Stories [8] How Not to Reassure (or Treat) a Patient

23 08 2010

The host of the next edition of the Grand Rounds is Fizzziatrist at A Cartoon Guide to Becoming a Doctor. Thus it is no surprise that the theme of this edition is “Humor in Medicine”. The Fizzziatrist:

When I host Grand Rounds, I will post the links in order of how many times each one made me go “ha!” (…) It’s all quite scientific.

Well that’s a tough job. First both as a medical librarian and  a patient, I’m not in the situation to experience a lot of the humorous aspects of a doctors job. Furthermore I’m not the HA-HA-HA LOL-REAL SCREAM type. I’m more of the smile and the grin.

So what to do? I hope you find the following enjoyable. And perhaps many little ha’s do make one big HA.

——————–

How not to reassure (or treat) your patients (own experience)

My GP (the leading character in this story; he resembles a bull in a china shop, sometimes, but other than that, he is o.k.)

  • At one of my first visits he was trying to (manually) find the card of my husband. 
    When he thought he found it, he muttered:
    “that old guy?”
    Apparently he had mistaken my father (I still had my maiden name) for my partner.
    Lucky (both for me and my gp)  he was wrong. But how embarrassing if he
    had been right.

    wikipedia (CC)

  • Once I phoned him for I don’t know what and he said:
    “I’m not seeing  you often”
    “Why, is that bad?”
    “Well, it is exceptional”
    “Exceptional?”
    “Yes, I see women of your age regularly”

    “For what kind of disease, if I may ask”.
    “Well, the flu .. and for pill or IUD-controls”
    [sneering] “Sure, but I’m never seriously ill and I have a gynecologist for the latter”.
  • When I was pregnant of my second child, I phoned him for a prescription for anti-Rh antibodies, which I needed for prenatal testing. Since I hadn’t visited my gynecologist after my first child, and the hospital nurses had assured me that gp’s and midwives normally prescribed, this should not be a problem.
    I began: “I’m a few weeks pregnant and ….”
    He interrupted me, confused: “but that..….. but ….. you were pregnant a few months ago“.
    He was half right. I had had a miscarriage then. (Dang! A heavy blow)
    After a curt explanation, I hung up.
  • Later he phoned me back (with a thin excuse) and I asked him for the anti-Rh antibodies, but he just didn’t get it.
    Ask your  midwife”.
    “But I don’t have a midwife”
    “Everyone has got a midwife, nowadays”
    “No, I got a gynecologist”
    “Then  ask your gynecologist”
    “But  I’m not his patient anymore”
    “Then ask him to be your doctor again”
    “But I need the prescription right now“.

    I tried to convince him in vain. He finally mumbled something like: That is of my beat, I don’t do pregnancies and deliveries anymore.
    [luckily one phone call to the gynecologists’ wife was enough to get the prescription. She passed the message immediately, and said that if I liked him to take care of me again, it was best to make an appointment soon after the test.]
  • My gp had the same attitude another time.  I had signs of a Addison crisis. I tried to explain to him what might be wrong. He asked one or two things, shrugged and then said: “You better make an appointment with your specialists. This disease is beyond my practice.”
    At the time it seemed ok to me, but my endocrinologist said it was irresponsible: “Suppose he wouldn’t immediately refer someone with an acute crisis: that could be fatal. [I was hospitalized in this case, but it was not that urgent] See also “the Doctor and the Patient”
The Doctor, by Sir Luke Fildes (1891)

Image via Wikipedia

My gynecologist/obstetrician [a friend of mine recommended him, because he was kind and puts you at ease. It really is a wonderful doctor, and after all those deliveries he still considered birth a miracle. However, his way of reassuring was not always effective]. 

  • March 31, late afternoon: “It is time to get your baby ( 2,5 weeks post-term), but we better postpone it for two days. It is not such a nice day to celebrate the child’s birthday, don’t you think” (meaning April Fools day)
  • When I had my first check-up he warmed the speculum, trying to break the ice with some humor: “they do warm the cutlery for each course at the Chinese”, don’t they?
    (I found it rather tasteless, but remained silent: he meant it well)
  • When we discussed where I would deliver, he said that that would be in his hospital. I sighed with relief. As any new mother I was nervous about it.
    But he didn’t want me to have false expectations:
    Of course I hope I can personally deliver your baby. However, the chances are real that someone else will be around at that time. But believe me, if the moment is there, you don’t care who stands at the foot of your bed. Even if it is a gorilla..”

