The widespread use of corticosteroids for treatment of inflammatory conditions has resulted in the need to promptly recognize drug-induced adrenal insufficiency. This scenario was inspired by an actual case and aims to enhance critical thinking. Our case is unique as we use a case-based format with written tests to track progress.
A pre-assessment was conducted to measure baseline knowledge with residents and medical students. A standardized patient played a 70-year-old female with sarcoidosis who was in the emergency department with weakness and fatigue. The learners obtained her history whereby they discovered that she had recently stopped taking prednisone. They identified adrenal insufficiency and reinstated glucocorticoid therapy. The scenario lasted 10 minutes after which there were a debriefing session and post-debriefing assessment. All were completed in under one hour.
Our pre-scenario assessment revealed that all learners had less knowledge of adrenal insufficiency than thyroid disease with average scores of 66.63% and 91.25%, respectively. The average score of the adrenal insufficiency test increased from 66.63% to 87.45% on the post-debriefing assessment and the largest improvement was seen in first-year residents. Assessments measured via the Likert scale determined that all learners found the case well-devised to contribute to their understanding of adrenal insufficiency.
The largest improvement unexpectedly was seen in first-year residents which may be due to variations in repetition and retention of medical knowledge in the months prior to starting residency. This module is best suited for first-year internal medicine, family medicine, and emergency medicine residents and upper-level medical students.
Adrenal insufficiency is an endocrine disorder in which one or more of the hormones that are normally secreted by the adrenal gland (i.e., aldosterone, cortisol, dehydroepiandrosterone, epinephrine, norepinephrine) are not produced in adequate amounts . Adrenal insufficiency can be categorized as primary, secondary, and tertiary depending on the origin of the disease .
The hypothalamus secretes corticotropin-releasing hormone (CRH) which stimulates the anterior pituitary to release adrenocorticotropic hormone (ACTH). ACTH then prompts the adrenal cortex to secrete cortisol. Cortisol itself self-regulates the axis via negative feedback to the hypothalamus and anterior pituitary to maintain cortisol levels in certain ranges throughout the day and in times of stress .
Primary adrenal insufficiency occurs due to adrenal gland dysfunction while secondary adrenal insufficiency is a result of anterior pituitary dysfunction . Tertiary adrenal insufficiency, on the other hand, occurs due to hypothalamic dysfunction. Secondary and tertiary adrenal insufficiency are commonly drug-induced, whereby exogenous corticosteroids suppress the normal physiologic function of the hypothalamus and anterior pituitary in regulating cortisol levels . This is an important physiologic process to understand because of the widespread use of steroids for a variety of autoimmune and inflammatory diseases.
Prednisone is an example of a corticosteroid commonly prescribed for its immunosuppressant properties and acts analogously to cortisol to suppress the hypothalamic-pituitary-adrenal axis . During times of physiologic stress, the body responds with inflammatory cytokines and molecules that stimulate secretion of cortisol via numerous complex pathways . Cortisol, in turn, reflexively stimulates gluconeogenesis to ensure adequate energy supplies, regulates ion transport, and works to maintain physiologic equilibrium . If CRH and ACTH are suppressed, then discontinuation of prednisone may result in adrenal insufficiency and in times of physiologic stress may precipitate a life-threatening adrenal crisis (acute adrenal insufficiency) .
Drug-induced adrenal insufficiency can be difficult to diagnose since symptoms mimic other conditions and patients may fail to mention which medications they have been taking unless a full history is elicited by the clinician. In drug-induced acute adrenal insufficiency, the constellation of symptoms includes confusion, fatigue, weakness, nausea, abdominal pain, and dizziness from postural hypotension. These findings, as well as laboratory values showing hyponatremia, hypoglycemia, and pre-renal failure, should prompt the clinician to consider secondary or drug-induced adrenal crisis . Primary adrenal insufficiency has similar findings but also includes hyperpigmentation from increased CRH and hyperkalemia due to superimposed mineralocorticoid deficiency .
Clinicians should not wait for laboratory results of cortisol levels to treat adrenal crisis due to its severity and the grave implications of delaying administration of steroids. Treatment of adrenal crisis involves large doses of intravenous (IV) or intramuscular (IM) doses of hydrocortisone, as well as rapid rehydration with approximately four to six liters of isotonic saline while frequently observing for signs of fluid overload . Recommended doses of steroid therapy include 100 mg of hydrocortisone IV or IM as a bolus dose, followed by continuous IV administration of 200 mg of hydrocortisone over a period of 24 hours . An alternate method includes pulse dosing of 50 mg of hydrocortisone IV or IM every six hours .
