Welcome, so today we wanna continue our discussion of the Endocrine systems.
The general concepts of the Endocrine systems.
And today we wanna talk about two specific things that is
the assessment of the system and its pathology.
The way you classify the pathology.
So first we wanna explain then the principles and
the limitations of how we measure the hormones.
And this is done in two ways.
One is by actually quantitating them and secondly asking whether or
not they're active.
And then secondly we wanna to explain classification
of these endocrine pathologies.
So assessment of functions.
So as we said the last time we were in here, that if we have too much hormone.
That we have a hyper secretion of the hormone.
We have hormone excess.
And the problem with the situation is that you can have down regulation
of the target cell receptor.
So we could desensitize the system.
So that it's not recognizing and that it's not giving us the biological activity.
Or we could have a really really strong response.
And so we have an over response to the amount of hormone that's being available.
The second was that we have too little concentration of the hormone,
we have hypo secretion of the hormone.
And this would be hormone insufficiency,
where not enough of the receptors on the target cells are occupied.
And we don't get the biological effect that we need, or
the biological response that we need.
And then we said we could also have target cell resistance.
And this is a problem where the receptors on the target cells are unresponsive.
And they could be unresponsive because they're uncoupled.
So they're still present on the cell surface.
This is what we see with Diabetes Type 2 Individuals often.
Or we have the receptors actually removed or degraded.
So it's not even present on the cell surface.
And then just right is a normal or eu-secretion.
And that's where the hormone, the endocrine system is working correctly.
So we have two assays for measuring our hormones.
And one of them is called competitive binding assay.
And remember that the hormones are a very,
very small concentrations within the blood.
So we have to have a very sensitive assay to find the amount of hormone,
that's within our sample.
And to do this we use a specific antibody.
So this antibody then recognizes the hormone.
And we have in our system, in the assay, we put in a labelled hormone.
So we have a known amount of labelled hormone
that would bind up all of the antibody that's within the system.
We mix this with a hormone that's from our patient or from the unknown.
We don't know the amount of hormone that's here, so this is our x amount.
We mix this then with the known or labeled hormone and our antibody.
And then assay for how much of the labeled hormone has been brought down.
And the unlabeled hormones should compete a finite amount of the labeled hormone.
And then by subtraction we know how much should have come down.
By subtraction we can figure out how much of the unlabeled hormone we have
present in the sample.
So this is high sensitivity because of the antibody and
is high specificity because of the antibody.
But it doesn't tell you if the hormone is active.
So when could this give us a false reading?
So let's say you have an individual who presents as if they are a diabetic type I.
These individuals have very high circulating levels of plasma glucose.
Yes, high circulating of plasma glucose, but when you assay for
the insulin in their bloodstream.
You find that insulin is also present.
So by this competitive binding assay, the insulin is present.
So the question is, is the insulin they're making functional?
So the way you test that,
would be that you give this individual some insulin that you know is functional.
And see whether or
not the amount of glucose that;s circulating in the plasma, will decrease.
If it does, then you know that the insulin that the individual is making,
is making an insulin that's not reactive.
It can not bind to the receptor, or it has some problem in its structure.
This hormone is secreted in response to low plasma glucose.
So we have low plasma glucose, then the hypothalamus.
Which is an area of your brain, will secrete a hormone called CRH,
This hormone binds to a second area of the brain called the anterior pituitary
to secrete ACTH, adrenal cortocotrophine.
This hormone works on the adrenal cortex to cause secretion of cortisol.
So that's our regular stimulation of the cortisol from the adrenal gland.
Cortisol happens to be a steroid hormone so
it takes about 30 to 60 minutes before cortisol will rise in the blood.
And the reason for the delay is that cortisol is
a steroid derivative so it has to be synthesized on demand.
And then cortisol is secreted into the blood and binds to a carrier and
then is delivered to its target tissue.
But it doesn't seem to be, it's too high.
So the question is do we have a tumor that's making this cortisol, or
do we have too much of this ACTH.
