruct our fellows on the role of nuclear medicine in; the diagnosis and treatment of thyroid disorders (in particular thyroid cancer and hyperthyroidism); parathyroid imaging; nuclear imaging of endocrine tumors, including carcinoid, adrenal and MEN syndromes; and methods and interpretation of bone density measurement.

e. Conferences based in the Department of Medicine

• Department of Medicine Grand Rounds (Fellows clinic schedules are cleared 8:00 A.M. to 9:00 A.M. on Friday to allow them to attend Medicine Grand Rounds at FMLH.
• Medical Mortality and Morbidity Conference ("CPC") – This is a monthly conference held at the VA on Thursdays 12:00 P.M. to 1:00 P.M. Fellows schedules are "cleared" to allow them to attend this conference.
• Seminars and Courses based at The Medical College of Wisconsin - Courses on Research Methods and Design, Epidemiology, Genetics, etc are offered to MCW housetaff, fellows, and junior faculty. Other lectures are given on bioethics. Our fellows are made aware of these opportunities and encouraged to attend.

f. Regional Endocrine Societies and Conferences

• Wisconsin Endocrine Society – This society meets an average of twice per year. The format varies from a dinner with a one hour lecture to a full day program.
• Wisconsin Lipid Club – The Lipid Club meets once or more a year at the University Club in Milwaukee and features a national authority on lipid disorders.
• Wisconsin Bone Club – This is an annual two day meeting held at a resort in Green Lake, Wisconsin. The speakers and attendees include endocrinologists, rheumatologists and orthopedic surgeons.

g. National Meetings (Fellows are provided time to attend one 1 week national conference per year, eg. Endocrine Society, American Diabetes Association).

III. Research
The NIH, VA, private grants, and industry support research programs of our full time faculty and also provide support for the fellow's research experience. Fully equipped laboratory suites at both FMLH and VAMC allow space and technical assistance during this endeavor. The General Clinical Research Center, funded by the NIH, provides a centralized unit for clinical investigations carried out by the fellow under faculty supervision. Participation of all fellow in some form of research, clinical or basic, is mandatory. Approximately 15% of their time is spent in this activity during the first year of fellowship and 30% in the second year of fellowship. These percentages are flexible depending upon the interest and research aptitude of the fellow. Each fellow chooses a research project and mentor during the first year of his/her fellowship. This research experience should be a project which can be initiated and completed during the two or three year fellowship. Mentors may be chosen from among faculty at FMLH, St. Luke's or the VA Hospital. This research may involve either clinical or basic research. Our fellows are encouraged to publish completed projects.

IV. The Evaluation Process

a. Evaluation of Fellows
Each fellow receives a written evaluation from each faculty with whom he/she worked with either on the inpatient or outpatient service on a bi-annual basis. An annual written performance summary is prepared for each fellow. All evaluations are maintained/retained as a part of the fellows permanent record. If the fellow wishes, he/she is free to read and respond to their evaluations.

b. Evaluation of Faculty
The fellow complete evaluation forms on each of the faculty with whom they have had interacted on a bi-annual basis. Fellows may discuss issues orally and confidentially if need be. Promotion and retention of fellows is recommended by a committee of three endocrine faculty. These are currently Drs. Jochen, Maas, and Findling.

V. Policies
Policies regarding duty hours, moonlighting, promotion, dismissal, etc. are based upon the MCW housestaff manual. A copy of these policies are available for review.