Figure“The time has come,” the Walrus said, “To talk of many things: Of shoes—and ships—and sealing-wax— Of cabbages—and kings—” —Through the Looking Glass, Lewis Carroll “Team approach” has become a popular medical buzzword, and in our mind's eye we easily envision a perfect interdisciplinary alliance of healthcare experts with diverse expertise. By contrast, traditional medical teams often seem more like restrictive closed shops. In its conventional application, the word team lacks nuance—it simply denotes the involvement of two or more people in some aspect of a patient's care. Such teams are often composed of interchangeable cogs, frequently from a single subspecialty, created for administrative and clinical efficiencies in accomplishing a singular task. That is not always a problem; for many tasks, there really is a best way. A wide variation in skill, experience, philosophy, or training is counterproductive on a venipuncture team. Diversity of thought is detrimental when adherence to evidence-based protocols is essential; everyone on a stroke team should follow the same thrombolytic rules. How, then, should we design an ideal healthcare team? Should membership be multidisciplinary to garner diverse perspectives and fresh insights, or should members be interchangeable clones to guarantee consistency? In reality, medical teams exist for a variety of reasons, and we must know a team's objectives before deciding on its optimal composition. Clear definitions of purpose are essential; vague definitions create confusion and disruption. “When I use a word,” Humpty Dumpty said, in rather a scornful tone, “it means just what I choose it to mean—neither more nor less.” “The question is,” said Alice, “whether you can make words mean so many different things.” —Through the Looking Glass, Lewis Carroll The research study in this month's JAAPA (“Primary care provider type: Are there differences in patients' intermediate diabetes outcomes?” on page 36) takes an important look at one team approach to the outpatient management of diabetes. The composition of the teams (physicians, PAs, NPs) suggests a multidisciplinary approach. In reality, though, clinicians functioned asynchronously as interchangeable providers of equal ability. The result? Intermediate markers of quality of care (A1C, systolic BP, and lipid control) were the same for physician plus PA teams, for physician-only care, and for PA-only care. This is not surprising to anyone familiar with the PA profession, but it is important confirmation of the essential role of the PA profession in optimizing access to superb care for all Americans. A caveat: the intermediate markers measured in the study are important, but they are not the end-all of diabetes care. Patient care is a humanistic endeavor, and the statistical analysis of data sets can never capture the caring part of medicine. Adding a new medication might bring an A1C from 7.5% to 7% and check off a box in the gradebook of “reaching goal”; gaining patient trust while overcoming educational and psychosocial barriers to bring an A1C from 14% to 10% is a far greater accomplishment, but will never show up in the box score of “patients reaching goal.” Preventing a patient's death from hypoglycemia by allowing A1C to drift upward from 6.9% to 7.5% is a therapeutic victory of monumental effect, but it will be listed in the failure column if A1C is the sole marker of quality of diabetes care. Despite the ubiquitous use of statistical data as a surrogate for quality of care, we must remember that clinical excellence often is the result of the intangible components of a therapeutic relationship: “Not everything that can be counted counts, and not everything that counts can be counted.”1 As we create newer systems of team-based care and try to measure their value, we should not lose sight of the importance of a primary clinician who is recognized by the patient. Some things in medicine cannot be delegated. Relationship-centered healthcare, the trademark of PA care, is where the magic of medical care takes place. Improving patient health, the ultimate purpose of what we do, usually begins when a trusted provider asks a patient, “What can WE do better?” “We”—the alliance of a patient and a devoted provider—is still the most important medical team ever invented.

