Rotation Handbook

01 Skills & procedures

Concrete, checkable skills. Track them; we'll sign off on what you demonstrate.

Data interpretation

• Download and interpret a CGM report: time in range, time below 70 and below 54, coefficient of variation, GMI, and the ambulatory glucose profile pattern
• Interpret pump and automated insulin delivery data: basal profile, bolus behavior, missed boluses, override patterns
• Calculate and adjust a correction factor and insulin-to-carbohydrate ratio, and explain the rules of thumb behind them
• Interpret a thyroid panel including discordant and interfering patterns (biotin, heterophile antibodies, assay issues)
• Read a DXA report: T-score versus Z-score, site selection, least significant change, and when a repeat scan is not useful
• Interpret a thyroid ultrasound report and apply a risk-stratification system to an FNA decision
• Interpret dynamic testing appropriate to your level

Patient-facing skills

• Teach injection or pen technique, including site rotation and lipohypertrophy assessment
• Teach hypoglycemia recognition and the 15-15 rule; teach a family member glucagon administration
• Deliver sick-day rules for insulin-treated diabetes
• Conduct a teach-back to confirm understanding of a changed regimen
• Counsel on a new GLP-1 or dual agonist: titration schedule, GI side effects, and what would make them stop
• Communicate an abnormal or serious result clearly and compassionately

Examination & procedures

• Thyroid examination, including describing a nodule accurately
• Comprehensive diabetic foot exam with monofilament and vibration testing
• Injection-site inspection for lipohypertrophy
• Observe, then assist with, in-office thyroid ultrasound (residents: progressive hands-on)
• Observe, then assist with, ultrasound-guided thyroid FNA (residents: progressive, at the supervising physician’s discretion)

Procedural participation is always at the supervising physician's discretion and requires the patient's consent to learner involvement. Skills are logged in your program's system; we verify what you actually performed, not what you observed.

02 Access, cost & systems of care

The part of endocrinology no lecture covers — and the part that most often determines the outcome.

A perfect regimen the patient cannot obtain is not a plan. We expect every learner above the observer level to leave here able to:

• Ask about cost routinely, as a normal part of the plan rather than an awkward aside, and adjust when the answer is a problem
• Explain how a formulary works — tiers, step therapy, preferred agents — and why the "right" drug is sometimes the second-best one
• Draft a prior authorization that has a chance of succeeding: what the payer needs documented, what phrasing matters, and what to do with a denial
• Navigate Medicare Part D and Advantage coverage for insulin, CGM, and endocrine medications, including the documentation CGM coverage requires
• Know the real safety nets: manufacturer assistance programs, discount cards, community resources — and where they fall short
• Recognize supply interruptions as a clinical event — a patient who ran out two weeks ago has a supply problem, not a control problem
• Use the whole team and understand who does what: MAs, nurses, diabetes educators, pharmacists, and front-desk staff who often know a patient's situation better than the chart does
• Close loops reliably: results communicated, referrals confirmed, follow-up booked before the patient leaves

03 Milestones through the rotation

A four-week arc. Compress or extend proportionally for shorter or longer rotations.

• Before day onePaperwork complete, EHR access requested, and two or three personal learning goals emailed to your supervising physician.
• Week 1 — Orient and observeLearn the clinic flow, the team, and the EHR. Shadow, then begin seeing straightforward follow-up patients. Aim to present at least one patient per session. Expect heavy correction on presentations — that is the point of week one.
• Week 2 — Take ownershipCarry 3–5 patients per session independently. Draft your own notes and pend your own orders. Start committing to a specific plan before precepting, every time. Midpoint feedback happens at the end of this week — ask for it if it hasn't been scheduled.
• Week 3 — Add complexityTake on new patients and more complex follow-ups. Work through a full diagnostic arc on at least one case — nodule, hypercalcemia, adrenal, or pituitary. Begin the systems work: a prior authorization, a denial, a CGM coverage request. Choose your presentation topic.
• Week 4 — ConsolidateRun a near-full panel with efficient, focused presentations. Deliver your 8–10 minute teaching presentation. Complete your case log, finish every open note, return your acknowledgment form, and sit down for your final evaluation and a conversation about where you're headed.

Shorter rotations: one- and two-week learners follow the same arc compressed — ownership by day three, midpoint feedback at the halfway mark, and a shorter presentation or a written case reflection instead of a formal talk.

04 How your goals are assessed

The evidence we use, mapped to the competencies your program grades on.

05 Our commitment to you

Teaching is a two-way agreement. Here's our half of it.

