'I'm Not Really an Expert on That...'
Medical training and subsequent experience generally lead to clinical proficiency, both with patients and with other specialists who seek your guidance. By now, I've encountered most of the variants of diabetes, from highly insulin-resistant people needing U-500 insulin injections 3 times a day to folks with gustatory neuropathies who describe their forehead breaking out in a sweat when they eat. (The first time I saw one of the latter, I had the good sense to watch him eat a sandwich instead of sending him to a psychiatrist.)

Richard M. Plotzker, MD

I've seen patients in whom radioiodine treatment for hyperthyroidism failed, and I've seen patients with refractory lipid disorders who were referred to the nearby university lipid research center in the usually unrealized hope that they might be able to do something I could not do with my prescription pad. Some of my hypogonadal male patients have Klinefelter syndrome, and I compare the size of their gonads with the wooden ovals on my Prader orchidometer; other men suspect they have "low T" after seeing a commercial on TV, but come to the office with a brand-new daughter sleeping in the wife's Snugli.

I see this wide range of patients, but am I really an expert on any of this, other than the high-grade insulin resistance? The short answer is probably not, but I am sufficiently familiar with these conditions to recognize them when I see them and research them as needed. Sometimes your professional title makes you the destination for some patients more than your real experience does.

I now approach my next invited grand rounds, on the truly excellent topic of residual pituitary tumors that persist after surgery. We have plenty of advances to convey: new medicines for residual Cushing' disease or acromegaly, and the gamma knife to help chip away at problems in the cavernous sinus, to minimize the infrequent misadventure of Nelson' syndrome, to remove adrenal glands and thus control hypercortisolism.

These advances are the fruits of creativity and doggedness by our most talented colleagues, who dedicate their professional lives to solving some of the most difficult medical conundrums around. But as much as I look forward to exploring these advances with the physicians at my medical center, the reality is that I have not sent anyone for a bilateral adrenalectomy since the 1980s; I have seen only 2 acromegalics since my fellowship, and I currently follow just 1 individual whose pituitary tumor could not be fully resected.

So, although I might be labeled as the resident expert here and can expect to see related questions on my board examinations every 10 years, I have not really dealt with these conditions much more than anyone else in the audience, unless the fellow who actually does the gamma knife therapy attends. Still, there is a benefit to familiarizing ourselves with conditions we may not encounter in clinical practice.

I remember in medical school being burdened with Goodman and Gilman's Pharmacological Basis of Therapeutics chapters on antihelminthic drugs or potions to reverse the ravages of the tsetse fly. Scurvy, night blindness, beriberi? No physician in the United States will see enough cases of this to acquire real expertise. Yet we need to be "resident experts" who can handle such conditions should they arise.

Someone must be available to manage the next person whose growth hormone and insulin-like growth factor 1 levels still test high after the pituitary surgeon has already done his or her part. We distribute that responsibility less by what we actually know and more by what people think we should know in a pinch. So, even though I hardly ever encounter a person whose pituitary tumor remains incompletely resected, knowing what to do for them still defaults in my direction.

I'd better go review the literature now in anticipation of acquiring more hands-on experience without advance warning.