A patient without a pituitary gland?

"Please see my MRI. Something is very wrong," my patient, Ms L. said to me.

I looked at her carefully. She appeared to be close to tears. Then I opened the large folder containing her MRI scan pictures and looked at the radiologist's report first. It read: Empty sella syndrome. There was no other abnormality in the scan.

"Who sent you for this scan?" I asked.

She looked embarrassed when she told me that she had been referred for the scan by a doctor in a private hospital because of her headaches. Of course I knew that she had been suffering from headaches because she had been my patient for over 2 years and I was treating her for migraine.

"I went to this doctor because some of friends told me that I should get a second opinion for my headaches," she explained.
"So, what did the doctor say after seeing this scan?"
"He said that I did not have a pituitary gland. He said I needed tests for different kinds of hormones." After a pause, she continued, "I cannot afford the costs of all those tests."

It was a familiar story. Patients are often attracted to doctors who "scan them" believing that scanned images of their bodies are better than clinical judgement.

I looked sympathetically at Ms L. How should I start explaining to her that she could not have lived all these years if she did not have a pituitary gland? Then I told her that the empty sella syndrome is a radiological diagnosis only. It simply means that the pituitary gland is not seen on MRI scans. Just because it is not seen on the scan, does not mean it is not there. Many people with the empty sella syndrome have normal pituitary function.

I ordered the tests for the relevant anterior pituitary hormones - TSH, FSH, LH, ACTH and Prolactin - and spent time reassuring her that her headaches were not due to a brain tumour. Two weeks later, I reviewed the results of these tests and found them all to be normal. Ms L was relieved.

"I wonder where my pituitary gland is hiding," she murmured.
With a straight face I told her, "We will not search for it with any more scans."

Even after she left, her question kept haunting me. Where was the gland if it was not in the sella tursica? I must find the answer to that.

When a doctor prescribes a drug with uncomfortable side effects.....

A 35 year old woman came to my clinic in the hospital because she had noticed discharge of milk from both her breasts. Her last pregnancy was more than 4 years ago. Her physical examination was normal. I wondered if she had hyperprolactinemia and I requested a test for the same.  I also asked her about her menstrual cycles and whether she experienced any hot flushes because I was aware that increased prolactin levels diminished secretion of estrogen from the ovaries. She said that her menstrual cycles were erratic. She did not have any hot flushes. I should have discussed about libido but I did not. Anyway, the serum prolactin levels were high in her and that made me suspect that she had a prolactin secreting tumour in the pituitary. I examined her cranial nerves, pupils, optic disc and visual acuity and field of vision. Nothing abnormal was detected.

The patient was worried when she realised that she might have a tumour in the brain. I explained to her that such tumours were never malignant and that, in most cases, it was so small that we did not even call it a tumour. Instead we called it a microadenoma. She wanted to know how small it was. I told her that a microadenoma is, by definition, something that is less than 10mm in diameter and I showed her how small it looked on paper.

An MRI was then done for her. It confirmed a microadenoma of the pituitary. I then tested her thyroid function and her serum cortisol level because, even though it was only a microadenoma, I wanted to make sure that it was not impinging on the function of the adjacent parts of the pituitary gland. These tests were normal.

In consultation with an endocrinologist she was then offered treatment with a dopamine agonist. We offered her bromocriptine because that was the only drug available with us in the hospital. I knew though that the best dopamine agonist for reducing serum prolactin was cabergoline. Dopamine agonists are also used to treat Parkinsonism and my patient had an uncomfortable moment when the pharmacist who dispensed her medication told her that she had Parkinsonism. It took me awhile to reassure her that she did not have that neurological disease.

When she began to suffer nausea and vomiting because of the bromocriptine, she consulted another doctor in a different hospital. Following the advice there, she underwent transsphenoidal resection of the microadenoma. This is a technique where the tumour is excised through an incision in the nose so that the lesion can be approached through the sphenoid sinus.

She came back to see me after the surgery, happy that she did not have to take the bromocriptine anymore. I learnt something useful from this encounter: when a doctor prescribes a drug that causes uncomfortable side effects, the patient blames the doctor, not the drug!

IMEC 2013

A report on some aspects of the International Medical Education Conference (IMEC) held in the International Medical University, Bukit Jalil, in March 2013.

The keynote address by Ronald Hardin was about excellent teachers for the 21^st century. He spoke on the type of teachers that we needed - comparing the different types of teachers to Carps, Sharks and Dolphins. Carps, he said, just muddled along without drawing attention to what they were doing, being interested only in maintaining the status quo. Sharks were aggressive and always wanted to win. They saw the world as filled with either winners or losers. The teacher of the 21^st century, Ron Hardin said, should be neither of these types. Instead they should be like the Dolphins who have good strategies and learn from previous experience. Dolphins like to win but they do want others to lose. Such teachers, he said, are unyielding on their principles unless those principles no longer make sense and they act on the big picture while being aware of the small details.

Cees van der Vleuten from Maastricht University, The Netherlands, spoke on how assessment should be used in medical schools for learning instead of being a mere tool for measuring learning.

A debate on whether professionalism can only be instilled by role modelling was held between Trudie Roberts from the University of Leeds and Dato’ Sivalingam from IMU. The debate was lively and filled with humour and references to people in music, arts and literature. The conclusion was that, while role models are important, professionalism should also be actively promoted as a goal in medical education.

A few of the research papers that I liked…..

1. A study looked at the awareness of palliative care among final year medical students and found that these students were aware of, and had interest in, this field.

2. A paper was presented on the adverse health effects of using Facebook. The authors found increasing social isolation from family and community as well as other adverse changes in health and behaviour occurred in medical students who used Facebook for an average of 2.5 hours or more per day.

3. A paper on plagiarism by medical students found that when students who indulged in plagiarism were counselled by mentors and peers, instead of being summarily punished, they showed improvement.  

4. A study looked at the role of nurses in the training of medical students and found that nurses do make significant contributions in this regard.

5. How do pre-clinical students view problem-based learning? A study found that while students generally like the PBL method of learning, their learning through PBL sessions can be improved by having smaller groups, by using better triggers, and by having content experts as facilitators.

6. A paper presented findings on how students are better able to understand illnesses from patients’ point of view when they are encouraged to write, and share, their own experiences during the time when they themselves were ill.

7. Google search is a useful tool for medical students when they wish to analyse clinical information and make diagnoses, according to a paper which studied the ability of fourth year medical students to make an appropriate diagnosis from clinical data.

8. End of life attitudes among final year medical students were surveyed in a study. The study showed that most medical students feel that decisions regarding life-prolonging treatment should be made by groups of doctors, nurses and other involved parties and not individually by anyone.

9. Do students use printed books or electronic books for study? A paper from University Technology Mara found that, for Pathology, medical students still use printed textbooks even though they have access to the Internet. Another study from Monash University found that second year medical students used mainly online resources instead of printed books.

10. A study on peer assisted learning found that when final year students are given the opportunity to teach medicine to third year students, both groups benefit from the program.