Continued Supervision for the Common Pediatric Subspecialty Entrustable Professional Activities May Be Needed Following Fellowship Graduation.

PURPOSE: Entrustable professional activities (EPAs) are one approach to competency-based medical education (CBME), and 7 EPAs have been developed that address content relevant for all pediatric subspecialties. However, it is not known what level of supervision fellowship program directors (FPDs) deem necessary for graduation. The Subspecialty Pediatrics Investigator Network (SPIN) investigated FPD perceptions of the minimum level of supervision required for a trainee to successfully graduate. METHOD: In 2017, SPIN surveyed all FPDs of accredited fellowships for 14 subspecialties. For each EPA, the minimum supervision level for graduation (ranging from observation only to unsupervised practice) was set such that no more than 20% of FPDs would accept a lower level. RESULTS: The survey response rate was 82% (660/802). The minimum supervision level for graduation varied across the 7 EPAs from 2 (direct) to 4 (indirect for complex cases), with significant differences between EPAs. The percentage of FPDs desiring a lower minimum supervision level ranged from 3% to 17%. Compared with the 4 nonclinical EPAs (quality improvement, management, lead within the profession, scholarship), the 3 clinical EPAs (consultation, handover, lead a team) had higher minimum supervision graduation levels (P < .001), with less likelihood that an FPD would graduate a learner below their minimum level (P < .001). CONCLUSIONS: Consensus among FPDs across all pediatric subspecialties demonstrates the potential need for ongoing supervision for graduates in all 7 common pediatric subspecialty EPAs after fellowship. As CBME programs are implemented, processes and infrastructure to support new graduates are important considerations for leaders.

New endocrine fellowship programs do not decrease the endocrine surgery experience of residents in co-located general surgery programs.

BACKGROUND: New pediatric and vascular surgical fellowship programs decrease resident operative experience in those subspecialties in co-located general surgery programs.After 2 decades of increases, the mean number of endocrine surgery cases performed by general surgery residents nationally has decreased since 2010 to 2011. We hypothesized that new endocrine surgery fellowship programs lead to a decrease in the number of endocrine surgery cases performed by co-located general surgery residents and may be a contributing factor in the recent national decline in endocrine surgery cases performed by general surgery residents. METHODS: Endocrine surgery fellowship programs associated with a single, Accreditation Council of Graduate Medical Education-accredited general surgery program that have completed training of 1 fellow by the 2014-2015 academic year were identified. Endocrine surgery cases performed by general surgery residents who completed co-located general surgery programs from 2002 to 2003 through 2017 to 2018 were recorded. Descriptive statistics are shown as mean ± standard deviation. Statistical significance was calculated using the Mann-Whitney U Test. RESULTS: In the 13 general surgery programs with 5 years of case log data after the matriculation of the first fellow, the mean number of total endocrine surgery cases/resident increased from 47 ± 23 in year 0 to 57 ± 25 in year 5 (z-score = 2.53; P < .05). CONCLUSION: New endocrine surgery fellowship programs do not decrease the endocrine surgery cases performed by general surgery residents and have not contributed to the national decline in endocrine surgery cases by general surgery residents.

Simulation via instant messaging-Birmingham advance (SIMBA) model helped improve clinicians' confidence to manage cases in diabetes and endocrinology.