Which is pushing the synthesis of this cortisol.
So is the problem occurring here, at the ACTH level, or
is the problem occurring here at the cortisol level, at the adrenal itself.
So to test this axis then, we run a suppression test.
And this is, that we give a drug called dexamethasone,
which inhibits the synthesis of ACTH by pituitary cells.
When we give this drug, if we administer the drug, the ACTH levels should fall.
And when the ACTH level should fall, then the cortisol levels should also fall.
So, if we had a very high amount of ACTH, then we've turned off the ACTH,
the cortisol should fall.
If on the other hand, the cortisol does fall and the ACTH,
let's say the ACTH under those circumstances did fall.
But that the cortisol stayed high,
that would tell you that there's a problem with the adrenal glands.
Or that there's a problem with a tumor someplace in the body
that's secreting cortisol.
We can give this individual ACTH, so exogenose ACTH to push the axis.
To see whether or not the adrenal is working.
And when we do that then the cortisol levels should rise.
We wait 30 to 60 minutes and we should see rise in cortisol.
If the gland, the adrenal gland is working correctly,
then the exogenous ACTH should correct this situation.
We should see a rise in cortisol.
That then tells us that there was a problem with the anterior pituitary,
that it was not secreting ACTH correctly.
Or there may have been a problem with the CRH,
which is then there's a decrease in the ACTH.
So how do you classify these endocrine pathologies?
So the endocrine pathologies then in this situation where we have this complex
negative feedback loop.
We have a primary pathology if the last endocrine organ is not working correctly.
So in our case we had low cortisol.
And that endocrine organ was the adrenal cortex.
If we have low cortisol, what we should have seen if the problem is sitting here.
Then what we should have seen is that ACTH levels would be high and
CRH levels would be high.
That the system would be trying to push to get an increase in the cortisol.
And if the problem is occurring at the level of the hypothalamus then this is
a tertiary problem.
Where we have low cortisol, we will have low ACTH, we will have low CRH.
The entire axis is down-regulated.
And the entire axis is down-regulated, we are missing CRH.
In these individuals then the individual can be given ACTH.
By giving them ACTH we then can move the cortisol levels up.
Because the adrenal gland was working correctly.
So these pathologies then as you're looking through these different problems.
And we wanna see whether not, what these different pathologies are.
And to be able to classify at what level the pathology is occurring.
And secondly, we can interpret the hormone levels.
And as we're interpreting the hormone levels,
we have to consider the trophic hormones that are above it.
And or the level of the nutrients which are controlled by the hormone.
And so in the case of the complex negative feedback loop.
We have to consider all of the hormones.
Which are within that negative feedback loop as to whether or
not they may be the problem.
And you start with the primary and then work backwards.
But you have assays where you can assay the amount.
For instance, we could assay the amount of ACTH.
We can assay the amount of cortisol.
But you start with assaying the amount of cortisol.
And then go back and see whether or not there was a problem with the ACTH.
So I hope this makes sense to everybody.
You should go ahead and try the problem sets.
Because this will allow you to apply
what you've learned from these various concepts in endocrinology.
Two actual cases and see whether or not you can think through these cases.
Okay, so see you next time.
Ten steps to plan, design, and implement an endocrinology and endocrine surgery module for the Faculty of Medicine, Al-Baha University
Walyeldin EM Elfakey1,2 and Ahmed H Al-Ghamdi1
1Pediatrics Department, Faculty of Medicine, Al-Baha University, Al-Baha, Saudi Arabia
2Pediatrics Department, University of Bahri, Khartoum, Sudan
Correspondence: Walyeldin EM Elfakey, Pediatrics Department, Faculty of Medicine, Al-Baha University, PO Box 1988, Al-Baha, Saudi Arabia, Tel +966 5 3745 9602, Email ku.oc.loa@nidleylaw
Author information ►Copyright and License information ►
Copyright © 2016 Elfakey and Al-Ghamdi. This work is published and licensed by Dove Medical Press Limited
The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.
