Section 1

CREIGHTON UNIVERSITY ENDOCRINOLOGY,

DIABETES AND METABOLISM

FELLOWSHIP PROGRAM

Overall Curriculum

Including

Progressive Competency Based Goals and Objectives

The CreightonUniversity Program is a two-year training program in the internal medicine sub-specialty of Endocrine, Diabetes, and Metabolism. The application for initial approval by the Accreditation Council for Graduate Medical Education was submitted on February 23, 2004 and the Program was fully approved on July 1, 2005.

The principal training facility is the CreightonUniversityMedicalCenter, with additional clinical experience at the VeteransAffairsMedicalCenter and Children’s Hospital. All training facilities are located in Omaha, Nebraska.

FELLOWSHIP PROGRAM PERSONNEL

PROGRAM DIRECTOR

Andjela Drincic, MD

Assistant Professor of Medicine; Attending Physician, CU Medical Center; Director, DiabetesCenter

CU Department of Medicine-Dundee Clinic
119 North 51st Street, Omaha, NE
phone: 402-449-5968; email:

LOCAL DIRECTORS

Robert J. Anderson, MD

Local Director, VA MedicalCenter; Professor of Medicine; Endocrine Division Chief,

OmahaVAMedicalCenter

4101 Woolworth Avenue, Omaha, NE 68105
email:

Jean-Claude Desmangles, MD

Local Director, Children’s Hospital; Assistant Professor of Pediatrics; Attending Pediatric Endocrinologist, Omaha Children’s Hospital

Children’s Hospital Diabetes Clinic - Endocrine Clinic

8200 Dodge Street, Omaha, NE 68114
Phone: 402-955-3871; Fax: 402-955-4184; email:

PROGRAM COORDINATOR

Vickie Reid

601 North 30th Street, Suite 5730, Room 5746, Omaha, NE68131

Phone 402-449-4479; email:

Additional contact:

Diane Franks

601 North 30th Street, Suite 5766, Omaha, NE 68131
phone 402-280-4471; email:

OTHER KEY CLINICAL FACULTY

Robert R. Recker, MD, FACE, MACP

Professor of Medicine; Endocrine Division Chief, CreightonUniversitySchool of Medicine; and Director, OsteoporosisResearchCenter

601 North 30th Street, Suite 5766, Omaha, NE 68131
phone 402-280-4471; email:

J. Christopher Gallagher, MD

Professor of Medicine; Attending Physician, CU Medical Center; Director, Bone Metabolism Unit

601 North 30th Street, Suite 6718, Omaha, NE 68131
phone 402-280-4516; email:

Marc S. Rendell, MD

Professor of Medicine; Attending Physician, CU Medical Center: Director; DiabetesCenter

601 North 30th Street, Suite 4, Omaha, NE 68131

phone 402-280-4319; e-mail:

Laura G. Armas, M.D.

Assistant Professor of Medicine;

601 North 30th Street, Suite 4, Omaha, NE 68131

phone 402-280-4470; email:

SENIOR FACULTY

J. Daniel Egan, M.D.

Professor of Medicine, CreightonUniversity
(402) 280-4470

Robert P. Heaney, M.D., F.A.C.P., F.A.C.N.

JohnA.CreightonUniversity Professor; Professor of Medicine
(402) 280-4029
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 required for all of the competencies needed by a consultant in this field. This 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.

Goals for trainees and programs:

1.Learn basic and advanced endocrine biochemistry, physiology and pathophysiology, which provide the basis for understanding diseases of the endocrine system.

2.Accumulate a critical mass of fundamental information and practical approaches for the diagnosis, management and prevention of endocrine disorders.

3.Acquire the technical and practical skills that are required by a consultant in endocrinology, diabetes and metabolism.

4.Acquire clinical skills in a progressive fashion and with increasing responsibility appropriate for a consultant in endocrinology, diabetes and metabolism.

5.Gain the knowledge and skills necessary for providing cost-effective, ethical and humanistic care of patients with diabetes and disorders of endocrinology and metabolism.

