Into the Unknown: Characterizing Fellow Uncertainty During the Transition to Unsupervised Practice

Background

Helping fellows confront and manage uncertainty in the course of diagnosis and treatment of patients has been a growing focus of medical education. How these same fellows confront uncertainty as they make a transition in their professional development is less commonly a focus of training programs. Better understanding of how fellows experience these transitions will allow fellows, training programs, and hiring institutions to navigate transitions more easily.

Objective

This study aimed to explore how fellows in the United States experience uncertainty during the transition to unsupervised practice.

Methods

Using constructivist grounded theory, we invited participants to engage in semi-structured interviews exploring experiences with uncertainty as they navigate the transition to unsupervised practice. Between September 2020 and March 2021, we interviewed 18 physicians in their final year of fellowship training from 2 large academic institutions. Participants were recruited from adult and pediatric subspecialties. Data analysis was conducted using an inductive coding approach.

Results

Experiences with uncertainty during the transition process were individualized and dynamic. Primary sources of uncertainty identified included clinical competence, employment prospects, and career vision. Participants discussed multiple strategies for mitigating uncertainty, including structured graduated autonomy, leveraging professional networks locally and non-locally, and utilizing established program and institutional supports.

Conclusions

Fellows' experiences with uncertainty during their transitions to unsupervised practice are individualized, contextual, and dynamic with several shared overarching themes.

Overview of Atypical Diabetes

Although type 1 diabetes mellitus and, to a lesser extent, type 2 diabetes mellitus, are the prevailing forms of diabetes in youth, atypical forms of diabetes are not uncommon and may require etiology-specific therapies. By some estimates, up to 6.5% of children with diabetes have monogenic forms. Mitochondrial diabetes and cystic fibrosis related diabetes are less common but often noted in the underlying disease. Atypical diabetes should be considered in patients with a known disorder associated with diabetes, aged less than 25 years with nonautoimmune diabetes and without typical characteristics of type 2 diabetes mellitus, and/or with comorbidities associated with atypical diabetes.

MON-184 Hypoglycemia During Mixed Meal Tolerance Testing and Early Glucose Dysregulation in Cystic Fibrosis

Post-prandial and oral glucose tolerance test (OGTT)-related hypoglycemia is common in cystic fibrosis (CF). The mechanisms underlying this “reactive” hypoglycemia are unclear. We hypothesized that late hypoglycemia would be associated with higher peak plasma glucose, impaired early-phase insulin secretion compared to PI-NGT, and augmentation of late insulin secretion. To understand these relationships, we performed standardized mixed-meal tolerance tests (MMTT) with timed blood sampling for determination of plasma glucose, insulin and C-peptide in non-diabetic adolescents and young adults with pancreatic insufficient CF (PI-CF). Glucose tolerance was defined by OGTT as: normal (NGT; 1-hour glucose <155 and 2-hour glucose <140mg/dL, n=13), or abnormal (AGT; 1-hour glucose ≥155 or 2-hour glucose ≥140 mg/dL and <200 mg/dL, n=21). Hypoglycemia was defined as plasma glucose <70mg/dL during MMTT and used to assign subjects to exposure groups for analysis. Insulin secretory rates (ISRs) were derived by parametric deconvolution of C-peptide kinetics using a two-compartment model. Glucose and ISR incremental areas under curve (Glc-AUC; ISR-AUC) were calculated. Peak plasma glucose and ISR-AUC_interval were compared between hypoglycemia groups [hypo(+) vs hypo(-)] using Student’s t-test and Mann Whitney U Tests, respectively. Linear regression was performed to explore whether ISR AUC was different in hypo(+) vs hypo(-) after adjustment for Glc-AUC. 34 subjects with PI-CF were evaluated. Participants were 50% female, aged 25±8.7 years, with FEV-1 % predicted 81±19, HbA1c 5.5±0.4%, and BMI z-score 0.17±1. Hypoglycemia occurred in 9 subjects (2 NGT, 7 AGT) at 163±30 min following the start of the meal. No group differences in gender, age, lung function, HbA1c, or BMI z-score were found. Peak plasma glucose was higher in hypo(+) vs hypo(-) (215±21 vs 168±33 mg/dL, p=0.0004). Moreover, early-phase ISR-AUC_{15-45 min} was lower in hypo(+) vs hypo(-) PI-NGT (609±190 vs 1313±850 µU/mL, p=0.03), including the 2 NGT-hypo(+): 430mg/dL and 548mg/dL, respectively. ISR-AUC_{120-180 min} was not different in hypo(+) than hypo(-) PI-AGT (2528 ±1723 vs 2219±1072 µU/mL, p=0.85); however, glc-AUC_{120-180 min} was lower in hypo(+) than hypo(-) PI-AGT (-785±1288mg·min/dL vs 750±1115 mg·min/dL, p=0.015). After adjusting for glc-AUC over this interval, hypo(+) tended to have higher late insulin secretion than hypo(-) PI-AGT (p=0.089). Meal-related hypoglycemia in CF is common and not only seen following the glucose load of an OGTT. Hypoglycemia is associated with early glucose dysregulation (higher peak plasma glucose), loss of early-phase insulin secretion (lower ISR AUC_{15-45 min}), and possible late compensatory hyperinsulinemia (higher ISR AUC_{120-180 min} relative to glucose). Whether hypoglycemia may predict progression to CFRD in individuals with PI-CF requires further study.

Hepatic amino acid transport primary to the urea cycle in regulation of biologic neutrality

A biologic determination appears to be made as to whether the nitrogenous portion of food amino acids reaches the kidney for excretion as ammonium ion, or whether it is sent to the liver to form urea. It now becomes likely that this determination occurs primarily by hydrogen ion inhibition of at least one transport system by which the liver receives amino acids, and not by regulation applied directly to the liver-ornithine cycle.