Self assessment and laboratory training

Dear Colleague,

Following the Trainers and Trainees meeting I have given further thought to the issue of a taught programme. The main aim of this programme was to prepare trainees for the self-assessment questions. Observations from the RITA suggested that reflective writing in relation to learning events were not truly reflective. They were mainly a regurgitation of the "knowledge" base with little critical appraisal of the evidence or any national guidance that may have been quoted. This makes undertaking the RITAs difficult. Despite these anxieties it is important that I stick to the principle of adult self directed learning and also make sure that I do not leave an albatross for my successors neck. Hence:

1. I have appended a set of 4 self-assessment essays to guide your self-directed learning. You can direct your learning individually or indeed discuss your answers with your peers or trainers. Also included is an optional essay which you can submitt to myself and Richard Quinton (one HARD copy to each of us) before 2nd February 2008. The winner will be notified at their post-RITA review meeting and the prize will be formally handed to them at the T&T meeting in June 2008. This is good for the CV.

2. I have appended a document providing guidance on laboratory training.

3. In next years RITAs the panels will be marking the reflective cases/writing much harder looking for critical appraisal skills, etc.

4. Given time issues I have abandoned the proposal of circulating self-assessment MCQs.

Kindest of regards,
Shaz.
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Self Assessment Essay Questions

Essay 1

A 55 year-old man with a history of paroxysmal AF treated with amiodarone for the last year is referred to you with the following TFTs, TSH less than 0.01 mU/l; fT4 56pmol/l; fT3 22pmol/l. He is thyrotoxic on examination. In no more than 500 words discuss how you would manage him.

A 25 year old woman presents with lethargy, change of voice and leg cramps. Her biochemistry is TSH= 206mU/l, FT4=6pmol/l, FT3=3.7pmol/l. What is the diagnosis, how are you going to treat her? Explain the FT4 and FT3 levels. What information does this patient need to know about her prognosis and ongoing treatment? Restrict your answers to no more than 500 words.

Essay 2

A 32 year-old man with a past history of hypertension treated with bendrofluazide is referred to you by his GP to rule out an endocrine cause. The GP does not think the patient is cushingoid and has already undertaken 2 24-hour urine cortisol measurements which were normal. In no more than 1000 words, discuss adrenal hypertension in relation to this case.

Essay 3

A GP has been struggling with the diabetic control of a 56 year old Caucasian man with Type 2 DM for 5 years, HbA1c 9%, BMI 32 kg/m², waist circumference 96 cm, well controlled BP and lipids. He is on top dose Metformin, gliclazide and was intolerant of rosiglitazone. Orlistat has been ineffective. The GP was wondering what therapeutic options are or would be available for this patient. In no more than 1000 words, discuss novel therapies for the treatment of Type 2 Diabetes in relation to this patient.

Essay 4

A 32 year old woman with a five history of Type 1 DM, background retinopathy and poor hospital attendance attends out-patients following a GP referral because of an eGFR of 29. The GP has advised her she has stage 4 kidney failure and she is very worried. Her HbA1c is 8.5% on bd Novomix 30, LDL-cholesterol is 3.2 and BP is 134/84 mmHg. Her GP advises you these results are typical of her repeat measures over the last year and her creatinine has varied between 120 and 140 micromole/l in the last 18-months. No urine results are available. In no more than 1000 words, discuss how you would manage this lady.

PRIZE ESSAY-If you wish to apply for the best Essay prize for the year submit this essay. In no more than 1000 words, describe the management of patients receiving chronic glucocorticoid replacement therapy, in relation to the available published data and reflect upon any ongoing controversies in the accepted “best practice” for monitoring therapy.

Laboratory Training

To function effectively as a Consultant specialising in Diabetes & Endocrinology it is essential that trainees experience training in laboratory medicine. The curriculum is a little “fuzzy” on this issue, hence the need for this guidance. A number of training units already provide multidisciplinary opportunities to interact with a biochemist, but it is important to arrange exposure to laboratory medicine during each unit attachment backed up by background reading. It is important to cover the following topics:

HbA1c assay measurement, cv, standardisation

Glucose measurements in the lab and meters with causes of errors

Hormone assay methods – Immunometric, RIA, ELISA, Chromatography; Reasons for variability and errors, e.g. hook effect, protein binding

Pitfalls in autoAb measuring, e.g. TBII, thyroid, adrenal

Pitfalls in measuring or assessing the following hormones or endocrine axis – TSH, fT4, fT4, thyroglobulin, total thyroid hormones; Prolactin; Cortisol, ACTH; PTH, calcitonin, calcium, vitamin D; Water & electrolyte handling; electrolytes, osmolality, ADH; GH, IGF1; LH, FSH, Testosterone, SHBG, E2; Renin, aldosterone, PRA; Catecholamines