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The Hospital for Sick Children
Endocrinology

Goals and Objectives

A.  General

These objectives are based on the objectives of training as set by the Royal College of Physicians and Surgeons of Canada. Upon completion of training, a resident is expected to be a competent specialist in Endocrinology and Metabolism capable of assuming a consultant’s role in the specialty. The resident must acquire a working knowledge of the theoretical basis of the specialty, including its foundations in the basic medical sciences and research.  Residents must demonstrate the requisite knowledge, skills, and attitudes for effective patient-centered care and service to a diverse population. In all aspects of Endocrinology and Metabolism practice, the graduate must be able to address issues of gender, sexual orientation, age, culture, ethnicity and ethics in a sensitive and professional manner.

At the end of training, the trainee will have demonstrated:

1)  Broad knowledge of basic and clinical endocrinology
2)  Expertise in a broad range of clinical problems in the ambulatory setting.
3)  Through a longitudinal ambulatory clinic experience, developed the knowledge and skills necessary for the long-term management of endocrine patients.
4)  Skills in inpatient consultation and investigation
5)  Effective team leadership skills and teaching skills
6)  Skills of critical appraisal of medical information as it pertains to endocrinology and metabolism.
7)  Effective clinical problem solving in the approach to pediatric endocrine problems.

B.   Specific

The trainee is expected to achieve all of the following CanMEDS competencies.

Medical Expert

By the end of training, the trainee should:

  • Be proficient in the assessment of patients, including performance of a endocrine relevant history and physical exam.
  • Integrate clinical and laboratory data to generate a plan of treatment.

1.  Diabetes

  • Know the etiology, investigation, diagnosis and management of Type 1, Type 2 and other forms of diabetes mellitus
  • Know the pathogenesis of the disease
  • Develop appropriate monitoring and treatment objectives for patients
  • Recognize and appropriately manage acute and chronic complications, including diabetic ketoacidosis hyperosmolar coma, hypoglycemia and  macro and micro vascular disease   
  • Make appropriate management decisions regarding the surgical patient with diabetes
  • Provide appropriate patient and family education
  • Recognize and address psychological issues
  • Know the genetics related to DM.

2.  Thyroid

  • Know the etiology, investigation, diagnosis and management of disorders of the thyroid (hyperthyroidism, hypothyroidism, congenital hypothyroidism, thyroid nodules)
  • Make appropriate diagnostic and therapeutic use of radioisotopes, ultrasound and thyroid biopsy

3.  Calcium/Bone

  • Know the etiology, investigation, diagnosis and management of disorders of calcium metabolism and bone health, including states of hyper and hypocalcaemia, metabolic bone disease, including various forms of rickets, bony dysplasias and osteoporosis.

4.  Disorders of Sex Development

  • Know the biology of normal and abnormal sexual differentiation and management of disorders of sex development.  

5.  Reproductive  Disorders

  • Know the endocrine aspects and management of reproductive disease including disorders of hypogonadism, delayed and precocious puberty, micropenis, androgen resistance, hirsutism, and gynaecomastia.

6.  Pituitary/Hypothalamus

  • Know the neuroendocrine control of pituitary function and disorders of the hypothalamic - pituitary axis and management of these disorders.

7.  Fluids/Electrolytes

  • Know the physiology and management of disorders of fluid and electrolyte metabolism related to endocrine dysfunction.

8.  Adrenal Disorders

  • Know the disorders of the adrenal cortex and medulla
  • Determine appropriate investigation for disorders of the adrenal cortex and medulla
  • Provide appropriate management of endocrine hypertension and acute and chronic adrenal
    insufficiency.

9.  Growth

  • Understand normal growth and development and its variants, and manage disorders of short and tall stature and abnormalities of growth rate.

10.  Hypoglycemia

  • Know the causes and  genetics of hypoglycaemia
  • Select appropriate  investigations for hypoglycaemia
  • Determine appropriate management of the different underlying conditions.

11.  Endocrine Tumours

  • Understand and manage hormone producing neoplasms, including ectopic hormone dysfunction and multiple endocrine neoplasia.

12.  Obesity

  • Understand the pathophysiology and management of obesity

13.  Endocrine Aspects of Systemic Disease

  • Demonstrate knowledge of the assessment of endocrine effects of systemic disease

14.  Lipid Disorders

  • Understand and assess pediatric lipid disorders

Communicator

By the end of training, the trainee should:

  • Be proficient in taking a complete history.
  • Communicate effectively with patients, physicians and families.
  • Demonstrate effective listening and counseling skills.
  • Identify the important determinants of health, as well as patients’ health belief systems, and use this knowledge to guide communication with patients and their families.   
  • Consider age, gender, cultural issues, religion and socioeconomic factors in their communication with patients and families
  • Respectfully treat all patients.

