Abstract Context Clinical endocrinology is a field driven largely by numerical parameters. To achieve outstanding patient care, however, the clinical endocrinologist must use a range of skills that can collectively be called “clinical excellence.” Although there is extensive published guidance regarding appropriate medical management and outcomes for endocrine patients, there has been no consensus definition of excellence in the field nor any recommendation as to how excellence can be achieved. Design Literature review, review of websites of professional societies, clinical organizations, and government agencies. Interventions After review of endocrine clinical outcomes guidelines and published descriptions of clinical excellence generally, key aspects of clinical excellence in endocrinology were derived: the ability to work in teams, communication and interpersonal skills, skillful negotiation of the health care system, and a strong knowledge base and scholarly approach. Examples of how these skills drive superior outcomes for patients are discussed. Conclusions Clinical excellence in endocrinology is necessary to optimize care for endocrine patients. A definition of clinical excellence should be adopted by professional societies and medical institutions and its importance in patient care recognized and emphasized. Efforts should be undertaken in the context of endocrine fellowship training and faculty development to foster the skills inherent in clinical excellence. The translation of endocrinology guidelines and treatment targets into conscientious and appropriate care of patients requires a set of physician skills that can collectively be called “clinical excellence.” The process of delivering care with clinical excellence is nuanced and requires cognitive and personal skills that are not as widely discussed nor as easily measured as achieving quantitative targets and following guidelines. To implement and promote clinical excellence in endocrinology, the concept needs to be defined and its place in endocrinology clarified. Professional societies, insurance entities, and government payers have developed numerical outcome and diagnostic measures for many endocrine conditions, although guidance regarding a holistic, integrated approach to the patient is lacking. Examples of published metrics include A1c targets in diabetes, TSH goals in pregnancy and thyroid cancer, as well as diagnostic cutoffs prompting intervention in osteoporosis and hyperparathyroidism (1–5). The National Committee for Quality Assurance awards practice recognition to those practices meeting quantitative criteria, including A1c control, blood pressure control, and nephropathy assessment (6). As part of the Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015, Medicare is moving to a reimbursement model that rewards achievement of targets such as A1c, frequency of peripheral neuropathy evaluation, and communication with ophthalmologists (7). Although achievement of these metrics may be part of clinical excellence, clearly this is not the whole story. For example, physicians whose patients achieve target A1c levels could do so because of careful patient selection or inherently healthier, more compliant patient populations rather than because of clinical excellence (8). What is missing from these guidelines and incentive programs is a description of the methods, behaviors, and cognitive abilities that facilitate the delivery of excellent endocrine care. The medical literature provides numerous general, non–specialty-specific definitions of clinical excellence. A survey of Department of Medicine faculty members at eight academic institutions yielded several domains of clinical excellence, including communication and interpersonal skills, professionalism and humanism, diagnostic acumen, skillful negotiation of the health care system, knowledge, and a scholarly approach to clinical care (9). From the perspective of house staff trainees, physicians seen as role models stress the importance of the physician-patient relationship and teach the psychosocial aspects of medicine (10). In another survey, Department of Medicine chairs identified several skills essential for physician leaders to negotiate the changes in health care delivery, including communication, team-building, and emotional intelligence (11). A literature review identified clinical reasoning, expert judgment, professionalism, and teamwork as areas of focus for the definition and assessment of physician competence (12). The practice of endocrinology comprises several distinctive features that call for certain of these skills in particular. This paper proposes that the ability to work in teams, communication and interpersonal skills, skillful negotiation of the health care system, and a strong knowledge base with a scholarly approach to clinical care are key aspects of clinical excellence in endocrinology. Although many endocrinologists use these skills routinely, there is no current standard definition of excellence by which to assess and guide physician performance. This article proposes that a definition of clinical excellence in endocrinology should be adopted by professional societies and medical institutions and its importance in patient care recognized and emphasized. Efforts should be undertaken in the context of endocrine fellowship training and faculty development to foster the skills inherent in clinical excellence. Consideration should be given to recognizing and rewarding clinically excellent endocrinologists. The outcome of such efforts