6.Gain the knowledge and skills necessary for critical analysis of the laboratory testing and the endocrine literature.

7.Acquire skills in design and performance of hypothesis-drivenendocrine research, and to participate in such research or equivalent scholarly activity. This may include gaining extensive experience in grant writing and scientific presentation.

8.Provide an environment that fosters “a spirit of inquiry and scholarship” which will thereby instill a commitment to life-long learning.

Objectives:

The program will provide training in:

  1. Endocrine biochemistry, genetics, developmental biology, physiology and pathophysiology.
    Hormone action including signal transduction pathways as well as the biology of hormone receptors and feedback inter-relationships.
    Diagnosis and management of endocrine diseases including:

A.History and physical examination with emphasis on examination of the fundi, thyroid, breasts, male and female reproductive organs.

B.Selection and interpretation of endocrine biochemical tests.

C.Selection and interpretation of imaging procedures such as sonography, radionuclide scans, computerized axial tomography, magnetic resonance imaging, positron emission tomography, etc.

D.Fine needle aspiration of the thyroid and interpretation of cytology and pathology.

E. Understanding pharmacotherapy for endocrine disorders and appropriate use of surgery, radiation therapy, treatment with radioisotopes, etc.

F.Selection and management of patients for whole organ or islet cell transplantation.

  1. Procedural and technical skills required by the endocrine subspecialist.
  2. Professionalism, including peer interactions, communication with patients, their families and other health care providers, confidentiality and avoidance of conflict of interest.
  3. Endocrine clinical and basic research.
  4. Understanding of existing and emerging endocrine literature.
  5. Personal scholarship and self-instruction.

Patient Care Experience

Trainees will be directly supervised and continually 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 hallmarks of this training program. Our faculty serves 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. Attributes of professionalism may also be the subject of conferences using examples in Project Professionalism, published by the American Board of Internal Medicine ( Each trainee will be provided a copy of Project Professionalism and will be expected to read and understand its contents and behave according to the highest professional standards.

General

The Endocrine Division at CreightonUniversity I include 15 full time faculty, eight physicians, eight doctorally prepared and one masters – prepared members. Six of our physicians are practicing endocrinologists caring for patients at CUMC, Dundee, and Omaha VA Center. All faculty members are involved in research and all participate in teaching. Under the leadership of Dr. Robert R. Recker and Dr. Robert P. Heaney, the Creighton University Osteoporosis Research Center (ORC) continues today a 40-year effort that has created an international center of excellence in bone research. This team carries out basic science research as well as clinical research focusing on drug treatment of osteoporosis, vitamin D metabolism, calcium absorption, and genetic regulation of bone mass. Dr. Gallagher isa nationally known scientist in women’s health issues, osteoporosis, and vitamin D research, recipient of multiple NIH awards. Dr. Rendell has more than twenty years of experience in diabetes research and has very active clinical research center. In his diabetes research center multiple trials are currently conducted including studies on new diabetes drugs, diabetic neuropathy trials and studies of would healing in diabetes. Dr Anderson has a basic research laboratory in the VA where he studies of metabolic pathways for phenol sulfotransferase isoenzymes, but also is involved in clinical trials drug treatment of diabetes mellitus and pituitary disorders. Dr. Drincic focuses predominantly on clinical care and teaching of residents and fellows but is also involved in multidisciplinary health services research as well as clinical pituitary research. Dr. Armas is a newest member of our division with interest in vitamin D research, and is rapidly gaining national recognition. Members of the division are recipients of NIH and other federal grants. More than 100 original scientific papers, reviews, book chapters are published yearly by the Division faculty and post-doctoral fellows

Members of the division participate in teaching second year medical students and in conducting clinical clerkships and resident rotations in endocrinology. Members of the division deliver CME lectures and other invited lectures nationwide and worldwide. In addition, members of the division conduct daily outpatient clinic sessions. These sessions include osteoporosis clinics, diabetes clinics, and general endocrine clinics.