Collaborator

By the end of training, the trainee should:

  • Acknowledge and respect the individual team members’ contributions.
  • Work collaboratively as a member of a multidisciplinary care team.
  • Consult effectively with other physicians

Manager

By the end of training, the trainee should
• Demonstrate cost effective diagnostic and management skills, respecting finite health care resources.   
• Participate in quality assurance in various settings (hospital, clinic, office).  
• Utilize information technology to provide optimal care to patients and to continue self-education.   
• Demonstrate effective time management (professional, personal).

Health Advocate

By the end of training, the trainee should:

  • Identify the important determinants of health for an individual and for communities.  
  • Know the role of the physician in health prevention and modification of risk factors.
  • Participate in education programs for patients, communities and physicians.

Scholar

By the end of training, the trainee should:

  • Demonstrate evidence of a personal learning strategy that involves reading around patient cases and critically appraising the literature.
  • Facilitate learning of others, including junior trainees and members of the interdisciplinary healthcare team.
  • Complete a scholarly project in an area of basic, clinical or education research in endocrinology

Professional

By the end of training, the trainee should:

  • Deliver care with integrity and compassion, using appropriate professional behaviour.
  • • Demonstrate the attributes of professionalism, namely: reliability, punctuality, integrity, and compassion.

C.  Rotation Specific Goals & Objectives

In addition to the general goals and objectives above, the rotations in inpatient care, ambulatory clinics and subspecialty clinics have specific goals and objectives as outlined below.

Inpatient Rotation

By the end of training, the trainee should:

Medical expert

  • Demonstrate understanding of the pathophysiology and acute management of:
    • Diabetes
    • Thyroid disorders
    • Calcium/Bone disorders
    • Disorders of sex development
    • Pituitary/hypothalamic disorders
    • Fluid and electrolyte disorders
    • Adrenal disorders
    • Hypoglycemia
    • Endocrine tumours
    • Endocrine aspects of systemic disease
  • Demonstrate acquisition of the skills to effectively deal with acute endocrine problems which include recognition, rapid problem formulation, rapid development of an appropriate management plan

Communicator

  •  Demonstrate a high level of skill in listening to concerns and communicating information about the illness, appropriate ways of dealing with families in crisis and eliciting and dealing with emotional aspects of illness
  • Present comprehensive and concise assessments and management plans in oral and written format

Collaborator

  • Work effectively with consulting services and interprofessional team to development shared management plans

Manager

  • Work effectively as the leader of the on service team to provide efficient and appropriate care, utilizing team resources effectively

Health Advocate

  • Recognize and respond to important determinants of health in the development of management plans

Scholar

  • Supervise the clinical experience of junior trainees in a safe and effective manner and to facilitate their learning

Professional

  •  Show honestly, integrity, commitment, compassion and respect when working with patients, families and colleagues

Outpatient Rotation

In addition to the general goals and objectives above, specific objectives for the outpatient experience in the General Endocrine and Diabetes clinics follow.

By the end of training, the trainee should:

Medical expert

  • Demonstrate understanding of the pathophysiology and outpatient management of:
    • Diabetes
    • Thyroid disorders
    • Calcium/Bone disorders
    • Disorders of sex development
    • Pituitary/hypothalamic disorders
    • Fluid and electrolyte disorders
    • Adrenal disorders
    • Hypoglycemia
    • Endocrine tumours
    • Endocrine aspects of systemic disease
    • Obesity
    • Lipid disorders
    • Growth
    • Reproductive disorders
  •  Demonstrate appropriate history and physical examination skills.
  • Complete effective clinical assessments showing appropriate clinical problem solving and judgment, including use and interpretation of endocrine testing.

Communicator

  • Demonstrate effective therapeutic relationships with patients and families.
  • Deliver information in a clear manner, being responsive to the patient and family.
  • Present comprehensive and concise assessments and management plans in clinic letters.

Collaborator

  •  Work effectively with the interprofessional team to development shared management plans.

Manager

  • Work effectively to manage outpatient practice to provide efficient and appropriate care, utilizing health care resources effectively.

Health Advocate

  • Recognize and respond to important determinants of health in the development of management plans, particularly those involving access to endocrine medications/supplies.

Scholar

  • Demonstrate the ability to evaluate the medical literature and apply it critically to the ambulatory patient.

Professional

  •  Show honestly, integrity, commitment, compassion and respect when working with patients, families and colleagues.

Specialty Clinics

While the general objectives remain the same for all outpatient clinics, there are additional objectives unique to each clinic.