will be improvements in patient care, training of endocrinologists, and retention of endocrinologists at the institutions where they practice. Working in Teams The care of endocrine disease often requires a multidisciplinary approach. The effective management of patients with diabetes, for example, is best handled by a clinical team. The Standards of Clinical Care in Diabetes of the American Diabetes Association states that patients with diabetes should receive care from a team that may include physicians, nurse practitioners, nurses, dieticians, and podiatrists, among others (1). Such a coordinated approach to diabetes care using the chronic care model, for example, lowers mean A1c and improves patient self-care behaviors (13). Because diabetes has broad systemic effects, clinicians from other specialties, such as ophthalmology, cardiology, nephrology, and gastroenterology, are often needed to co-manage the patient (1). Patients with thyroid cancer and patients with other endocrine neoplasms are routinely evaluated by teams including surgeons, radiologists, and pathologists (14), which can improve clinical outcomes. A multidisciplinary team, including endocrinologists, managing pituitary surgical patients in the hospital, for example, decreases length of stay (15). The ability of an endocrinologist to work with other clinicians in a coordinated effort is thus an essential aspect of clinical excellence in this field. To be successful in a team setting, the physician must be responsive, considerate of others, and flexible (9), whereas the overall effectiveness of a clinical team depends on communication, task orientation, and leadership (16). The clinically excellent endocrinologist, therefore, must not only participate in a team, but must value all team members as worthy of respect and united in a common purpose. At our institution, the endocrinologist often emerges as a team leader, coordinating the other members to assure that the patient’s welfare remains central. The Department of Medicine at Vanderbilt University Medical Center has recently implemented a policy for patients, often from geographically remote locations, who see numerous specialists at the medical center but do not have a primary physician on campus. One specialist is designated as the de facto primary care physician who coordinates the treatment team. For individuals with complex endocrine disorders, that physician is the endocrinologist. Vanderbilt, as with many other institutions, has also arranged centers for evaluation and treatment of patients with endocrine neoplasms and gestational diabetes, for example, so that patients can see multiple specialists on the same day in the same location. Institutions must be educated as to the value of endocrinology clinical teams in improving care so that appropriate support can be provided. Communication and Interpersonal Skills Although effective communication and interpersonal skills are essential traits for any excellent physician, the practice of endocrinology presents some special challenges in this regard. The need for an endocrinologist to communicate in an effective fashion emerges at the beginning of the first visit with a patient. Conversations with endocrinology colleagues indicate that new patients frequently need the physician to describe what an endocrinologist is and to explain the reason for the referral. Patients often have no previous knowledge of the gland that is the source of the referral, or even what a gland is. Patients referred for conditions other than diabetes are sometimes confused by the presence of the word “diabetes” in the name of the clinic and may wonder whether they are at risk for the condition. In recognition of this issue, the Endocrine Society’s Hormone Health Network website includes webpages entitled “What is an Endocrinologist?”, “Endocrinology,” and “Value of an Endocrinologist” (17). This section of the website garners an average of 7280 unique page views monthly (Endocrine Society staff, personal communication). The websites of the American College of Cardiology and the American Society of Clinical Oncology, in contrast, include no such lengthy descriptions (18, 19). It is not routine, therefore, for specialties to feel a need to define themselves. That endocrinologists have identified that need and find themselves conveying this frequently to patients highlights a communication challenge that the clinically excellent endocrinologist must overcome at the outset of an office visit. In addition, the complexity of the endocrine system with its feedback loops and numerous laboratory measurements is not often intuitively grasped by patients. Endocrinologists may draw pictures representing the various pituitary axes, for example, or review with patients online resources such as those provided by the Endocrine Society or the American Thyroid Association (20, 21). Careful communication regarding endocrine pathophysiology is important because lack of patient education is a factor in treatment nonadherence (22). Empathy and interpersonal skills are valuable in every medical specialty. As we define clinical excellence in endocrinology, however, it is useful to understand how such abilities influence the outcomes of endocrine patients specifically. Diabetes in particular requires extensive self-management, especially among those patients requiring multiple daily insulin injections. The endocrinologist’s interaction with the patient is an important determinant of outcomes. Patients of physicians with high scores on the Jefferson Scale of