The Mayo Clinic
Michael D. Brennan,
Kim M. Miner and
Robert A. Rizza
Division of Endocrinology, Metabolism, and Nutrition, Mayo Clinic,
Rochester, Minnesota 55905
Address all correspondence and requests for reprints to: M. D. Brennan, M.D., F.R.C.P.I., Division of Endocrinology, Mayo Clinic, 200 First Street, SW, Rochester, Minnesota 55905.
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Introduction
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The Mayo Clinic (Rochester, MN) is a
physician-led, multispecialty, highly integrated, academic medical
center. It is the largest entity within the Mayo Foundation, which
includes clinics in Jacksonville, FL; Scottsdale, AZ; and the Mayo
Health System, which comprises clinics and hospitals that provide a
network of community-based physicians in Minnesota, Wisconsin, and
Iowa. The establishment of endocrinology as a discipline at Mayo can be
traced back to Dr. Henry Plummer, whose many contributions included the
introduction of iodides in the preoperative management of Graves
disease, and to Nobel laureate Dr. Edward Kendall, who isolated
T4 and went on to discover cortisone. Since those early
days, the Division of Endocrinology, Metabolism, and Nutrition has
continued to evolve, so that today with 36 clinical endocrinologists
and 2 career scientists, it is the third largest of the 14 divisions
that comprise the Department of Medicine. This contribution to the
journal series Profiles of the Endocrine Clinic will attempt to outline
the clinical activities of the Endocrine Division at Mayo, which will
serve to emphasize the important role this discipline plays in a modern
medical center.
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Patient demographics
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On a typical day at Mayo Medical Center, 1300 new patients arrive,
of whom 140 are hospitalized. The remainder, if not commuting, stay at
hotels adjacent to the Medical Center occupying, on the average, 2000
rooms. The profile of patients seen at the Division of Endocrinology
(Fig. 1
) is similar to that of other
divisions within the Department of Medicine. Although the percentage of
patients covered by various capitated contracts has increased, the
majority remains fee for service. In 1997, 65% of patients were new to
the Division of Endocrinology, and the remainder were seen for annual
or more frequent follow-up visits or for continuing care.
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Divisional structure
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The consultant staff is engaged in practice, research, education,
and, as befits a physician-led organization, divisional and
institutional administration. Although the focus of this review is
endocrine practice, it should be viewed in the context of both the
institutional and divisional mission, which also emphasizes research
and education. Currently, over 80% of divisional staff have either
extramurally or intramurally funded research time. Thirteen members
have independent research programs funded by the NIH, including two
program projects (Osteoporosis and Aging) and an Obesity and Nutrition
Research Center. Extramural funding, which in 1997 exceeded $6.5
million, consistently ranks first or second among all divisions of the
Department of Medicine.
Division consultants actively participate in both graduate and
undergraduate teaching. The number of patients seen and the broad
spectrum of disease they present make the Endocrine Clinics a rich
educational experience. The Clinics have been a central component in
the Endocrine Training Program, which has graduated 120 endocrine
trainees since 1969. Two years are spent in the Clinics and 1 yr in a
laboratory-based research program. The Division also has a
NIH-supported training grant that can provide six postdoctoral
endocrine fellows with additional laboratory-based research
training.
All divisional members belong to one or more core groups reflecting
their areas of interests and expertise (Table 1
). The primary goals of these core
groups are to 1) identify and critically review new or emerging
diagnostic and treatment strategies and, when appropriate, incorporate
them into divisional practice; 2) foster, encourage, and coordinate
research and education within their areas of expertise; and 3) monitor
the activities of and provide staffing to the corresponding
subspecialty clinic.
Insight into the diverse nature of the endocrine practice is provided
by review of the scope of clinical activities undertaken daily (Fig. 2
). The high degree of integration of
endocrinology into the overall institutional practice is reflected by
the number of affiliations with other disciplines within Mayo (Fig. 3
). The nature of such affiliations range
from the sharing of clinical FTEs to the participation by
physicians from other disciplines in divisional core group
policy-making decisions.