BACKGROUND: Simulation-based learning (SBL) has been increasingly used in both undergraduate and postgraduate medical training curricula. The aim of Simulation via Instant Messaging-Birmingham Advance (SIMBA) is to create a simple virtual learning environment to improve trainees' self-reported confidence in diabetes and Endocrinology. METHODS: This study was done as part of the continuous professional development for Health Education England West Midlands speciality trainees in diabetes and Endocrinology. Standardized transcripts of anonymized real-life endocrinology (endocrine session) and diabetes cases (diabetes session) were used in the simulation model. Trainees interacted with moderators through WhatsApp® in this model. All cases were then discussed in detail by a consultant endocrinologist with reference to local, national and international guidelines. Trainee acceptance rate and improvement in their self-reported confidence levels post-simulation were assessed. RESULTS: 70.8% (n = 17/24) and 75% (n = 18/24) strongly agreed the simulation session accommodated their personal learning style and the session was engaging. 66.7% (n = 16/24) strongly felt that the simulation was worth their time. In the endocrine session, there was a significant improvement in trainees' confidence in the management of craniopharyngioma (p = 0.0179) and acromegaly (p = 0.0025). There was a trend towards improved confidence levels to manage Cushing's disease and macroprolactinoma. In diabetes session, there was a significant improvement in trainees' confidence to interpret continuous glucose monitor readings (p = 0.01). There was a trend towards improvement for managing monogenic diabetes, hypoglycaemic unawareness and interpreting Libre readings. Overall, there was a significant improvement in trainees' confidence in managing cases that were discussed post-simulation. CONCLUSION: SIMBA is an effective learning model to improve trainees' confidence to manage various diabetes and endocrine case scenarios. More sessions with a variety of other speciality case scenarios are needed to further assess SIMBA's effectiveness and application in other areas of medical training.

Reproductive surgery and in vitro fertilization: the future reevaluated.

A crisis is occurring in that reproductive endocrinologists are not doing the surgeries that are a part of their discipline. We list those procedures as a blueprint for training reproductive endocrinologists.

MANAGEMENT OF ENDOCRINE DISEASE: Unmet therapeutic, educational and scientific needs in parathyroid disorders.

PARAT, a new European Society of Endocrinology program, aims to identify unmet scientific and educational needs of parathyroid disorders, such as primary hyperparathyroidism (PHPT), including parathyroid cancer (PC), and hypoparathyroidism (HypoPT). The discussions and consensus statements from the first PARAT workshop (September 2018) are reviewed. PHPT has a high prevalence in Western communities, PHPT has a high prevalence in Western communities, yet evidence is sparse concerning the natural history and whether morbidity and long-term outcomes are related to hypercalcemia or plasma PTH concentrations, or both. Cardiovascular mortality and prevalence of low energy fractures are increased, whereas Quality of Life is decreased, although their reversibility by treatment of PHPT has not been convincingly demonstrated. PC is a rare cause of PHPT, with an increasing incidence, and international collaborative studies are required to advance knowledge of the genetic mechanisms, biomarkers for disease activity, and optimal treatments. For example, ~20% of PCs demonstrate high mutational burden, and identifying targetable DNA variations, gene amplifications and gene fusions may facilitate personalized care, such as different forms of immunotherapy or targeted therapy. HypoPT, a designated orphan disease, is associated with a high risk of symptoms and complications. Most cases are secondary to neck surgery. However, there is a need to better understand the relation between disease biomarkers and intellectual function, and to establish the role of PTH in target tissues, as these may facilitate the appropriate use of PTH substitution therapy. Management of parathyroid disorders is challenging, and PARAT has highlighted the need for international transdisciplinary scientific and educational studies in advancing in this field.

Straddling medical specialties: should we have more comprehensive advanced training?

Over careers spanning 35 years each, we have witnessed great advances in medicine especially in genetics, imaging, immunotherapies and targeted cancer therapies. Our respective specialties of endocrinology and medical oncology have come to overlap significantly necessitating better communication and skills across both specialties. We will highlight common scenarios that straddle endocrinology and medical oncology. The same broad issues apply to other closely related specialties, albeit with different clinical challenges. At present, we see expensive and inefficient cross-referrals to other subspecialists or sometimes no referral at all, leading to significant clinical omissions. Opportunities for dual advanced training, or for more comprehensive single advanced training could more efficiently lead to enhanced patient care and communication.

