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.


    Introduction
 Top
 Introduction
 Patient demographics
 Divisional structure
 Practice model
 Endocrine clinics
 Other practice activities
 In-patient endocrine services
 Summary
 
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.


    Patient demographics
 Top
 Introduction
 Patient demographics
 Divisional structure
 Practice model
 Endocrine clinics
 Other practice activities
 In-patient endocrine services
 Summary
 
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. 1Go) 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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Figure 1. Patient demographics (1997).

 

    Divisional structure
 Top
 Introduction
 Patient demographics
 Divisional structure
 Practice model
 Endocrine clinics
 Other practice activities
 In-patient endocrine services
 Summary
 
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 1Go). 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.


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Table 1. Divisional core groups

 
Insight into the diverse nature of the endocrine practice is provided by review of the scope of clinical activities undertaken daily (Fig. 2Go). 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. 3Go). 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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Figure 2. Clinical services and activities (1998).

 


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Figure 3. Clinical affiliations (1998).

 

    Practice model
 Top
 Introduction
 Patient demographics
 Divisional structure
 Practice model
 Endocrine clinics
 Other practice activities
 In-patient endocrine services
 Summary
 
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.


    Endocrine clinics
 Top
 Introduction
 Patient demographics
 Divisional structure
 Practice model
 Endocrine clinics
 Other practice activities
 In-patient endocrine services
 Summary
 
Out-patient divisional practice is organized primarily around seven Endocrine Clinics. The patient mix in 1997 (Fig. 4Go) 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.



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Figure 4. Diagnostic categories (1997).

 
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. 5Go). 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.



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Figure 5. Appointment types (1997).

 
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. 6Go). 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.



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Figure 6. Endocrine surgery (1997).

 
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. 7Go) 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.



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Figure 7. Diabetes Clinic diagnoses (1997).

 
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 physician’s 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. 8Go). 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.



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Figure 8. Diabetes Unit census (1982–1997).

 
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. 9Go). 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.



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Figure 9. Lipid Clinic diagnoses (1997).

 
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. 10Go). 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.



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Figure 10. Metabolic Bone Disease Clinic diagnoses (1997).

 
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. 11Go). 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 2Go). 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.



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Figure 11. PGA Clinic diagnoses (1997).

 

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Table 2. PGA clinic

 
Thyroid Clinic. This Clinic evaluates patients with a wide array of thyroid disorders (Fig. 12Go) 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. 13Go). 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.



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Figure 12. Thyroid Clinic diagnoses (1997).

 


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Figure 13. FNA of the thyroid (1980–1996).

 
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.

Women’s 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.


    Other practice activities
 Top
 Introduction
 Patient demographics
 Divisional structure
 Practice model
 Endocrine clinics
 Other practice activities
 In-patient endocrine services
 Summary
 
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 3Go) 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. 14Go). This has been accompanied by some interesting trends (Fig. 15Go), 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.


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Table 3. Endocrine testing center test menu

 


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Figure 14. Endocrine Testing Center census (1976–1996).

 


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Figure 15. Endocrine test patterns.

 
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 Paget’s 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.


    In-patient endocrine services
 Top
 Introduction
 Patient demographics
 Divisional structure
 Practice model
 Endocrine clinics
 Other practice activities
 In-patient endocrine services
 Summary
 
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.


    Summary
 Top
 Introduction
 Patient demographics
 Divisional structure
 Practice model
 Endocrine clinics
 Other practice activities
 In-patient endocrine services
 Summary
 
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 endocrinologist’s 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.





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