Establishment of the Clinician-Scientist Investigator Opportunity Network to Develop Military Medical Research Leaders.

INTRODUCTION: The ability of military clinicians to conduct military medical research is often limited because of competing priorities and a lack of research mentorship. The Clinician-Scientist Investigator Opportunity Network (CSION) was developed with the intent of training clinicians how to engage in requirements-driven research within the DoD. MATERIALS AND METHODS: Three to five academic medical faculties were selected from a pool of applicants each year to participate in a 2-year research fellowship. To be eligible for the CSION program, applicants had to meet the following criteria: (1) Completed residency graduate medical education training, (2) not be currently enrolled as a graduate medical education trainee, and (3) obtained permission from their department leadership to focus 25% of their duty hours on CSION participation to include didactic and research efforts. The remaining 75% of fellows' time was dedicated to clinical duties. Monthly didactics, intensive mentorship, and consistent support were offered to each fellow by the CSION leadership team. Metrics were recorded to include both research and clinical productivity. RESULTS: Between January 2019 and December 2022, 12 CSION fellows graduated from the program (four in the class of 2020, three in 2021, and five in 2022). From 2019 to 2021, the 12 CSION fellows initiated 204 research protocols, generated 489 publications/presentations, and secured 33 research grants. All graduates of the program remain active in clinical research with multiple graduates currently assigned to research positions. CONCLUSIONS: The CSION research education program is a 2-year additional duty research fellowship producing clinician-scientists conducting military-relevant medical research and publications and may be considered a low-cost/highly efficient alternative to achieve the reported benefits of the MD-PhD tract. The expansion of the CSION program may improve the quality of military medical research and health care.

Developing Military Doctors: An Institutional Approach to Medical Force Readiness in Graduate Medical Education.

Military physicians are required to not only meet civilian accreditation standards upon completion of their Graduate Medical Education (GME) training programs but also be proficient in the military-unique aspects of their field, including medical care in austere environments and management of combat casualties. They must also be familiar with the administrative and leadership aspects of military medicine, which are often absent from the training curriculum. The San Antonio Uniformed Services Health Education Consortium Military Readiness Committee, by incorporating questions of military relevance into each GME program's mandatory Annual Program Evaluation, identified curricular gaps upon which military readiness training objectives and opportunities were developed. These activities included a lecture series on the sustainment of medical and military readiness, an interactive procedural skills training event, trainee involvement in operational pre-deployment exercises, and the development of an elective operational rotation in Honduras. The Military Readiness Committee provides a model for other military GME institutions to develop training goals and opportunities to strengthen the preparedness of their trainees for military service.

Are We Missing an Opportunity? Prediabetes in the U.S. Military.

INTRODUCTION: The prevalence of prediabetes is estimated to be one-third of Americans with approximately 80% of these individuals unaware of the diagnosis. In the active duty military population, the prevalence of prediabetes is largely unexplored. The purpose of this study was to investigate the prevalence of prediabetes in military service members by quantifying those meeting prediabetes screening criteria, those actually being screened, and those being appropriately diagnosed. MATERIALS AND METHODS: Data were analyzed from calendar years 2014 to 2018 for active duty service members 18 years of age or older. Vitals records were collected to obtain body mass index values. Composite Health Care System laboratory data were queried for hemoglobin A1c (HbA1c) results as well as fasting plasma glucose (FPG) and oral glucose tolerance test (OGTT) results. The percentage of active duty service members meeting criteria for prediabetes screening was determined by totaling members age 45 and older with members age 18- to 44-year old with a body mass index ≥25.0 kg/m2, then dividing by the total number of members for each respective military branch. The percentage of active duty service members actually screened for prediabetes was determined based on members meeting prediabetes screening criteria who in fact had FPG, OGTT, or HbA1c labs. The total number of labs meeting prediabetes criteria was determined based on those aforementioned labs with results in the prediabetes range (FPG between 100 and 125 mg/dL, OGTT between 140 and 199 mg/dL, or HbA1c range of 5.7%-6.4%). The total number of service members with appropriate prediabetes International Classification of Disease (ICD) code was determined by identifying members with ICD-9 and ICD-10 codes 790.21, 790.22, and R73.01-R73.03 in their medical record. RESULTS: From 2014 to 2018, 53.9% of 332,502, 56% of 543,081, and 47.3% of 531,313 active duty service members in the Air Force, Army and Navy, respectively, met criteria for prediabetes screening. The rates of actually screening for prediabetes were similar across the Air Force (4.8%), Army (6.7%), and Navy (5.5%). The percentage with labs meeting prediabetes criteria ranged from 17.9% to 28.4% in the Air Force, 24.2% to 30.3% in the Army, and 24.2% to 30.9% in the Navy. The rate of ICD coding for prediabetes increased from 2014 to 2018 across all branches (29.8%-65.3% for the Air Force, 24.6%-46.8% for the Army, and 40.0%-45.5% for the Navy). CONCLUSION: Screening for prediabetes in the active duty military population is grossly inadequate, and even of those screened, diagnosing those meeting prediabetes criteria is similarly inadequate. Although this scenario is not unique to the Military Health System, but reflective of a larger national problem, efforts should be made within the Military Health System to increase the screening for this common disorder. Identifying service members with prediabetes enables opportunities for targeted interventions to delay or prevent the progression to diabetes mellitus.