My Dentist (the best, most skillful, pleasant dentist there is, but still ….  a dentist)

  • Once, just finished drilling, she said carefully: “Don’t be scared when you look into the mirror….. I just touched your tongue”.

This concludes my experiences.  If you would like to read more serious stuff about “how (not) to reassure”, then you can read this old article The Art Of Reassurance (PDF) or this recent blog post at « HealthSkills WeblogIs reassurance reassuring?

One main advise (from the latter blog):

Never reassure a patient about something they are not already worried about. It would be a mistake, for example, to earnestly reassure patients that they do not have cancer when the thought had never entered their minds!”

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The New PubMed: Trick or Treat?

31 10 2009

31-10-2009 8-53-21 the new pubmed entry

The New PubMed: Trick or Treat?

After a long days work, when looking at the screen,

there it was: PubMed’s new interface, so it seemed,

But one blink – and it had gone

To come back the following dawn.

The change itself was long announced,

we could play with the new “Advanced”.

Still I postponed and procrastinated,

Pointless: the new PubMed couldn’t wait

any longer, but this Redesign isn’t it for me….

Sure, the front page looks web-2-ish, minimalistic & clean,

which is perfect for the Google-Generation,

the hurry-don’t think-just-slash-i-got-one-publication-

PhD’s, for whom all alterations have been made. 2989360212_882aff28d8 trick or treat

Some people think you just have to wait

& see and get used to it.

but I’m already fed up with it.

I know you all think it is just a Librarian-rant.

Librarians they can stick with the new “Advanced”,

“Advanced” however, is just Limits & Index…

But boy did they make this page look complex!

Sure, the basic researchers seem to be quite pleased.

Busy physicians too, they think it is more easy.

They tell me librarian not to wine:

Go MEDLINE OVID! we stay with this design.”

This is no new idea, didn’t you know:

I long seek refuge in OVID MEDLINE, although1810987271_9044fb5ca0 candy

only for exhaustive searches, that much is true.

So why -having this alternative- am I still feeling blue?

Well, I’m not complaining for myself, but for you.

I don’t speak as a searcher, but as a teacher too.

It is so frustrating that I have to explain to you

that each step you take is now multiplied by two.

NLM says all functionalities are still there.

The problem is you have to find where

I don’t mind the present front page,

but the so called “Advanced” gives no advantage,

at least not for doctors searching evidence.

I teach them “Googling doesn’t make sense“.

Just choose the most important concepts,

work from the History and search words separately.

Begin to find the MesH-terms, and although it is complex

add textwords too, to find papers not yet indexed.

Combine synonyms with “OR” and concepts with “AND”,

Go to the Clinical Queries and use the appropriate command”..

But now it takes so many steps. It is a BIG FAIL

sometimes. You start at the front page, look at the Details,

mapping is wrong, go to Advanced, scroll, scroll, scroll..

to Mesh, “send to Pubmed”, where am I? out of control,

again on the Start page? Go to Advanced again.

Away with Limit and other boxes! – I don’t need them!

The Index yields a MeSH that doesn’t exist?!

Darn, via automatic mapping the multi-term-word is split

in 3 separate words, complete out of context,

as I see In the Details -so I have to re-enter them,

And where have the Clinical Queries gone?

Right, have to scroll the entire “Advanced” page… Yawn…

While it is true that I’m a “bit” exagerating,

my point is that the new PubMed creation

could have been so much better:

not only the functionality, the route also matters.

The redesign is a missed opportunity,

to build an entire new PubMed you see.

The interface is still quite orthodox.2946761628_2eb3e8b009 bittersweet

I want clickable and movable boxes

with MESH in clouds thru which you can “walk”

and Clinical Queries that you can drag and drop

with a mapping tool-you can adjust,***

and savings of your settings, that is  a must.

“But the new PubMed”, you ask me

“what is it: a-trick-or-a-treat?”….

“It looks like a nicely wrapped candy,

but tasting a bit bittersweet?!”

Notes

* These links come from Eagle Dawg-blog: Pubmed: All in the attitude

** doesn’t apply to quick and dirty searches on the front page

*** i.e. allow to split or not

Photo Credits:

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The importance of early intervention in Addisonian crises

27 10 2008

In a previous post entitled “changing care for addison patients“ (see here), I mentioned that Addison’s disease is often misdiagnosed and Addison crises not adequately dealth with.