With recent articles and an editorial, the Journal of the American Geriatrics Society has taken the initiative to propose a revision in the way medical care is provided to older adults with multimorbidity to provide an increased focus on patient-centered care (PCC). We encourage further submissions on this topic, particularly clinical investigation studies. In this article, we assert that the complexity of our current menu-driven care for older persons with multimorbidity can undermine PCC and must be revised. We state that we must shift from our current reimbursementdriven system with an exclusive focus on physician management of specific disease to a system driven more by patient preferences with a comprehensive view of the totality of care. This is especially important in hospital care. In recent decades, enormous progress has been made in the care of older persons, including those with multimorbidity. Patients with major acute and chronic medical disorders, who might not have lived previously, now routinely survive. Medical science and subspecialty medicine now drive care that enables most medically complex older patients to live longer than would have been expected a few decades ago, but this progress has created questions about the process of care. Our view is that care of older persons has become too menu driven, based on lists of medical problems, with insufficient attention to patient goals regarding function and quality of life and the inherent tradeoffs in complex care. The current piecemeal approach to care of complex multimorbidity can result in iatrogenic complications, excessive testing, and high-technology interventions, plus patient and family confusion. Although improvements have been made in tracking clinical detail and in linking medical records across sites of care, our current arcane computerized medical records exacerbate work complexity and take time and focus away from detailed interactions with patients. Our rapid growth in sophistication has been accompanied by ever-greater subspecialization and fragmentation, particularly in complex older patients. To feel competent to master the ballooning detail in each subspecialty, we tend to split areas of clinical focus into ever-smaller fields of endeavor. As inpatient attending physicians today, we frequently wonder who is looking at the overall big picture. In years past, this was the responsibility of the patient’s primary physician and the hospital ward team. These days, all care is compressed in time and space, which drives the internal medicine team to become scribes and servants for subspecialty experts who themselves have an increasingly narrow focus. The speed of this fragmented care is driven by our anachronistic reimbursement system, which rewards technology and interventions over personal care and a focus on functional status. With this growing fragmentation and narrowing of focus, we are now reminded of an activity from our youth: “paint by numbers.” As children, paint by numbers allowed us to follow a simplistic coloring format and create an image of the subject desired. The goal was to provide a template for potential artists to create a recognizable image. However, these images were lifeless and flat, and they failed to evoke any larger understanding or insight on the part of the viewer. On today’s hospital internal medicine wards, the combination of time pressures and volume incentives forces most of us to rely on simple menus and specialty recommendations as the primary drivers of our clinical decisions. We see vanishingly little evidence that guidelines and subspecialty opinions are applied after thoughtful deliberation of the complexities and tradeoffs of caring for older persons with multiple chronic disorders. Deliberation regarding care delivery for the individual patient has been replaced by a paint by numbers approach. We often see younger consultants relying primarily on their mobile telephones to get the right “recipe” of recommendations for a given older patient. Often, such consultants have much of the note written based on the chart and a report template before they ever see the individual patient. In times past, attending rounds would be the time when perspective and thoughtful deliberation could be applied, important for nuanced care and for role modeling how the seasoned attending artist can go beyond an initial paint by numbers approach. Now, we usually see regurgitation by both learners and faculty of a menu of standard recommendations focused only on a specific organ system. Little time is allowed for reflection and consideration of individual patient preferences or differences. We believe that this system of care has perverse effects on the training of new physicians and nurses. Our current paint by numbers system does not provide learners with a perspective on comprehensive or well-integrated care. In most hospitals today, physicians spend surprisingly little time examining and talking with patients or their families. House staff spend most of their time in computer rooms, in part to draft notes to facilitate faculty third-party billing. For expediency, rounds are frequently conducted in these same computer rooms and notes may be typed during these “rounds.” It is often not clear who has examined and discussed goals with the patient. In these settings, care plans are usually devised without patient or family input. At most, the house staff tend to report back to the patient and (occasionally) family what the care plan will be, with little input or discussion of goals and preferences. These rounds then take on a “flat dimension” devoid of humanity. DOI: 10.1111/jgs.15693