You are joining a busy subspecialty clinic caring for people with diabetes, thyroid disease, osteoporosis, and adrenal, pituitary, and reproductive disorders. Many of our patients have been with us for years. You are joining a relationship that already exists, and we take that seriously — which is the reason behind most of what follows.

While you are with us, you can expect that we will:

• Orient you on day one to the clinic, the team, the EHR, and where things live
• Give you a defined role appropriate to your training level, not busywork
• Precept every patient you see, every time, with a licensed provider
• Give you specific feedback in real time, plus a scheduled midpoint check-in
• Protect teaching time even when clinic is full — and tell you honestly on the days it isn't possible
• Complete your evaluation forms on time, and write letters when we can speak to your work with confidence
• Treat you respectfully. If any member of our team, or a patient, treats you otherwise, tell the supervising physician or education coordinator directly. We will address it.

06 Before your first day

Complete these in advance. We cannot let you see patients until they're done.

• Affiliation agreement in place between your school or program and the clinic, signed by both parties
• Proof of liability coverage through your training program — we do not extend clinic coverage to learners
• Immunization and TB records current, including annual influenza vaccination in season
• HIPAA and privacy training completed; your program's module is acceptable — send the certificate
• Signed confidentiality agreement with our clinic, separate from your school's
• Background check and drug screen per your program's requirements
• EHR access request submitted at least one week ahead. Access is provisioned to match your role and deactivated the day your rotation ends
• Name badge showing your full name and training level, worn visibly at chest height at all times
• Your learning goals — two or three things you want from this rotation, emailed to your supervising physician before day one

07 Attendance & punctuality

Clinic starts when the first patient is roomed, not when you arrive.

• Arrive 15 minutes before the first scheduled patient. Use that time to review the schedule, pull up labs, and identify who you'll be seeing
• Stay until the work is finished — last patient seen, notes drafted, and released by your preceptor. Clinic does not end at a clock time
• Notify us before the start of the day if you'll be absent or late. Text or call the supervising physician and the education coordinator — not a classmate, and not a message left with the front desk after the fact
• Planned absences (interviews, exams, conferences, religious observances) require written notice at least two weeks ahead, approved by us and your program
• Illness: stay home if you are febrile, vomiting, or have an infectious respiratory illness. Our patients include people who are immunosuppressed and people with poorly controlled diabetes. Do not come in to prove your commitment
• Excessive absence — generally more than 10–20% of scheduled days, per your program's standard — may mean the rotation cannot be credited. We'll tell you as soon as we think you're approaching that line
• Duty hours and rest apply here as anywhere. If our schedule would push you past your program's limits, tell us. We will adjust; we will not ask you to under-report

08 Dress & appearance

Business professional plus a clean white coat, unless told otherwise.

09 Professionalism & communication

The behaviors we notice, in both directions.

With patients

• Introduce yourself accurately, every time: name, training level, role today. "I'm Sam Patel, a third-year medical student working with Dr. Varughese." Never imply you are a physician if you are not one, and never let a patient's assumption stand uncorrected
• Ask permission for your involvement and accept a decline gracefully. Any patient may decline to be seen by a learner, for any reason or none. That is their right, and it is not a judgment of you
• Use person-first, non-judgmental language. "A person with diabetes," not "a diabetic." "Blood sugars are above target," not "bad" or "non-compliant." Say "hasn't been able to take it" — then find out why
• Chaperones are offered and documented for every breast, genital, or rectal exam, and available on request for any exam. As a learner, do not perform a sensitive exam without both the supervising provider present and a chaperone
• Knock, wait, and confirm before entering. Sit down when you can. Ask before touching. Cover the patient back up

With the team

• Introduce yourself to the medical assistants, front-desk staff, and nurses on day one, and learn their names. They will teach you more about how this clinic actually runs than anyone
• Ask before taking a task off someone's plate, and never redirect staff work without checking with your preceptor
• Answer email and secure messages within one business day, from your institutional address — never personal email for anything clinical
• Say "I don't know." It is always the right answer when it's the true one, followed by "…but I'll look it up and tell you after clinic." Fabricating a number, a lab value, or an exam finding you didn't perform is the fastest way to end a rotation early
• If you make a mistake — wrong dose quoted, wrong chart open, something you forgot to pass on — tell someone immediately. We respond to disclosed errors with teaching. We respond to concealed ones very differently

10 Patient privacy & HIPAA

The one section with no gray area.

