Endocrinology and Diabetes —
Training activity: 1

Details

Perform and interpret the analyses to laboratory standard operating procedures on patients with:

• Pituitary tumours
• Hypopituitarism
• Growth hormone deficiency and acromegaly
• Multiple endocrine neoplasia
• Diabetes insipidus
• Oral glucose tolerance tests
• Insulin tolerance test
• Glucagon stimulation test
• Water deprivation test and utility of copeptin

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.

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 analyses related to these pituitary/dynamic function disorders according to laboratory standard operating procedures (SOPs).
• Consider how the learning outcomes apply, specifically in relation to performing clinical and laboratory investigation, analysis and management of endocrine disorders and diabetes mellitus.
• Discuss with your training officer to gain clarity of what is expected of you in relation to expectations for equipment setup for dynamic tests (e.g., Oral Glucose Tolerance Test (OGTT)), patient flow logistics for prolonged tests, and integrating necessary safety protocols during dynamic testing.

What is your prior experience of this activity?

• Think about what you already know about performing and interpreting these specific analyses and dynamic function tests (e.g., pre-analytical considerations for insulin tolerance tests).
• Consider possible challenges you might face during the activity, such as sample handling issues (e.g., chilling samples for hormone analysis), assay performance issues for niche analytes, or complex interpretation in specific patient conditions like Multiple Endocrine Neoplasia.
• 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 the complexity of the interpretation in a patient with Multiple Endocrine Neoplasia requires specialised pathological guidance or if an unforeseen physiological response occurs during a water deprivation test.
• Acknowledge how you feel about embarking on performing and interpreting these specific, often complex, analyses.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as planning complex clinical procedures, executing meticulous laboratory work for dynamic function tests, and interpreting co-dependent hormone results.
• Identify the specific insights you hope to gain into the laboratory procedures for time-sensitive tests, test interpretation in the context of these conditions (e.g., Growth Hormone deficiency), or handling dynamic function test protocols.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of pituitary/dynamic function tests or complex analyses that required specific technical troubleshooting or interpretive steps.
• Identify important information you need to consider before embarking on the activity, such as specific patient information (e.g., patient medication that might interfere with results), detailed test protocols for the Insulin Tolerance Test, or reviewing academic content related to the physiology of pituitary hormone feedback loops.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst performing the analysis or initial interpretation for a pituitary disorder?
• Are you encountering situations such as:
  • Unexpected instrument flags or unusual measurement values during the assay run for a pituitary hormone?
  • Interpreting results from a dynamic function test, like the Water Deprivation Test or Insulin Tolerance Test (ITT), that contradict the patient’s expected physiological response?
  • Issues with assay performance specifically for low-concentration pituitary hormones?

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 verifying sample integrity or selecting appropriate quality control?
• Consider the steps you are taking in the moment, such as:
  • Immediately re-running a quality control sample or performing a dilution study to verify instrument performance and linearity.
  • Halting the initial interpretation to consult the dynamic test protocol guide or seeking immediate clarity on pre-analytical requirements.
  • Seeking advice from the Training Officer to resolve an unexpected result for a complex case like Multiple Endocrine Neoplasia.
• How are you feeling in that moment? For instance, are you finding it difficult to troubleshoot an unexpected instrument issue? Is it affecting your confidence in verifying sample integrity or interpreting dynamic function test results?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully troubleshooting the instrument flag according to SOPs? Or are you needing support because the complexity of the interpretation of a dynamic function test exceeds routine scope?
• What are you learning as a result of the unexpected development? For example, are you mastering a more effective technique for verifying sample integrity during dynamic tests? Or gaining insight into the importance of consulting guidelines for pituitary pathophysiology when faced with unexpected results?

On action

What happened?

• Begin by summarising the key steps you took when performing the chosen pituitary/dynamic analysis (e.g., Insulin Tolerance Test, ITT) and interpreting the results.
• Consider specific events, actions, or interactions which felt important, such as observing instrument performance or quality control results during the assay run or applying the patient’s clinical history (e.g., hypopituitarism) to interpret the dynamic response curve.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, pausing the interpretation to verify the precise timing of a critical sample (e.g., cortisol level during an ITT) due to an unexpected low value.
• How did you feel during this experience, e.g., did you feel confident in applying the SOPs for analysis or stressed by the complexity of correlating results from a dynamic function test?

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding performing and interpreting complex pituitary and dynamic function analyses. What strengths did you demonstrate, e.g., meticulous adherence to the analytical SOPs for unstable hormones?
• What skills and/or knowledge gaps were evident, e.g., unfamiliarity with differentiating between types of diabetes Insipidus based on water deprivation test results and copeptin utility?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in understanding the relationship between analytical results and complex pituitary pathophysiology (e.g., acromegaly)?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding interpreting contradictory results from a Glucagon Stimulation 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 accuracy and adherence to SOPs in future dynamic endocrine analyses.
• What will you do differently next time you approach interpreting results for complex pituitary conditions, for instance, by proactively reviewing academic guidelines on Multiple Endocrine Neoplasia test interpretation prior to viewing the results?
• Do you need to practise any aspect of the activity further, such as performing detailed interpretation of dynamic test curves or key learning outcomes related to understanding the critical pre-analytical steps for pituitary samples?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences of managing complex dynamic function tests and pituitary disorder analyses since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, how a subsequent challenging case requiring differential diagnosis (e.g., distinguishing primary from secondary hypopituitarism) forced you to re-evaluate the meticulousness of sample handling and timing checks during your first attempt at an Insulin Tolerance Test (ITT)?.
• Considering what you understand about biological variation, dynamic test protocols, and pituitary axis pathophysiology 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 pre-analytical integrity for dynamic tests based on further learning and experiences? For example, how you proactively reviewed and integrated specific departmental guidelines on copeptin utility to inform the interpretation of the water deprivation test, demonstrating you have adapted improvements based on further learning?
• Has discussing challenging dynamic test results or the impact of delayed sample processing 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 time when a Glucagon Stimulation Test result was discarded due to timing issues refined your understanding of the critical nature of procedural adherence during endocrine investigations?

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent pituitary disorder analysis and dynamic testing experiences, contributed to your overall confidence and competence in efficiently performing analysis and interpretation, particularly in preparing for assessments like Direct Observations of Practical Skills (DOPS) or Case-based Discussions (CBDs)? For example, how your accumulated ability in performing accurate analysis and troubleshooting dynamic tests (e.g., Insulin Tolerance Test, ITT, or Water Deprivation Test) now enables you to confidently present the necessary contextual information during a CBD assessment.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to dynamic function testing and pituitary analysis? 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 sample integrity and timing immediately when interpreting complex dynamic tests (e.g., ITT or Copeptin utility), recognising deviations from expected physiological response require senior review or escalation.
• Looking holistically at your training journey, how has this initial pituitary 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? For example, how this foundational experience has supported your development in practicing safely by providing the necessary knowledge base for the subsequent learning outcomes focused on accurate interpretation.

Relevant learning outcomes

#	Outcome
# 1	Outcome Perform clinical and laboratory investigation, analysis and management of endocrine disorders.
# 2	Outcome Perform clinical and laboratory investigation, analysis and management of diabetes mellitus.