Telemedicina como herramienta de enseñanza de la endocrinología en estudiantes de medicina / Telemedicine as a teaching tool for endocrinology in medical students

INTRODUCCIÓN: El estudiante de medicina actualmente está inmerso en una sociedad altamente tecnologizada, dónde la telemedicina podría ser utilizada como un instrumento hacia un mayor aprendizaje. OBJETIVO: El objetivo del estudio es analizar el logro de competencias y el grado de satisfacción de los estudiantes medicina con la utilización de la telemedicina como estrategia didáctica en la enseñanza de la endocrinología. MATERIAL Y MÉTODO: Estudio preexperimental, correlacional, transversal y con medición posterior a la intervención. La muestra estuvo constituida por los 40 estudiantes de tercer año de medicina (24 hombres y 16 mujeres) que realizaron su práctica de endocrinología durante el segundo semestre del 2017. Se les evaluó los logros alcanzados en las competencias a través de una escala de apreciación y se midió el grado de satisfacción con la actividad docente a través de un cuestionario validado (α de Cronbach de 0,9565). RESULTADOS: El rendimiento de los estudiantes en el módulo de teleendocrinología al evaluar las competencias de analizar, sintetizar y presentar un caso clínico teleconsultado fue de 6,1 en una escala de 1 a 7, y no se encontraron diferencias según sexo. El 90% de los estudiantes consideró muy motivadora la metodología de enseñanza basada en la telemedicina y el 82,5% consideró que esta metodología favorece la integración de los contenidos. CONCLUSIONES: La telemedicina puede ser utilizada como una herramienta para evaluar competencias académicas de endocrinología en los estudiantes de pregrado de medicina, y que estos muestran un alto grado de satisfacción con este tipo de actividad docente.

INTRODUCTION: The medical student is currently immersed in a highly technological society, where telemedicine could be used as an instrument towards greater learning. OBJECTIVE: The objective of the study is to analyze the achievement of competences and the degree of satisfaction of medical students with the use of telemedicine as a didactic strategy in the teaching of endocrinology. MATERIAL AND METHOD: Pre-experimental, correlational, cross-sectional study and measurement after the intervention. The sample consisted of 40 third-year medical students (24 men and 16 women) who performed their endocrinology practice during the second semester of 2017. They were evaluated the achievements in the competences through a scale of appreciation and The degree of satisfaction with the teaching activity was measured through a validated questionnaire (Cronbach's de 0.9565). RESULTS: The performance of the students in the teleendocrinology module when evaluating the competences of analyzing, synthesizing and presenting a teleconsultated clinical case was 6.1 on a scale of 1 to 7, and no differences were found according to sex. 90% of the students considered the teaching methodology based on telemedicine very motivating and 82.5% considered that this methodology favors the integration of the contents. CONCLUSIONS: Telemedicine can be used as a tool to evaluate endocrinology academic competences in undergraduate medical students, and that they show a high degree of satisfaction with this type of teaching activity.

Workforce Trends and Analysis of Selected Pediatric Subspecialties in the United States.

OBJECTIVE: To update pediatric subspecialty workforce data to support evidence-based legislation and public policy decisions by replicating the American Academy of Pediatrics' 1998 Future of Pediatric Education (FOPE II) workforce survey. METHODS: A descriptive and comparative analysis of survey responses from 9950 US pediatric subspecialists who completed an electronic survey. RESULTS: Pediatric subspecialists are working fewer hours and spending less of their time in direct patient care than they did in 1998 but the mean hours worked differs significantly according to subspecialty. Most subspecialists continue to be board-certified, white, non-Hispanic men, although the percentage who are women and from minority groups has increased. The proportion of subspecialists practicing in an academic medical center has increased since 1998. Thirty percent of pediatric subspecialists reported appointment wait times of >2 weeks and pediatric subspecialists in developmental pediatrics, endocrinology, and neurology identified much longer wait times than other subspecialists. CONCLUSION: The demographic and practice characteristics of pediatric subspecialists have changed since the FOPE II survey and access to subspecialty care in a family's community remains a challenge. However, pediatric subspecialties are not monolithic and solutions to workforce shortages will need to take into account these differences to improve access to subspecialty care.

Utilizing a rat delayed implantation model to teach integrative endocrinology and reproductive biology.