Empathy are more likely to have good control of A1c and low-density lipoprotein values than are patients of physicians with low empathy scores (23). Patients with diabetes who perceive physician inattention and lack of engagement are less adherent to an insulin regimen and display higher A1c values (24). In addition, patients receiving extensive education regarding osteoporosis demonstrated an adherence rate to pharmacologic therapy of 92% compared with 80% for controls (25). Patients with adrenal insufficiency were better able to manage their disease and treat with stress glucocorticoid appropriately after receiving intensive instruction (26). Patients with hypothyroidism often present to endocrinologists with nonspecific symptoms that they assume are due to the thyroid disease itself or its inadequate treatment. When test results are normal, an empathetic approach requires that the patient be given the opportunity to tell a story, followed by a careful discussion and explanation. Such a process builds patient trust and may encourage willingness from patients to consider nonthyroidal explanations for their symptoms (27). Because endocrinology is a cognitive, nonprocedural discipline, the specialty depends heavily on communication and physician-patient rapport. Though the delivery of procedure-oriented care also benefits from effective communication skills, a physician performing a procedure may compensate for deficiencies in interpersonal skills by demonstrating superb technical abilities, whereas the endocrinologist does not have that option (28). An additional hurdle to good face-to-face communication with the patient has been the widespread adoption of electronic health records. Physicians are rated by patients as having less effective communication when they spend more time looking at the computer. The effective endocrinologist, therefore, must overcome this challenge and adopt a communication strategy that facilitates the flow of conversation while using the computer and must learn to manage the electronic record in a way that avoids prolonged gazing at the screen (29). Skillful Negotiation of the Health Care System To ensure that patients have access to appropriate medical care, the endocrinologist must provide a medication regimen that is both effective and affordable. From 2011 to 2016, wholesale costs of several insulin brands increased 160%, dramatically increasing out-of-pocket costs for the patient (30). The proliferation of new, branded, noninsulin treatments for diabetes has markedly increased expenditures for diabetes management as well. The 2016 report from pharmacy benefit manager Express Scripts indicated that expenditures on diabetes medication exceeded those of any other traditional drug class, with per-member, per-year costs tripling those of heart-related medications (31). A survey of patients covered under Medicare drug benefit plans indicated that cost-related nonadherence to medication was 16% overall, and substantially higher in patients with lower incomes (32). Because medication adherence is associated with improved health outcomes (33), the clinically excellent endocrinologist must take cost into account when prescribing medication. This requires substantial sophistication with regard to awareness of insurance coverage as well as an evidence-based understanding of when less expensive alternatives may be appropriate. Insulin analogs, for example, are markedly more expensive than synthetic human insulin. In type 2 diabetes particularly, insulin analogs do not improve glycemic control and reduce risk of hypoglycemia only modestly. Human insulin can generally be substituted for insulin analogs in a safe and effective manner (34). Strong Knowledge Base and Scholarly Approach A distinguishing aspect of endocrinology is that it encompasses several separate and unrelated organ systems. This requires the endocrinologist to master information on a variety of disease states and their treatment. These include endocrine hyperfunction and hypofunction, endocrine neoplasia, and metabolic conditions such as hyperlipidemia. To help the endocrinologist, professional societies have developed numerous clinical guidelines. The American Diabetes Association Standards of Care alone take up an entire supplemental journal edition of >100 pages (1). The Endocrine Society, the American Association of Clinical Endocrinologists, and the American Thyroid Association have published a total of 63 treatment guidelines (35–37). This is not a comprehensive list. The clinically excellent endocrinologist needs to be aware that numerous clinical guidelines exist and that these guidelines are regularly updated. Because each patient is unique, the endocrinologist must apply the guidelines judiciously and with great skill and clinical acumen. The Endocrine Society’s guidelines on Evaluation and Treatment of Adult Growth Hormone Deficiency, for example, makes 20 recommendations, 11 of which are based on low-quality or very-low-quality evidence (38). A scholarly approach means that the endocrinologist will interpret the recommendations in light of the available evidence and apply these to the individual patient thoughtfully and with appropriate skepticism. An additional challenge for the endocrinologist is the large number of journals dedicated to subfields of endocrinology, such as the Journal of Bone and Mineral Research, Thyroid, and Pituitary. Clearly, it is not possible for a busy practitioner to keep up with this substantial volume of information. Using online services that cull the most