Endocrinology and Diabetes —
Training activity: 4

Details

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

• Primary hypo- and hypercortisolism
• Secondary hypo- and hypercortisolism
• Hyperaldosteronism
• Disorders of adrenal steroidogenesis
• Adrenal androgen excess
• Disorders of the adrenal medulla

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 adrenal cortical (e.g., cortisol, aldosterone) and medullary (e.g., catecholamines) disorders according to laboratory 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 key considerations for adrenal analyses, such as sample timing (circadian rhythm), assay methodologies, and interfering substances (e.g., drugs).

What is your prior experience of this activity?

• Think about what you already know about performing and interpreting analyses for adrenal hormones (e.g., cortisol, aldosterone, catecholamines) and related markers (e.g., renin).
• Consider possible challenges you might face during the activity, such as understanding complex negative feedback loops, interpreting results from dynamic tests like the short synacthen test, or dealing with rare disorders of steroidogenesis (e.g., congenital adrenal hyperplasia).
• 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 a patient’s cortisol result significantly contradicts the expected circadian rhythm, potentially suggesting an issue with sample timing or collection, or if reporting on findings for an adrenal medulla disorder (e.g., phaeochromocytoma).
• Acknowledge how you feel about embarking on performing and interpreting these specific analyses.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as precise timing of sample collection relative to drug administration (for dynamic tests) and integrating multiple biochemical markers to diagnose complex conditions like Conn’s syndrome.
• Identify the specific insights you hope to gain into the test interpretation in the context of diverse adrenal conditions (cortical and medullary) or the impact of stress and medication on cortisol results.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of adrenal analyses that involved specific pre-analytical checks or interpretation challenges.
• Identify important information you need to consider before embarking on the activity, such as understanding of circadian rhythms, effects of stress, impact of medications (e.g., exogenous steroids), and specific protocols for dynamic tests (e.g., 24-hour urine collection requirements).

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst running an adrenal assay or interpreting results?
• Are you encountering situations such as:
  • A cortisol result that contradicts the expected diurnal rhythm or the sample timing is unclear?
  • Issues with interpreting dynamic test results (e.g., ACTH stimulation or dexamethasone suppression) in an atypical patient?
  • Detecting signs of interfering substances affecting catecholamine or other adrenal hormone measurements?

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 timing or troubleshooting the assay?
• Consider the steps you are taking in the moment, such as:
  • Immediately checking the recorded time of sample collection against the requested dynamic test protocol
  • Consulting the SOP to troubleshoot an unexpected assay failure for a complex marker like metanephrines
  • Seeking guidance from a senior colleague about the interpretation of a complex profile involving aldosterone and renin ratio
• How are you feeling in that moment? For instance, are you finding it difficult to ensure accurate sample timing influences the result? Is it affecting your confidence in interpreting the results from dynamic adrenal tests?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully verifying the results of a simple overnight dexamethasone suppression test? Or are you needing support because the profile suggests a rare disorder of adrenal steroidogenesis requiring specialist guidance?
• What are you learning as a result of the unexpected development? For example, are you mastering the importance of sample timing verification for cortisol and ACTH? Or gaining insight into the complex relationship between aldosterone and renin in hyperaldosteronism?

On action

What happened?

• Begin by summarising the key steps you took when performing the chosen adrenal analysis (e.g., serum cortisol or aldosterone/renin ratio) and interpreting the results.
• Consider specific events, actions, or interactions which felt important, such as verifying the sample timing relative to the patient’s medication schedule (e.g., dexamethasone suppression test) or observing unexpected matrix effects during the metanephrine assay.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, halting interpretation immediately to contact the ward and confirm the patient’s posture before assessing the aldosterone/renin ratio.
• How did you feel during this experience, e.g., did you feel focused on differentiating between primary and secondary adrenal dysfunction or stressed by managing the critical pre-analytical requirements of adrenal testing?

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding adrenal analysis and the interpretation of dynamic tests. What strengths did you demonstrate, e.g., detailed review of pre-analytical considerations like sample timing and medications?
• What skills and/or knowledge gaps were evident, e.g., unfamiliarity with the complex biochemical profiles seen in rare disorders of adrenal steroidogenesis?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in understanding the technical challenges of measuring adrenal hormones?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding interpreting a borderline result from a short synacthen 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 all critical pre-analytical steps are rigorously met for adrenal testing.
• What will you do differently next time you approach interpreting results for hyperaldosteronism, for instance, by systematically reviewing clinical guidelines to differentiate between primary and secondary hypo/hypercortisolism?
• Do you need to practise any aspect of the activity further, such as interpreting dynamic function test data for Cushing’s Syndrome or key learning outcomes related to managing analytical interferences in metanephrine assays?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences of adrenal hormone analysis and dynamic test interpretation 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 patient required complex investigation of a rare disorder of adrenal steroidogenesis (e.g., congenital adrenal hyperplasia) forced you to re-evaluate the diligence of your review regarding precursor steroids and analytical limitations?
• Considering what you understand about adrenal steroid pathways, diurnal variation, and the impact of stress/medications on hormone levels 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 adrenal testing verification checklist based on further learning and experiences? For example, how you proactively reviewed and integrated specific departmental guidelines on interpreting aldosterone/renin ratio in the context of interfering medications, demonstrating you have adapted improvements based on further learning?
• Has discussing discordant adrenal dynamic test results (e.g., dexamethasone suppression or short synacthen test) or the investigation of adrenal medulla disorders 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 false positive metanephrines result due to pre-analytical error refined your understanding of the critical nature of patient preparation for disorders of the adrenal medulla?

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent adrenal hormone 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 verifying pre-analytical factors (e.g., sample timing for cortisol) and interpreting dynamic adrenal tests (e.g., short synacthen test) now enables you to confidently execute procedural steps during a DOPS assessment or interpret a Hyperaldosteronism profile in a CBD.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to adrenal hormone 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 for medication interference or sample time relative to circadian rhythm (e.g., cortisol) and seek advice immediately when interpreting complex profiles suggesting rare disorders of steroidogenesis or adrenal malignancy, recognising this requires specialist pathological input.
• Looking holistically at your training journey, how has this initial adrenal 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 understanding the impact of stress or medications on hormone levels.

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.