Cushing's

This book is perhaps something a little different than most would expect. Firstly, it's a single-author book on Cushing's syndrome. It is not, like most textbooks, a compendium of edited submissions from multiple authors where there are often divergent opinions from one chapter to the next. Instead, it's a treatise reflecting my education and experience. It is not referenced but instead each chapter is followed by suggested readings. It represents my thoughts, understanding and a personal reflection on a career of evaluating a multitude of patients suspected of having the disorder and treating those confirmed to have hypercortisolism due to one cause or another. It reflects my perspectives of the art and science of the field.

In this book you'll find my personal opinions about all matters from diagnostic testing to approaches to management. I share patient stories that are particularly informative and indicate how I learned from those patients and built on the foundation of my knowledge to take better care of subsequent patients. I relate scientific information, results of studies, and comment on the utility and practicality of these results. While you are reading, you might learn a thing or two about statistics. I also relate some of the general essentials of the "art of medicine" that I have learned not only from professors I had encountered in my training and education, but also from my patients and colleagues as well as my nursing and administrative colleagues.

I trained in the era of what I like to think of as the modern-day Renaissance of "evidence-based medicine." This approach dramatically changed the face of medicine, the doctor-patient relationship, and even the influence of third-party payors and government entities. Unfortunately, however, much of the art of medicine has been seemingly deemed less important than data mining and interpretation. I firmly believe that most physicians can acquire the skills and attitudes required to practise medicine with artful expression while incorporating evidenced-based recommendations. Much of this book illustrates an approach to using data and knowledge with experience to formulate action plans for the benefit of patients. I don't think of the approaches I share as unconventional, but they may be unfamiliar to those who practise with an emphasis on evidence-based medicine and who have not seen a lot of patients with the set of disorders leading to Cushing syndrome.

I think of the art and science of our craft as the foundation of what we now call "medical decision-making." So many different factors need to be considered to make the right choices about diagnosis and treatment of diseases. Medical decision-making implies that one looks at all the evidence and facts about a patient, with an understanding of the applicable scientific evidence of medicine, and then utilises one's experience to make several decisions, including whether a diagnosis is present or absent, the need for further diagnostic studies, and the best approach to treatment.

This approach should treat patients as individuals, according to need based on a multitude of assessments. I have often said, that if you show me 100 patients with Cushing's disease, all with the same duration of the condition, identical biochemistry, and tumour sizes, you will show me 100 different illnesses. Everybody is different and I relate some examples in this book. Every patient deserves to be treated as an individual. This is where guidelines fail both physicians and patients. They try to fit square pegs into round holes where all patients are treated equally or according to a formulaic approach rather than according to individual needs. I suggest that physicians use their minds to devise an evaluation and management plan rather than defaulting to and following a guideline. If you're unable to do so, then you probably should refer the patient to an expert.