Endocrinology and Diabetes —
Training activity: 6

Details

Perform and interpret the analyses to laboratory SOPs on patients with:

• Hyperinsulinaemia  (Insulinoma)
• GI hormone-secreting tumours (Zollinger-Ellison syndome, carcinoid tumours and rare GI tract tumours)
• Markers of neuroendocrine tumours (e.g. chromogranins)
• Prolonged fast (insulin and C-peptide analysis)

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 pancreatic and GI neuroendocrine tumours and prolonged fasts according to laboratory SOPs.
• Consider how the learning outcomes apply, specifically in relation to performing clinical and laboratory investigation, analysis and management of diabetes mellitus.
• Discuss with your training officer to gain clarity of what is expected of you in relation to key considerations for these analyses, such as specialised sample handling for GI peptides or insulin, interpreting results in the context of a prolonged fast, and understanding the utility of neuroendocrine tumour markers.

What is your prior experience of this activity?

• Think about what you already know about performing and interpreting analyses for insulin, C-peptide, gastrin, chromogranins, and other relevant markers.
• Consider possible challenges you might face during the activity, such as managing the extreme instability of some GI hormone samples, interpreting results from prolonged fasts for insulinoma diagnosis, or dealing with the non-specificity of certain tumour markers.
• 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 interpreting results from a prolonged fast that are borderline for insulinoma, requiring consultation on continuation of the test, or if classifying results suggesting Zollinger-Ellison syndrome.
• 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 meticulously adhering to pre-analytical protocols for unstable analytes and applying interpretation criteria for complex conditions like neuroendocrine tumours.
• Identify the specific insights you hope to gain into the test interpretation in the context of neuroendocrine tumours or fasting states (e.g., differentiating exogenous insulin administration from endogenous production), or the pathophysiology of GI hormone action.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of these specialised analyses where the complexity of the pre-analytical phase was challenging.
• Identify important information you need to consider before embarking on the activity, such as specific patient history related to fasting or symptoms, understanding of tumour types (e.g., carcinoid tumours), and the specific pre-analytical requirements for hormone assays.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst performing specialised assays or interpreting neuroendocrine profiles?
• Are you encountering situations such as:
  • Unexpected analytical issues with a specialised GI hormone assay (e.g., gastrin) requiring non-routine troubleshooting?
  • Difficulties with interpreting results from a prolonged fast test for hyperinsulinaemia?
  • Detecting high levels of Chromogranin A which may be elevated due to a non-tumour condition?

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 handling unstable samples or complex interpretation criteria?
• Consider the steps you are taking in the moment, such as:
  • Immediately verifying sample handling and storage conditions for unstable analytes like specific GI peptides
  • Consulting senior staff regarding the interpretation criteria for complex neuroendocrine markers (e.g., Zollinger-Ellison syndrome)
  • Reviewing the insulin/C-peptide ratio in real-time during a prolonged fast to determine if the test needs continuation
• How are you feeling in that moment? For instance, are you finding it difficult to ensure the integrity of the often unstable specialized samples? Is it affecting your confidence in applying interpretation criteria for rare conditions like insulinoma?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully applying standard interpretation criteria to identify a likely carcinoid tumour marker profile? Or are you needing support because the case involves a rare GI tract tumour requiring specialist pathological review?
• What are you learning as a result of the unexpected development? For example, are you mastering meticulous pre-analytical steps for specialised hormone assays? Or gaining insight into differentiating endogenous vs. exogenous hyperinsulinaemia via C-peptide analysis?

On action

What happened?

• Begin by summarising the key steps you took when performing and interpreting the specialised GI hormone or tumour marker analyses (e.g., insulin, c-peptide, or chromogranin).
• Consider specific events, actions, or interactions which felt important, such as verifying the patient’s fasting status before releasing results for a prolonged fast investigation or noting the critical sample stability requirements for GI peptides like Gastrin.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately seeking consultation to confirm the cut-off criteria for diagnosing hyperinsulinaemia during a prolonged fast.
• How did you feel during this experience, e.g., did you feel the responsibility of interpreting results for potentially rare conditions like Insulinoma or were you stressed by measuring highly specialised analytes?

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding analysis and interpretation of GI/neuroendocrine hormones. What strengths did you demonstrate, e.g., meticulous adherence to sample collection and handling protocols for unstable analytes?
• What skills and/or knowledge gaps were evident, e.g., unfamiliarity with the clinical utility and limitations of chromogranin markers in differentiating tumour types?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in understanding the specific challenges of measuring rare analytes?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding interpreting a complex insulin/c-peptide ratio suggestive of exogenous insulin administration, 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 proper sample collection and accurate interpretation for specialised GI hormones.
• What will you do differently next time you approach interpreting neuroendocrine tumour markers, for instance, by proactively reviewing current guidelines on Zollinger-Ellison Syndrome diagnosis?
• Do you need to practise any aspect of the activity further, such as correlating insulin and c-peptide results during a prolonged fast or key learning outcomes related to understanding the analytical challenges of measuring GI hormones?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences of analysing and interpreting specialised GI/neuroendocrine hormones 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 differentiation between exogenous insulin administration and endogenous hyperinsulinaemia (insulinoma) forced you to re-evaluate the interpretation protocol for the insulin/c-peptide ratio during the prolonged fast?
• Considering what you understand about neuroendocrine tumour markers (e.g., chromogranins), GI hormone stability, and diagnostic pathways for hypoglycaemia 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 pre-analytical checklist for unstable specialised assays based on further learning and experiences? For example, how you proactively reviewed and integrated specific institutional protocols concerning sample handling for gastrin or other GI hormone-secreting tumours, demonstrating you have adapted improvements based on further learning?
• Has discussing rare neuroendocrine tumour (NET) marker results or the management of patients undergoing prolonged fasts 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 borderline Insulinoma case that required specialized confirmation refined your understanding of the critical steps required for complex diagnostic challenges?

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent specialised GI/neuroendocrine hormone analysis and interpretation experiences, contributed to your overall confidence and competence in effectively performing analysis and interpretation, particularly in preparing for assessments like Case-based Discussions (CBDs) or Direct Observations of Practical Skills (DOPS)? For example, how your accumulated ability in managing specialised assays (e.g., Insulin, C-peptide) and interpreting results from prolonged fasts now enables you to confidently present findings related to insulinoma differential diagnosis 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 specialized GI/neuroendocrine 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 double-check pre-analytical protocols for unstable GI hormones and seek advice immediately when interpreting complex neuroendocrine marker profiles (e.g., chromogranins) or borderline prolonged fast results, recognising this requires specialist pathological verification.
• Looking holistically at your training journey, how has this initial specialised 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 diabetes mellitus? For example, how this foundational experience has supported your development in collecting relevant clinical details and considering rare conditions when interpreting results.

Relevant learning outcomes

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