FigureLife is a series of discoveries; our cumulative discoveries become our life's education. When we are students, our teachers prearrange discoveries for us with specific goals in mind to form the basis of our formal education. Most of the major discoveries (“lessons,” if you will) in our lives take place out of the classroom, though. They are not formatted in any systematic style; they are encountered erratically, unexpectedly, inconsistently, and without prequel or pattern. They come to us in unanticipated contexts and usually at the most inconvenient times. Such discoveries often create an initial sense of disorientation, as we tend to encounter them when we stray away from familiar territory. Each life discovery, with its inherent discomfort, has the potential to change us, often in wonderful ways. Discoveries can be mundane or monumental. We might find a new shortcut to work that saves 10 minutes of driving every day (discovered after being forced into an annoying detour); a wonderful new restaurant (discovered by eavesdropping on a conversation); the work of a remarkable artist or author previously unknown to us (spotted on a friend's coffee table); an old photograph of the grandfather we never met (the ancestor responsible for all of our undesirable traits, according to mother, and thus the one who has always been our unsung hero); or perhaps $3.37 in small change under the sofa cushion, discovered while fishing for lost car keys. The word that best describes the unanticipated findings of life is one of the hardest words to translate from English into other languages. These fabulous occurrences that come out of nowhere and result in wondrous, unanticipated consequences are serendipitous discoveries. The English author Horace Walpole invented the word serendipity on January 28, 1754, to signify “a happy discovery made by accident.” He crafted the word from the story The Three Princes of Serendip. Serendip is an old term for Sri Lanka, and its princes were lucky travelers, for “as their highnesses traveled, they were always making discoveries, by accidents and sagacity, of things which they were not in quest of.” A serendipitous discovery leaves us better off than we were before. Sometimes the value is in the thing discovered; other times the simple joy of discovering is worth more than the thing discovered. If we pay attention, life often presents us with all sorts of possibilities for serendipitous discoveries. The exception is medicine. Without question, we do stumble across all sorts of unexpected things in our patients. Rarely, though, are these happy or fortuitous discoveries. Our medical discoveries tend to be abnormal physical findings and abnormal lab results. Medicine is different from most of life. In most of life, things could always be better. In medicine, being healthy is the ideal, the absolute, and you can't be better off than that. We don't consider the finding of an enlarged spleen or an elevated alkaline phosphatase or microscopic hematuria to be serendipitous, as they all portend a journey with potentially worrisome destinations. Serendipitous is not a medical word. If a discovery is tangential to our original search or purpose, found by accident, we label it an incidental finding. Incidental findings are not happy findings or serendipitous findings; they are a departure from the ideal state of health. They may not turn out to be anything serious, but they will be disruptive in the sorting out phase. The best we can hope from them is an ultimate neutrality, a conclusion that the incidental finding does not mean something bad. It can't mean anything good. At first I thought the question was a joke. After a month or more of unexplained dyspnea, nonproductive cough, and generally feeling lousy, a chest CT scan showed I was the owner of an extensive load of pulmonary emboli. I was hurried to the ICU to receive evaluation, oxygenation, and anticoagulation. My attending physician dropped in to check on my well-being, examine me, discuss my oxygen saturation, review my warfarin dose, ponder whether I needed a filter in my inferior vena cava, and wonder if I needed testing for aberrant blood clotting factors. I had been doing my best to be a good patient, which to me mostly meant “not being a doctor.” I trusted my healthcare team to make