Medical School 2020, Year 2, Week 27
From our anonymous insider…
Our last week of classes. Next week we take the block exam and after that we study independently for Step 1.
An endocrinologist specializing in thyroid disease leads 5 hours of lectures on the thyroid, the adrenal glands, and the gonads. She dedicated an additional 1.5 hours for the master pituitary gland, a pea-sized gland on the underside of the brain that regulates all the endocrine glands. “20 percent of normal individuals have a pituitary adenoma (benign tumor). Most are non-functional, and never will give the patient any issue. When I started teaching, there was a much lower threshold for removing these adenomas with transsphenoidal surgery [through the nose]. Now we typically wait and monitor.”
She described how several types of pituitary adenomas can now be managed with drugs instead of surgery. For example, the most common functional pituitary adenoma, a prolactinoma, which secretes the breast milk-producing prolactin hormone, causes amenorrhea and breast formation in both males and females. It can be managed with bromocriptine, a dopamine agonist. “These are much more common in females, but I do not know if this is because they are diagnosed easier in females than in males. Males predominately get breast formation, but with all the obesity in this country, most people will attribute this to the obesity horse, not the tumor zebra.”
What else is new in her practice? “Patients now have complete access to the same imaging reports we read. The patient reads her report and thinks, “Oh my God, cancer.” We call these incidentalomas.” She continued: “What do you do with this information? If we want to rule out a functional pituitary adenoma, we need to run another more expensive MRI study. It’s hard to tell these patients to not worry about this small tumor in their skull. I mean, I would want to know. It will be up to your generation to decide the the right course. With great power comes great responsibility!”
A fertility endocrinologist leads 2-hours on hormonal pregnancy changes. She described Sheehan’s syndrome, a emergent condition in which the pituitary gland infarcts (dies due to blood flow loss) because of loss of blood during delivery. “Throughout pregnancy, the blood volume expands considerably to supply the baby and all the demands on the mother’s body. The pituitary gland enlarges to meet the hormonal demand. If you lose too much blood during delivery, you are at risk of causing ischemic necrosis of the pituitary from hypoperfusion.” She concluded: “This is a terrific example of how medicine can improve lives. In the US, Sheehan’s syndrome occurs 3 times in 1 million births, whereas in India it occurs 3 times in 100 births!”
A recently-retired, Russian-trained physician discussed acromegaly (enlarged skull and soft tissue structures) and gigantism (enlarged bones). He brought in his former patient and current friend Conan, a 45-year-old accountant with acromegaly due to a growth-hormone pituitary adenoma. “Look at his chin, look at his forehead,” exclaimed the Russian. Mischievous Mary was a little taken aback by the physician’s bluntness in front of his friend. “If the adenoma occurs in childhood before the growth plates fuse, the child gets gigantism. This creates the tallest people in the world. If the pituitary adenoma occurs in adulthood, it causes soft tissue swelling (e.g., heart, tongue, hands, feet) and facial bone protuberance (brows, chin).” Patients die of hypertrophic cardiomyopathy and associated-arrhythmias if left untreated.
Thursday morning features an applied workshop with five stations, each run by a physician covering a rare endocrine disease. “In all your future careers you might see one of these diseases,” joked my first station internist. “The boards believe if you understand the pathology of the disease, though, you can understand more common issues.”
We had a station on John F. Kennedy. Most people know that John F. Kennedy had Addison’s disease (primary adrenal insufficiency) requiring cortisol shots. This is believed to have given him his characteristic bronze skin and round face. In addition to Addison’s, a review of JFK’s health records revealed a multi-endocrine autoimmune disease including hypothyroidism. We learned about other multi-endocrine organ disorders such as Multiple Endocrine Neoplasia 1 (parathyroid, pancreas, and pituitary adenomas; prevalence 1:100,000) and Multiple Endocrine Neoplasia 2 (pheochromocytoma, an adrenal tumor that secretes life-threatening levels epinephrine, and thyroid cancer; 1:50,000). The physician concluded: “both are highly testable on board examinations.”
Endocrine disorders may impair kidney function because hormones can determine how much salt and fluid to absorb. A station on renal disorders is led by a 75-year-old physician. Straight-Shooter Sally: “He must have had had a mid-life crisis and turned Zen.” My group struggled through the case on Conn’s syndrome (primary hyperaldosteronism), an adrenal tumor that secretes too much aldosterone, which increases fluid reabsorption in the kidney. Patients with Conn’s syndrome have hypertension (high blood pressure) due to increased blood volume. Most doctors work them up for idiopathic hypertension (unknown cause, as with 95 percent of U.S. cases). He continues: “Patients keep getting put on more and more anti-hypertensive drugs. This patient was taking 5 drugs at once. One simple lab test is all it takes.” Patients with Conn’s syndrome can be successfully managed with spironolactone ( aldosterone antagonist) or a curative surgical resection of the affected adrenal gland. “Listen up. If you want patients to love you, this is your chance. The patient that I diagnosed with Conn’s syndrome gave me the ‘World’s Greatest Doctor’ plaque that hangs in my office. I mean this is what it is all about.”
Our patient case: Janet, a 26-year-old ED nurse presents with fatigue, cold-intolerance, and dry hands after delivering her second child Charlie nine months ago. She is frustrated that, despite eating a restricted diet, she has not been able to lose 25 pounds of her pregnancy weight.
