Consultant physicians working with patients - Royal College of ...

2 Specialties Diabetes and endocrinologyDiabetes and endocrinologyProfessor Geoff Gill MSc MD PhD FRCPConsultant physician (diabetes and endocrinology)Dr John Newell-Price PhD FRCPReader in endocrinology, consultant endocrinologist1 Description of the specialtyThe specialty of diabetes and endocrinology deals withthe diagnosis and management of a diverse range ofhormonal and metabolic disorders. It encompasses awide variety of conditions ranging from the mostcommon (eg type 2 diabetes) to those that are rare buteminently treatable (eg pituitary tumours). Mostconditions are chronic, requiring long-term and oftenlifelong management. There is a strong evidence basefor the management of disorders encountered withinthe specialty. Delayed, inadequate or inappropriatetreatment leads to poor health, reduced lifespan andincreased burden on the health service.Main disease patternsType2diabetesisacommonmultifaceteddisorderthatis rapidly increasing in incidence. The demands ofglucose control management are progressive, andconcurrent management of hypertension, obesity anddyslipidaemia is usually required. Type 1 diabetes oftenstarts in childhood and is usually compounded byemotional and behavioural problems common toadolescent and young adult medicine. In either kind ofdiabetes, potential complications are protean. Untreatedthey lead to disability and early death.Increasingly the clinical presentation of type 1 and type2 diabetes is becoming more complex. There is growingrecognition of the monogenic varieties of diabetes andtherefore diagnosis of the type of diabetes is becomingmore difficult. There is also a greater emphasis onpatient empowerment and education, with increasingdevelopment of newer treatment options such asthiazolidinediones (TZDs), glucagon-like peptide(GLP1) analogues, dipeptidyl peptidase-IV (DPP IV)antagonists, newer insulins and insulin pumps. Theproblems of diabetes in pregnancy have been outlinedin the Confidential Enquiry into Maternal and ChildHealth (CEMACH) report (www.cemach.org.uk). Withthe increasing prevalence of obesity and type 2 diabetesin women of childbearing age this problem is going togrow.Endocrinology covers disorders of the endocrine glands,in particular the thyroid, pituitary and adrenal glands,testes and ovaries. Thyroid disorders are the mostcommon, usually presenting as under-activity(hypothyroidism) or over-activity (thyrotoxicosis).2 Organisation of the service and patternsof referralSources of referral from primary, secondary andtertiary levelsDiabetes servicesDiabetes services are largely outpatient based. Acomplex local network of services is required toencompass the needs of all people with diabetesthroughout their lifelong pathway of care. Much ofthe process of care can be provided in primary careby nurses, dietitians, podiatrists and GPs. A corerequirement for all patients is self-care, whichnecessitates effective, ongoing patient educationprogrammes. The majority of diabetes care is inprimary care, but specialist input is required tosupport the primary care team with clinicaladvice and education for health professionals andpatients.At various stages, further specialist physicianmanagement is required: at the time of transitions: eg new diagnosis of type 1diabetes, younger type 2 patients, monogenicdiabetes or the progression to more complex therapyfor someone with poorly controlled type 2 diabetes in particular clinical scenarios: eg young people withdiabetes, diabetic pregnancy, metabolic emergencies,C○ Royal College of Physicians 2013 91