Training activity information
Details
Perform and interpret four of the following analyses to laboratory standard operating procedures on patients with:
- Primary and secondary diabetes mellitus
- Newly diagnosed type 1 and type 2 diabetes mellitus
- Gestational diabetes mellitus
- Stable diabetes mellitus on treatment
- Acute diabetic complications
- Chronic diabetic complications
Differential diagnosis and monitoring of diabetes using the following test(s):
- HbA1c
- Fasting glucose test
- Oral glucose tolerance test
- Insulin and C-peptide
- Urinary albumin
Type
Entrustable training activity (ETA)
Evidence requirements
Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion.
Reflection at multiple timepoints on the trainee learning journey for this activity.
Considerations
- Local and national training guidelines, including standards and pathways
- Method selection, including assay advantages and limitations, quality parameters, and interferences
- Equipment calibration and maintenance
- Quality control; EQA and IQC
- National and international guidelines
- Role of the duty biochemist
- Application of point of care testing, including methodology, governance, and patient experience
Reflective practice guidance
The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.
Before action
What does success look like?
- Identify what is expected of you in relation to effectively performing and interpreting at least four of the listed diabetes analyses (HbA1c, fasting glucose, OGTT, insulin/c-peptide, urinary albumin) according to laboratory SOPs, for diverse diabetes patient groups.
- Consider how the learning outcomes apply, specifically in relation to performing clinical and laboratory investigation, analysis and management of endocrine disorders and diabetes mellitus, and interpreting and reporting investigations in the correct clinical context.
- Discuss with your training officer to gain clarity of what is expected of you in relation to key procedural steps for the chosen four analyses, acceptable measurement ranges, and interpretation for specific contexts (e.g., diagnosing Gestational Diabetes Mellitus).
What is your prior experience of this activity?
- Think about what you already know about performing and interpreting these specific diabetes tests (e.g., the principles of the HbA1c assay or insulin/C-peptide analysis).
- Consider possible challenges you might face during the activity, such as managing pre-analytical issues for glucose/insulin samples, dealing with factors that affect HbA1c (e.g., haemoglobinopathies), or performing/interpreting Oral Glucose Tolerance Tests (OGTTs) accurately.
- Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example if an OGTT result is abnormal but the patient reports non-compliance with the fasting requirement, compromising the validity of the result, or if distinguishing a classification of diabetes in an atypical presentation using C-peptide.
- Acknowledge how you feel about embarking on performing and interpreting these specific diabetes analyses.
What do you anticipate you will learn from the experience?
- Consider the specific skills you want to develop, such as precise technical performance of complex analyses (e.g., OGTT performance) and systematic evaluation of diabetes markers for differential diagnosis.
- Identify the specific insights you hope to gain into the importance of pre-analytical integrity, test interpretation in the context of different types and stages of diabetes (e.g., acute vs chronic complications like diabetic nephropathy), or applying current diagnostic guidelines.
What additional considerations do you need to make?
- Consult actions identified following previous experiences of diabetes testing where technical accuracy or interpretive complexity arose.
- Identify important information you need to consider before embarking on the activity, such as understanding of diabetes classification, acute vs chronic complications, specific testing protocols for the chosen four analyses, and sources of assay interference for HbA1c.
In action
Is anything unexpected occurring?
- Are you noticing anything surprising or different from what you anticipate whilst performing analysis or interpreting results for a diabetes case?
- Are you encountering situations such as:
- Discordant HbA1c and glucose results suggesting potential assay interference or haemoglobinopathy?
- Difficulties applying complex diagnostic criteria during an Oral Glucose Tolerance Test (OGTT) interpretation (e.g., Gestational Diabetes Mellitus)?
- Analytical issues affecting urinary albumin measurement in a chronic complication screen?
How are you reacting to the unexpected development?
- How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to troubleshooting the assay or verifying diagnostic thresholds?
- Consider the steps you are taking in the moment, such as:
- Immediately re-running the HbA1c on a different instrument to check for assay interference
- Consulting national or institutional guidelines to verify the diagnostic thresholds for GDM during OGTT interpretation
- Seeking guidance on using Insulin and C-peptide analysis for differential diagnosis (Type 1 vs Type 2 diabetes, or considering other types such as MODY)
- How are you feeling in that moment? For instance, are you finding it difficult to apply diagnostic criteria to borderline OGTT results? Is it affecting your confidence in ensuring pre-analytical requirements (e.g., fasting state) were met?
What is the conclusion or outcome?
- Identify how you are working within your scope of practice. For example, are you successfully interpreting a fasting glucose and HbA1c profile for stable Type 2 diabetes? Or are you needing support because complex sample issues (e.g., haemolysis impacting HbA1c) require senior technical input for resolution?