The Sum is Greater Than the Parts: Aligning Graduate Allied and Medical Health Education at a Training Institution.

Analysis of military Graduate Medical Education (GME) remains in the discussion forefront as resources continue to face scrutiny along with military-specific obligation challenges. The Military Health System Quadruple Aim of Better Care, Better Health, Lower Cost, and Increased Readiness continues to drive debate of the right approach to both GME and Graduate Allied Health education. In this paper, we expand the discussion beyond traditional physician-focused GME and include the military's highly trained allied health specialists. Graduate Allied Health medical providers provide quality and effective medical care to the military's service members and dependents. These specialists also carry a significant deployment and operational medicine footprint complimenting core physician medical specialties delivering cost-efficient, optimal patient care and providing a ready force. This paper addresses GME and GAH interprofessionalism, institutional culture endorsement, patient safety, increasing demand, research productivity, and encouraging physician retention altogether benefiting the Military Health System. This institution's support for the interprofessional GME model works well, expanding physician and GAH specialists' professional application and knowledge while garnering mutual respect across all medical disciplines ultimately benefiting all.

Novel Formative Approach of the ESAP-ITE Provides Strong Predictive Value for ABIM Certification Outcomes.

BACKGROUND: The Endocrine Self-Assessment Program In-Training Examination (ESAP-ITE) has the novel formative approach of allowing open access to all questions and answers after secure examination administration is complete, resulting in the creation of an entirely new in-training examination annually. OBJECTIVE: To determine whether scores on the novel ESAP-ITE predict pass/fail outcomes on the American Board of Internal Medicine Endocrinology, Diabetes, and Metabolism Certification Examination (ABIM-ECE). METHODS: All endocrine fellows-in-training who took the ESAP-ITE between 2016 and 2019 and then subsequently attempted the ABIM-ECE within the same calendar year were included (n = 982). Primary analyses used the ESAP-ITE score from the final year of fellowship training. Covariates included sex, age on date of ABIM-ECE, medical school country, fellowship program region, pass/fail outcomes on the ABIM Internal Medicine Certification Examination, and ESAP-ITE score. All variables were analyzed using multivariable logistic regression. RESULTS: ESAP-ITE score (P < 0.001), ABIM Internal Medicine Certification Examination outcome (P < 0.001), and age (P = 0.005) were each significant predictors of passing the ABIM-ECE on the first attempt. ESAP-ITE score was the strongest predictor of passing the ABIM-ECE, and this relationship was such that a score of 75% correct yielded a 97% probability of passing the ABIM-ECE, whereas a score of 50% correct generated only a 70% probability of doing so. Sex, fellowship program region, and medical school country were not significant predictors of ABIM-ECE outcomes. CONCLUSIONS: In addition to serving as an important learning instrument for endocrine fellowship programs, ESAP-ITE is a robust predictive tool for pass/fail outcomes on the ABIM-ECE.

The Impact of Graduate Medical Education on Scholarly Activity at a Military Medical Treatment Facility.