the necessary decisions about my care and to inform me of my status. Right then, it just wasn't my job to be a doctor. No problem. I was perfectly capable of not being a doctor, I was sure. The fact that I am a physician could not be totally overlooked, of course. It did create certain efficiencies. During my initial history and exam, I was asked, “Is there anything positive in your entire review of systems?” “No,” I replied, proud to be a part of the fastest review of systems in the history of medicine. There were some communication efficiencies too. Medical jargon was not an obstacle. My caregivers unabashedly used medical words and didn't have to explain concepts like pulmonary artery, V/Q mismatch, or right ventricular strain. “Oh, by the way,” my ICU attending said as he walked toward the door, almost as an afterthought after his previous wondering and pondering, “the CT also showed that you have a 2-cm nodule in your left adrenal gland.” Then he paused. Hmmm, I thought. I bet I am supposed to say something now, to react to this news. But this was too weird. When I am healthy and not a patient in the ICU—when I am “a doctor”--I am an endocrinologist in an academic medical center. I am consulted on a regular basis to evaluate patients with adrenal “incidentalomas.” I am the guy who gets called to see patients with incidentally discovered adrenal bumps. I am not the guy who has one. Typically, I am the doctor who would be called in to see … me. So, maybe the question was a joke, a quip to lighten the intensity of the intensive care unit. One of those bad news/good news one-liners: “Well, it could be worse; in addition to pulmonary emboli, you could have an adrenal incidentaloma to worry about too!” It was not a joke. My intensive care doctor was serious. I did have a bump in an adrenal gland. About 2 cm in diameter. Smooth edges. Benign in appearance. The other shoe dropped. “What would you like to do about it?” “What would I like to do with it? ... As in, me?” I had been doing my best to be the patient, remember? I remembered the words of Sir William Osler, “A physician who treats himself has a fool for a patient.” But now I had a problem. I had to answer a direct question. The answer, frankly, should have been easy. My “incidentaloma” had characteristics that screamed it was benign, as did the overall statistics around such findings for all patients. I had no clinical features to hint that it was making excessive hormones. I am relatively non-Cushingoid, at least by my own self-assessment, and nothing about me or my clinical course or on my blood pressure monitor or in my routine labs suggested I had Cushing syndrome or an aldosteronoma or a pheochromocytoma. And if an adrenal incidentaloma is benign and not making excessive hormones, we should just leave it alone. That's easy. But how should I answer the question? One option was to continue in my role as a trusting patient, untainted by any medical background, and answer, “Just do whatever you need to do. You are my doctor.” The second possibility might be a proposal, “Let's get an endocrinology consult.” Implying, of course, an endocrinologist who is not me. Third option, I tell the ICU attending what to do (“Nothing!”), as though I am functioning as an endocrinologist who is consulting on someone who is not me. Or would that self-consultation make things too strange? I would become a chimeric, two-beings-in-one-body creature if I made myself a patient-physician, a hyphenated being like a soldier-citizen or a student-athlete. (Are the two roles ever equal for hyphenated people? Doesn't one usually dominate? Would I be representing the best interests of the patient, who didn't need any tests? Or the doctor, who might recommend some testing “just to be sure,” because doctors are bad to do that?) In the back of my brain, I hear Osler scoffing. “A physician who treats himself [didn't you hear me the first time!?] has a fool for a patient,” he reminds me again. But the reality was simple. Options 1 and 2 leave open the possibility that more tests could be done, with my implied permission. And I don't want a cortisol measurement. I don't want catecholamine measurements. I am in the ICU with pulmonary emboli, tachycardia, and a right ventricle that is working overtime. Cortisol and catecholamines are stress hormones that can be (and should be) high under those circumstances. That doesn't make a disease; that makes physiology. Laboratory testing now resolves nothing, but it might create confusion, or even foster bad clinical decisions. (Shouldn't I be the patient's advocate here?) As clinicians, it is often difficult for us to avoid doing more tests to try to resolve uncertainty. In doing more testing, we often create more uncertainty. Clinical wisdom is often a matter of knowing what not to do. To get Osler's harping out of my head (can I disregard his wisdom?), I reminded him of something else he said, “Medicine is a science of uncertainty and an art of probability.” That