DEFINITION:Endocrinology and metabolism is the branch of medicine concerned with the study of the diseases of the endocrine organs, disorders of hormone systems, and their target organs and disorders of the pathways of glucose and lipid metabolism in health and disease. It encompasses the assessment of patients with such disorders and the use of laboratory methods for diagnosis and monitoring of therapy. An endocrinologist is a specialist trained in the diagnosis and management of a broad range of diseases that are caused directly by disorders of the endocrine organs or disorders that secondarily affect the endocrine system. An endocrinologist is knowledgeable in endocrine physiology, particularly regarding normal control of hormone secretion and action. 

GENERAL OBJECTIVES:A resident in endocrinology and metabolism may have primary certification in internal medicine or pediatrics and will emphasize the acquisition of knowledge, skills and attitudes in areas of greatest relevance to the appropriate age group but must nonetheless have a sound understanding of the principles of endocrine and metabolic disease as they affect both children and adults. The residents in endocrinology and metabolism may plan a residency program geared towards independent private practice in the community or an academic teaching and research career in the university setting. Residents wishing to pursue a career in academic endocrinology and metabolism are encouraged to take a minimum of two years of research training in addition to clinical training in endocrinology and metabolism.

On completion of the program, the graduate physician will be competent to function as a consultant in endocrinology and metabolism. This requires the physician to have acquired the knowledge, skills and attitudes to fulfill the essential roles and key competencies of an endocrinologist, namely medical expert, communicator, collaborator, manager, health advocate, scholar, and professional.

SPECIFIC OBJECTIVES:

Medical Expert/Clinical Decision-Maker

General Requirements

• Demonstrate diagnostic and therapeutic skills for ethical and effective patient care.
• Access and apply relevant information to clinical practice.
• Demonstrate effective consultation services with respect to patient care, education and legal opinions.

Specific Requirements

Access and apply relevant information to clinical practice for persons with endocrine disorders including:

• Alterations in the endocrine system in persons with systemic disease.
• Alterations in the endocrine system in pregnant women.
• Disorders of glucose metabolism including hypoglycemia and hyperglycemia.
• Disorders of lipid metabolism especially hyperlipidemia.
• Disorders of protein metabolism (especially as they relate to atherosclerosis).
• Type 1 and Type 2 diabetes mellitus including the role of nutrition, exercise, and pharmacological management.
• Acute and chronic complications of diabetes mellitus.
• Metabolic bone disease and disorders of calcium metabolism including disorders of the parathyroid glands and the Vitamin D system.
• Disorders of the thyroid gland and thyroid metabolism including hypothyroidism, hyperthyroidism and thyroid cancer.
• Disorders of reproduction including ambiguous genitalia and gender identity, abnormalities of puberty, menstrual disorders, infertility and hyperandrogenic states in females.
• Disorders of growth in children and adolescents (limited to pediatric endocrinology).
• Disorders of the adrenal cortex and the adrenal medulla.
• Endocrine hypertension.
• Fluid, electrolyte and acid-base disorders related to the endocrine system.
• Screening for endocrine disorders and autoimmunity as it relates to the endocrine system.
• Nutrition as it applies to endocrine disorders.
• Cytogenetics as it relates to disorders of sexual differentiation, infertility and other inherited endocrine disorders.

Demonstrate diagnostic and technical skills for ethical and effective patient care related to endocrinology and metabolism including the ability to perform the following:

• A medical history that is relevant, concise, accurate and appropriate to the endocrine problem.
• A comprehensive physical examination relevant to the endocrine problem.
• Interpretation of results of hormonal assays in basal, stimulated and suppressed states.
• Fine needle thyroid biopsy (limited to adult endocrinology).
• Use of radioisotopes in diagnosis and management of endocrine disorders.
• Interpretation of neuroradiographic and ultrasound tests in the diagnosis of endocrine disorders.
• Interpretation of bone density measurements in the evaluation of metabolic bone disease.

Demonstrate effective consultation skills and services in presenting timely assessments and recommendations for patients with endocrine disorders in response to a request from another health care provider with respect to patient care, education of provider and legal opinions.

Communicator

General Requirements

• Establish therapeutic relationships with patients and families.
• Obtain and synthesize relevant history from patients, families and communities.
• Listen effectively.
• Discuss appropriate information with patients and families and the health care team.