“I was a healthy person up until this. When this happened, I realized I really never had a general practitioner. It took several weeks to get an appointment with a doctor accepting new patients.”
[Editor: I wonder if Janet stuck around long enough to learn that her entire audience was seeking desperately to avoid becoming stuck in primary care.]
She continued, “My primary care physician’s first thought was depression.” (Postpartum depression afflicts 1 in 9, typically resolving within a year of giving birth.) Janet continues, “I was depressed because i was tired, not the other way around. Simple tasks were exhausting.” On the second visit, the physician tested thyroid function, which showed low thyroxine levels despite normal thyroid-stimulating hormone response. Janet was diagnosed with primary hypothyroidism due to Hashimoto’s thyroiditis (immune destruction of thyroid gland) and started on Synthroid, which she has been taking now for 30 years. Her aunt and sister are also on Synthroid for hypothyroidism.
Janet and her husband George are retired now and he joined her at the session. George said, “it is so clear in retrospect. Immediately after delivering Charlie, she lost all of her usual spunk and energy. I had just started a new job as a history professor when Charlie was born. I was working non-stop, but we hosted a family reunion. We were both so excited about the party when we planned it, but for most of the party she was sitting on the coach. When the party ended, she went straight to bed. Did not help clean up at all.”
Janet describes her cold-intolerance: “I returned to work a few months after Charlie was born. It was a beautiful spring day, but I just felt freezing everywhere I went. I took out my packed winter clothes and put them on to get to work. I just could not put on enough layers.” She added, “It did not stop there. I would get to work and go straight for the coffee machine. Not for the coffee, but to grab the pot to warm my hands. It was a physician co-worker in the ED who noticed that a crazy lady bundled up in winter jackets hogging the coffee pot should be seen.”
Janet concludes: “You guys are all young and healthy but you still need to get a doctor. You’ll need it when you least expect it. I truly believe this whole episode would have been resolved much sooner if I had a regular internist. You are not invincible!”
Fashionable Fiona, who has hypothyroidism as well asks, “Have you had any issues once you began Synthroid treatment? Have you switched doses?” Janet: “I have never had to adjust my dose. I once tried to switch to the generic version, but started to feel tired again, so my physician switched me back to the brand-name.” Our professor added: “I hear that a lot. The generic is identical for most drugs, but I see variability in biologics. The patent describes the chemical formula of the drug, not the manufacturing process. So different companies may prepare the compound differently.”
Despite Janet’s positive response, our lecturer cautioned us to be careful in prescribing Synthroid. “Everyone hears about the energy-boosting, weight-busting miracle of thyroid hormone. There are serious health complications if you take too much, and long-term use can damage the health of the thyroid. Be conservative in diagnosing hypothyroidism.”
I attend a conference for working orthopedic surgeons on Friday. An example hour-long lecture was on anterior lateral cruciate (ACL) ligament tears in female athletes, 4-6 times more common than among men playing the same high-risk sports. This is believed to be from several factors, including wider hips, decreased femoral notch width, and the impact of estrogen on connective tissue tensile strength. “Title IX is the gift that keeps on giving for orthopedic surgeons,” said the lecturer, but researchers are looking at screening and training processes to reduce injuries. “Sports physicians may be able to screen for ACL tear risk by measuring the mechanical forces with various exercises. Individuals with high risk need to begin training before they jump straight into competition. Several companies are developing tests to monitor neuromuscular synchronization to strengthen muscle tone via biofeedback to minimize the ligament load.”
Several classmates appear right before the free catered lunch. I overhear a few orthopedic surgeons discuss the impact of reimbursements being tied to outcomes and customer-reported feedback. “Medicine is now a product, health systems need good reputations, not just good care. In the past I might have told a patient that he didn’t qualify for disability, but today I would not confront him. I will just refer him out.”
An email titled “Self-Defense Class Sign-Up” from our Dean of Diversity and Inclusion: “This course is taught by [police officer] and [yoga instructor]. It is designed to help individuals who identify as female protect and defend against unwanted physical advances. Participants will learn general safety tips as well as defense techniques including kicks and strikes during the session. Every individual (faculty, student, physician, staff) who identifies as female is welcome to contact [yoga instructor] to participate.”
We are done with classes for our second year of medical school.
Statistics for the week… Study: 20 hours until burn out. Sleep: 8 hours/night; Fun: 1 night. Example fun: After our last day of class, 25 students go downtown to our favorite burgers and beers joint. We discuss our most memorable moments so far. Our class VP: “This was Year 1, Month 2. I was working at the free clinic with Dr. House. He asked, ‘The patient in Room 3 is having stomach pain, can you go in and report back your abdominal exam findings.’ I come out after a few minutes, and say, ‘Looks all good to me.’ He had gone in beforehand and diagnosed her with metastatic ovarian carcinoma that had spread to her peritoneum (abdominal cavity). Dr. House said, ‘Now you won’t make that mistake again’.” Lanky Luke: “I was waiting in the lab for a Path report for my research project. After 30 minutes, a freaking leg came through the door and the severed leg was just plopped on the pathologist’s table.”
More: http://fifthchance.com/MedicalSchool2020
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