The Faculty of Medicine, Al-Baha University (FMBU), is a newly established medical school that implements a community-oriented and integrated system-based curriculum which is suitable for both medical students and serving the needs of the local community.
The aim of this study is to describe the steps that were followed to plan, design, and implement an endocrinology and endocrine surgery module (EESM) for the fourth-year medical students, as an example of how system-based modules are designed at FMBU.
Ten questions based on Harden’s methodolgy were asked in order to design, plan, and implement an endocrinology and endocrine surgery module. The module committee determined the needs of the module and accordingly stated the aims and objectives of the module. The module planners selected the relevant contents, teaching methods, and assessment strategies and organized them.
After addressing each of the ten questions, the results indicated the need, aim, objectives, and contents for the endocrinology and endocrine surgery module at FMBU. The implementation strategies were chosen according to the SPICES model. The teaching methods and the assessment strategies were selected and arranged. The module is well communicated at all levels, and the module committee used every effort to create a productive teaching environment. The module is well managed and follows the hierarchy of FMBU.
Implementing Harden’s ten steps methodology resulted in an integrated module of endocrinology and endocrine surgery where related disciplines and systems were merged and medical and surgical endocrine topics were included.
Keywords: endocrinology, endocrine surgery, module, curriculum
The Faculty of Medicine, Al-Baha University (FMBU) was established in 2008. It adopts a fully integrated system-based curriculum. This is applied in three phases, namely the premed phase (phase I), preclinical phase (phase II), and clinical phase (phase III). There is a new level of integration in which all disciplines related to the respective system are merged into one module. In this endocrinology and endocrine surgery module (EESM), both medical and surgical endocrine topics are taught.
As well, the school applied the strategies of community-oriented education, with partial implementation of problem-based and student-centered learning concepts.
As it is clear that there is the application of horizontal integration to its maximum end, the vertical integration is carried out in almost all modules. At FMBU, both horizontal and vertical integrations are implemented to the latter. As well FMBU implements a triangular approach in teaching and the assessment places as described by Abdelaziz and Koshak.1 The curriculum and some courses like cardiology and cardiovascular surgery were well received by both the academic staff and the students.2
For developing FMBU curriculum guidelines and strategies, a module committee was tasked with designing, planning, and implementing the EESM. Since it is the first time that such a course was being planned and taught, we followed Harden’s methodology (ten questions to ask when planning a course or curriculum) for developing the curriculum.3
The work was assigned to two FMBU faculty members in addition to personnel from the Medical Education Development Unit. In this article, a description of how Harden’s questions were answered to design, plan, and implement EESM at FMBU is provided in this paper.
The needs of endocrinology and endocrine surgery module at the FMBU
The main objective of the whole curriculum is to produce doctors who will serve their local community and country, and the world. Many studies (for example Abdullah et al4 and Al Jurayyan5) have revealed that the incidence of endocrine disorders has increased in the Kingdom of Saudi Arabia in recent decades. After studying the growing incidence of endocrine disorders, Abdullah et al4 recommended the establishment of special health care services for adolescents at the primary, secondary, and tertiary care levels. Al Jurayyan as well stated that the frequency and pattern of endocrine disorders show the need for well-trained pediatricians to improve the health of the population. The need for well-trained doctors in endocrinology and endocrine surgery are clear.5
The newly founded medical school in Al-Baha is community based. The main target of this school is to interact with the community, raise awareness within the community about the dangers of endocrine disorders like diabetes, carry out screening services for apparent endocrine problems like short stature and others, and offer follow-up and refer the needy cases to the health care system.
Our curriculum should respond to the needs of the community by explaining what the product will be able to do by the time he/she has successfully completed the program.
The aims and objectives of EESM
This is a cardinal step in developing the EESM before putting up intended learning outcomes for the module; a module committee was formed and asked to carefully revise the Undergraduate Program Objectives of FMBU. It is an essential step to revise these objectives as the intended learning outcomes of the EESM should match as a part from that whole. Table 1 shows the curriculum aims and the module learning outcomes.