Specific Requirements

• Establish therapeutic relationships with patients and their families and other caregivers that are characterized by understanding, trust, respect, empathy and confidentiality.
• Listen effectively to patients, families and members of the health care team.
• Present clinical problems clearly, concisely and correctly in verbal reports or written letters.
• Demonstrate ability to provide appropriate support and counsel to a patient and family with chronic endocrine or metabolic disease.
• Demonstrate an appreciation of the patients' perception of health, concerns and expectations and the impact of the endocrine disease on the patient and the family while considering factors such as the patient's age, gender, cultural and socioeconomic background and spiritual values.
• Demonstrate open-mindedness to consideration of alternative health care practices in the treatment of endocrine diseases.
• Demonstrate an understanding of the importance of communication among health care professionals involved in the care of individual patients such that the roles of these professionals are delineated and consistent messages are delivered to patients and their families.

Collaborator

General Requirements

• Consult effectively with other physicians and health care professionals.
• Contribute effectively to other interdisciplinary team activities.

Specific Requirements

• Consult effectively with other physicians particularly those most often associated with endocrinology such as neurosurgery, neuroradiology, ophthalmology, nephrology, urology, genetics, obstetrics, and general internal medicine and pediatrics.
• Contribute effectively to other interdisciplinary team activities particularly those most often associated with endocrinology such as diabetes mellitus, lipid disorders, metabolic bone disease, hypertension and newborn screening.

Manager

General Requirements

• Utilize resources effectively to balance patient care, learning needs, and outside activities.
• Allocate finite health care resources wisely.
• Work effectively and efficiently in a health care organization.
• Utilize information technology to optimize patient care, life-long learning and other activities.

Specific Requirements

• Allocate finite health care resources wisely in the context of the health care system for individual patient care, the institution, and the community.
• Work effectively and efficiently in health care organizations such as inpatient wards, outpatient clinics, metabolic day treatment centers, acute and chronic care institutions, and regional or provincial health systems.
• Recognize the role of audits, budget reviews, quality improvement, risk management, incident reporting, and complaint management in various settings including metabolic day treatment centers, clinical investigation units, the laboratory and the ambulatory care setting.
• Demonstrate the use of cost/benefit ratios of diagnostic and therapeutic interventions for endocrine disorders as well as cost containment, efficacy and efficiency as they relate to decision making and quality assurance.

Health Advocate

General Requirements

• Identify the important determinants of health affecting patients.
• Contribute effectively to improved health of patients and communities.
• Recognize and respond to those issues where advocacy is appropriate.

Specific Requirements

• Identify the important determinants of health affecting patients particularly those contributing to the burden of illness from endocrine disorders such as diabetes mellitus, hypertension, metabolic bone disease and lipid disorders.
• Contribute effectively to improved health of all patients and communities including education on aspects of prevention of endocrine disorders, specifically environmental, genetic and lifestyle risk factors.

Scholar

General Requirements

• Develop, implement, and monitor a personal continuing education strategy.
• Critically appraise sources of medical information.
• Facilitate learning of patients, housestaff/students, and other health professionals.
• Contribute to the development of new knowledge.

Specific Requirements

• Critically appraise sources of medical information particularly as it pertains to endocrinology and metabolism.
• Educate patients, housestaff, students and other health professionals in formal and informal educational settings regarding endocrine disorders and the impact of chronic disease on the endocrine system.
• Demonstrate an understanding of preferred learning methods in dealing with students, residents and colleagues.
• Contribute to development of new knowledge in endocrinology and metabolism.

Professional

General Requirements

• Deliver highest quality care with integrity, honesty and compassion.
• Exhibit appropriate personal and interpersonal professional behaviours.
• Practice medicine ethically consistent with the obligations of a physician.

Specific Requirements

• Demonstrate understanding of the principles of medical ethics as they relate to patient care and clinical research including autonomy, beneficence/nonmalificence, confidentiality, truth-telling, justice, respect for persons, conflict of interest and resource allocation.
• Demonstrate a willingness to accept peer and supervisor reviews of professional competence.
• Demonstrate recognition of personal limitations of professional competence and demonstrate a willingness to call upon others with special expertise.
• Demonstrate flexibility and willingness to adjust to changing circumstances.