- What are you learning as a result of the unexpected development? For example, are you mastering the pre-analytical requirements for glucose and OGTT? Or gaining insight into the factors that necessitate differential diagnosis using C-peptide?
On action
What happened?
- Begin by summarising the key steps you took when performing and interpreting the four specified diabetes analyses (e.g., HbA1c, OGTT, fasting glucose, urinary albumin).
- Consider specific events, actions, or interactions which felt important, such as verifying the patient’s adherence to fasting protocols for the OGTT or noting discrepancies between HbA1c and glucose results.
- Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately consulting diagnostic criteria when presented with borderline results for Gestational Diabetes Mellitus (GDM).
- How did you feel during this experience, e.g., did you feel focused on differentiating between Type 1 and Type 2 diabetes using C-peptide or stressed by managing pre-analytical requirements for glucose samples?
How has this experience contributed to your developing practice?
- Identify what learning you can take from this experience regarding performing and interpreting fundamental diabetes tests. What strengths did you demonstrate, e.g., accurate interpretation of results in the context of chronic diabetic complications?
- What skills and/or knowledge gaps were evident, e.g., unfamiliarity with factors affecting HbA1c measurement (e.g., haemoglobinopathies)?
- Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in using these tests for differential diagnosis and classification of diabetes?
- Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding the validity of a poorly executed Oral Glucose Tolerance Test, and how you reacted to this.
What will you take from the experience moving forward?
- Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to ensuring accurate performance and interpretation of fundamental diabetes tests.
- What will you do differently next time you approach interpreting results for newly diagnosed diabetes, for instance, by proactively reviewing national diabetes guidelines (e.g., for GDM) before interpretation?
- Do you need to practise any aspect of the activity further, such as investigating factors affecting HbA1c results or key learning outcomes related to using Insulin and C-peptide for differential diagnosis?
Beyond action
Have you revisited the experiences?
- How have your subsequent experiences of performing and interpreting these fundamental diabetes analyses since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, how an instance where a subsequent complex case required interpretation of discordant HbA1c and glucose results (e.g., due to a haemoglobinopathy or specific patient conditions) forced you to re-evaluate the rigidity of relying on a single analytical result during your first attempt at interpreting a Gestational Diabetes Mellitus (GDM) diagnosis?
- Considering what you understand about acute/chronic complications, factors affecting test results (e.g., HbA1c variants, pre-analytical glucose issues), and the use of Insulin/C-peptide for differential diagnosis now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? How have you since implemented or adapted improvements in your validation of HbA1c results based on further learning and experiences? For example, how you proactively reviewed and integrated pre-analytical checks for potential glucose sample degradation, demonstrating you have adapted improvements based on further learning?
- Has discussing borderline Oral Glucose Tolerance Test (OGTT) results or the impact of analytical interference on diabetes monitoring markers with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a case where C-peptide was critical in distinguishing Type 1 vs Type 2 diabetes refined your understanding of the diagnostic value of these specialised tests?
How have these experiences impacted upon current practice?
- How has the learning from this initial training activity, in combination with subsequent diabetes analysis experiences, contributed to your overall confidence and competence in performing diagnostic tests and monitoring diabetes, particularly in preparing for assessments like Direct Observations of Practical Skills (DOPS) or Observed Clinical Events (OCEs)? For example, how your accumulated ability in performing accurate diabetes analysis (e.g., OGTT) and interpreting differential diagnosis markers (e.g., C-peptide) now enables you to confidently perform HbA1c analysis during a DOPS assessment or interpret an abnormal Oral Glucose Tolerance Test during an OCE.
- How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to diabetes diagnostics? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely check for pre-analytical interference (e.g., haemoglobinopathies affecting HbA1c) and seek advice immediately when diagnosing complex Gestational Diabetes Mellitus (GDM) or when results are highly discordant, recognising the need for specialist clinical correlation.
- Looking holistically at your training journey, how has this initial diabetes analysis experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to performing clinical and laboratory investigation, analysis and management of endocrine disorders and diabetes mellitus and interpreting and reporting on clinical and laboratory investigations in the correct clinical context? For example, how this foundational experience has supported your meticulousness about pre-analytical handling of glucose samples.
Relevant learning outcomes
| # | Outcome |
|---|---|
| # 1 |
Outcome
Perform clinical and laboratory investigation, analysis and management of endocrine disorders. |
| # 4 |
Outcome
Interpret and report on clinical and laboratory investigations for endocrinology and diabetes mellitus in the correct clinical context. |