“I’m by no means an exception. Addison’s disease is often missed or diagnosed late. That early diagnosis can be a challenge is frequently addressed in the medical literature and many poignant examples can be read on patient forums. In fact I know very few prompt and swift diagnoses.”

“…But there are far more upsetting stories of other Addison crises. Even in this era there are unnecessary deaths due to inadequate intervention.”

While preparing this post I came across a recent paper in “Het Nederlands Tijdschrift voor Geneeskunde” (something like the Dutch Lancet) with a relevant clinical lesson on this very subject. It is entitled:

“Addisonian crisis in patients with known adrenal insufficiency: the importance of early intervention”, written by Mulder of the group of Professor Hermus from the Universitair Medisch Centrum St Radboud, Nijmegen.

The paper decribes 3 fatal cases of Addisonian crisis in patients with adrenal insufficiency, which formed the basis for the development of a regional protocol to prevent any further unnecessary death from Addisonian crisis (see PubMed abstract here).

The cases

Patient A was a 47 year old male with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Since this leads to deficient glucocorticoid and mineralocorticoid hormone production, replacement therapy consisted of daily replacement with glucocorticoid (hydrocortisone, HC) and mineralocorticoid (fludrocortisone).
A got a sudden gastroenteritis (acute abdominal pain, watery diarrhea, no fever), for which he doubled his HC dose. The next day he became weak and dizzy. The consulted physician didn’t deem parenteral cortisol (proposed by the patient’s partner) necessary, but prescribed loperamide instead. Indeed the diarrhea improved, but the condition of the patient worsened overnight, his temperature dropped to 34,4 C, he was confused and finally became comatose. Upon arrival at ED the hypotensive patient developed ventricular fibrillation. The neurological sequelae after CPR were so severe that active medical treatment was withheld, after which the patient died.

jmr_photo/2738016554/

The other two patients had panhypopituitarism and adrenal insufficiency secondary to their ACTH deficiency. With respect to replacement of adrenal hormones, these patients only require replacement of (ACTH driven production of) glucocorticoids, not mineralocorticoids. (On the other hand, they need extra replacement of other hypophysis-(regulated) hormones, like levothyroxine, gonadotropins and growth hormone).

Patient B, a 28 year old male got a sore throat and fever (41 C), for which he didn’t increase his HC-dose. His mother called a physician in vain: patient B didn’t respond and was found dead two hours later. Obduction showed tonsillitis, bronchopneumonia and an enlarged spleen, indicative of sepsis. This all took place in one and a half day.

Patient C was vomiting and had fever during a couple of days. Soon after her doctor visited her, she suffered a cardiac arrest and died. Her family physician was not familiar with her medical history nor with the prescribed medication. In retrospect, patient C had poor treatment compliance (never came to a consult and didn’t take replacement medication, including HC, for a year).

Conclusions

Even patients known to have adrenal insufficiency can develop a life-threatening Addison crisis in case of inadequate adjustment of the glucocorticoid dosage during intercurrent illness. Treatment consists of a high parenteral dose glucocorticoids, preferentially HC (because this also has a mineralocorticoid action).

The chance of hypovolemic shock accompanying a crisis is greater in patients with primary Addison, lacking mineralocorticoids (case A).

Preventive measures

These casualties led to a new protocol. According to the authors:

“Patients with known adrenal insufficiency, as well as their relatives and general practitioners, should repeatedly receive verbal and written instructions on how to deal with physical and severe psychic stress. We teach the patients and their relatives how to use an emergency injection of hydrocortisone, and the patients can consult the on-call endocrinologist by telephone 24 hours a day.”

I. Points to be adressed in the yearly instruction of patients with primary or secondary adrenal insufficiency, preferably in presence of his/her partner or close relative:

  • explain importance of glucocorticoid use.
  • describe the symptoms of an Addisonian crisis
  • give instruction on increasing glucocorticoid dose in case of illness or severe stress
  • stress the importance of an alert bracelet
  • verify whether the patient has an emergency ampule with hydrocortisone (i.e. Solucortef) at home
  • give instruction on the use of an emergency intramuscular injection (standardly given by a nurse)
  • inquire about traveling abroad, provide letter with advice in case of (written in English) if required*
  • provide written information, including telephone number of on-call endocrinologist (24 hours a day service)!!
  • In addition the family physician receives a yearly letter with a standard treatment advice in case of an imminent Addisonian crisis. He is advised to inform his colleagues at the Central GP post.