CONTENT AND ORGANIZATION OF THE RESIDENCY PROGRAM:

There must be an organized program of rotations and other educational experiences, both mandatory and elective, designed to provide each resident with the opportunity to fulfill the educational requirements and achieve competence in the specialty.

The content and organization of each accredited program in adult or pediatric endocrinology and metabolism must be consistent with the specialty training requirements.

For both adult and pediatric endocrinology and metabolism, there should be opportunities for community-based learning experiences.

Residents must be provided with individual professional responsibility, under appropriate supervision, according to their level of training, ability and experience in both the clinical and laboratory aspects of the specialty. The equivalent of at least one year must be spent in clinical work, during which time the resident has supervised responsibility for the care of patients with endocrine and metabolic disease and experience in the interpretation of laboratory procedures required to manage these patients

RESOURCES:There must be sufficient resources including teaching faculty, the number and variety of patients, physical and technical resources, as well as the supporting facilities and services necessary to provide the opportunity for all residents in the program to achieve the educational objectives and receive full training as defined by the specialty training requirements in endocrinology and metabolism.

In those cases where a university has sufficient resources to provide most of the training in adult or pediatric endocrinology and metabolism but lacks one or more essential elements, the program may still be accredited provided that formal arrangements have been made to send residents to another accredited residency program for periods of appropriate prescribed training.

1. Teaching Faculty

There must be a sufficient number of qualified teaching staff to supervise the residents and provide teaching in the basic and clinical sciences related to endocrine and metabolic disorders in both adults and children. The teaching staff should have an appropriate nucleus of full-time teachers.

2. Number and Variety of Patients

The number and variety of patients, both pediatric and adult, available for teaching must be adequate to provide experience in the following areas: general aspects of endocrinology and metabolism as manifested by excess or deficient hormone production by the glands of internal secretion (pituitary, thyroid, parathyroid, pancreas, adrenal, testis and ovary), disorders of the hypothalamic-pituitary axis, pathophysiology of neuroendocrine and paracrine secretion, and mechanisms of hormone action. Training of those registered in pediatric endocrinology should be integrated with the adult program.

3. Clinical Services Specific to Adult and Pediatric Endocrinology and Metabolism

Clinical training must be based on adequate resources to insure full training for each resident in all areas of endocrinology and metabolism. The description of the program should specify how each of the components is to be provided.

1. In-Patient

Endocrinology and metabolism services participating in the program must have either an adequate number of beds, or access to an adequate number of beds both pediatric and adult. Clinical facilities must be organized for teaching the investigation and treatment of endocrine and metabolic diseases. These must be under the supervision of a qualified specialist. In order to provide consistent supervision there should be a group of specialists to staff this service.

Specific aspects of knowledge with which a resident should become familiar include:

• diabetes mellitus, including special training in ophthalmological assessment, as well as training in the use of special instrumentation pertinent to the field;
• thyroid disease, including interpretation of radioisotope studies, ultrasound and thyroid biopsy;
• metabolic bone disease and other disorders of calcium metabolism;
• disorders of reproduction in males and females as they pertain to disorders of the endocrine glands, including disorders of male infertility, impotence and androgen resistance;
• cytogenetics as it pertains to sexual differentiation and infertility;
• normal growth and development and its variations;
• fluid and electrolyte disorders related to endocrine dysfunction;
• pathogenesis and management of endocrine hypertension;
• autoimmunity as it pertains to endocrinology and metabolism;
• aspects of nutrition as they apply to this specialty including management of diabetes, lipid disorders, and inborn errors of metabolism.
1. Ambulatory

Both pediatric and adult in-patient and out-patient teaching services should be integrated as much as possible, in order to provide continuity of observation of patients both in and out of hospital. Organized clinics or other ambulatory care facilities must be available to provide opportunities for pre-admission investigation and post-discharge follow-up of patients with endocrine and metabolic disease with appropriate facilities dedicated to patient education (e.g. diabetes, hyperlipidemia). Specialty clinics in neuroendocrinology, diabetes, or other more specialized subgroups of patients, should be recognized as providing an important part of a residency program.

3. Consultation

The program must provide residents with the opportunity to obtain experience in the provision of an in-patient and out-patient consultation service to primary care physicians and other specialists (community organizations and government institutions). Residents should also have experience in providing advice to community organizations related to endocrinology and metabolism.