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Practice model
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Clinical activities include primary, secondary, and tertiary care
which are coordinated by a divisional appointment and scheduling
office. Appointment types include those for comprehensive evaluations,
focused consultations, limited exams, and continuing care. The
appointment office staff is guided by physicians regarding
appropriateness of appointment types, coordination, and, when
appropriate, prescheduling of tests, thereby reducing patient length of
stay. Physician scheduling and the coordination of such a large and
diverse endocrine practice require considerable planning. Physicians
rotate through clinical activities, usually in 2-week time blocks.
Assignments are developed every 6 months and involve staff physicians
completing a questionnaire ("wish list") identifying anticipated
clinical, research, and education full-time equivalent (FTE); dates of
absences; and clinical assignment preferences. These data are then fed
into a software program (Docworks), which has been modified for
divisional use, and the schedule is created. Manual adjustments are
performed, and the completed schedule is entered into a spreadsheet,
which calculates daily divisional staffing and capacity. The
institutional and divisional appointment offices share these data to
coordinate appointment activities.
Nonurgent appointments are made up to 3 months before the anticipated
visit. A number of appointment slots are reserved for
physician-referred patients who require more urgent attention. Patients
arriving at Mayo Medical Center without an appointment are seen on the
same day by a consultant who assesses illness acuity and assigns an
appointment priority.
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Endocrine clinics
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Out-patient divisional practice is organized primarily around
seven Endocrine Clinics. The patient mix in 1997 (Fig. 4
) was similar to that in recent years.
Patient triage within the clinics generally assures that they are
directed to a consultant whose core group affiliation and clinical
expertise best fit the endocrine disorder if known. An important
feature of the Endocrine Clinic practice is the degree of both
intercore group as well as intracore group dialogue regarding patients
who present particularly challenging diagnostic or management problems.
There are four endocrine clinic conferences weekly attended by
consultants, trainees, and residents. Two of these are devoted to
patient case presentations and discussions. This provides a rich
educational experience, while furthering the goal of providing each
patient with the best consultation available within the Division every
day.
General Endocrine Clinic. All consultant staff rotate through
this Clinic, which caters to new or established patients who require
comprehensive examinations, focused consultations, or limited
evaluations (Fig. 5
). Comprehensive
examinations are provided to either self- or physician-referred
patients who have more complex endocrine disorders or who present with
combined endocrine and internal medicine conditions. Focused
consultations are provided to physician-referred patients from within
the region, including the Mayo Health System, as well as to those
referred from other Mayo departments. The average length of stay for
new patients undergoing a detailed evaluation is 3 days compared to
less than 2 days for established patients for whom prescheduling of
tests and consultations is possible.
The goal of same or following day consultations is generally achieved,
but can be subject to seasonal pressures, peak demand being during the
summer months. Both endocrine and neurological surgeons provide daily
consultations within the Endocrine Clinic. If after completion of
diagnostic studies surgery is considered necessary, it is offered and
usually performed the next day. Patients and their families
consistently emphasize the value they place on the highly visible
coordination of care between endocrinologists and surgeons. Close to
800 endocrine surgical procedures were performed at Mayo in 1997 (Fig. 6
). Trends during the past 15 yr have
included a marked reduction in the rates of thyroid surgery for benign
conditions and transsphenoidal surgery for prolactinomas. Such trends
reflect the impact of fine needle aspiration (FNA) cytology of the
thyroid and the emergence of effective medical therapies for
hyperprolactinemic states, respectively. An important element in the
relationship between endocrinology and surgery is the contribution by
endocrine surgeons to core group deliberation and practice guideline
development and implementation. The frequency of coauthorship of
scientific papers by these groups is also reflective of the integrated
nature of this practice model.