INTRODUCTION: Graduate medical education (GME) faculty and trainees have required scholarly activities to meet accreditation requirements. The impact of this contribution to the Military Health System, especially regarding innovations in military medicine, has not been previously examined. This study measured the contribution of GME in published manuscripts from a tertiary military medical center. MATERIALS AND METHODS: Utilizing the Scopus database, published manuscripts from the primary military GME institutions for the San Antonio Uniformed Services Health Education Consortium were identified from 2008 to 2018. Manuscripts were sorted based on the number of citations in Scopus and analyzed for their overall impact in medicine to include military unique topics. RESULTS: A total of 3,700 manuscripts were identified through Scopus and based on a 10 citation minimum, 1,365 manuscripts were further analyzed; 1,152 (84.4%) included authors with GME affiliation and 554 (40.6%) had direct applicability to unique aspects of military medicine. The mean number of citations per manuscript was 39.2 ± 63.6; Mean Cite Score was 2.97 ± 2.14 and Field Weighted Citation Index of 2.22 ± 3.27. Analysis of number of citations (10-19; 20-39; or >40) did not show any significant differences in Cite Score or military relevance, whereas the percentage of military relevant articles remained consistent yearly. CONCLUSIONS: These findings highlight the importance of military medical research and addressing specific medical needs of the warfighter. Graduate medical education in a tertiary Military Health System facility has enormous impact in scholarly activity, in particular the importance related to military medicine topics that emphasize combat casualty care and military readiness.

Leadership Training in Graduate Medical Education: Time for a Requirement?

INTRODUCTION: The need for all physicians to function as leaders in their various roles is becoming more widely recognized. There are increasing opportunities for physicians at all levels including Graduate Medical Education (GME) to gain leadership skills, but most of these opportunities are only for those interested. Although not an Accreditation Council for Graduate Medical Education (ACGME) requirement, some US graduate medical education programs have incorporated leadership training into their curricula. Interestingly, the Royal College of Physicians and Surgeons of Canada adopted the Leader role in its 2015 CanMEDS physician training model and requires leadership training. We sought to understand the value of a leadership training program in residency in our institution. MATERIALS AND METHODS: Our 2017 pilot leadership training program for senior military internal medicine residents consisted of four one-hour sessions of mini-lectures, self-assessments, case discussions, and small group activities. The themes were: Introduction to Leadership, Emotional Intelligence, Teambuilding, and Conflict Management. Participants were given an 18-question survey (14 Likert scale multiple-choice questions and 4 open-ended response questions) to provide feedback about the course. The Brooke Army Medical Center Institutional Review Board approved this project as a Quality Improvement effort. RESULTS: The survey response rate was 48.1% (26 of 54). The majority of respondents (84.6%) agreed the leadership training sessions were helpful and relevant. Following the sessions, 80.8% saw a greater role for physicians to function as leaders. Most (88.4%) agreed that these sessions helped them understand the importance of their roles as leaders, with 80.8% feeling more empowered to be leaders in their areas, 76.9% gaining a better understanding of their own strengths and weaknesses as leaders, and 80.8% feeling better prepared to meet challenges in the future. After exposure to leadership training, 73.1% indicated a plan to pursue additional leadership development opportunities. All respondents agreed that internists should be able to lead and manage a clinical team, and every respondent agreed that leadership principles should be taught in residency. CONCLUSIONS: This pilot project supports the premise that leadership training should be integrated into GME. Initial results suggest training can improve leadership skills and inspire trainees to seek additional leadership education. Moreover, much like the published literature, residents believe they should learn about leadership during residency. While more effort is needed to determine the best approach to deliver and evaluate this content, it appears even small interventions can make a difference. Next steps for this program include developing assessment tools for observation of leadership behaviors during routine GME activities, which would allow for reinforcement of the principles being taught. Additionally, our experience has led our institution to make leadership training a requirement in all of our GME programs, and we look forward to reporting future progress. Finally, an ACGME requirement to incorporate leadership training into GME programs nationwide would prove useful, as doing so would reinforce its importance, accelerate implementation, and expand knowledge of best approaches on a national level.

The Choice Should Be Yours: Diabetes-Related Distress by Insulin Delivery Method for People with Type 1 Diabetes.

