school that combines both medical and health care ... lottery. SIR,-I have great sympathy with the paediatric registrar who found that he or she had registered.
a short intravenous tetracosactrin test disclosed a baseline plasma cortisol value of 410 nmol/l, increasing after 30 minutes to 590 nmol/l. Unfortunatelv, the results were not immediatelv available and treatment was not started. Two days later another test was performed, showing further deterioration in adrenal function; the baseline plasma cortisol value was 470 nmolIl, increasing to 490 nmol/l after 30 minutes. Replacement treatment was started, and cardiovascular stability returned. We therefore suggest that in patients with septicaemia adrenal insufficiency should be suspected and a short intravenous tetracosactrin test performed. Treatment may need to be started before the results become available. When these are available the decision to continue treatment or not should be based on the increase in plasma cortisol concentration in response to tetracosactrin rather than its basal concentration. A peak plasma cortisol concentration of >400 nmolI may indicate a normal response in an outpatient but in a critically ill patient the "normal" basal concentration mav be much higher, at 550-1500 nmol/l. An increase in plasma cortisol concentration in response to tetracosactrin indicates that some adrenocortical response remains; no increase mav indicate a relative insufficiency. G R I'ARK P RAGGATT
Intensive (are Unilt, Addcnbrooke's Hospital, Carnbridgc C132 2QQ I Clavton RN. Diagnosis ot
adrcinal insufficiency. Br lIed j7
1989;298:271-2. '4 I-cbruarv.
2 Park (JR, Manara AR. A handbook of intensive care. Tunbridge Wells: Castlehouse Publications, 1988. 3 IMloore A, Aitken R, Buirke C. et al. Cortisol assays: guidelincs tor the provision otf a clinical bimohermistry service .Alnmnm C/in
Several factors may have contributed to the discrepancy between the results of the two tetracosactrin tests in these cases. Firstly, both patients showed some degree of adrenal reserve and neither presented with a life threatening adrenal crisis. Secondly, the short tetracosactrin test was performed before we started adrenal replacement so the adrenal glands were still subject to high circulating concentrations of adrenocorticotrophic hormone. This mav also explain why in case 2 the plasma cortisol values attained during the depot test were much lower than those attained during the short test. Both patients might have shown subnormal responses to the short tetracosactrin test if they had started treatment before testing. Dr Clayton alludes to this potential pitfall, but it is not mentioned in several medical and endocrinological texts. -6 As the use of the short test for excluding Addison's disease is so widely described"6 we reviewed its original description.- The accepted criteria for a normal short tetracosactrin test response seem to have arisen from the results obtained in 66 control subjects, but the test was validated by the subnormal responses of 40 subjects receiving long term prednisolone. Of nine patients with suspected Addison's disease, however, only one had a subnormal response. Even assuming that the remaining eight subjects all had normal adrenal function we are not sure why this test was subsequently adopted as a means of excluding primary adrenal insufficiency. Presumably it was not fully appreciated at the time that the adrenal suppression caused by long term glucocorticoid treatment is at least partly due to suppression of the hypothalamicpituitary-adrenal axis. We suggest therefore that there is a need to re-evaluate the use of the short tetracosactrin test in excluding Addison's disease. DOROTHY TRUMP GRAHAM C TOMS JOHN P MONSON WAYNE H BRADBURY
Blot/htmrn 1985;22:435-54.
SIR,-While we do not dispute that the short tetracosactrin test is valuable in diagnosing secondary adrenal insufficiency,' we have found this test to yield misleading results in two paients with primary adrenal insufficiency. Case I-A 32 year old Bangladeshi man was referred with a three month historv of excessive tiredness, generalised weakness, and pain in his legs on standing. His general practitioner had recorded blood pressures of 70/50 and 80/40 mm Hg. On examination there was a questionable increase in pigmentation of the lips and mouth, his blood pressure was 100/60 mm Hg when lying and 100/55 mm Hg on standing, and he was otherwise clinically eupituitary. On the clinical suspicion of Addison's disease physiological doses of hydrocortisone and fludrocortisone were started after a short tetracosactrin test. This showed a basal plasma cortisol concentration of 140 nmoUl (at 1500) rising to 560 nmol/l after 60 minutes. Nevertheless, we still suspected Addison's disease and a depot tetracosactrin test (1 mg intramuscularly) was performed after withdrawal of hydrocortisone. This showed a subnormal rise in plasma cortisol, from 125 nmol/l to 514 and 560 nmol/l at three and five hours respectively (a rise to over 1000 nmolUl being normal).) Case 2-A 29 year old white woman was referred with increasing tiredness, malaise, and dizziness on standing of several months duration. On examination there was pigmentation of the knuckles, lips, and mouth. Her blood pressure was 120/80 mm Hg when lying and on standing. A short tetracosactrin test performed before starting hydrocortisone and fludrocortisone showed a basal plasma cortisol value of 215 nmol/I rising to 690 nmoUl at 60 minutes. Subsequently a 1 mg depot tetracosactrin test, performed after the withdrawal of hydrocortisone, confirmed Addison's disease: the plasma cortisol value rose from 65 nmolUl to 236 nmol/l at three hours and to 276 nmoUl at five hours.