II. Advice to patients with primary or secondary adrenal insufficiency for dosage of cortisone in case of stress. Normal Dose is 15 to 30 mg HC daily (or equivalent dose of other glucocorticoid)

  • outpatient or dental interventions (i.e. local anesthesia): double HC dose before intervention
  • fever (>38 C), severe psychological stress** (difficult exam, death family member): at least triple HC-dose, i.e. 60 mg in the morning and 30 mg in the evening, taper till normal dose after symptoms are relieved. Contact doctor if there is no improvement.
  • vomiting or diarrhea, unconsciousness: parenteral administration of 100 mg hydrocortison by patient or partner (im) or physician (im, iv); direct consult of on-call endocrinologist, always check afterwards at ED
  • surgery or hospitalization: the treating physician should contact the patient’s endocrinologist for advice on dose adjustments.

What is special about this protocol is the 24h endocrinologist on call service, the earlier (and consistent) referral to endocrinologists and ED, in case of possible emergency, and the structural approach: all patients with adrenal insufficiency, including their relatives and physicians, are well-informed about the preventive measures that should be taken (including HC emergency ampule and alert bracelet).

That is a great improvement! Hopefully other regions and countries will follow this example.

Notes and Sources:

Sources: Mulder AH, Nauta S, Pieters GF, Hermus AR. Addisonian crisis in patients with known adrenal insufficiency: the importance of early intervention. Ned Tijdschr Geneeskd. 2008 Jul 5;152(27):1497-500. [Article in Dutch] (see PubMed abstract here).
* The Dutch Addison and Cushing Society NVACP since long has a small booklet “SOS stressboekje”, which is specially designed to inform physicians abroad when on vacation. Short guidelines for dosages of (hydro)cortisone in stress and medical information for physicians is translated in 6 languages.
** Advices based on what is usually advised in the literature. There is little evidence for a particular dose in case of physical or psychological stress.
Photo’s acknowledgments.
Burning and burned matches derive from Flickr, respectively from
http://www.flickr.com/photos/bholak/309005330/
and http://www.flickr.com/photos/jmr_photo/2738016554/

———————————————

De Nederlandstalige samenvatting van het artikel:
Addison-crisis bij patiënten bekend wegens bijnierschorsinsufficiëntie: het belang van vroegtijdig ingrijpen
A.H.Mulder, S.Nauta, G.F.Pieters en A.R.M.M.Hermus in het Ned Tijdschr Geneeskd. 2008 5 juli;152(27)

Dames en Heren,
Patiënten met een bijnierschorsinsufficiëntie kunnen over het algemeen goed functioneren indien zij worden behandeld met glucocorticoïden en – in geval van een primaire bijnierschorsinsufficiëntie – mineralocorticoïden. Tijdens ziekte, koorts en ernstige psychische stress is de natuurlijke
behoefte aan cortisol verhoogd. Patiënten met een bijnierschorsinsufficiëntie moeten in deze gevallen dan ook de substitutiedosering glucocorticoïden verhogen. Alhoewel zij tijdens de poliklinische controles hierover uitleg ontvangen blijken de instructies niet altijd adequaat te worden opgevolgd. De ernst van de situatie wordt soms door de patiënt zelf, en soms door de geraadpleegde huisarts of specialist, onvoldoende onderkend.
Met de beschrijving van de volgende drie ziektegeschiedenissen willen wij onder de aandacht brengen dat een addison-crisis bij patiënten met een bekend hypocortisolisme levensbedreigend is, en dat vroegtijdig adequaat ingrijpen noodzakelijk is. Tevens beschrijven wij de maatregelen die wij namen om patiënten nog beter te informeren over glucocorticoïdgebruik bij lichamelijke en psychische stress en om de bewustwording bij medebehandelaren te verhogen.





Changing care (for Addison patients)

19 10 2008

This post is inspired by the theme for this weeks Grand Rounds at PalliMed, a Hospice and Palliative Medicine Blog: “Changing Goals of Care”. According to Christian Sinclair, M.D. of Pallimed:

It can be changing the goals in any direction, not just the curative towards palliative route, although I expect that is a common touchstone for many in the medical field.