In this teaching laboratory, the students are directed in an exercise that involves designing and performing an experiment to determine estrogen's role in regulating delayed implantation (diapause) in female rats. To encourage active participation by the students, a discussion question is provided before the laboratory exercise in which each student is asked to search the literature and provide written answers to questions and to formulate an experiment to test the role of ovarian estrogen in inducing implantation in female rats. One week before the laboratory exercise, students discuss their answers to the questions with the instructor to develop an experiment to test their hypothesis that estrogen is involved with inducing implantation in the rat. A rat delayed implantation model was established that utilizes an estrogen receptor antagonist (ICI 182,780), which inhibits the action of ovarian estrogens. Groups of mated females are treated with either carrier (control) or ICI 182,780 (ICI) every other day, starting on day 2 postcoitus (pc) until day 8 pc. One-half of the females receiving ICI are injected with estradiol-17ß on day 8 pc to induce implantation 4 days after the controls. If the ICI-treated females are not administered estradiol, embryo implantation occurs spontaneously ~4 days after the last ICI injection on day 8. This is a very simple protocol that is very effective and provides an excellent experiment for student discussion on hormone action and the use of agonists and antagonists.

A model for a career in a specialty of general surgery: One surgeon's opinion.

BACKGROUND: The integration of general and endocrine surgery was studied as a potential career model for fellowship trained general surgeons. METHODS: Case logs collected from 1991-2016 and academic milestones were examined for a single general surgeon with a focused interest in endocrine surgery. Operations were categorized using CPT codes and the 2017 ACGME "Major Case Categories" and there frequencies were determined. RESULTS: 10,324 operations were performed on 8209 patients. 412.9 ± 84.9 operations were performed yearly including 279.3 ± 42.7 general and 133.7 ± 65.5 endocrine operations. A high-volume endocrine surgery practice and a rank of tenured professor were achieved by years 11 and 13, respectively. At year 25, the frequency of endocrine operations exceeded general surgery operations. CONCLUSION: Maintaining a foundation in broad-based general surgery with a specialty focus is a sustainable career model. Residents and fellows can use the model to help plan their careers with realistic expectations.

TRANSCULTURALIZATION RECOMMENDATIONS FOR DEVELOPING LATIN AMERICAN CLINICAL PRACTICE ALGORITHMS IN ENDOCRINOLOGY--PROCEEDINGS OF THE 2015 PAN-AMERICAN WORKSHOP BY THE AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY.

The American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE) convened their first Workshop for recommendations to optimize Clinical Practice Algorithm (CPA) development for Latin America (LA) in diabetes (focusing on glycemic control), obesity (focusing on weight loss), thyroid (focusing on thyroid nodule diagnostics), and bone (focusing on postmenopausal osteoporosis) on February 28, 2015, in San Jose, Costa Rica. A standardized methodology is presented incorporating various transculturalization factors: resource availability (including imaging equipment and approved pharmaceuticals), health care professional and patient preferences, lifestyle variables, socio-economic parameters, web-based global accessibility, electronic implementation, and need for validation protocols. A standardized CPA template with node-specific recommendations to assist the local transculturalization process is provided. Participants unanimously agreed on the following five overarching principles for LA: (1) there is only one level of optimal endocrine care, (2) hemoglobin A1C should be utilized at every level of diabetes care, (3) nutrition education and increased pharmaceutical options are necessary to optimize the obesity care model, (4) quality neck ultrasound must be part of an optimal thyroid nodule care model, and (5) more scientific evidence is needed on osteoporosis prevalence and cost to justify intervention by governmental health care authorities. This 2015 AACE/ACE Workshop marks the beginning of a structured activity that assists local experts in creating culturally sensitive, evidence-based, and easy-to-implement tools for optimizing endocrine care on a global scale.

Role of telemedicine technology in endocrine surgery knowledge sharing.