The use of a simulated clinical scenario is a valuable tool in the medical armamentarium whereby learners improve analytical and processing gaps in medical decision-making and diagnostic accuracy . Our case was inspired by an actual patient experience, and the simulation was originally implemented as a neurosarcoidosis scenario. Due to its natural complexity, however, very few residents were able to identify neurosarcoidosis and were stumped as to its diagnosis and treatment. We changed the focus to adrenal insufficiency to create a more effective teaching tool and implemented a new standardized scenario.
It is interesting to note that we incidentally found a simulation module published in MedEd from 2015 in which a patient with sarcoidosis presented with adrenal crisis . This leads us to consider that the presentation of adrenal insufficiency in sarcoidosis may have a higher incidence than originally thought. We have created this module to be an integral part of strengthening and solidifying understanding of adrenal insufficiency in the clinical setting. Our case is unique as we can track residents and medical students’ understanding of adrenal insufficiency with objective tests. With respect to the educational format of the module, our simulation is in an enhanced simulation format with comprehensive and thorough simulation components.
This is a formative activity designed to enhance these cognitive processes, as well as the ability to diagnose and treat adrenal insufficiency. Our case format is useful for first-year internal medicine, family medicine, and emergency medicine residents, as well as upper-level medical students, to improve clinical knowledge and enhance cognitive capabilities.
Materials & Methods
This scenario was conducted during noon conference for four internal medicine residents and two upper-level medical students. Due to the limitations of being in a community hospital, senior internal medicine residents familiar with standardized patient scenarios were recruited to play the roles of the patient and nurse. Prior to the scenario, Dr. Malakooti coached the resident actors and underwent a thorough review of the supplemental materials with them, including the standardized case development tool (Table 1), scenario introduction (Table 2), a note from the husband (Table 3), and a standardized patient scenario (Table 4). Prior to the start of the scenario, a pre-simulation questionnaire was distributed to the residents for self-assessment of their comfort with (and knowledge of) adrenal insufficiency and associated topics (Table 5).
The environment was modeled after an emergency room. The patient was found lying down in a hospital bed or stretcher. A blood pressure cuff, heart rate monitor, and oxygen saturation monitor were present, along with an IV pole and simulation bottles of various intravenous medications, including hydrocortisone. A document with an introduction to the scenario was provided to the learners which included the patient’s chief complaint and initial vital signs (Table 2). Lab values were provided on request (Table 6). A supplemental document containing a note from the patient’s husband would be presented to the learners at the fifth minute of the scenario if they had not yet discovered the patient’s past history of long-term prednisone therapy (Table 3). The patient scenario is described in further detail in Table 4.
Learners went through the 10-minute standardized patient scenario in groups of two. After the scenario concluded, the instructor discussion guide was used for discussion and debriefing (Table 7). Debriefing involved a case summary from the participants and feedback regarding strengths and areas of improvement for the learners. The critical action checklist (Table 4) was reviewed, and a group discussion was facilitated regarding the clinical presentation and lab abnormalities corresponding with adrenal insufficiency and differential diagnoses. Diagnosis and treatment of adrenal insufficiency were emphasized. After the debriefing session concluded, learners who participated in the case scenario were re-assessed with the post-scenario questionnaire (Table 5).
Each learner completed the encounter once. On average, the learners took 10 to 15 minutes to complete the pre-scenario questionnaire. The actual standardized patient scenario lasted 10 minutes. The debriefing was completed in under 20 minutes and the post-scenario questionnaire (Table 5) took 10 to 15 minutes to complete. Each case in its entirety concluded in less than one hour.
We used five-point Likert scales for learner self-assessment, as well as learner evaluation of the module. We constructed an objective written test to determine baseline knowledge of adrenal insufficiency which was compared with a post-scenario test (Table 5). These diverse forms of assessment were used to create a comprehensive understanding of the utility of our module.
Learners who completed the encounter included two third-year medical students (MS-III), two first-year residents (PGY-I), and two second-year residents (PGY-II). All except for one medical student had completed a simulation case or standardized patient scenario in the past. A five-point Likert scale was used in both pre- and post-assessment questionnaires. In the pre-assessment, when asked regarding their knowledge of six topics, on average, they considered themselves to have the least knowledge of adrenal insufficiency, thyroid storm, and sarcoidosis (Figure 1).