Metabolic Clinic. This highest volume area of our practice
provides evaluation and management for patients with diabetes, lipid
disorders, and other metabolic diseases, including hypoglycemia. The
metabolic team includes physicians, five diabetes nurse educators, and
dietitians assigned to the out-patient practice. The diabetic patient
mix in 1997 (Fig. 7
) was similar to that
of preceding years. Initial physician assessment of patients with
diabetes includes a determination of disease type, treatment program,
metabolic control, and presence or absence of complications. A
customized and comprehensive treatment plan is then developed and
coordinated with nurse educators and dietitians. A major emphasis is
placed on education, so that patients are equipped with the knowledge
essential for ongoing home management. This is achieved through
one-on-one instruction covering a variety of topics, including home
glucose monitoring, insulin or oral hypoglycemic agent dose adjustment,
management of hypoglycemia, and strategies for the prevention of both
acute metabolic and chronic degenerative complications. These clinical
activities are supported by small groups of physicians drawn from other
disciplines, including nephrology, ophthalmology, neurology, and
cardiovascular medicine, as well as podiatrists with special interest
in diabetes. Located within the Metabolic Clinic is a laboratory where
blood can be drawn and tubed to the main laboratory for rapid analysis
and turnaround and where glucometer checks are performed and
immunizations provided. Daily monitoring and insulin administration are
provided to diabetic patients undergoing tests and consultations at the
Medical Center. This serves to lessen the adverse metabolic impact that
such testing and attendant disruptions may cause.
Diabetes practice includes a Continuity Clinic that serves patients
from Olmsted County and surrounding communities. This permits long term
monitoring and follow-up of diabetic patients by the same physician
over several years. This service is highly valued by patients and
provides practice enrichment for the consultant endocrinologist that
results from having a mix of primary, secondary, and tertiary care
patients.
Practice activities are supported by a diabetes electronic medical
record (DEMR) developed within the Division and supported by Mayo
Information Systems. A large number of data elements, including dates
and results of fundus examinations, microalbumin determination, and
laboratory indexes, including lipids, glycosylated hemoglobin,
urinalysis, and creatinine, are entered by trained paramedical
personnel before the physicians visit. Recommendations concerning
diabetes control and the presence of treatment or chronic complications
are then entered by the consulting physician upon completion of the
consultation. The availability of such on-line information greatly
facilitates long term patient monitoring and practice guideline
adherence.
The Diabetes Unit was established in 1982 to instruct and educate
patients in intensive insulin programs. Since then, over 2000 patients
have graduated from the program, which is offered every other week.
Class size is limited to 6, and family members are encouraged to attend
and participate. Meals and exercise facilities are provided within the
Unit. After admission, patients on conventional insulin programs are
switched to either multiple daily injection of Lispro insulin combined
with evening Ultralente or to alternative insulin delivery systems,
including insulin pumps. The profile of glycemic excursion is mapped,
and algorithms are developed for insulin adjustment. Comprehensive
diabetes education, which includes both individual instruction and
group sessions, is also provided. This formula proved highly effective
in achieving superior metabolic control among patients enrolled in the
Diabetes Control and Complications Trial, in which Mayo was a
participant center. We had anticipated that the Diabetes Control and
Complications Trial results, confirming reduced incidence of
complications among tightly controlled patients, might result in
increased Diabetes Unit enrollment; however, this has not occurred
(Fig. 8
). This reflects several factors,
including, ironically perhaps, reluctance of some third party payers to
provide coverage despite the proven reduction in complication rates and
resultant cost avoidance. It is to be hoped that recently introduced
changes, including reduction of instruction to 3 days, will encourage
more third party payers to provide needed insurance coverage for this
important activity.