INTRODUCTION: This retrospective study was designed to assess the outcome of telemedicine technology supportive of educational collaboration among endocrine surgery peers and its impact on knowledge and skill development. MATERIALS AND METHODS: The study was carried out in the Department of Endocrine Surgery in collaboration with School of Telemedicine and Biomedical Informatics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India, during October 1999-December 2012. Telemedicine activities were divided into various modules (e.g., case/problem-based learning, clinical grand rounds, postgraduate course/continuing medical education/conference). Endocrine surgeons participating in such sessions were divided into two groups (faculty and residents). A multimodule questionnaire was constructed based on a Likert scale (2-7 points) to test various aspects (e.g., technical performance, role in knowledge exchange, skill development, level of satisfaction, and future recommendations). Responses were expressed in proportions, and the chi-squared test was used to find the differences in opinions of the study groups. RESULTS: The questionnaire was sent to 38 surgeons, of whom 36 replied (response rate, 94.74%); of these respondents, 14 were faculty and 22 were residents. More than 80% of participants felt that the technology helped in learning new things and strengthening relations with peers, whereas >90% were of the view that it helped in knowledge exchange and development of skills as well as was helpful in supporting clinical decisions. More than 90% of participants were satisfied and enjoyed using this technology and also were of the opinion that the technology should be integrated into other specialties. Satisfaction with the technology was excellent to good for 94.44% of participants. Both faculty and residents were of the same opinion, and there was no significant difference in their replies. CONCLUSIONS: Knowledge sharing in a collaborative environment using telemedicine technology has been found successful in a low-resource setting and is now adopted in the departmental educational program.

Techniques of parathyroid exploration at North American endocrine surgery fellowship programs: what the next generation is being taught.

BACKGROUND: Minimally invasive techniques are now often used to treat primary hyperparathyroidism but with uncertain conformity and some controversy. Endocrine surgery fellowships (ESFPs) have recently proliferated. METHODS: The directors of the 19 ESFPs recognized by the American Association of Endocrine Surgeons were polled to identify the approaches currently taught to trainees. RESULTS: With 100% participation, all ESFPs obtain ≥1 imaging study, and 95% use ultrasound to assess for concurrent thyroid nodules that require care. For an apparent single adenoma, all ESFPs minimize dissection, use intraoperative parathyroid hormone monitoring, and, if multiglandular disease is identified, perform 4-gland exploration. Outpatient surgery (89%) and postoperative oral calcium use (68%) are common. All programs define cure as durable normocalcemia (median, 6 months). CONCLUSIONS: American Association of Endocrine Surgeons fellowship programs teach congruent management strategies that include focused dissection, intraoperative parathyroid hormone use, and intent to cure. These consistencies define a future standard for assessment of parathyroidectomy outcomes.

[What patients need to know about the risk of bone fracture and its prevention]. / Ce que les patientes doivent savoir sur le risque osseux et sa prévention.

Post-menopausal osteoporosis is one of the classic complications of prolonged estrogen deficiency associated with menopause. It is defined as a state of the skeleton characterized by decreased bone strength with an increased risk of fracture. The natural history of osteoporosis and, in particular, the rapid increase in fracture recurrence after a first major fracture should justify a priori an approach for early detection of women at higher risk from the early postmenopausal phase. It is more of a chronic disease that requires support in the long term, in the absence of a truly curative treatment. Indeed, currently available therapies can at best reduce the incidence of fractures by about 50%, especially at the vertebral site, but do not cancel the disease. Moreover, duration of treatment is currently recommended for 5 to 10 years, which does not allow to consider that a single molecule could be taken "for the whole life". The fracture risk assessment based on the combination of densitometric measurement by DXA and the search for clinical risk factors is a prerequisite to any therapy. The first choice of treatment is especially important for a relatively young woman with high fracture risk. In early menopause (generally within the first decade of post-menopausal) and in the absence of contraindication, menopausal hormone therapy should remain the preferred option for first-line whenever possible. Raloxifene is an interesting alternative, due to its mechanisms of action and multiplicity of targets with, in particular, its preventive effect on the risk of estrogen receptor-positive breast cancer. It is only when there are contraindications to one or the other of these two molecules, that other osteoporosis treatments can be discussed. They should nevertheless be considered only in women whose 10-year-fracture risk is significantly increased. Indeed, it is mainly in this high risk of fracture, particularly because of an age greater than 65 years and a history of vertebral fracture, that their antifracture efficacy has been validated. In addition, it is mostly beyond this age that the question of the prevention of hip fracture has to be considered.