• Access only the records of patients involved in your assigned care that day. Not your family. Not your friends. Not yourself. Not a patient whose case sounded interesting. Every chart access is logged, audited, and attributable to your login
• Never share your login or work under another person's credentials, even for a moment, even if offered
• No photographs, screenshots, screen recordings, or video of patients, charts, screens, schedules, or whiteboards on any personal device — including for a case log or presentation. If you need an image for teaching, ask; there is an approved process with written patient consent
• De-identify everything you take with you. No names, MRNs, dates of birth, or addresses in your notes, on index cards, in your case log, or in any file on a personal laptop
• No clinical discussion in public spaces — hallways, elevators, waiting rooms, the parking garage, restaurants, rideshares. Voices carry farther than you think, and Houston is smaller than you think
• Log out or lock every workstation when you step away, even for thirty seconds
• Shred anything with patient information before you leave. Nothing goes home in a coat pocket

11 What you may do, by level

Your scope here is set by your training level and your program's agreement — not by how confident you feel.

Your supervising physician may narrow these based on demonstrated skill.

12 Supervision & escalation

Every patient, every visit, every learner — reviewed with a licensed provider before the patient leaves.

• You are never the final decision-maker. Every plan is discussed with and confirmed by the supervising physician before it reaches the patient. There is no such thing as a "quick one" you handle yourself
• Know who is precepting you each session and how to reach them, before clinic starts. If you don't know, ask at the huddle
• The supervising physician sees every patient you see, re-examining relevant findings and confirming the key history themselves
• Escalate immediately — interrupt whatever is happening — for: symptomatic hypoglycemia or glucose below 54 mg/dL, chest pain, altered mental status, suspected DKA or HHS, suspected adrenal crisis, severe symptomatic hypertension, features of thyroid storm or myxedema, suicidal ideation, or any patient who looks unwell to you and you can't say why
• Trust the "something's off" feeling. An early learner's discomfort is a real signal. Bring it to us before you finish reasoning it out
• If you cannot reach your preceptor, escalate to any physician on site, then to the clinic manager. Never wait it out, and never leave a patient unattended to go looking

13 Documentation & the EHR

Your note is a legal document and a clinical handoff, not a homework assignment.

• Document only what you personally did. If you did not perform part of the exam, it does not appear in your note. Ever
• Notes are drafted, not signed. Every learner note is reviewed, edited, and attested by the supervising physician, who remains responsible for its content and for the billing based on it
• Same-day completion. Draft notes are finished before you leave, so your preceptor can attest and close the encounter. Charts left open overnight are the second most common reason a rotation review goes poorly
• No copy-forward without verification. If you carry a prior assessment forward, you own every word of it — including the medication list, the A1c, and the resolved problem still listed as active. Clean it up or don't carry it
• Reconcile the medication list at every visit: insulin doses, GLP-1 dose and titration date, supplements, and what the patient is actually taking versus what's on the list
• Be specific with endocrine data. Record A1c with date, CGM time-in-range and time-below-range with the download period, insulin regimen in units with timing, and hypoglycemia frequency, severity, and awareness — not "sugars okay"
• No documentation of a plan not yet approved. Write the note after the preceptor discussion, or clearly mark the plan as pending review
• Never chart under someone else's login, and never ask staff to enter something you should be entering yourself

14 Clinic flow & presenting

How a session runs, and what a good presentation sounds like.

The rhythm of the day

1. Pre-clinic huddle. We review the schedule, flag complex patients, and assign who you'll see. Come having already looked at labs and last visit's plan
2. See the patient. Aim for 10–15 minutes for a follow-up, 20 for a new patient. Watch the clock — a preceptor waiting on you delays every patient after
3. Present outside the room, concisely, then discuss
4. Return together. The preceptor confirms findings and finalizes the plan with the patient. Stay in the room and listen — this is where most of the teaching actually happens
5. Close the loop. Draft the note, pend the orders, arrange follow-up
6. End-of-clinic wrap. Five to ten minutes of teaching, questions, and feedback before you leave

A good endocrine presentation

Two to three minutes for a follow-up, five for a new patient. Brevity is a skill we'll help you build — if you run long we'll redirect you, and that's teaching, not criticism.

15 Making the most of your time

Habits that separate a rotation you remember from one you sat through.