Background: American Diabetes Association (ADA) recommends psychosocial assessment for people with diabetes, including diabetes-related distress. Elevated diabetes-related distress is associated with poor self-management, lower medication adherence, and poorer quality of life. Insulin delivery methods are multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII). Because people with type 1 diabetes mellitus (T1DM) require comprehensive insulin therapy to manage blood glucose, we explored the association of insulin delivery methods and diabetes distress in this group. Methods: The U.S. Air Force Diabetes Center of Excellence (DCOE), a specialty clinic for adults who are Military Health System beneficiaries, administers the validated 17-item Diabetes-related Distress Scale (DDS-17) as part of standard care. Patient data were analyzed from June 2015 to August 2016 using SPSS version 22. Patients were free to choose the method of insulin delivery with minimal or no additional cost. Results: There were 203 patients with T1DM who completed the DDS-17 as part of standard care during the time period. Patients were categorized as CSII (57.6%) or MDI (42.4%). Women were significantly more likely to choose MDI over CSII than men (P = 0.003). DDS-17 scores were low in both groups, and there were no significant differences in DDS-17 by insulin delivery method. Furthermore, no significant differences were found in hemoglobin A1c (HbA1c) between CSII (7.9% or 63 mmol/mol) and MDI (8.1% or 65 mmol/mol) users (P = 0.22) and no significant differences in body mass index (BMI) between patients using CSII (M = 28.33 kg/m2) and MDI (28.49 kg/m2) users (P = 0.15). Conclusions: Our study demonstrated that if patients are relatively free to choose the insulin delivery method (minimal or no financial constraints), there were no differences in diabetes distress scores, HbA1c, or BMI between CSII and MDI. Therefore, people with T1DM may benefit from choosing the method of insulin delivery that will enable them to achieve individual goals and manage diabetes-related distress.

Diabetes by Air, Land, and Sea: Effect of Deployments on HbA1c and BMI.

INTRODUCTION: Service members (SMs) in the United States (U.S.) Armed Forces have diabetes mellitus at a rate of 2-3%. Despite having a chronic medical condition, they have deployed to environments with limited medical support. Given the scarcity of data describing how they fare in these settings, we conducted a retrospective study analyzing the changes in glycated hemoglobin (HbA1c) and body mass index (BMI) before and after deployment. MATERIALS AND METHODS: SMs from the U.S. Army, Air Force, Navy, and Marine Corps with diabetes who deployed overseas were identified through the Military Health System (MHS) Management Analysis and Reporting Tool and the Defense Manpower Data Center. Laboratory and pharmaceutical data were obtained from the MHS Composite Health Care System and the Pharmacy Data Transaction Service, respectively. Paired t-tests were conducted to calculate changes in HbA1c and BMI before and after deployment. RESULTS: SMs with diabetes completed 11,325 deployments of greater than 90 days from 2005 to 2017. Of these, 474 (4.2%) SMs had both HbA1c and BMI measurements within 90 days prior to departure and within 90 days of return. Most (84.2%) required diabetes medications: metformin in 67.3%, sulfonylureas in 19.0%, dipeptidyl peptidase-4 inhibitors in 13.9%, and insulin in 5.5%. Most SMs deployed with an HbA1c < 7.0% (67.1%), with a mean predeployment HbA1c of 6.8%. Twenty percent deployed with an HbA1c between 7.0 and 7.9%, 7.2% deployed with an HbA1c between 8.0 and 8.9%, and 5.7% deployed with an HbA1c of 9.0% or higher. In the overall population and within each military service, there was no significant change in HbA1c before and after deployment. However, those with predeployment HbA1c < 7.0% experienced a rise in HbA1c from 6.2 to 6.5% (P < 0.001), whereas those with predeployment HbA1c values ≥7.0% experienced a decline from 8.0 to 7.5% (P < 0.001). Those who deployed between 91 and 135 days had a decline in HbA1c from 7.1 to 6.7% (P = 0.010), but no significant changes were demonstrated in those with longer deployment durations. BMI declined from 29.6 to 29.3 kg/m2 (P < 0.001), with other significant changes seen among those in the Army, Navy, and deployment durations up to 315 days. CONCLUSIONS: Most SMs had an HbA1c < 7.0%, suggesting that military providers appropriately selected well-managed SMs for deployment. HbA1c did not seem to deteriorate during deployment, but they also did not improve despite a reduction in BMI. Concerning trends included the deployment of some SMs with much higher HbA1c, utilization of medications with adverse safety profiles, and the lack of HbA1c and BMI evaluation proximal to deployment departures and returns. However, for SMs meeting adequate glycemic targets, we demonstrated that HbA1c remained stable, supporting the notion that some SMs may safely deploy with diabetes. Improvement in BMI may compensate for factors promoting hyperglycemia in a deployed setting, such as changes in diet and medication availability. Future research should analyze in a prospective fashion, where a more complete array of diabetes and readiness-related measures to comprehensively evaluate the safety of deploying SMs with diabetes.