The total number of insulinoma patients seen in the Metabolic Clinic
during the past 20 yr exceeds 200. If initial clinical and biochemical
assessments suggest organic hypoglycemia, patients are admitted to the
Endocrine Hospital Service for studies, including a 72-h fast. These
with fasting-induced hypoglycemia who have the typical profile of
insulinoma are seen in surgical consultation supplemented, as
indicated, by preoperative and intraoperative pancreatic imaging. Lipid
patient profile includes those with pure or mixed lipid profiles as
well as secondary lipid disorders, which are most frequently associated
with poorly controlled diabetes mellitus (Fig. 9
). All patients complete a nutrition
questionnaire that serves to quantitate caloric intake and cholesterol
and saturated fat content. The results are made available to the
endocrinologist at the time of consultation. The central importance of
nutritional management is emphasized during both the endocrine and
dietetic phases of the consultation. Pharmacological treatment is
usually deferred until the impact of nutrition and lifestyle changes
can be assessed. The Lipid Core Group has recently introduced low
density lipoprotein apheresis based upon FDA guidelines for familial
type IIA hypercholesterolemia patients with vascular disease in whom
diet and drug therapy has failed to achieve treatment goals or has
resulted in intolerable side-effects.
Metabolic Bone Disease Clinic. Both hyperparathyroidism (HPT)
and osteoporosis have long been the focus of both basic and clinical
research at Mayo and are the most common disorders managed within the
Metabolic Bone Disease Clinic (Fig. 10
). The availability of same day,
whole molecule, PTH assays combined with reliable assays of vitamin D
metabolites and PTH-related peptide has refined and improved the
diagnostic accuracy of hypercalcemic patients. Same day consultations
and next day surgery are provided to patients with biochemically
confirmed primary HPT. Success rates for HPT patients undergoing
initial neck operations at Mayo exceed 99%. Localization procedures
are, therefore, considered unnecessary in this patient population.
Patients with suspected HPT referred after negative neck exploration
elsewhere undergo multidisciplinary investigation. This includes
endocrine confirmation of the diagnosis, preoperative imaging, surgical
review of operative reports, and pathological review of tissue.
Successful preoperative imaging by modalities including ultrasound
(with FNA) and radionuclide scanning (technetium-99 sestamibi), singly
or in combination, are highly predictive of subsequent surgical
success. HPT patients with target organ damage and/or severe
hypercalcemia who by virtue of advanced age or concurrent illness are
considered prohibitively high operative risks have been successfully
treated with ultrasound-guided alcohol ablation of parathyroid
adenomas.
A recent sharp increase in demand for Metabolic Bone Clinic
consultations has coincided with increased public awareness of
osteoporosis and the well publicized availability of newer drug
treatments. Clinical assessment includes a comprehensive physical
examination to identify secondary varieties of osteoporosis, hormone
and chemistry profiles, and dual photon x-ray absorptiometry of the
lumbar spine and femoral neck supplemented, when indicated, by
measurements of biochemical markers of bone turnover. Management
strategies include an emphasis on trauma avoidance, home physical
therapy programs provided by a bone core group psychiatrist, dietary
and supplementary calcium and vitamin D therapy, and a discussion
regarding options for antiresorptive drug therapy. The Divisional Bone
Histomorphometry Laboratory supports the activities of the Bone Core
Group. Laboratory personnel process bone samples obtained by iliac
crest biopsy performed in the Endocrine Testing Center by Bone Core
Group members who are also responsible for subsequent histomorphometric
analysis. Examination of iliac crest bone samples sent to Mayo by
referring physicians is also undertaken. The volume of this practice
has declined since the introduction of reliable biochemical markers of
bone formation and resorption. Histomorphometry continues to provide
important information in patients with suspected bone mineralization
defects and renal osteodystrophy and is a valuable research tool in the
investigation of new skeletally active drugs.
Nutrition Clinic. Nutritional disorders are an important focus
of both research and practice activities within the Endocrine Division.