‘Goals of Care’ is a subject that is outside of my area of professional expertise, being a medical biologist and an information specialist.

But as a consumer and patient I can easily see how I would like health care to change.

  • affordable healthcare for everyone who needs it
  • More personal and personalized care
  • And -indeed- more attention for palliative healthcare (my mother in law has a bearable life, since low doses morphine were prescribed)

But those issues can be better addressed by persons in the field. I just simply want to restrict to “changing care in a very specific area, adrenal diseases, simply because I’m a hands-on expert, having secondary Addison’s Disease (Sheehan’s syndrome)”.

Main conclusions:
Healthcarefivers look (and act) beyond your specialty! Try to be a good generalist as well. Please adapt protocols if it suits the patients. Take the patient seriously.

Diagnosis
Primary Addison (damage or destruction of the adrenal cortex) as well as secondary Addison (absent pituitary signal(s)) often have a slow onset and are difficult to diagnose.
In theory this may be different for Sheehan’s Syndrome. According to Google Knol:

Sheehan’s syndrome (…) is a condition in which the pituitary gland is injured as result of heavy blood loss during complicated childbirth. This heavy loss of blood deprives the pituitary gland of oxygen and other nutrients and leads to necrosis (death) of pituitary tissue and therefore pituitary failure (hypopituitarism). Failure to produce breast milk after delivery (due to lack of the pituitary hormone prolactin) may be a presenting sign of Sheehan’s syndrome. Fortunately, Sheehan’s syndrome is now rare cause of pituitary failure, particularly in developed countries as a result of improved obstetric care.

Looking back I’m stunned that Sheehan was not directly diagnozed by the gynecologists themselves.
And perhaps even more surprised why it happened to me in the first place, being hospitalized in Europe, and having a previous cesarean. (For good reason it is: “Once a cesarean, always a cesarean” According to present protocols I had many negative predictors for success (no prior vaginal birth, short stature, age >40, induction of labor, gestational age almost 43 weeks, failed second stage), but worst of all they didn’t take me serious when I said I didn’t feel well and got a sudden neck pain. When standing up I fainted. So I have every reason to believe all this could have been prevented).

I lost more than 3 litres of blood (and had puerperal fever as well), developing all signs of Sheehan (and Addison crisis) in the days that followed: breast milk “disappearing”, loss of appetite, severe muscle pain, fatigue, headache, lethargy, extreme nausea, diarrhea & vomiting and finally speaking with double tongue, feeling like I fell when lying down, sensitive to cold etc. But nurses pressed to try to give breastmilk (till bleeding), reprimanded me in presence of other patients (you have to break the circle, please do your best (!) and eat something; you have to take care of your child, come on!) and a psychiatrist was being ordered. Finally (after 10 days), when I plead them to check whether I was not dehydrated, they did some tests and found out my blood Natrium was dangerously low (106; normal 140), and could apparently not be corrected by giving saline transfusion. I “missed’ this part, but when I woke up the internist told me proudly he found out I had Sheehan (practically no cortisol or any other hormones under regulation of the anterior hypophysis). Normal natrium levels were achieved after giving cortisol-replacement.

I’m by no means an exception. Addison’s disease is often missed or diagnosed late. That early diagnosis can be a challenge is frequently addressed in the medical literature and many poignant examples can be read on patient forums. In fact I know very few prompt and swift diagnoses.

For instance (from the Newsletter of “The Canadian Addison Society”, issue 27, 2002

After being admitted and discharged what seemed to feel like every weekend, I was finally admitted for bronchitis that affected my asthma. I went on Prednisone* to treat the infection. I felt much better to my surprise. After being “cured” of bronchitis, back in the hospital I went. The pain was unbearable; doctors were questioning if I was anorexic, I saw a psychiatrist who put me on Paxil because I “appeared” to be depressed. Demerol became my new best friend and was the only thing that put me at ease.
My mother continued to stay by my side the entire time. Whether it be stroking my hand, brushing my hair, or encouraging me to walk just a few steps a day. This felt like a marathon to me; in reality it was only a few steps.
After every “possible” test was completed my internist had suggested performing one more test. The results had come back positive! Addison’s Disease….**

(*Prednisone is a glucocorticosteroid that can replace cortisol; this patient also had pigmented handpalms, specific for primary Addison.)

well-ville.com/images/adrenalQA2.jpg

The same is true for other adrenal diseases. Cushing’s Disease (excess of cortisol) is often mistaken for (manic) depression. See for instance wrongdiagnosis.com or here (Dutch).