Modules general aims and intended learning outcomes
Endocrinology and endocrine surgery contents
The module planning committee included the most important contents related to endocrinology and endocrine surgery. The contents were divided into three categories: 1) core knowledge, 2) clinical skills and cases to be seen, and 3) practical skills.
As shown in Table 2, the most important topics were included. It is sometimes difficult to choose what is suitable for undergraduate study. The extremes are not desirable; therefore, the module committee chose to tread the middle path by excluding both rare and difficult topics that do not suit undergraduate study and important and common topics.
Module contents, instruction methods, and organization
In the selection of topics, the committee was guided by the recommended standards in endocrinology and diabetes for undergraduate medical education and suggested strategies prepared by the UK Endocrine Society.6
The module determined the clinical skills that should be learned by the students. These skills to be learned included common endocrine problems with special interest in diabetes mellitus, thyroid problems, and endocrinology of the reproductive system.
On completion of this module, the students were expected to perform an excellent clinical history and proper physical examination in an endocrine-focused manner. As well, this module would give them the opportunity to follow complex endocrine cases through their treatment and complications. A structured logbook was prepared for this reason.
In addition to the special skills of performing clinical history and physical examination, the procedures that should be practiced and learned by the students during this module (Table 2) are listed.
Endocrinology and endocrine surgery module organization
In response to Harden’s question, how should contents be organized, the distribution of module contents in many categories is shown in Table 2. These include lectures, skill laboratory sessions, hospital-based clinical and practical teaching, problem-based teaching, seminars, and self-directed learning. The distribution of the topics was based on their nature and the committee studied the best way for delivery.
Educational strategies adopted in the EESM
The six major issues described by Harden, the famous SPICES model for curriculum planning is applied. Each issue of these six cover a continuum, the committee chose where to lie in planning this module according to the circumstances, available resources, and directions of the undergraduate medical curriculum at FMBU.
EESM is a mainly teacher centered curriculum. Students in the fourth year are not yet mature enough to be involved in all the issues included in the curriculum. However, the committee discussed with the students and involved them in the selection of some contents and assessment methods.3
Problem solving/information gathering
Due to the short time available for the implementation of this module, which was 3 weeks, and the variety of objectives to be covered, the module committee adopted the strategy of problem solving and case-based learning in which the students would be taught and trained to cover multiple problems in a short time. This strategy was chosen with the aim of saving time and raising the clinical skills of students more than information-gathering strategy.
Many studies have concluded that applying problem-solving techniques lead to an increase in the efficiency of learning, develop experienced physicians, and also improve patient care.7
Integrated (multidisciplinary)/specialty (disciplinary)
EESM is delivered through a multidisciplinary approach. The FMBU is adopting a system-based fully integrated curriculum. This integrated strategy was applied in all the modules and despite the difficulties related to human resources and academic staff shortage, this strategy has shown to be successful.2
Despite the fact that the main activities of EESM are hospital based, community-based activities still take place during the implementation of this module. Two main activities are counted in this respect. First is organizing an open activity with the families of children with diabetes mellitus in which health education messages and handouts are distributed, training is conducted in insulin handling, and dietary control methods are taught by the students, all under the supervision of teaching physicians. Second is organizing visits to homes of such families that have many members suffering from diabetes. These activities are few but they have a strong educational impact when compared to the gained outcome.