should trump his other aphorism about having a fool for a patient. I knew the probabilities as well as anyone. And any uncertainties were going to have to be my uncertainties to live with. And the reality was that I did not have features of Cushings or a pheochromocytoma. I didn't want anyone checking my cortisol or catecholamines and generating uninterpretable results that would only lead to confusion. I was not a surgical candidate in any case; I needed anticoagulation to survive. Testing made no sense. All of those thoughts rushed through my brain in about 5 seconds, and then I answered my ICU attending before he even noticed any hesitation. I chose Option 3. “I don't need any adrenal workup right now.” I received a quizzical look and a shrug of the shoulders. His nonverbal reply seemed nonjudgmental in the gesturing, and I translated it loosely as: “OK … it's your life.” Hey! That was easier than I anticipated. I was geared for a big argument. It was my good fortune that the ICU attending for this week is known for being conservative in his test-ordering, and open-minded and attentive to his patient's perspective. I guess it was serendipitous that I came into the ICU when I did….Box 1

Twain has always been America s spokesman, and his comments on a wide range of topics continue to be accurate, valid, and frequently amusing. His opinions on the medical field are no exception. While Twain s works, including his popular novels about Tom Sawyer and Huckleberry Finn, are rich in medical imagery and medical themes derived from his personal experiences, his interactions with the medical profession and his comments about health, illness, and physicians have largely been overlooked.In Mark Twain and Medicine, K. Patrick Ober remedies this omission. The nineteenth century was a critical time in the development of American medicine, with much competition among the different systems of health care, both traditional and alternative. Not surprisingly, Twain was right in the middle of it all. He experimented with many of the alternative care systems that were available in his day in part because of his frustration with traditional medicine and in part because he hoped to find the perfect system that would bring health to his family.Twain s commentary provides a unique perspective on American medicine and the revolution in medical systems that he experienced firsthand. Ober explores Twain s personal perspective in this area, as he expressed it in fiction, speeches, and letters. As a medical educator, Ober explains in sufficient detail and with clarity all medical and scientific terms, making this volume accessible to the general reader.Ober demonstrates that many of Twain s observations are still relevant to today s health care issues, including the use of alternative or complementary medicine in dealing with illness, the utility of placebo therapies, and the role of hope in the healing process.Twain s evaluation of the medical practices of his era provides a fresh, humanistic, and personalized view of the dramatic changes that occurred in medicine through the nineteenth century and into the first decade of the twentieth. Twain scholars, general readers, and medical professionals will all find this unique look at his work appealing.

General Adaptation Syndrome: An Overview, David J. Torpy and George P. Chrousos. Developmental Considerations: The Fetal and Neonatal Endocrine Response to Stress, C. Richard Parker. Growth, Development, and Critical Disease, Pamela A. Clark and Alan D. Rogol. Pituitary Response to Stress: Growth Hormone and Prolactin, Mark E. Molitch. The Sympathoadrenomedullary Response to Critical Illness, Otto Kuchel. The Adrenocortical Response to Critical Illness: The CRH-ACTH-Cortisol Axis, Jay Watsky and Matthew C. Leinung. Adrenocortical Response to Critical Illness: The Renin-Aldosterone Axis, Paul I. Jagger. Thyroid Response to Critical Illness, Jonathan S. LoPresti and John T. Nicoloff. Pathophysiology of Water Metabolism During Critical Illness, Mary H. Parks and Joseph G. Verbalis. Alterations in Fuel Metabolism in Critical Illness: Hyperglycemia, Barry A. Mizock. Alterations in Fuel Metabolism in Critical Illness:Hypoglycemia, K. Patrick Ober. Critical Illness and Calcium Metabolism, Jack F. Tohme and John P. Bilezikian. Skeletal Metabolism in Critical Illness, Steven R. Gambert and Stephen J. Peterson. Testicular Function in Critical Illness, Stephen R. Plymate and R.E. Jones. The Female Gonadal Response to Critical Disease, Mark D. Nixon and Robert W. Rebar. Effects of Aging on the Hormonal Response to Stress, G.A. Wittert and John E. Morley. Index.

