Professionalism
TO THE EDITOR: With regard to the editorial on professionalism by Hafferty (Nov. 16 issue),1 fu- eling the “hidden curriculum” is the day-to-day dis- connect between academic leaders, who establish standards, and trainees, who are expected to meet them. In medical education, the distance between these goals and actual practice can be vast. For ex- ample, how do trainees respond to real-time chal- lenges to professionalism?
Role modeling is one response, although it may be insufficient alone.2 In his editorial, Hafferty rightly stresses personal reflection; at least one medical school encourages trainees and faculty to record signal clinical events when they occur for active reflection later.3 The benefits of role mod- eling and reflection might best be combined in organized reflection groups, facilitated by experi- enced clinicians chosen for their high standards of professionalism. Such “master clinical profes- sionals” should be fundamental to the next wave of teaching professionalism, their time and exper- tise sought and rewarded.
Clayton J. Baker, M.D. University of Rochester School of Medicine and Dentistry Rochester, NY 14642 clayton_baker@urmc.rochester.edu
1. Hafferty FW. Professionalism - the next wave. N Engl J Med 2006;355:2151-2.
2. Stern DT, Papadakis M. The developing physician - becom- ing a professional. N Engl J Med 2006;355:1794-9.
3. Inui TS, Cottingham AH, Frankel RM, et al. Educating for professionalism at Indiana University School of Medicine: feet on the ground and fresh eyes. In: Wear D, Aultman JM, eds. Professionalism in medicine: critical perspectives. New York: Springer, 2006:165-84.
THE EDITORIALIST REPLIES: Baker’s concerns about the “day-to-day disconnect” between ideals and their manifestation on the shop floor and his com- ments about the remedial importance of “signal clinical events,” role modeling, organized reflec- tion groups, and “master clinical professionals” are excellent points. I would add only that all socio- cultural and occupational groups routinely nor- malize their life and work practices and settings. One consequence is that appreciable segments of a group’s daily routines slip uncritically beneath (in this case) any such “professionalism radar.” Efforts to monitor the workplace for issues of professionalism should therefore be not only or- ganized and proactive but also hypervigilant. Out- siders (those who are not part of the occupation- al group with its assumptions about the way things are and should be) thus need to be involved in the monitoring process. Patients are one such group. Others include new recruits, members of other (related and unrelated) occupational groups, and trained social observers such as anthropologists and sociologists. The ultimate goal is high-qual- ity patient care, and professionalism is too impor- tant a part of this praiseworthy effort to be left solely to insiders.
Frederic W. Hafferty, Ph.D. University of Minnesota Medical School Duluth, MN 55812 fhaffert@d.umn.edu
Case 36-2006: A Pregnant Woman with New Hypertension
TO THE EDITOR: The Case Record discussion by Klibanski et al. (Nov. 23 issue),1 concerning a woman with hypertension due to a cortisol-pro- ducing adrenal adenoma, illustrates that serious forms of secondary hypertension (e.g., pheochro- mocytoma and Cushing’s syndrome) can present in an unorthodox fashion in gestation. However, the normal ranges in Table 1 of the article appear to be for nonpregnant populations. For example, a serum sodium level of 145 mmol per liter is hy- pernatremia during pregnancy. Increases in glo-
merular filtration rates and creatinine levels above 0.9 mg per deciliter are suspect; the published upper limits of 1.5 mg per deciliter for creatinine and 25 mg per deciliter for urea nitrogen are too high for pregnant women. Gestational changes in protein filtration increase normal amounts of protein excreted into the urine to a limit of 300 mg per 24 hours. In Table 2 of the article, normal production, secretion, and circulating levels relat- ed to the renin-aldosterone axis change in preg- nancy; this patient’s renin level (twice the upper
limit for a nonpregnant person) is normal for preg- nancy. Similarly, there is conflicting information regarding biologically active circulating cortisol and other variables in the pituitary-adrenal axis2; only recently have attempts to set rigid criteria to diagnose adrenal disease in gestation been pub- lished.3
Marshall D. Lindheimer, M.D. University of Chicago Chicago, IL 60637 mlindhei@medicine.bsd.uchicago.edu
1. Case Records of the Massachusetts General Hospital (Case 36-2006). N Engl J Med 2006;355:2237-45.
2. Molitch ME. Pituitary, thyroid, adrenal, and parathyroid disorders. In: Barron WM, Lindheimer MD, eds. Medical disor- ders during pregnancy. 3rd ed. St. Louis: Mosby, 2000:101-46. 3. Suri D, Moran J, Hibbard JU, Kasza A, Weiss RE. Assessment of adrenal reserve in pregnancy: defining the normal response to the adrenocorticotropin stimulation test. J Clin Endocrinol Metab 2006;91:3866-72.