1

  1. Ambulatory Care

Since most endocrine care is delivered in an ambulatory setting, the ambulatory experience is emphasized throughout the entire duration of the program.

  1. Educational Purpose: To learn about a variety of diseases of endocrinology and metabolism, through consultation and provision of continuing care.
  2. Teaching Methods: 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 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.

Practice Setting: Continuity clinic
Location of clinic / Dundee and VA
Number of fellows/session / 1
Number of fellows/faculty / 1
Number of exam rooms/fellow / 3
Number of patients/fellow/session / 6-8
Allied health professionals in clinic
Nurse (R.N. or L.P.N.) / yes
Nurse educator / yes
Certified diabetes educator / yes
Nutritionist / yes
Frequency of clinic
Number of sessions/week / 2
Duration through training / 2 years
Practice Setting: Other ambulatory clinics / Bone clinic
Location of clinic / CUMC
Number of fellows/session / 1
Number of fellows/faculty / 1
Number of exam rooms/fellow / 3
Number of patients/fellow/session / 6
Allied health professionals in clinic
Nurse (R.N. or L.P.N.) / yes
Nurse educator / yes
Certified diabetes educator / n/a
Nutritionist / 1
Frequency of clinic
Average number of sessions/week / 3
Duration through training / 4 months
Practice Setting: Other ambulatory clinics / Pediatrics
Location of clinic / Children’s hospital
Number of fellows/session / 1
Number of fellows/faculty / 1
Number of exam rooms/fellow / 2
Number of patients/fellow/session / 6
Allied health professionals in clinic
Nurse (R.N. or L.P.N.) / yes
Nurse educator / yes
Certified diabetes educator / yes
Nutritionist / yes
Frequency of clinic
Average number of sessions/week / 3
Duration through training / 2 months
Practice Setting: Other ambulatory clinics / Reproductive
Location of clinic / Community
Number of fellows/session / 1
Number of fellows/faculty / 1
Number of exam rooms/fellow / 3
Number of patients/fellow/session / 6
Allied health professionals in clinic
Nurse (R.N. or L.P.N.) / yes
Nurse educator / yes
Certified diabetes educator / n/a
Nutritionist / n/a
Frequency of clinic
Average number of sessions/week / 3
Duration through training / 2 months
Practice Setting: Other ambulatory clinics / Thyroid
Location of clinic / Dundee
Number of fellows/session / 1
Number of fellows/faculty / 1
Number of exam rooms/fellow / 2
Number of patients/fellow/session / 1
Allied health professionals in clinic
Nurse (R.N. or L.P.N.) / yes
Nurse educator / yes
Certified diabetes educator / n/a
Nutritionist / yes
Frequency of clinic
Average number of sessions/week / 2
Duration through training / 4 months
Practice Setting: Other ambulatory clinics / VA endo
Location of clinic / VA
Number of fellows/session / 1
Number of fellows/faculty / 1
Number of exam rooms/fellow / 2
Number of patients/fellow/session / 6
Allied health professionals in clinic
Nurse (R.N. or L.P.N.) / yes
Nurse educator / yes
Certified diabetes educator / n/a
Nutritionist / n/a
Frequency of clinic
Average number of sessions/week / 0.75
Duration through training / 12 months
Diabetes
Location of clinic / CUMC
Number of fellows/session / 1
Number of fellows/faculty / 1
Number of exam rooms/fellow / 3
Number of patients/fellow/session / 6
Allied health professionals in clinic
Nurse (R.N. or L.P.N.) / yes
Nurse educator / yes
Certified diabetes educator / yes
Nutritionist / yes
Frequency of clinic
Average number of sessions/week / 1
Duration through training / 12 months
Practice Setting: Other ambulatory clinics
Location of clinic
Number of fellows/session / √ 123456Other
Number of fellows/faculty / √ 123456Other
Number of exam rooms/fellow / √ 123Other
Number of patients/fellow/session / √ 45678Other
Allied health professionals in clinic
Nurse (R.N. or L.P.N.)
Nurse educator
Certified diabetes educator
Nutritionist
Frequency of clinic
Average number of sessions/week / √ 123456Other
Duration through training / √ 12 months18 months24 months36 monthsOther
  1. Disease Mix and Patient Characteristics: Patients are 21 years of age or older including adequate representation of geriatric patients. The distribution of ages and sex in our clinics approximates their distribution among the general populationwith endocrine disease. At least 25% of all patients will be either gender. Trainees care for patients with a wide range of clinical problems in stages of illness appropriate to the ambulatory setting.