THE IMPACT OF GLP-1 RECEPTOR AGONISTS ON PATIENTS WITH DIABETES ON INSULIN THERAPY.

Objective: The clinical benefit of adding a glucagon-like peptide-1 receptor agonist (GLP-1RA) to basal-bolus or very high dose insulin regimens is unclear. This study investigated the impact of adding a GLP-1RA to a spectrum of insulin regimens (basal, basal-bolus, and U-500) to determine the impact on hemoglobin A1c (HbA1c), weight loss, and total daily insulin dose (TDD) over the course of 12 months. Methods: A retrospective chart review was conducted on 113 participants with type 2 diabetes mellitus using insulin therapy. Each participant's HbA1c, body weight, and TDD were recorded prior to initiation of GLP-1RA therapy and at the 3, 6, and 12-month time points while on combination therapy. Results: Across all participants, the HbA1c values decreased significantly from a baseline of 8.9 (74 mmol/mol) ± 0.14% to 8.2 (66 mmol/mol) ± 0.14% (P<.01) in the first 3 months, 8.0 (64 mmol/mol) ± 0.12% (P<.01) at 6 months, to 8.3 (67 mmol/mol) ± 0.14% (P<.01) at 12 months. There was no significant decrease in weight or TDD with the addition of a GLP-1RA overall or in different insulin groups. However, there was a clinically significant decrease in weight over the study duration. Conclusion: The results of this study suggest that adding a GLP-1RA to various insulin regimens may help to achieve glycemic goals while avoiding the less desirable side effects of weight gain and increasing insulin regimens. However, the expected weight loss and decrease in TDD may not be as sizable in the clinical setting. Abbreviations: DCOE = Diabetes Center of Excellence; DM = diabetes mellitus; GLP-1RA = glucagon-like peptide-1 receptor agonist; HbA1c = hemoglobin A1c; RCT = randomized controlled trial; TDD = total daily dose.

Is It Distress, Depression, or Both? Exploring Differences in the Diabetes Distress Scale and the Patient Health Questionnaire in a Diabetes Specialty Clinic.

IN BRIEF Patients (n = 314) completed the Patient Health Questionnaire and the Diabetes Distress Scale as part of standard care. Although most patients (70.4%) had no symptoms of depression or diabetes-related distress, 23.9% scored high on the distress questionnaire in at least one of its four domains. Regular screening for distress related to the demands of living with diabetes is crucial in identifying and preventing poor health outcomes associated with diabetes-related distress.

Evaluation of an interprofessional continuing professional development course on comprehensive diabetes care: A mixed-methods approach.

RATIONALE: Since there are only 33 endocrinologists within the Department of Defence and over 150 000 beneficiaries with diabetes, most patients with diabetes will be treated by primary care providers (PCPs). Comprehensive diabetes care visits are extensive and the clinical practice guidelines (CPGs) routinely change; thus, providing current evidence-based care is difficult. Most professional development courses aim to update PCPs on CPGs but are often inadequate as they focus on only the PCPs (not the interdisciplinary team) without a plan to implement changes into practice. OBJECTIVE: To evaluate the biannual (twice yearly), 3-day, interprofessional Diabetes Champion Course (DCC) developed by the US Air Force Diabetes Center of Excellence on comprehensive diabetes care. METHODS: A mixed-methods approach was used to evaluate three iterations of the DCC course (Sept 2014-Sept 2015). Quantitatively, pre-course and post-course surveys were used to obtain impact on knowledge, skills, and intention to change clinical practice. Qualitatively, semi-structured phone interviews were conducted with participants to obtain benefits to their clinic related to attending the DCC and barriers to implementation of the CPG process improvement project. RESULTS: Twelve of 19 responding clinics (63%) reported implementing all or part of their original CPG project developed at the DCC, and 17 of 19 clinics (89%) reported improvements associated with attending the DCC. Post-course surveys, from on location participants, revealed significant improvements in knowledge (P < 0.01). Likewise, foot exam skills and ability to demonstrate glucose meters to patients improved. Even with high pre-course confidence, 97% of providers reported acquiring new knowledge about prescribing and titrating insulin. CONCLUSION: The DCC is innovative as it employs a team-based, interprofessional, didactic, and interactive approach that is effective in improving knowledge, skills, and intention to change clinical practice, which should translate to better care for patients with diabetes.

Assessing Mentorship Experiences of Faculty at a Military Academic Center: Challenge and Opportunity.

