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Diabetes/Endocrine

This is what our GP trainees need to achieve during their time at your department. We've classified them under the six main compentency domains for general practice..

1. PRIMARY CARE MANAGEMENT

• Manage primary contact with patients who have a metabolic problem.
• Co-ordinate care with other primary care health professionals, such as diabetes nurse specialists, dieticians, district nurses, community matrons, chiropodists and opticians to enable chronic disease management.
• Explain the indications for referral to an endocrinologist for management of complex metabolic problems or investigation of endocrine disorders.

The knowledge base

Symptoms
Patients with metabolic problems are frequently asymptomatic or have non-specific symptoms, such as tiredness, malaise, weight loss or gain etc.
Certain symptoms raise clinical suspicion of metabolic problems:
• Diabetes mellitus – tiredness, polydipsia, polyuria, weight loss, infections
• Hypothyroidism – tiredness, weight gain, constipation, hoarse voice, dry skin, and hair menorrhagia
• Hyperthyroidism – weight loss, tremor, palpitations, hyperactivity, exopthalmos, double vision
• Hyperlipidaemia – xanthelasma
• Hyperuricaemia – gout
• Individual endocrine disorders have typical symptom complexes

Common and/or important conditions
• Obesity
• Diabetes mellitus – type 1 and 2
• Impaired Glucose Tolerance
• Thyroid disorders – hypothyroidism, hyperthyroidism, goitre, nodules
• Hyperlipidaemia
• Hyperuricaemia
• Endocrine problems – pituitary disease (e.g. prolactinoma, acromegaly, diabetes inspidus), adrenal disease (e.g. Cushing’s syndrome, hyperaldosteronism, Addison’s disease, phaeochromocytoma) and parathyroid disease.

Investigations
• Body mass index calculation
• WHO diagnostic criteria for diabetes mellitus
• Near patient capillary glucose measurement (including patient self-monitoring)
• HbA1c and fructosamine to assess glycaemic control
• Albumin: creatinine ratio or dipstick for microalbuminuria
• Interpret serum electrolyte and urate results
• Interpret thyroid function tests and understanding their limitations – TSH, T4, free T4, T3, Auto antibodies
• Interpret lipid profile tests – total cholesterol, HDL, LDL, triglycerides
• Visual acuity and retinal photography
• Knowledge of secondary care investigations including the glucose tolerance test, thyroid ultrasound and fine needle aspiration, specialised endocrine tests

Treatment
• Understand principles of treatment for common conditions managed largely in primary care – obesity, diabetes mellitus, hypothyroidism, hyperlipidaemia, hyperuricaemia
• Chronic disease management including specific disease management, systems of care, and multidisciplinary team work for people with established metabolic problems
• Communication with patients and their families and inter professional communication both within the PHCT and between primary and secondary care

Emergency care
• Acute management of diabetic emergencies – hypoglycaemia, hyperglycaemic ketoacidosis and hyperglycaemic hyperosmolar non-ketotic coma.
• Acute management of thyroid emergencies – myxoedema coma and hyperthyroid crisis

Prevention
• Health promotion activities include dietary modification and exercise advice
• Understand when prevention of hyperuricaemia is appropriate e.g. patients treated for myelo/proliferative disorders
• Obesity and diabetes mellitus are risk factors for other conditions, so optimal management is preventative

2. PERSON CENTRED CARE

• Recognise that non-concordance is common for chronic metabolic conditions (e.g. diabetes) and respect the patient’s autonomy when negotiating management.
• Communicate the patient’s risk of complications from obesity and diabetes mellitus clearly and effectively in a non-biased manner.
• Develop a flexible approach to health promotion which reflects that certain groups with obesity or diabetes mellitus require different approaches e.g. children, adolescents and young adults, pregnant women, ethnic minorities, elderly and housebound patients.
• Negotiate a programme of weight reduction sensitively with patients, giving appropriate health promotion advice regarding diet, exercise and pharmacological therapies.
• Utilise disease registers and data recording templates effectively for opportunistic and planned monitoring of metabolic problems to ensure continuity of care between different health care providers.
• Recognise the potential for abuse of thyroxine and propose strategies to reduce dosage.

3. PROBLEM SOLVING SKILLS

The knowledge base

Specific problem-solving skills
• Intervene urgently when patients present with a metabolic emergency e.g. hypoglycaemia and hyperglycaemic conditions.
• Recognise that patients with metabolic problems are frequently asymptomatic or have non-specific symptoms, and that diagnosis is often made by screening or recognising symptom complexes and arranging appropriate investigations.
• Demonstrate a logical, incremental approach to investigation and diagnosis of metabolic problems.

Moved from Psychomotor skills
• Calculate body mass index

4. COMPREHENSIVE APPROACH

• Recognise that patients with diabetes often have multiple co-morbidities and consequently polypharmacy is common.
• Develop strategies to simplify medication regimes and encourage concordance with treatment.
• Advise patients appropriately regarding lifestyle interventions for obesity, diabetes mellitus, hyperlipidaemia and hyperuricaemia.

5. COMMUNITY ORIENTATION

• Recognise that environmental and genetic factors affect the prevalence of metabolic problems e.g. Diabetes is more prevalent in the UK in patients of Asian and Afro-Caribbean origin. Hyperuricaemia is more common in prosperous areas and is associated with obesity, diabetes, hypertension and dyslipidaemia.
• Recognise that public health interventions are likely to have the largest impact on obesity and diabetes mellitus and support such programmes where possible e.g. exercise on prescription
• Describe the exemptions from prescription charges for patients with metabolic conditions

6. HOLISTIC APPROACH

• Recognise the psychosocial impact of diabetes and other long-term metabolic problems e.g. risk of depression, restrictions on employment and driving for diabetes, sexual dysfunction.
• Recognise that stigma is associated with obesity.
• Empower patients to self-manage their conditions as far as practicable.

All these 6 domains have a

7. Contextual Aspect

• Recognise the central role of primary care in managing diabetes and hypothyroidism.
• Understand the key government policy documents that influence healthcare provision for metabolic problems.
• Understand the systems of care for metabolic conditions, including the roles of primary and secondary care, shared care arrangements, multidisciplinary teams and patient involvement.

8. Attitudinal Aspect

• Ensure that a patient’s weight does not prejudice the information communicated or the doctor’s attitude towards the patient.
• Ensure that the risks of diabetic complications are not over-stated in order to coerce a patient into complying with treatment.

9. Scientific Aspect

• Understand and implement the key national guidelines that influence healthcare provision for cardiovascular problems (e.g. NICE guidelines, British Hypertension Society Joint Committee Recommendations, National frameworks and quality markers).
• Describe the key research findings that influence management of metabolic problems (e.g. UKPDS, DCCT).
• Describe the role of particular groups of medication in the management of diabetes (e.g. antiplatelet drugs, angiotension converting enzyme inhibitors, angiotensin-II receptor antagonists, and lipid lowering therapies).