TO THE EDITOR: We disagree with the choice of glyburide as initial treatment for gestational dia- betes mellitus in the patient discussed by Kliban- ski et al. Glyburide has been shown to be effec- tive and safe in treating gestational diabetes1 and is increasingly being used by physicians as an al- ternative to insulin. However, data do not support the use of glyburide in all patients with gestation- al diabetes. The degree of hyperglycemia, based on the fasting blood glucose level and the 1-hour postprandial blood glucose level, has been shown to be predictive of the failure or success of treat- ment with glyburide.2-4 Other significant predic- tors of glyburide failure include advanced mater- nal age (34 years vs. 29 years, P=0.001) and earlier diagnosis of gestational diabetes (at 23 weeks vs. 28 weeks, P=0.002).2 Glyburide treatment is 8.3 times as likely to fail in women in whom gesta- tional diabetes was diagnosed at less than 25 weeks of gestation as in those in whom the diagnosis was made at or after 25 weeks.2 Gestational diabe- tes diagnosed at 16 weeks and 6 days in a 35-year- old patient with a 1-hour postprandial blood glu- cose level of 346 mg per deciliter suggests a high risk of glyburide failure.
Aman Khurana, M.D. Namita Vinayek, M.D. Sioux Valley Hospital University of South Dakota Medical Center Sioux Falls, SD 57117 akhurana@usd.edu
1. Langer O, Conway DL, Berkus MD, Xenakis EM, Gonzales O. A comparison of glyburide and insulin in women with gesta- tional diabetes mellitus. N Engl J Med 2000;343:1134-8.
2. Kahn BF, Davies JK, Lynch AM, Reybolds RM, Barbour LA. Predictors of glyburide failure in the treatment of gestational diabetes. Obstet Gynecol 2006;107:1303-9.
3. Rochon M, Rand L, Roth L, Gaddipati S. Glyburide for the management of gestational diabetes: risk factors predictive of failure and associated pregnancy outcomes. Am J Obstet Gyne- col 2006;195:1090-4.
4. Chmait R, Dinise T, Moore T. Prospective observational study to establish predictors of glyburide success in women with gestational diabetes mellitus. J Perinatol 2004;24:617-22.
TO THE EDITOR: In the case discussed by Kliban- ski et al., Dr. Utz states that “after the operation, glucocorticoid replacement with dexamethasone was begun” and then says that “prednisone (5 mg twice daily) was continued throughout the preg- nancy.” The otherwise excellent discussion that fol- lows does not touch on glucocorticoid coverage during pregnancy. Dexamethasone would have been a poor choice for replacement of this moth- er’s glucocorticoid needs because it readily passes the placenta as a result of its low affinity to ma- ternal corticosteroid-binding globulin and lack of metabolism by placental steroid-metabolizing enzymes (mainly 11ß-hydroxysteroid dehydroge- nase).1 Prednisone is a better choice, despite its long half-life2; it is also preferable when endoge- nous cortisol levels need to be monitored, although this depends on the assay.3 We have used hydrocor- tisone, a substrate for 11ß-hydroxysteroid dehydro- genase, at the usual dose of 12 to 15 mg per square meter of body-surface area without maternal or fe- tal complications in pregnant patients at our insti- tution,4 and we recommend its use for glucocorti- coid replacement in pregnant women with primary or secondary adrenocortical insufficiency.
Constantine A. Stratakis, M.D.
National Institutes of Health Bethesda, MD 20892 stratakc@mail.nih.gov
1. Diederich S, Hanke B, Burkhardt P, et al. Metabolism of syn- thetic corticosteroids by 11 beta-hydroxysteroid-dehydrogenases in man. Steroids 1998;63:271-7.
2. Malchoff CD, Carey RM. Adrenal insufficiency. Curr Ther En- docrinol Metab 1997;6:142-7.
3. Pujos E, Flament-Waton MM, Paisse O, Grenier-Loustalot MF. Comparison of the analysis of corticosteroids using different techniques. Anal Bioanal Chem 2005;381:244-54.
4. Lindsay JR, Jonklaas J, Oldfield EH, Nieman LK. Cushing’s syndrome during pregnancy: personal experience and review of the literature. J Clin Endocrinol Metab 2005;90:3077-83.
THE DISCUSSANTS REPLY: We agree with Lind- heimer that the normal values for several labora- tory tests reported in Tables 1 and 2 of the Case Record do not apply to pregnant women. However, our laboratory, like others, reports normal ranges established in the laboratory from samples from nonpregnant persons. Although normal ranges have been reported for some of these tests at vari- ous gestational ages, these ranges are not report- ed by most clinical laboratories, including ours. It is the responsibility of the physician caring for the patient to know whether the patient is pregnant, the gestational age of the fetus, and the expected values for that stage.
We agree with Khurana and Vinayek that in patients with more severe degrees of hyperglyce- mia early in pregnancy, treatment with glyburide
is more likely to fail to achieve adequate metabolic control. This was true in the patient under discus- sion, which is why we started to give her insulin as soon as we saw her.
We agree with Stratakis regarding glucocorti- coid replacement during pregnancy. In this pa- tient, dexamethasone was started postoperatively, as is routinely done to assess cure of Cushing’s syndrome, before the use of prednisone replace- ment for the remainder of the pregnancy at the doses stated in the text. As Stratakis notes, hydro- cortisone is also recommended.
Anne Klibanski, M.D. Michael F. Greene, M.D. Massachusetts General Hospital Boston, MA 02114
Correspondence Copyright @ 2007 Massachusetts Medical Society.
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