OBJECTIVES: Mentor relationships are a key component of professional development within academic medicine. To date, there are no investigations into the prevalence and effects of mentor relationships within military academic medicine. This quality improvement initiative aimed to establish the prevalence and effects of mentorship, including whether sex differences exist among faculty at a military academic center, the San Antonio Uniformed Services Health Education Consortium, and identify opportunities to improve faculty development efforts for mentorship to benefit faculty at this institution. METHODS: A 17-item survey was developed using an iterative process. Using the SurveyMonkey platform, the survey was distributed to each faculty member within the 33 Accreditation Council for Graduate Medical Education-accredited programs. RESULTS: A total of 104 responses (26%) were received from 393 total faculty members, including 48 Air Force, 45 Army, 3 Navy, and 8 Contractor/Government Service respondents. Thirty-four respondents were women (33%) and 70 were men (67%). Only 42% of faculty reported currently having a mentor. Thirty-nine respondents (38%; 44% men and 27% women) received formal mentorship at their first staff physician position after residency training. Mentorship helped respondents the most in the areas of clinical skills, understanding departmental/institutional culture, professionalism/officership, academic promotion/advancement, and clarification of priorities/goals. When asked whether more effective mentorship would affect their own decision to remain on active-duty military service, 14% responded "yes" and 28% responded "possibly." CONCLUSIONS: Increased mentorship has the potential to positively affect career development in military academic military medicine. Results from this study affirm previous reports that effective mentorship potentially represents a powerful tool for faculty retention. Future study should include other military medical academic centers to assess the generalizability of these results across US military medicine.

Effect of Military Deployment on Diabetes Mellitus in Air Force Personnel.

Introduction: Military deployments relocate service members to austere locations with limited medical capabilities, raising uncertainties whether members with diabetes can participate safely. Military regulations require a medical clearance for service members with diabetes prior to deployment, but there is a dearth of data that can guide the provider in this decision. To alleviate the lack of evidence in this area, we analyzed the change in glycated hemoglobin (HbA1c) and body mass index (BMI) before and after a deployment among active duty U.S. Air Force personnel who deployed with diabetes. Materials and Methods: A retrospective analysis was conducted using HbA1c and BMI values obtained within 3 mo before and within 3 mo after repatriation from a deployment of at least 90 d between January 1, 2004 through December 31, 2014. The study population consisted of 103 and 195 subjects who had an available pre- and post-deployment HbA1c and BMI values, respectively. Paired t-tests were conducted to determine significant differences in HbA1C and BMI values. Results: The majority (73.8%) of members had a HbA1c <7.0% (53 mmol/mol) prior to deployment. For the overall population, HbA1c before and after deployment decreased from 6.7% (50 mmol/mol) to 6.5% (40 mmol/mol) (p = 0.03). Subgroup analysis demonstrated a significant decline in HbA1c among males, those aged 31-40 yr, and those with a pre-deployment HbA1c of >7%. BMI declined for the overall population (28.3 kg/m2 vs. 27.7 kg/m2, p < 0.0001) and for most of the subgroups. Conclusion: Air Force service members who deployed with diabetes, including those with a HbA1c > 7%, experienced a statistically significant improvement in HbA1c and BMI upon repatriation. A prospective study design in the future can better reconcile the effect of a military deployment on a more comprehensive array of diabetes parameters.

Evaluation of the Group Lifestyle Balance Program in a Military Setting: An Investment Worth Expanding.

Introduction: The Diabetes Prevention Program (DPP) demonstrated that lifestyle intervention programs were effective in preventing or delaying the onset of diabetes. The Group Lifestyle Balance (GLB) program translated the DPP curriculum into a 12-wk group intervention for those at risk for diabetes. This retrospective evaluation examined clinical outcomes for patients in the Diabetes Center of Excellence GLB program located at Wilford Hall Ambulatory Surgical Center from 2009 to 2013. Objectives included determining rates of retention, demographic characteristics of program completers, and changes in metabolic surrogates of disease prevalence. Study Design: Adults with prediabetes or metabolic syndrome (MetS) were referred to the GLB program. Updated participant metabolic data were collected at regular intervals during their participation. Results: During the 5-yr study, 704 patients attended the initial class. Overall, 52% of all participants completed the program with the greatest decline in participation occurring by the fourth week (30%). Baseline prevalence of conditions of interest for those who completed the program was prediabetes (93.2%), obesity (56.1%), and MetS (31.5%). GLB completers were older and retired (p < 0.05). A significant number of active duty military members (44.9%, p < 0.01, n = 53) dropped out of the program before the fourth week. Furthermore, those who completed the program saw a 2.0% reduction in prediabetes prevalence (p < 0.001), obesity decreased by 8.7% (p < 0.001), and MetS decreased by 6.8% (p < 0.01). Significant differences were found for central obesity, triglycerides, and fasting blood sugar (p < 0.001). Conclusions: The GLB program is a valuable DPP and was effective at improving clinical outcomes and reducing the incidence of prediabetes, obesity, and MetS for participants who completed the program. Every effort should be made to support and encourage GLB participants to complete the program.