Institutional clinical dietetics is located within the Division of
Endocrinology. Nutrition Clinic patients include those with obesity,
eating disorders, and nutritional deficiencies of various etiologies as
well as patients considered potential candidates for tube-feeding
programs. Treatment of obesity places emphasis upon diet, exercise, and
behavior modification. Drug therapy is considered if conservative
measures fail in patients with body mass indexes greater than 28
kg/m2 and those with complications that are likely to
improve if greater than 10% weight reduction is achieved. Enthusiasm
for drug treatment was tempered by the finding of heart valve
abnormalities in patients referred to Mayo who were taking combination
phenteramine-fenfluramine or dexfenfluramine. Newer, centrally acting
agents, now available, are the subjects of a prospective study.
Patients whose weights exceed 100% of ideal and who have complicating
medical conditions that might be expected to improve with weight
reduction are considered candidates for surgical treatment. During the
past decade, over 400 gastric bypass procedures have been performed,
which have succeeded in achieving significant weight reduction in
greater than 80% of patients. Postoperative follow-up of these
patients is essential and is provided within the Nutrition Clinic.
Pituitary, Gonad, and Adrenal (PGA) Clinic. Both new and
established patients are seen within the PGA Clinic. They present a
wide spectrum of endocrine disorders (Fig. 11
). The diverse and complex nature of
PGA investigation and management requires a coordinated
interdisciplinary approach. The PGA Clinic may be considered as one
"without walls," comprising endocrinologists working with a network
of affiliated physicians drawn from various medical and surgical
departments (Table 2
). The often complex
nature of PGA disorders combined with their relatively low incidence
rates require that their management be concentrated in the hands of
this small, highly integrated, and expert group. Diagnostic precision
and therapeutic expertise, critical to the successful management of
these patients, has been well served by this practice model. This is
perhaps best reflected in the highly favorable treatment outcomes for
patients with pituitary, gonad, and adrenal disorders reported from
Mayo.
Thyroid Clinic. This Clinic evaluates patients with a wide
array of thyroid disorders (Fig. 12
)
and, like the other Endocrine Clinics, is one of the most popular
rotations for Mayo trainees, residents, and medical students. Large
numbers of nodular goiter patients continue to be seen and managed.
This practice was revolutionized by the introduction in 1980 of FNA
cytology. As with most new innovative tests, the volume of this
procedure performed within the Division of Endocrinology peaked soon
after its introduction in the early 1980s and has remained relatively
stable during the past 10 yr (Fig. 13
). Over 13,000 patients have
undergone aspiration cytology, which proved benign in 70%, malignant
in 5%, and suspicious for malignancy in 10%. Of the latter, 20% were
subsequently found at the time of surgery to harbor a malignancy.
Nondiagnostic cytology in 15% of patients usually reflects the highly
vascular or cystic nature of the aspirated nodules. Subsequent
ultrasound-guided FNA yielded diagnostic samples in over 60% of these
patients. Thyroid ultrasonography is performed by Thyroid Core Group
members to assess nodule size or number and to facilitate guided needle
aspiration. We continue, however, to rely on the expertise of our
radiological colleagues in situations that call for a more detailed
examination of the neck, such as for thyroid cancer follow-up.
Management of patients with thyroid cancer includes postoperative risk
assessment based upon prognostic indicators developed within the
Division. Thyroid remnant ablation is reserved for papillary cancer
patients, considered high risk by the prognostic scoring system, as
well as for those with invasive follicular tumors.
The Thyroid Core Group also provides endocrine staffing (0.2 FTE) to
the Department of Nuclear Medicine. This physician performs neck
examinations on all patients referred for thyroid scanning. The
appropriateness of scanning and the radionuclide to be used are then
decided. The report includes correlation of the scan images with the
physical findings as well as recommendations regarding management.
Radioactive iodine is the preferred treatment in over 80% of patients
diagnosed with Graves disease, which is similar to the national
experience. Follow-up care is coordinated with the referring physician
and includes a return visit to the Division within 10 to 12 weeks, at
which time over 75% of patients have clear-cut biochemical evidence of
thyroid failure but are usually only mildly symptomatic. Subsequent
thyroid hormone therapy is guided by clinical findings combined with
results of free T4 and TSH determinations. Management of
patients living at a distance from Rochester is facilitated by analysis
of blood specimens mailed into Mayo Medical Laboratories.