• Read about your own patients the same night. Twenty focused minutes on the patient you saw today beats two hours of a chapter you'll forget
• Bring one question to the end-of-clinic wrap every day — clinical, practical, or about the specialty itself
• Ask to see the unglamorous parts: refill queues, results triage, prior authorizations, the call schedule. This is most of what a practicing endocrinologist's week actually contains, and no one shows it to you in lecture
• Follow a patient across visits if the timing allows. Seeing what your plan actually did is the single most valuable thing available to you here
• Use our education library. Our patient education articles and clinical calculators are the same materials we hand our patients — knowing them makes your counseling far more concrete
• Own your case log if your program requires one — de-identified, and completed daily rather than reconstructed the night before it's due
• Revisit your day-one goals at the midpoint. If you're not on track for them, say so; there's usually still time to fix it

16 Feedback & evaluation

No one should be surprised by their final evaluation.

• Real-time feedback is normal here and is not a reprimand. If we correct your presentation or exam technique in the moment, that's the rotation working as designed
• Midpoint check-in: a scheduled 15-minute conversation about what's going well and what to change while there's still time to change it. Ask for it if it hasn't been scheduled by the halfway point
• Final evaluation is completed within two weeks of your last day, on your program's form, reflecting clinical reasoning, professionalism, communication, reliability, documentation, and growth across the rotation — not a single bad morning
• You evaluate us too. Complete your program's rotation evaluation honestly, including the critical parts. We read them and change things because of them
• Letters of recommendation: ask directly and early, and be prepared for an honest answer. We would rather decline than write a letter that reads as lukewarm to a program director
• Concerns about your rotation — supervision, workload, mistreatment, or a grade you believe is unfair — go first to the supervising physician or education coordinator here, and in parallel to your program's clerkship director if you prefer. Raising a concern will not affect your evaluation

17 Health, safety & exposures

Know this before you need it, not after.

• Needlestick or body-fluid exposure: stop immediately, wash the site with soap and water (flush mucous membranes or eyes with saline or water for 15 minutes), then tell the supervising physician right away. Do not finish the visit first — timing matters for post-exposure prophylaxis
• We will complete a clinic incident report and direct you to occupational health or the nearest emergency department the same day. Notify your program's student or employee health office as well; they manage follow-up testing and cost coverage
• Standard precautions for all patients. Hand hygiene before and after every patient contact, no exceptions. Never recap a needle
• Know where things are on day one: sharps containers, glucometer and glucagon, emergency medications, AED, fire extinguisher and exits, and the emergency contact list
• If a patient becomes acutely unwell — hypoglycemia, syncope, chest pain, allergic reaction — call for help first, stay with the patient, and let licensed staff lead. Your job is to summon and assist, not to manage
• Your own health matters. Eat, hydrate, use the restroom, and speak up if you feel faint watching a procedure. Sitting down early is professional; fainting into a sterile field is not
• If you're struggling with stress, burnout, or mental health during this rotation, tell us or your program. We will accommodate what we can, confidentially

18 Devices, AI tools & social media

Assume anything you type anywhere is permanent and discoverable.

• Phones stay silenced and pocketed in patient areas. If you need to look something up, say so out loud — "let me check the dosing" — so the patient knows you aren't texting. Modeling that you look things up is good medicine
• Personal calls and texts happen in the break room, on your break
• AI and reference tools: you may use point-of-care references and general AI tools for your own learning, but never paste patient information — names, dates, MRNs, or a narrative detailed enough to identify someone — into any tool that is not our approved, HIPAA-covered clinic system. A de-identified clinical question is fine; the patient's story is not
• AI output is a starting point you must verify. It never substitutes for your own reasoning or your preceptor's judgment. Anything you present or document, you own. See our AI in Your Care page for how we use these tools with patients
• No social media about the clinic, its patients, or your rotation — including vague posts without names, photos of the building with staff visible, or a story a patient could recognize as their own. Small details are more identifying than people expect
• Do not photograph or record staff or other learners without their explicit permission

19 When expectations aren't met

What happens, in order, so there are no surprises.

1. Direct conversation. Most issues — lateness, an incomplete note, a presentation that isn't landing — are raised with you privately and directly, with a specific fix. This is the ordinary case, and it usually ends here
2. Documented feedback with a written plan and a date to reassess, shared with your program if the pattern continues
3. Notification to your program director for persistent professionalism concerns or unresolved performance issues
4. Immediate removal from the rotation for a privacy or HIPAA breach; falsified documentation; acting beyond your authorized scope; being impaired at work; harassment or discriminatory conduct toward patients, staff, or other learners; or any action that puts a patient at risk of harm

Removal is reported to your program and your school. We have very rarely needed to do this, and we state the standard up front precisely so we don't have to.

20 Acknowledgment

Sign and return before your first patient encounter.