4. Supporting Services — Clinical, Diagnostic, Technical

The following special facilities and services must be available for the training of residents and closely coordinated with the overall program:

1. Core diagnostic radioimmunoassay facilities for steroid and peptide hormones;
2. A department of pathology with provision for the study of endocrine material obtained surgically or at post-mortem;
3. An active neurosurgical teaching service providing opportunities for collaborative investigation and management of patients with neuroendocrine dysfunction;
4. Clinical and diagnostic investigation units for both in-patient and/or out-patient assessment of patients with endocrine or metabolic disorders;
5. A department of nuclear medicine and/or radiology including specialized staff and facilities in the following areas: radioisotopic diagnosis, scanning, and ultrasonography;
6. Intensive care units organized for teaching and management in the collaborative care of severely ill patients with endocrine and metabolic disorders.
7. Clinical endocrinology and metabolism laboratory facilities must be available to ensure that each resident gains adequate experience in the laboratory aspects of the specialty, especially with regard to quality control of assays and interpretation of results.

ACADEMIC AND SCHOLARLY ASPECTS OF THE PROGRAM:

The academic and scholarly aspects of the program must be commensurate with the concept of a university postgraduate education. The quality of scholarship in the program will in part, be demonstrated by a spirit of enquiry during clinical discussions, rounds, and conferences. Scholarship implies an in-depth understanding of basic mechanisms of normal and abnormal states and the application of current knowledge to practice.

1. Organized Scholarly Activities

Organized scholarly activities must be a regular part of every program. The program may include lectures and/or seminars, which may be interdisciplinary in nature, teaching rounds, special conferences, assignments of laboratory work, technical demonstrations and critical appraisal of the literature. The milieu of scholarship should be enhanced, wherever possible, by close association between residents and active investigators on the staff.

Where certain clinical conditions occur so infrequently that clinical material is not always available, the teaching program must ensure that by formal means, journal clubs, or other suitable forums, adequate exposure to these areas is achieved.

2. Basic and Clinical Sciences Relevant to Endocrinology and Metabolism

The program must include organized teaching in the basic sciences related to the specialty, including the physiology, pathophysiology and pathology of the endocrine glands.

3. Biomedical Ethics

The academic program must provide opportunities for residents to gain an understanding of the basic principles of biomedical ethics as it relates to endocrinology and metabolism. There should be a defined training experience in the medical ethics issues that arise in relation to specific clinical problems in endocrinology and metabolism.

4. Communication Skills

There must be opportunities for residents to learn effective communication skills for interacting with patients and their families, colleagues, allied health professionals, and students. Clearly defined educational objectives for teaching these skills and mechanisms of formal assessment should be in place.

5. Teaching Skills

Residents must be given opportunities to develop effective teaching skills by teaching junior colleagues and students, as well as through conference presentations, clinical and scientific reports, and patient education.

6. Quality Assurance/Improvement

The program must provide residents with opportunities to gain an understanding of the principles and practice of quality assurance/improvement. Opportunities should be provided for residents to participate actively in such programs in their hospital departments.

7. Research Opportunities for Residents

The academic program must provide the opportunity for residents to learn biostatistics and the critical appraisal of research methodology and medical literature. A laboratory or clinical research facility in which a resident may spend a full year should meet the following requirements: (i) the director of the laboratory should be a scientist with university rank; (ii) the research program of the laboratory and the role of the resident in this program should be clearly defined; (iii) there should be adequate space, equipment, technical assistance, and where indicated animal facilities. All residents should be encouraged to participate in a research project.

8. Faculty Research

A satisfactory level of research and scholarly activity must be maintained among the faculty identified with the program.

9. Outside Conferences

The program should provide opportunities for residents to attend conferences outside their own university.

GENERAL REQUIREMENTS:

1.Certification in Internal Medicine or Pediatrics.

2.Approved residency in adult or pediatric endocrinology and metabolism

PROGRAMS (WITH TRAINING REQUIREMENTS):

Diplomas(Dip):

Six months of approved residency training.

Doctor of Medicine(M.D):

Eighteen months of approved residency training.

Doctor of Philosophy(Ph.D):

Forty eight months(four years)of approved residency training