Interdisciplinary management of patients with Graves ophthalmopathy
is provided by a team drawn from the Thyroid Core Group and the
Department of Ophthalmology. During 1997, 170 patients underwent eye
surgery for Graves ophthalmopathy, which included orbital
decompression, eye muscle alignment, and eyelid procedures in roughly
equal proportions.
Womens Endocrinology Clinic. This clinic was introduced in
1996 to serve the special needs of women presenting with combined
endocrine, metabolic, and nutritional disorders as well as
gender-specific conditions. This core group draws its membership from
all others within the Division of Endocrinology. Examples of the case
mix include patients with diabetes and polycystic ovary syndrome, lipid
disorders in women considered candidates for hormone replacement
therapy, osteoporotic patients requiring thyroid hormone therapy, and
endocrine disorders during pregnancy and at menopause. The
comprehensive, yet focused, nature of the service provided has proven
popular with both patients and referring physicians, and we anticipate
continued growth of this practice.
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Other practice activities
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Outreach endocrinology. This eight-member Endocrine Core Group
supports community-based physicians within the Mayo Health System
through the provision of regularly scheduled on-site subspecialty
consultations. Endocrinology as a discipline was not represented in the
network of practices that originally comprised the Mayo Health System.
This activity has proven extremely popular with primary care physicians
and patients within these tristate communities. The volume of practice
has expanded dramatically, so that in 1997, endocrinology was second
only to cardiology in the number of consultations provided. The full
spectrum of endocrine disorders is encountered; most of which can be
adequately managed locally. Some, however, require attendance by the
patient at the Mayo Medical Center for completion of diagnosis and
treatment. A demonstration project assessing the impact of introduction
of the DEMR into the practices of the Mayo Health System is underway.
It is hoped that the benefits resulting from the DEMR at Mayo can be
translated into a community-wide setting. Although winter travel to
these practice sites can be challenging, participating core group
members report the enrichment of their professional experience that
stems from this activity.
Endocrine Testing Center. Accurate endocrine diagnosis
requires that testing procedures be performed in a highly standardized
manner. In recognition of this, the Endocrine Testing Center was
established in 1976 and now offers a wide array of tests (Table 3
) performed by trained nursing personnel
working under the supervision of a medical director from the PGA Core
Group. Test volume has progressively increased over the years (Fig. 14
). This has been accompanied by some
interesting trends (Fig. 15
), most
notably perhaps the decline in insulin tolerance tests and TRH
stimulation tests, which coincided with the introduction of
nonoperative management of PRL-secreting pituitary tumors and the
introduction of third generation TSH assays, respectively. The high
volume of glucose tolerance testing reflects referral to the Endocrine
Testing Center of pregnant patients requiring gestational
screening.
Procedures performed within the Endocrine Testing Center include iliac
crest bone biopsies, FNA of the thyroid, thyroid ultrasonography, and
pamidronate infusions for the treatment of patients with Pagets
disease of bone and hypercalcemia of malignancy.
Wound Care Center. Multidisciplinary staffing of the
outpatient Wound Care Center includes the participation by a small
group of endocrinologists who have received special training in wound
management. In 1997, over 1100 patients were seen, 65% of whom had
diabetes complicated by lower extremity ischemic or neurogenic ulcers.
Endocrine staff actively participate in wound-healing strategies,
including debridement and the use of platelet-derived growth factor
therapy. Tight diabetic control, critical to successful wound healing,
is also facilitated by the active participation of endocrine staff.
Establishment of this center was followed by a decline in both
hospitalization rates and length of stay for diabetic patients with
lower extremity ulcerations.
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In-patient endocrine services
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An endocrine presence in both hospitals of Mayo Medical Center is
provided by three in-patient services: 1) Primary Endocrine Admitting
Service, 2) Diabetes Consulting Services, and 3) Nutrition Support
Services.