Letters15 July 1997Twain: Differences of Opinion on the Worthiest of All OccupationsRichard L. Golden, MDRichard L. Golden, MDState University of New York at Stony Brook School of Medicine; Stony Brook, NY 11794Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-127-2-199707150-00037 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:I read with interest Dr. Ober's informative and entertaining paper [1]. Although the medical practices of the 19th century, particularly as viewed through the acerbic wit of Mark Twain, appear crude and often dangerous, it seems inappropriate to state that “Nineteenth century medicine was as stagnant as it was toxic; therapeutic bloodletting had been championed in James' Medicinal Dictionary of 1743, and it was still being strongly advocated in 1892 by William Osler.” In a broad sense, the therapeutics of the 19th century saw the discovery of emetine, chloral, pilocarpine, antipyrine, ephedrine, suprarenal extract, general anesthesia, antisepsis, ...References1. Ober KP. The pre-Flexnerian reports: Mark Twain's criticism of medicine in the United States. Ann Intern Med. 1997; 126:152-6. Google Scholar2. Osler W. The Principles and Practice of Medicine. New York: D. Appleton; 1892:530. Google Scholar3. Osler W. The Principles and Practice of Medicine. 3rd ed. New York: D. Appleton; 1898:135. Google Scholar4. Osler W. Typed letter signed to G. Gregory. Oxford: 25 July 1910. Google Scholar5. Twain M. Pudd'nhead Wilson: a tale. In: Cardwell G, ed. Mississippi Writings. Library of America; 1982:1029. Google Scholar Author, Article, and Disclosure InformationAuthors: Richard L. Golden, MDAffiliations: State University of New York at Stony Brook School of Medicine; Stony Brook, NY 11794 PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 15 July 1997Volume 127, Issue 2Page: 171KeywordsGeneral anesthesiaHemochromatosisPhlebotomyPneumoniaPolycythemiaPorphyriaRacial and ethnic issuesRadiation therapy ePublished: 15 August 2000 Issue Published: 15 July 1997 Copyright & PermissionsCopyright © 1997 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

By the time Mark Twain was born, in 1835, the political forces of Jacksonian democracy had created an era of unregulated medical practice in the United States. Licensure laws were almost nonexistent, and any citizen could practice medicine. Regular (''allopathic'') medicine was competing with at least two dozen other sects, including homeopathic, botanical, and hydropathic medicine. Although allopathy presented itself as the ''scientific'' branch of medicine and proclaimed the practices of the other sects to be ''quackery,'' its therapies were aggressive and toxic and had no proven advantage over the treatments used by competitors. Through the efforts of the American Medical Association (AMA), allopathic medicine eliminated its competition by promoting the reestablishment of licensure laws in the late 1800s. In a continuation of the same endeavor, the AMA sought to identify weak and inadequate medical schools and commissioned Abraham Flexner to write the famous Flexner report of 1910 (the year of Mark Twain's death).Twain, an insightful political observer and social critic who was familiar with the competing medical systems and the medical politics of the 19th century, questioned the wisdom of limiting patients' medical options. He doubted the competence and intentions of physicians as a group lit even as he maintained confidence in the abilities of his own physicians. He was critical of the empirical medical practices used during his youth, but he saw hope in the new scientific orientation of medicine in the early 20th century. Twain's commentaries provide a unique perspective on pre-Flexnerian medicine in the United States.

Pheochromocytoma, although rare, is associated with a high degree of morbidity and mortality if not recognized. A high degree of suspicion in patients with new-onset hypertension; hypertension with sudden worsening or development of diabetes mellitus; or a family history of MEN, neuroectodermal tumors, or simple pheochromocytoma should prompt biochemical confirmation with either 24-hour urine catecholamines (norepinephrine and epinephrine) or total MET (NMET plus MET). Following confirmation of the diagnosis, radiologic studies with CT and (if needed) MIBG are employed to localize the tumor. Surgical removal is the only definitive therapy. Medical management with alpha-blocking agents, to control symptoms and prevent a hypertensive crisis, is generally advocated for 2 weeks preoperatively and intraoperatively. Occasionally, beta-blockers, employed only after adequate alpha-blockade, are necessary to control tachycardia and tachyarrhythmias. High-dose MIBG and combination chemotherapy have been used adjunctively to treat malignant pheochromocytoma, although neither modality provides lasting satisfactory results. Normal urine assays performed 2 weeks postoperatively ensure the complete removal of all tumor. Additionally, lifelong follow-up (yearly initially) is necessary to detect any signs of benign recurrence or malignancy because these have been reported to occur as long as 41 years after the initial surgical resection. Biochemical evidence of excess catecholamine production usually precedes the clinical manifestations of catecholamine excess when these tumors recur.