III.  Calcium/Bone Health Clinic

By the end of training, the trainee should:

Medical expert

  • Demonstrate the knowledge and skills to manage disorders of the following:
    • Hyper and hypocalcemia; specifically, knowledge of the differential diagnosis, investigations needed to reach a specific diagnosis and management of these conditions.
    • Rickets.  Understanding of the differential diagnosis, investigations needed to reach a specific diagnosis and management of these conditions.
    • Bone Health.  Knowledge of normal bone mass development and appropriate use of the current diagnostic tools in the assessment of bone health.  Knowledge of the impact of chronic disease and nutritional impairment on bone health.
    • Impaired Bone Health.  An understanding of the spectrum and differential diagnosis of impaired bone health in childhood and adolescents.  Skills in integrating the physical findings and investigations so as to reach a diagnosis.  Knowledge of the treatment and prevention of the various forms of impaired bone health

Communicator

  • Explain the relevant concepts regarding the diagnosis and treatment of calcium and bone health disorders to the patient and family.

Collaborator

  • Work effectively within an interdisciplinary team whose members are involved in bone health or its disorders.

IV.  Disorders of Sexual Development (MUG) Clinic

By the end of training, the trainee should:

Medical expert

  • Demonstrate the knowledge and skills to manage Disorders of Sex Development (DSD):
    • Approach to newborn with genital ambiguity with focus on physical exam, differential diagnosis and rational choice of investigations.
    • Genetics and biochemistry of DSD:   The basic science of genital development, genetic and hormonal pathways of androgen production and action
    • Surgical management of DSD: indications for surgery, controversies around surgery, issues in surgical outcomes
    • Psychosocial Issues in DSD: awareness of issues throughout childhood and adolescence, concerns of parents, approach to education/disclosure, understanding of gender identity and role.
    • Puberty in DSD Patients:   Approach and management of gonadal failure, sensitivity to issues of sexuality, future infertility, incomplete pubertal development

Communicator

  • Approach issues of gender and sexuality in an open and non-judgmental manner.  
  • Consider how age, gender, cultural issues, religion and socioeconomic factors impact the patient and family.

Collaborator

  • Work effectively in an interprofessional health care team.

Professional

  • Deliver care with integrity and compassion, demonstrating ethical values in care of this patient population.

V.  Pediatric Gynecology-Endocrine Clinic

By the end of training, the trainee should:

Medical expert

Demonstrate the knowledge and skills to manage common female pubertal and menstrual disorders including:

    • Polycystic Ovarian Syndrome:  With particular focus on diagnosis, pathophysiology, associated metabolic risks and pharmacological and non-pharmacological management.
    • Precocious puberty:  Assessment of normal versus abnormal pubertal onset and tempo, etiology, investigations and management  strategies, psychosocial benefits/harms of treatment.
    • Primary and Secondary amenorrhea:  Evaluation and management including diagnostic tests, treatment, including approach to hormonal induction of puberty.
    • Dysfunctional Uterine Bleeding:  Approach to menorrhagia, oligomenorrhea and their treatment strategies; when to refer to gynecology.

Communicator

  • Effectively discuss sensitive issues such as disclosure of infertility to patients and parents and sexual health issues of the female adolescent, conducting these discussions in an open and non-judgmental manner while considering how age, cultural issues and religion may impact communication.

Health Advocate

  • Respond to the individual needs and issues of the patients seen in the clinic.  For example, particular issues of advocacy may include: teen sexual health and menstrual suppression in adolescents with developmental delay.

Collaborator

  • The trainee will learn to work effectively in an interprofessional health care team, respecting others viewpoints and communicating with team members.

VI: STOMP (SickKids Team Obesity Management Program)

By the end of training, the trainee should:

Medical Expert   

  • Develop the knowledge and skills to manage children with severe obesity associated with medical comorbidities and in those with other chronic illness.
  • Demonstrate understanding of the impact of excessive weight gain on the development of comorbidities, whom and when to screen, and how to manage these complications.  
  • Be able to distinguish endocrine causes of obesity and develop an approach to the investigation of the obese child.   
  • Demonstrate knowledge of risks and benefits of different obesity management approaches, (including non-pharmacologic, pharmacologic and surgical) should be acquired.

Communicator

  • Accurately elicit and synthesize relevant information from patients and families, as well as from the other STOMP team members (dietitian, psychologist, exercise therapist, nurse practitioner, social worker) to develop a shared plan of care
    • Convey effective oral and written information to the family and other health care professionals involved in their care.

Collaborator

  • The trainee will learn to work effectively in an interdisciplinary health care team, respecting the knowledge, skills and attitudes of others.