This module planned and implemented the adoption of a standard strategy for choosing and delivering the contents. However, students were given a chance to select topics for self-directed study from a list of uncovered topics. The self-directed topics stated in Table 2 are the most frequently selected topics by the students.3
Systematic (planned)/apprenticeship (opportunistic)
The nature of the curriculum at FMBU and the limited time to learn it led to making the module systematic (planned) rather than apprenticeship. The students were handed the module study guide on the first day so that they could familiarize themselves with all the activities, instruction methods, teaching places, assessment methods, and marks distribution.3
Teaching methods used in EESM
The teaching methods planned by the module planner are listed in Table 2. Lectures and seminars are organized for the whole class in the faculty building. Students are divided into small groups during the skill laboratory sessions, hospital-based clinical teaching, and problem-solving sessions. In individual learning, the students study on their own; this is referred to as self-directed learning. In self-directed learning, the students choose topics of their interest from a structured list and are assessed in this topic by two means. They are asked to prepare a report from the literature and as well will be asked in the written exam. Teaching modalities described by Lisa Vaughn and Raymond Baker are all selected with some modifications to suit our situation.8
At FMBU, there are two approaches for teaching endocrinology topics. The relevant endocrinology topics are taught in relevant system-based and basic medical sciences modules. During the first 3 years, some of the basic concepts related basic medical science like physiology of the endocrine system, hormones biochemistry, and anatomy of the endocrine glands are taught. In basic medical science modules, practical sessions conducted in the laboratory are dominant.
During later clinical years, relevant endocrinology and endocrine surgery topics are taught in the relative body system modules. In these modules, the hospital-based clinical teaching is dominant. Most of the time, availability of teaching place and technology-based learning tools affect the choice of the teaching method.
The assessment methods in the EESM
The module planners defined all items of the assessment. These items are clearly described in the module study guide. Table 3 shows the items of assessment and marks distribution.
Assessment methods and marks distribution
Both formative and summative assessment techniques are used. The formative techniques include module portfolio in which the students are asked to record the cases seen, learning points, procedures attended and performed, and the reports of community activities and mid-module quizzes.
The summative assessment includes multiple-choice questions, short essays, and objective structured clinical examination.
Choice of the assessor
The academic staffs who take part in teaching are selected to perform the assessment in addition to the clinicians from the hospitals who also take part in clinical teaching. The external assessors are oriented to the methods of assessment and marking system.
Timing of the assessment
The formative assessment consists of monitoring during the course, while the summative assessment is performed at the end of the module.
The standard used for the assessment is criterion based, rather than norm based. Criterion-based assessment was chosen because the module planners wanted to make sure that the students achieved the planned specific standards of competency. Those who did not fulfill the criterion stated would not be able to pass.
After implementation, feedback was obtained from the students and the academic staff for evaluation of the module. The results were excellent, in spite of the presence of some weak points. Identifying these weak points would give a chance to improve them during the next implementation.
How the module issues are communicated?
The choice of a module planner and forming the module committee is based on the specialty. There were many levels of communication:
Planners communicated with departments to include departments output.
Module committee communicated on technical issues with medical education, academic affairs, and the quality assurance.
Communication with hospitals and vice-dean for clinical teaching.
Coordinating meetings with teachers who participated in teaching the module.
Meeting with students at the start to discuss all issues related to the module and maintaining contact throughout the module with the students’ representative.
The educational environment
Planners were concerned with the implementation environment and worked hard to make it encouraging and productive. Genn described the importance of educational climate and the module committee tried to apply the same in EESM.9
There are many factors that helped to create a productive environment in the EESM such as:
A variety of activities: the module includes different activities such as classroom teaching, hospital-based teaching, and community-based activities. The aforementioned teaching methods cultivate an enthusiastic attitude in both the students and teachers and makes the curriculum interesting.
Group distribution helped to create a reactive environment between students themselves and with their tutors alike. This, in turn, proved more supportive and encouraging for both involved.
Students were very enthusiastic with community-based activities and enjoyed interacting with people at the community level.
The module committee comprised members from related departments. It included physicians, adult endocrinologists, pediatricians, pediatric endocrinologists, surgeons, biochemists, physiologists, and anatomists.
The module committee prepared the basic documents including the plan. Then they presented their initial plan to the medical education department which revised and added amendments to the plan and contents. These documents were again revised by the faculty and academic affairs and the clinical teaching coordination committee. Approval was obtained from the quality assurance department before the module plan and documents were finally approved by the faculty board and signed by the dean, faculty of medicine, and became ready for implementation. The hierarchy of the module management is shown in Figure 1.
Hierarchy of the module management.
The authors report no conflicts of interest in this work.
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