The endocrine response to stress is complex. Elevations in the serum concentrations of the "classic" stress hormones, epinephrine and cortisol, occur following many kinds of physiologic challenge and are accompanied by elevations in corticotropin, GH, and glucagon levels. These changes are probably responsible for the hyperglycemia and hypercatabolism common to most critical illness. If volume depletion is present, vasopressin, renin, and aldosterone secretion are also likely to be stimulated. These hormones, if present in excess, may produce fluid retention and hyponatremia. In some critically ill patients, there is a dissociation of renin and aldosterone production called hyperreninemic hypoaldosteronism, but the clinical importance of this syndrome is poorly understood. Thyroid hormone metabolism is commonly affected by critical illness, which results in characteristic abnormalities of thyroid function testing known as the euthyroid sick syndrome. The reproductive axis is exquisitely sensitive to physiologic stress; hypogonadotropic hypogonadism is a common finding in critical illness. The ongoing challenge to the clinician is to determine whether seemingly abnormal hormone measurements in critically ill patients reflect an appropriate homeostatic response to severe illness or, instead, whether they denote an independent metabolic disorder that might actually cause or contribute to the patient's unstable condition. In view of the exceedingly complex (and poorly understood) interactions involved in the human response to a severe illness, a thoughtful approach to the whole patient is essential and far preferable to indiscriminate hormone testing. Such testing, at best, may be uninterpretable in light of the clinical circumstances or, at worst, may lead to therapeutic misadventures.

A previously healthy 34-year-old woman developed diabetes insipidus 5 months after an uncomplicated pregnancy and delivery. MRI showed marked thickening of the pituitary stalk and prominence of the median eminence of the hypothalamus, with a somewhat small anterior pituitary gland. Further endocrine testing documented mild hyperprolactinemia and evidence of Hashimoto's disease (elevated TSH and an elevated titer of antimicrosomal antibodies). The radiographic abnormalities resolved spontaneously over the next 3 months, leaving a partially empty sella turcica. The prolactin level also normalized, but diabetes insipidus persisted. Although the diagnosis was not biopsy-proven, this case has a number of features that are typical of lymphocytic hypophysitis (which are discussed); however, unlike the typical presentation of lymphocytic hypophysitis (in which anterior pituitary involvement is prominent, usually as a pituitary mass with anterior pituitary hypofunction), this case is unusual in its presentation with diabetes insipidus and in the localization of radiographic abnormalities to die pituitary stalk and hypothalamus. These features expand and further define die spectrum of the clinical presentation of lymphocytic hypophysitis. This patient's course confirms the recent observations of others that the natural history of this disorder may be that of a self-limiting disease with spontaneous resolution. As a result, the risks associated with confirmation of the diagnosis by biopsy (or surgical resection of involved tissue) are unnecessary and inappropriate if the clinical presentation is consistent with lymphocytic hypophysitis, and if subsequent follow-up demonstrates the anticipated radiographic normalization (as seen here and in other cases). Empty sella syndrome may represent the end stage of lymphocytic hypophysitis in some patients.

Pituitary apoplexy is a clinical syndrome of headache, visual deficits, ophthalmoplegia, and alteration in mental status resulting from the sudden hemorrhage or infarction of a pituitary adenoma. Infarction of a normal gland also may occur in certain circumstances. Its manifestations are variable, ranging from a clinically benign event to a catastrophic presentation with permanent neurologic deficits or even death. It frequently mimics other intracranial processes and, without a high index of suspicion, may be difficult to diagnose. Radiographic studies, particularly CT and MR imaging, are helpful for diagnosis in both the acute and subacute settings. In its most fulminant presentation, prompt neurosurgical decompression is necessary to preserve sight and life. Corticosteroid replacement is also essential in the acute phase because of the high incidence of adrenal insufficiency. Fortunately, however, with proper management most patients may have good outcomes.

Acute adrenal insufficiency is a rare disorder associated with high morbidity and mortality if allowed to progress unrecognized. A constellation of nonspecific symptoms including weakness, easy fatigue, nausea, anorexia, and weight loss are typical features of adrenal insufficiency. The index of suspicion should be particularly high if the patient has hyperpigmentation; hyponatremia and/or hyperkalemia; a history of autoimmune disease (hypothyroidism, diabetes) or recent prior use of exogenous steroids or if the patient is on anticoagulant therapy. Any decline in clinical status (hypotension, fever, decreasing mental status), especially in the setting of an acute intercurrent illness, should be treated aggressively, even before laboratory confirmation of the diagnosis. Diagnostic testing is fairly straightforward and readily available. The development of purified synthetic corticosteroid preparations has provided a safe and effective means of replacement. Early awareness, recognition, and intervention remain significant steps in altering the course of acute adrenal insufficiency.