670
Departments of Metabolism and EndcocrinologN and Chemical Pathology, The London Hospital, ltondonE I 1BB I Clayton RN. l)iagnosis f adrenal insufficiency. Br Med 7 1989;298:271-2. 4 Februars.) 2 Galvao-Teles A Burke C(', Fraser TR. Adrenal ftinction tested with tetracosactrin depot. Lancet 1971 i:557-60. 3 Irvine W`J. Fhc adrcnal glands. In: M1acleod J, ed. Davidson's principles and practkes of medicine. Edinburgh: ChurchillLivingstone 19844 43-54. 4 W'illiams GH, Dluhv RG. Diseases ot the adrenal cortex. In: Braunwald , Isselbaher KJ, Petersdort RG, Wilson JD, Martin JB, Fanci AS, eds. Hamsoni's principles of internal medicine. Ncu Y'ork: \cGrau -Hill, 1987:1753-74. 5 Burke CW. Adreitocortical insufficiencv. Clin Endocrinol .feiab
1985;14:947-76. I)tsorders of the adrenal cortcx. Itn: W'ilson JD, Foster DV', cds UI"lliam's textbook of endocrinologv. lPhiladelphia: W` B Sauiiders, 1985:816-90. 7 WVood JB, James \VH F, Frankland AW, Landon J. A rapid test ot adrenocortical luicttion. Ioanet 1965;i:243-6.
6 Bondv PK.
Doctors becoming managers SIR,-As a recently formed organisation of registered medical practitioners with formal business training-that is, masters of business administration-we read the discussion between Sir Anthony Grabham and Professor Cyril Chantler' with great interest, but sadly, considerable dismay. We agree that doctors understand patients' best interests and that the non-medically qualified manager will inevitably be less certain in making decisions with a large clinical component. Unfortunately, it is also true that managers will have a better grasp of the complexity of modern business and have the tools to cope with this complexity in a more competent manner than doctors with no business training. The skills which underlie exemplary medical practice do not transfer very
readily to the modern methods of management that will be necessary to keep hospitals running as economically and as competitively as possible. Neither participants of the discussion believe that doctor-managers will require formal business training. Charles Handy refutes this premise, saying, "managers need to be well and appropriately educated before they start managing."2 He maintains that management makes a difference and it can be developed. Leading corporations would not take management education so seriously and spend so much time and money on it if it did not improve performance directly-in their profits. Handy summarises this by saying that "common sense and character will always be important, but they should not be handicapped by an absence of training." A King's Fund working party reinforced this view in 1977, recommending that "the high and demanding responsibilities of the NHS requires explicit systems of training."' The assumption that managing is something that doctors are "doing all day long, and by and large do it very well" is a fallacy. As Drs Lyn Pilowski and Geraldine O'Sullivan point out, poor relationships with consultants is one possible cause of the unacceptably high degree of stress and depression that junior doctors suffer.4 This is likely to be the thin end of the wedge and is an indictment of poor interpersonal management skills-an area to which a good business training could attend. There is a case to make for doctors becoming clinical directors, but it is important to realise the implications of defining the role of the doctormanager in this limited way. General managers are the focus of decision making in the hospital. This position is unlikely to change in the near future. By establishing themselves as clinical managers doctors will find their autonomy and therefore their job satisfaction decline. It is vital therefore for doctors to strive towards professional business training. Firstly, they would then be able to match the lay manager's business skills and with a medical perspective spot the areas where their overlapping skills energise, leading towards more imaginative and yet balanced management decisions in hospitals. The Americans lead the way with a medical school that combines both medical and health care management training. United States hospital directors are often required to be doubly qualified. With the advent of the white paper the United Kingdom needs doctors with these combined skills now. To dismiss this need is a dangerous precedent. M A HUNT P K H WALTON
Medical Association for Masters of Business Administration,
Manchester Business School, Manchester Al 16 6PB I Smith R, (irabham A, Chantler C. Doctors becoming managers. BrMled_7 1989;298:3 11-4. v4 February.) 2 Handy C. Mlaking better managers. London: National Economic Development Organisation, 1987. 3 King's Fund Working Party. The education and training of senior managers in the ,NHS. London: King Edward's Hospital Fund for London, 1977. 4 Pilowski L, O'Sullivran Gi. Mcntal illness in doctors. Br Med] 1989;298:269-70. (4 Februars.)
Finding a doctor: too much of a lottery SIR,-I have great sympathy with the paediatric registrar who found that he or she had registered with a less than satisfactory general practitioner.' As he or she says, "If it wasn't so serious it would be laughable." Unless lucky enough to be totally healthy until one drops down dead, choosing a general practitioner is an important decision, but one that is
BMJ VOLUME 298
1 1 MARCH 1989