Health Advocate

  • Respond to the individual needs and issues of the patients seen in the clinic while considering the context of their ability to function and incorporate lifestyle changes at home and in their communities.  

Scholar

  • Facilitate the learning of patients, families, other trainees and allied health care professionals on the STOMP team.

Professional

  • Exhibit appropriate professional behaviours in practice, including honesty, integrity, commitment, compassion and respect.

VII.  Neuro-oncology Long Term Follow Up Clinic

By the end of training, the trainee should:

Medical Expert

Demonstrate the knowledge and skills to diagnose and manage endocrine disorders in survivors of pediatric brain tumour and to identify patients at risk for endocrinopathies based on their therapeutic exposures:

  • Growth: Identification of patients at risk for growth hormone deficiency even prior to evidence of abnormal growth.
  • Evaluation and monitoring of growth and development in a cancer survivor on growth hormone therapy.
     Understanding the challenges of monitoring the pubertal influence on growth in this patient population.
  • Monitoring for side effects of growth hormone therapy in a population with inherent risks for disease recurrence, second malignancies and skeletal concerns including scoliosis and poor spinal growth.
  • Hypothyroidism: Understanding of risk factors for primary vs. central hypothyroidism and the implications for diagnosis, therapy and monitoring.
  • Thyroid cancer:  Accurate physical examination and choice of investigations
  • Hypogonadism:
    -Understand the difficulties of pubertal evaluations in patients treated with alkylating agents, particularly males.
    -Demonstrate an approach to puberty induction and hormonal replacement therapy in females and males with hypogonadism.
  • Precocious/early Puberty: Understand an approach to diagnosing and treating early/precocious puberty in the pediatric brain tumour survivor.
  • Adrenal Insufficiency: Understand the approach to screening and management of central adrenal insufficiency in an at risk population.
  • Reduced Bone Mineral Density: Demonstrate an approach to reduced bone mineral density in the brain tumour survivor particularly in those with other hormonal deficiencies.
  • Diabetes Insipidus: Know how to diagnose and manage central diabetes insipidus

Communicator

  • Be especially sensitive to the needs of this patient population when delivering news about endocrine dysfunction, therapeutic interventions and risk for side effects in particular as it applies to growth hormone therapy and gonadal failure.

Collaborator

  • Work effectively within an interdisciplinary health care team.

Professional

  • Demonstrate an understanding of the particular issues faced by a group of patients and families who have undergone painful and difficult treatments and are now faced with side effects of their therapy.
  • Deliver care with empathy and consideration for the needs of this group.

VIII.  Adult Endocrinology Rotation

By the end of training, the trainee should:

Medical Expert

Demonstrate the knowledge and skills to manage common Adult Endocrinology conditions including:

  • Type 2 diabetes: With particular focus on pharmacological and non-pharmacological management (i.e. classes of drugs, mechanisms of action, indications, contraindications, adverse effects).
  • Type 1 diabetes: With particular focus on complications screening and complication management.
  • Diabetes and pregnancy:   Risks to mother and newborn, Diagnostic criteria of GDM, management strategies during pregnancy and labour.
  • Dyslipoproteinemia:   The basic science of lipid disorders, etiology and risk assessment, management with particular attention to pharmacology – classes of drugs, mechanisms of action, indications, contraindications, adverse effects.
  • Pituitary disorders: Evaluation and management of pituitary tumours with particular attention to prolactinomas and acromegaly. Assessment and management of panhypopituitarism.
  • Adrenal disorders: Diagnosis and management of Cushings syndrome and endocrine hypertension.
  • Thyroid disorders: Approach to thyroid nodules and malignancy.
  • Parathyroid/Calcium disorders: Diagnosis and management of hypo/ hypercalcemia and osteoporosis.
  • Gonadal disorders: Approach and management of testicular insufficiency, ovarian failure and ovarian hyperfunction and infertility.

Communicator

  • Know the important determinants of health as well as patients’ health belief systems

Collaborator

  • Consult effectively with other physicians involved in the care of endocrine patients.

Manager

  • Demonstrate cost effective diagnostic and management skills, respecting finite health care resources

Health Advocate

  • Know the role of the physician in health prevention and modification of risk factors,
    participating in education programs for patients, communities and physicians.

Scholar

  • Share information in a clear and concise way and provide an opportunity to ensure understanding by those who have been taught (patients, families and colleagues).

Professional

  • Deliver care with integrity and compassion, demonstrating ethical values in all aspects of clinical practice.

Second Year Residents:

As a supplement to the above goals and objectives, additional specific goals and objectives are developed by the program director, research supervisor (if appropriate) and resident that reflect the individualized nature of the second year of training.