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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
Consultant physicians working with patientsserious intercurrent non-diabetic illness orpsychosocial interactions for the identification and collaborative managementof complications: eg severe diabetic foot disease,diabetic nephropathy, erectile dysfunction, painfuland autonomic neuropathy, or macrovasculardisease.Rapid changes in the structure and delivery of servicesare occurring as a result of: treatment developments such as continuoussubcutaneous insulin infusion technological developments such as remotelyaccessed blood glucose results, call-centre supportand electronic care records GPs with a special interest (GPwSIs) in diabetes changing organisational relationships andcommissioning in primary and secondary care structured educational programmes relationships with acute medical care and generalmedicine.Endocrine servicesFor common conditions, such as polycystic ovarysyndrome (PCOS) and thyroid disorders, services areoften organised on a multidisciplinary or multisectorbasis, which is much less complex but in other respectssimilar in structure to that for diabetes. Unusualendocrine disorders require sophisticated laboratoryand clinical imaging support for diagnosis and closeliaison with highly specialised surgical services fortreatment. In England From April 2013 these will fallunder the remit of the specialised services nationaldefinitions set, and be commissioned nationally(www.specialisedservices.nhs.uk).3 Working with patients: patient-centredcareWhat you do with patientsInvolving patients in decisions abouttheir treatmentTreatment choices in diabetes and endocrinology areoften complex and entail difficult risk assessments.Lengthy, well-informed negotiation between specialistsand patients is necessary in order to achieve optimumoutcome. Young people with diabetes and endocrinedisorders require support and negotiated managementappropriate to their stages of physical and emotionaldevelopment. Long-term clinical records areindispensable; ideally, they should integrate informationand results from all the healthcare providers and beaccessible to both professionals and patients.Access to information, opportunities foreducation and promoting self-careDiabetes is always a chronic condition and manyendocrine disorders are also lifelong. Therefore,self-care and empowerment are a core part of deliveringthe appropriate services. Patient education programmesare an essential component of management for type 1and type 2 diabetes, and feature increasingly in themanagement of endocrine conditions such as PCOS,pituitary disease and hypogonadism. National and localpatient organisations are prominent and supportive inthese areas.4 Interspecialty and interdisciplinary liaisonMultidisciplinary team working and working withother specialtiesMultidisciplinary team (MDT) working andcollaboration with other specialists is a characteristicof almost all aspects of diabetes and endocrinespecialist care.The diagnosis and ongoing care of children, youngpeople and adults with type 1 diabetes demand closecollaboration among paediatricians, paediatric diabetesspecialist nurses, physicians with a special interest indiabetes, adult diabetes specialist nurses and dietitians,and, often, contributions from podiatrists, optometristsand psychologists. For type 2 diabetes, primary careteams make the majority of the diagnoses and providethe ongoing care. Specialist services provideconsultative advice at intervals and, at times, temporaryongoing care for particularly difficult metabolic orcomplicated management problems. Specialist serviceswill be increasingly involved in the ongoing educationof the primary care teams.Diabetic foot care requires an extensive MDT includingcommunity podiatrists and district nurses, hospitalpodiatrists, orthotists, microbiologists, vascularsurgeons and orthopaedic surgeons, in addition todiabetes specialist nurses and physician specialists.Diabetes pregnancy care requires integrated teamworking with obstetric and midwifery colleagues.Other aspects of diabetes care involve collaborativemanagement with ophthalmologists, nephrologists,92 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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