Analysis of current thyroid function test ordering practices.

RATIONALE: Current guidelines recommend thyroid stimulating hormone (TSH) alone as the best test to detect and monitor thyroid dysfunction, yet free thyroxine (FT4) and free triiodothyronine (FT3) are commonly ordered when not clinically indicated. Excessive testing can lead to added economic burden in an era of rising healthcare costs, while rarely contributing to the evaluation or management of thyroid disease. OBJECTIVE: To evaluate our institution's practice in ordering thyroid function tests (TFTs) and to identify strategies to reduce inappropriate FT4 and FT3 testing. METHODS: A record of all TFTs obtained in the San Antonio Military Health System during a 3-month period was extracted from the electronic medical record. The TFTs of interest were TSH, FT4, thyroid panel (TSH + FT4), FT3, total thyroxine (T4), and total triiodothyronine (T3). These were categorized based on the presence or absence of hypothyroidism. RESULTS: Between August 1 and October 31, 2016, there were 38 214 individual TFTs ordered via 28 597 total laboratory requests; 11 486 of these requests were in patients with a history of hypothyroidism. The number (percent) of laboratory requests fell into these patterns: TSH alone 14 919 (52.14%), TSH + FT4 7641 (26.72%), FT3 alone 3039 (10.63%), FT4 alone 1219 (4.26%), TSH + FT4 + FT3 783 (2.74%), and others 996 (3.48%); 36.0% of TFTs ordered were free thyroid hormones. Projected out to a year, using Department of Defense laboratory costs, $317 429 worth of TFTs would be ordered, with free thyroid hormone testing accounting for $107 720. CONCLUSION: Inappropriate ordering of free thyroid hormone tests is common. In an era of rising healthcare costs, inappropriate thyroid function testing is an ideal target for efforts to reduce laboratory overutilization, which in our system, could save up to $120 000 per year. Further evaluation is needed to determine strategies that can reduce excessive thyroid hormone testing.

Leadership Training in Endocrinology Fellowship? A Survey of Program Directors and Recent Graduates.

CONTEXT: There is growing recognition that more physician leaders are needed to navigate the next era of medicine. OBJECTIVE: To determine current opinions about leadership training in endocrinology fellowship programs. DESIGN/PARTICIPANTS: Twenty-seven-question survey addressing various aspects of leadership training to current nationwide fellowship program directors (PDs) and fellowship graduates since 2010. INTERVENTION: In partnership with the Endocrine Society, the electronic survey was advertised primarily via direct e-mail. It was open from March through July 2016. MAIN OUTCOME MEASURES: The survey addressed leadership traits, importance of leadership training, preferred timing, and content of leadership training. RESULTS: Forty-six of 138 PDs (33.3%) and 147 of 1769 graduates (8.3%) completed the survey. Among PDs and graduates, there was strong agreement (>95%) about important leadership characteristics, including job knowledge, character traits, team-builder focus, and professional skills. PDs (64.5%) and graduates (60.8%) favored teaching leadership skills during fellowship, with PDs favoring mentoring/coaching (75.0%), direct observation of staff clinicians (72.5%), and seminars (72.5%). Graduates favored a variety of approaches. Regarding topics to include in a leadership curriculum, PDs responded that communication skills (97.5%), team building (95.0%), professional skills (90.0%), clinic management (87.5%), strategies to impact the delivery of endocrinology care (85.0%), and personality skills (82.5%) were most important. Graduates responded similarly, with >80% agreement for each topic. Finally, most PDs (89%) expressed a desire to incorporate more leadership training into their programs. CONCLUSIONS: Our survey suggests a need for leadership training in endocrinology fellowships. More work is needed to determine how best to meet this need.