In addition to continuity clinics in which the trainee encounters the broad range of endocrine pathology, rotations through disease-specific clinics are an integral part of the training program. In addition, topics are routinely covered in conferences, discussions, journal club and other didactic sessions. However, clinical rotations are also available during the fellows’ training.

In Year 2 schedule Elective Clinics can be arranged; these largely observational experiences will correspond to individual needs and interests of the trainees. Typically, each elective experience will consist of one to four half-day clinic sessions (or equivalent time in contact with patients). Here is a preliminary list of Elective Clinics that can be arranged:

Ophthalmology (diabetic retinopathy, etc.)

Radiology (specialized imaging techniques)

Critical Care (treatment of hyperglycemia; fluid/electrolyte disorders, etc.)

Orthopaedics (diagnosis/treatment of fractures, rare metabolic bone diseases, etc.)

Surgery (surgical treatment of morbid obesity, HPT, thyroid disease, etc.)

Nephrology (renal osteodystrophy, renal complications of diabetes, etc.)

These clinical opportunities are either required or elective and include:

Required / Elective
Pediatric endocrine / yes
Reproductive endocrine / yes
Thyroid / yes
Bone / yes
Nutrition / yes
Nuclear medicine / Yes

Summary of available outpatient clinics:

CUMC Endocrinology/Bone Clinics
Mon PM / Dr. Recker / CUMC 4820
Wed PM / Dr. Gallagher / CUMC 6718
Wed PM / Dr. Armas / CUMC 4820
CUMC Endocrinology/Diabetes Clinics
Mon AM &PM,
Tue AM
Wed PM, Fri PM / Dr. Drincic / Dundee Clinic, 119 North 51st St.
Wed, Fri AM / Dr. Anderson / CUMC 6715
Tue AM, Wed, Fri PM / Dr. Rendell / CUMC 6715
VAMC Endocrinology Clinics
Thu PM / rotating / VA Medical Center, gold clinic
Omaha Children’s Hospital Endocrinology/Diabetes Clinics
4 to 5 half-day clinics/wk / Dr. Desmangles / Omaha Children’s Hospital, 8200 Dodge St.,
  1. 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. In addition to thyroid biopsy, our fellows also participate in bone biopsy procedure. 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.
  1. Reading Lists and Educational Resources: These are listed below under the disease specific sections of the curriculum.
  1. Evaluation: See section on evaluation, below.

Trainees follow their continuity clinic/ambulatory patients for the duration of the program. By means of the ambulatory experience provided in this program, the trainee has the opportunity to observe and learn the course of endocrine diseases and their treatments.

  1. In-patient Care

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. Typically, fellows spend 5-7 months each year providing inpatient consultation.

  1. Educational Purpose: To learn about a variety of diseases of endocrinology and metabolism as they occur in the hospitalized patient.
  2. Teaching Methods: 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.

Practice Setting: In-patient consultative service
Number of consults/week / 15
Number of fellows/team / 1
Are students/residents included in the team / yes
Average duration of rounds (hours) / 2-3
Duration of rotation (weeks) / 50
  1. 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, orthopedic surgery, etc. Patients will have a variety of diseases that impact on 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 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.
  1. 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.
  2. Reading Lists and Educational Resources: These are listed below under the disease specific sections of the curriculum.
  3. Evaluation: See section on evaluation, below.

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.