After years of non-recognized Cushing one of my fellow patients was treated by many specialists. One expert (being an orthopedic, I believe) totally missed the Cushing, because she fixated on other causes of the severe osteoporosis and didn’t notice the patient’s bruises, mania, belly fat, striae to name just a few other symptoms, typical for Cushing. Missing her diagnosis means she is mostly in a wheel chair now, and not able to do the things she liked to do (for those interested and able to read Dutch she has written a book about it: “Aftakelen and Ophijsen”)

Action (in case of a crisis)
With hormone replacement therapy, most Addison patients disease are able to lead normal lives. However extreme stress can precipitate an Addison crises, which is a medical emergency. Patients therefore often wear alert bracelets or necklaces, so that emergency personnel can identify them as having adrenal insufficiency and provide stress doses of steroids in the event of trauma, surgery, or hospitalization.

Luckily I don’t seem very vulnerable to crises (still producing aldosterone), but the one time I had something like it (presumably due wrong capsules, thus more insidious), family physicians reacted inadequatly. One gave me a lab form emphasizing twice that lab tests should ONLY be done when I was really, really ill. Very stupid, because determining Natrium costs nothing compared to hospitalization, and my pride prevented me taking the test, afraid that I made a fool of myself. My own physician said a few weeks later that I should consult a endocrinologist, because he found Addison “much too difficult”. I thought that wasn’t bad, but my endocrinologist didn’t agree, because “he would have been too late in case of a real emergency”. (I had a Na of 123, but was hospitalized, because my endo (a wonderful female doctor) found I behaved differently and wasn’t ok – I also lost >18 pounds in 2 months)

But there are far more upsetting stories of other Addison crises. Even in this era there are unnecessary deaths due to  inadequate intervention. What is also worrying is that paramedics often miss the alert bracelets. A Dutch paramedic wrote on the bulletin board of our patient’s association, that paramedics don’t even look at it, because they aren’t allowed to do anything going beyond first aid and stabilization. However, if my husband may give me an intramuscular injection of corticosteroids, why can’t a paramedic? It is the most essential emergency measure that can and should be taken. He advised that we would bundle our forces with other patient groups to change the protocols of the ambulance personnel. Paramedics won’t do anything when they are not legally entitled to.

I also hear from many Addison patients that it takes ages before there is adequate action. Apparantly routine tests have to be performed first. A nurse even told me that glucose is tested first, because it is such an easy and fast test. O.k. an addison crisis is often accompanied by low blood glucose. So what? Get those corticosteroids in!!! Intravenous injection is often difficult, because of the low blood pressure. It often takes too long and often fails, at least that is what I hear from other patients.

Iatrogenic Cushing and Addison

Apart from natural causes, Cushing and Addison’s disease can have a iatrogenic cause (unintended harmful effects by a physician’s activity, manner, or therapy). It is well known that longlasting treatment and/or high doses of corticosteroids can give Cushing-like symptoms as well as Addison-crises in case of sudden withdrawal (because of feedback mechanisms the body can’t make cortisol any longer).
Laurens Mijnders has developed long lasting Addison’s Disease because of his asthma treatment. His letter in Contrastma, a paper of a Dutch Asthma Foundation (Astma fonds) evoked many responses of patients who had used high doses corticosteroids (up to 50 mg/day Prednison per day). The reactions showed that doctors had given little or no information about adverse effects of corticosteroids and had never warned against a possible Addison crisis (see here).
An endocrinologist revealed at a meeting that they still regularly see Addison crises in patients who received high-dose steroids for their asthma, rheuma, dermatologic or other inflammatory condition
Of course some of these diseases can only be controlled by corticosteroids, but the treating physician should try to sail safely between Scylla and Charybdis, and prepare the patient for any (anticipated) danger.

Wasn’t it: “Primum non nocere” (Latin for “First, do no harm”)?!

Thus physicians, look beyond the border of your specialty and always take patients seriously, please?

Addison's disease info (nvacp)