Primary Endocrine Service. The nationally experienced decline
in both hospital admission rates and length of stay has resulted in a
reduction in the number of primary endocrine services at Mayo hospitals
from three in 1980 to one currently. This service is staffed by a
consultant endocrinologist drawn from the six-member Hospital Core
Group who makes rounds daily with an endocrine trainee and internal
medicine residents. Rotations are for 2 weeks and are of sufficient
frequency for physicians to maintain expertise in the hospital setting.
A review of 1997 admissions shows that 65% were for patients with
diabetes or other endocrine disorders, and the remaining 35% were for
those with other medical conditions. This service provides same day
endocrine consultation to medical and surgical colleagues and includes
the development of management strategies for postoperative endocrine
surgical patients. The service is also responsible for the medical
management of patients and study subjects admitted to the General
Clinical Research Center. A rich educational experience is provided to
residents and endocrine trainees through the opportunity to manage
disorders ranging from acute endocrine emergencies to chronic diabetic
complications and the knowledge gained from assessment of the impact of
acute illness on the endocrine system.
Diabetes Consulting Service (DCS). The management of all
diabetic patients hospitalized at Mayo Medical Center has for several
decades been undertaken by the DCS, which is staffed by an endocrine
consultant, an endocrine trainee, and 10 diabetes nurse educators.
Consultations, provided on the day of admission, assess diabetes
control and complications, and the special needs of the patient and
family. The monitoring activities of this group are centralized and
include the review of glucose results for all medical and surgical
patients throughout the day. This permits early intervention in
patients with deteriorating glycemic control. An average of 60 patients
is managed daily and includes acutely ill medical as well as surgical
postoperative patients and those on a nutritional program. The DCS
controls the insulin orders, including patients receiving insulin
infusions as well as those taking oral hypoglycemic agents. This
practice model provides the opportunity for patient education and needs
assessment during the hospital stay as well as the development of long
term management strategies. Although the DCS is a relatively
resource-intensive activity, it does also result in significant cost
avoidance. Our experience is similar to that of others in that
consultations provided to diabetic patients on the day of hospital
admission significantly reduce the length of stay while facilitating
good glycemic control known to improve outcomes.
Nutrition Support Service (NSS). The NSS team includes a
pharmacist, dietitian, and nurse practitioner, all working as a team
under consultant physician leadership. Physician staffing is provided
by Endocrinology, with support from Gastroenterology and Critical Care
Services. Consultations include assessment of optimal nutritional
strategies for hospitalized patients, including identification of those
most likely to benefit from parenteral nutrition. On any given day, 40
patients receive parenteral nutrition at Mayo Medical Center hospitals.
Management decisions rely upon NSS-developed cost-effective
guidelines for metabolic monitoring and iv solution preparation and
batching. A computerized model was developed that supports this
clinical activity. Detailed analysis and measurement of this activity
point to the highly significant institutional savings that result from
the cost avoidance attendant with this model of hospital nutrition
practice.
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Summary
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It is evident that clinical endocrinology, as a discipline, is
entering a particularly exciting period in its evolution. Knowledge
gained from basic and clinical research is being translated at the
bedside for the benefit of our patients. The emergence of new drugs and
novel treatment strategies has equipped clinical endocrinologists with
the tools to more successfully combat many old enemies, such as
diabetes and osteoporosis. Realization of full benefit from these
exciting new tools requires a practice model in which the clinical
endocrinologists role is preeminent and is coordinated and integrated
with those of practitioners drawn from other disciplines. The Mayo
Division of Endocrinology, Metabolism, and Nutrition provides one such
model of highly integrated care. We believe that as the pace of
knowledge regarding basic mechanisms of disease and their treatment
quickens, such integrated divisions will prove well suited to deliver
the highest quality care to people with endocrine
disorders.
Received April 23, 1998.
Revised May 29, 1998.
Accepted June 20, 1998.