Day Four: General Endo clinic

Today, we split up again in the morning (nothing personal!)

Dr. Mandel's morning:

While Ilona attended the Type 1 DM clinic, I had the privilege of observing the final clinical examinations of the senior medical students from Wits medical school.  This is a real clinical exam with real patients (not simulated standard cases as we sometimes do in the US). Kershlin identified the patients from inpatients on the medical wards so that there were at least 5 patients with each of the following diagnoses:  respiratory, cardiac, neurology, and “other”.  The medical students are unaware of the specific diagnosis and spend 20 minutes evaluating the patients.  Then the student presents the clinical assessment supported by the details of the hx and PEx to a team of 2 attending examiners.  For the next 15 minutes,  the examiners question the student about pertinent topics including pathophysiology, physical examination findings, therapeutic recommendations, diagnostic testing and pharmacology.  

Afterwards, the student is assigned a grade: 1^st class, Pass, Fail.  I would have failed I think, rather I know.  The clinical physical examination skills and pathophysiology knowledge of the medical staff and trainees are fantastic and are evident each time we participate in clinical teaching with the medical teams. 

Then, I got my chance to do some bedside teaching on a patient with Graves’ disease to the interns, registrars (residents to us) and endocrine fellows. 

Dr. Mandel and Dr. Alan Peter (pulmonology)

Ilona's morning:

I spent my morning in type I diabetes clinic at Bara with Dr. Pauly and Dr. Nasrin Goolam-Mahyoodeen. The day started off with a group teaching session for the patients in the waiting room. The main topic for the day was reviewing the symptoms and treatment of hypoglycemia. Dr. Pauly also answered patient's questions and the patients helped each other, guided by Dr. Pauly, understand why they experienced hypoglycemic symptoms at different blood glucose levels. The patients also shared their hypo treatments with each other, helping to foster a sense of community. The clinic also runs camps four times a year, where patients with type I diabetes go away together for part of the weekend and learn more about diabetes. Pediatric patients are referred to the endocrine clinics usually about age 14, at Penn they are transitioned usually around age 18-21. On the wards at Bara however, the adult wards are for patients age 12 and up.

diabetes teaching in the morning prior to the start of clinic.

The diabetes education board, used to guide education classes. 

I then joined the medical team for bedside teaching rounds. One of the registrars (quick side bar: internship is the very beginning of physician training. In SA, after graduating from medical school (six years for the traditional route: this is our equivalent of 4 years of college and 4 years of medical school, or 7 years for the non-traditional route - for people who do not select to go into medicine until later - 3 years of "college" and then medical school) - the medical training begins with two years of an internship rotating through all the major specialties, then one year of service in the community - usually at rural sites. During the community years, physicians do both surgery (most often C-sections) and internal medicine, as well as anesthesia, basic orthopedics, etc. They learn a tremendous amount and gain the skills necessary to practice medicine when you are the only physician for a large community of patients, far from a specialty hospital. No wonder physicians trained in SA are highly sought after by other countries to practice in the rural areas. After these three years you are then a generalist and can obtain more advanced training. You spend usually fours years as a registrar to become a consultant. After that, specialty training begins. Endocrine training is 3 years.)....to continue, one of the registrars presented a patient admitted with Graves' disease. We reviewed the history and carefully reviewed the physical exam findings associated with Graves's disease, with special attention to the thyroid exam. 

The anterior thyroid examination.

The team rounding.

In the afternoon, we attended the Bara General Endocrine clinic and the Williams’ Textbook of Endocrinology paraded through the exam rooms—Cushing’s, recurrent prolactinoma (?malignant), acromegaly, transgender patients, several cases of Graves’, anaplastic thyroid cancer, pseudohypoparathyroidism (and a wonderful history of the contributions of Fuller Albright by Dr. Shires), hyperparathyroidism, osteoporosis, osteomalacia, Hashimoto’s in association with B12 deficiency and a severe hemolytic anemia, hyperphagia with obesity and hypogonadotropic hypogonadism (new presentation, etiology unknown, ?Leptin R. deficiency), probable Turner’s syndrome (karyotype pending). There were 90 patients in seen in clinic today.

The endocrine clinic waiting room.