notable findings from these journals is one approach to keeping current. In the end, however, an endocrinologist must be self-aware about the limits of knowledge for a particular disorder and recognize that a scholarly approach sometimes necessitates referring a patient to a more subspecialized endocrinologist with a narrower clinical focus. Implications A set of structured interviews with leaders at academic medical centers indicated that failure of these institutions to recognize clinical excellence has substantial negative effects. These included low morale, a decline in the quality of care, and loss of talented physicians, meaning fewer clinically excellent role models to inspire trainees (39). This is particularly concerning in light of the substantial and growing shortage in the endocrinology physician work force (40). Although some of the work force gap is attributable to an insufficient number of fellowship slots, the fill rate of these slots will have to be maximized even if the number of positions increases. Without an ample population of clinically excellent endocrinology mentors, adequate growth in the number of endocrine trainees cannot be assured. We cannot afford to lose outstanding endocrinologists because of a failure to identify and reward clinical excellence. Although there is mention in fellowship training recommendations of skills and qualities connected to clinical excellence, explicit discussions of approaches to promoting excellence are absent. The Accreditation Council for Graduate Medical Education, for example, in its program requirements for fellowship training, includes a section on interpersonal and communication skills, indicating that “fellows are expected to communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds” as well as describing other aspects of communication fellows should master. Fellows are also expected to display compassion and should be able to work in interprofessional teams (41). Although the program requirements do stipulate that fellows should be observed and evaluated regarding these elements of training, there is no provision for teaching these behaviors. Clinical guidelines similarly touch on qualities related to clinical excellence. The American Diabetes Association Standards of Care emphasizes a patient-centered communication style and individualized care, and identify the necessity of multidisciplinary teams to deliver care, but does not specify how these approaches, emblematic of clinical excellence, are to be implemented (1). A promising concept arising in a few medical centers is the establishment of programs designed to recognize outstanding physicians at these institutions. One such program, at the University of Pennsylvania, uses a robust selection procedure including an institution-wide nominating process and a special selection committee that reviews a substantial volume of supporting documentation. Those physicians elected receive a substantial honorarium (42). Endocrinology divisions could certainly consider adapting such a program on a smaller scale to implement within their own ranks. If a system of evaluation of clinical excellence were developed, the qualities of clinical excellence discussed here could be included along with more objective performance measures and used to increase compensation through, for example, relative value units. Larger private practices and multispecialty groups could also consider such programs. Conclusions For clinical excellence to flourish in endocrinology, it must be defined and then recognized as a valuable part of clinical care. This description of clinical excellence in endocrinology has been proposed in hopes that professional societies and health care institutions will adopt such a definition and incorporate it into their training programs, mission statements, and clinical guidelines. To assure that clinical excellence is fostered and propagated, fellowship program directors should develop approaches to teaching teamwork, communication, negotiation of the health care system, and a strong knowledge base with a scholarly approach to clinical care. By embracing clinical excellence in endocrinology as a priority, endocrinology divisions can identify and reward faculty members who display such excellence, and can develop programs to enhance in clinicians at all levels of seniority the important skills described here. Because endocrinology is so heavily reliant on clinical teams, and because endocrine disease encompasses such a wide range of organ systems, it is my opinion that clinically excellent endocrinologists are well positioned to be leaders at their medical institutions. Clinical initiatives by endocrinologists typically involve large networks of other professionals and have broad implications for patient care. This means that if clinical excellence in endocrinology can be defined, taught, promoted, and rewarded, we can, in addition to providing outstanding care, foster retention and leadership among our endocrine colleagues and thus inspire a pipeline of future practitioners of the specialty. Acknowledgments The author acknowledges the thoughtful comments and suggestions of Dr. Carolyn Becker and Dr. Al Powers regarding this manuscript. Disclosure Summary: H.B.A.B. has received research support from Boehringer Ingelheim, GlaxoSmithKline, and Novo Nordisk. References 1. 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Journal of Clinical Endocrinology and Metabolism – Oxford University Press
Published: May 3, 2018
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