7/8/2013
The Clinical Case Conference:
Solving Diabetes Mysteries

On this particular Tuesday, a group of clinicians and scientists convened to discuss the challenging case of an 18-year-old who was recently diagnosed with type 1 diabetes (T1D). Soon after his diagnosis at an outside hospital, he came to the Berrie Center for a second opinion, and arrived in such a weakened state that he needed a wheel chair to get out of the car and up to the office. 

His blood sugars were well controlled and he was not in DKA, thus his presentation could not be explained solely by his recent diagnosis of type 1 diabetes.  Due to his profound weakness and the severity of his abdominal pain, he was admitted to the hospital for further evaluation.

This case could have been the subject of a column in the “Think Like a Doctor” Section of the New York Times, or even (if it were still being televised) a segment on the medical mystery drama House; however it was a recent presentation that was given at the well-attended weekly Clinical Case Conference at the Naomi Berrie Diabetes Center. The eventual diagnosis for the teenager was so unusual—porphyria, a rare inherited enzyme disorder that has nothing to do with type 1 diabetes. This disorder was something that most of the clinicians and scientists had only read about in medical school.    

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Every Tuesday pediatric and adult endocrinologists, other clinicians, educators, fellows and research scientists at the Naomi Berrie Diabetes Center meet (over a healthy lunch) on the sixth floor of the Russ Berrie Science Pavilion and try to solve some of the more difficult problems they encounter, day to day, taking care of people with diabetes.  Discussions range from common issues, like management of obesity and insulin adjustments for exercise, to the unknown—like the teenager with porphyria. 

Dr. Lauren Golden, who has been running the conference since 2009, says that, “The conference is just one of the ways people benefit from being at the Berrie Center, which is always working to be integrative. As a patient, you’re not just seeing the person sitting across from you at a desk. Potentially, you are seeing everybody at the Berrie Center. That’s a lot of brainpower and diverse expertise.”

When Dr. Golden was asked to take over the Clinical Conference, it had been part of the education curriculum for Columbia’s endocrine fellows at the Berrie Center. “We decided to turn it into something more than just an educational experience for the fellows,” said Dr. Golden. “Now it’s education for the whole clinical and research team at the Berrie Center—and a chance for everybody to come together and work in a collaborative way.”

Cases presented at the Clinical Case Conference fall into three categories. “Sometimes we present a case as a pure teaching point,” said Dr. Golden. “Maybe it’s about medical management of type 1 or type 2 diabetes, steroid-related diabetes, HIV and diabetes, pregnancy and diabetes, neonatal diabetes, or cystic fibrosis and diabetes.”  Sometimes a doctor will present something where it’s not clear what’s going on, she said, a perfect example being the teenager with porphyria. “We are always looking for the input from the group of assembled clinicians and scientists, including the students and trainees.  The forum is very open to foster discussion and thinking outside-the-box.” 

The group also meets to discuss patients who have asked for help with various events in their lives such as athletic events—like the college graduate who wanted to climb Mt Rainier, or the long distance runner or scuba diver, both of whom wanted to know how to eat and adjust their insulin before, during and after an event. Educators and clinicians, who had worked through similar challenges in the past, suggested different approaches and ultimately, this lead to individualized recommendations for the specific patients.  Recently, a Hassidic rabbi addressed the group about the sensitivities of people with diabetes in the Orthodox Jewish community. 

If a landmark, important or controversial scientific paper is published, the conference is also used to present, analyze and discuss current literature.

“We run the gamut of topics,” said Dr. Golden, “but I do want to make sure that we cover certain core topics every year. I often take July and August for what we call the ‘bread and butter cases.’ The rest of the year I keep it pretty flexible for the cases and literature that are the most impactful.”

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