To assess objective medical knowledge of adrenal insufficiency and thyroid disorder, the learners completed eight pre-encounter questions for each topic. The average score of the adrenal insufficiency test was 5.33 out of 8 (66.63% correct), and no learner answered more than six out of eight questions correctly. The average score of the thyroid disorder test was 7.33 out of 8 (91.25% correct), and all learners answered at least six out of eight questions correctly (Figure 2).
In the post-encounter questionnaire, all learners found that the simulation case contributed to their understanding of adrenal insufficiency and that the simulation case was well-devised to achieve this goal (Figure 3). Learner self-assessment of their own knowledge and comprehension of sarcoidosis and adrenal insufficiency improved post-encounter.
When asked regarding their self-assessment of knowledge and comprehension of adrenal insufficiency and sarcoidosis post-encounter and debriefing, overall, the learners’ reported that their knowledge and comprehension had improved in comparison to the pre-assessment (Figure 4).
After completing the encounter and debriefing, the learners were asked the same eight pre-encounter questions to re-assess medical knowledge of adrenal insufficiency. The mean score on the adrenal insufficiency knowledge test went up from an average of 66.63% to 87.50% correct (Figure 5).
In the pre-assessment, we asked the learners whether they had more knowledge of thyroid disease or adrenal insufficiency, and they were more confident in their knowledge of adrenal insufficiency. It was interesting to note that there was a discrepancy between the self-assessment and objective assessment. In the pre-assessment, learners overall answered 91.25% of questions correctly regarding thyroid disorder, but only 66.63% of adrenal insufficiency questions were answered correctly. The learners were initially overconfident in adrenal insufficiency and less than confident in thyroid disorder despite objective tests of medical knowledge indicating that they were less knowledgeable in adrenal insufficiency and had good knowledge of thyroid disorder.
During the debriefing session, the learners indicated that they were surprised that they were not able to diagnose adrenal insufficiency quickly from the onset of the simulation. We discussed the classification of primary, secondary, tertiary, and acute adrenal insufficiency, and how to differentiate them clinically. Defining types of adrenal insufficiency unexpectedly became the main focus due to extensive questions from the participants. There was less discussion regarding treatment of adrenal insufficiency. During our debriefing, the learners indicated they were more comfortable with initiating treatment with steroid therapy than they were in making the diagnosis.
Overall, the first-year internal medicine residents had the least knowledge of adrenal insufficiency and improved the most on our objective tests. This unexpected finding may be due to the third-year medical students having recently completed a knowledge-based medical board examination. Another possible explanation is the flexibility of fourth-year medical school resulting in variations in baseline knowledge in the months prior to starting residency training. As a result of these findings, this module may be best suited for first-year residents in internal medicine, emergency medicine, or family medicine, and upper-level medical students. Alternatively, it could be used for upper-level residents who may require remediation. Our case can be utilized alongside a MedEd adrenal insufficiency workshop to solidify basic science concepts .
A challenge to this approach is in representing a real-life scenario during the enactment of the scene. In hospitals that do not have standardized patients or simulation centers, it is important to fully prepare and guide the individual who will be performing as the patient in the scenario. For the sake of realism, the individual should develop a familiarity with the script, as well as rehearse the scenario prior to enacting the simulation with the learners. As noted previously, we incidentally found a similar simulation scenario published in MedEd from 2015 in which a patient with sarcoidosis presents with adrenal crisis . It is reasonable to consider that sarcoidosis predisposes patients to adrenal insufficiency in ways that we had not originally anticipated. Further investigations of hospitalized patients with adrenal insufficiency may determine whether sarcoidosis is correlated with an increased incidence of adrenal insufficiency than in other disease processes when chronic steroids are abruptly discontinued.
Overall, feedback from our residents as determined in a five-point Likert scale, as well as objective tests of knowledge, showed we were able to improve knowledge and comprehension of adrenal insufficiency within a short period of time using a learner-based scenario. The success of our simulation in developing participants’ medical knowledge adds to current evidence showing that using simulation scenarios as an adjunct to teaching improves education and enhances comprehension.
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A Sarcoidosis Patient Presents with Adrenal Insufficiency: A Standardized Patient Scenario for Medical Students and Residents
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Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.
Cite this article as:
Malakooti S K, Simon L V (June 18, 2018) A Sarcoidosis Patient Presents with Adrenal Insufficiency: A Standardized Patient Scenario for Medical Students and Residents. Cureus 10(6): e2833. doi:10.7759/cureus.2833
Received by Cureus: March 12, 2018
Peer review began: June 10, 2018
Peer review concluded: June 12, 2018
Published: June 18, 2018
© Copyright 2018
Malakooti et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.