Sunday, April 20, 2014

Malaysian night

Kris and I are host parents to 4 Malaysian students at the local university. Apparently there are hundreds of Malaysian kids (yea, makes me sound old) running around. Anyway, we attended the Malaysian night this weekend, an evening of performances and Malaysian cuisine. They did a good job with soto and mamak mee I think.  Though the wife found it spicy

Anyway, one of their performances was about a Malaysian boy who left for the USA for 3 years of his studies. And I have to say, for some stupid reason, that brought back a surge of memories and emotions. After all, I remember that August night, when my buddies came over for a farewell party in my honor, of how I told them "Take care of yourselves. Don't have too much fun without me. See you in 3 years."  That was before residency turned into a 3 year additional fellowship. And then meeting my soulmate and deciding to settle down here. Gosh, that was 12 years ago. And though I feel blessed to have so much, there will always be a part of me that ponders the 'what ifs'.  What if I had never stayed? What if I was there with my family, to be able to be a better son to my parents? A better friend to my buddies? What if, what if?

Often, I get emails from Malaysians who are thinking of emigration. And I try to tell them that as much as you think Malaysia is dysfunctional, there will always be ties within your heart, ties that will always make you yearn, and miss what you have grown up to call home. It's a home that your children, bred in a land foreign still to you, will never know. And so, despite how I've been away since 1998, there is much I miss. But it was at least fun to have had the chance lays night to have a taste of Malaysian food, and to hear so many people speak in the accent with which I am so familiar. 

Wednesday, April 16, 2014

An Interesting Case of Hypocalcemia

I saw this patient for the first time last month. Young guy, who was found on routine exam to have marked hypercalcemia of 12.1. His parathyroid hormone was high as well.
Pretty slam-dunk case of hyperparathyroidism, and given his young age, extent of hypercalcemia, surgery is clearly indicated, so I sent him for parathyroid localization via sestamibi scanning, followed by a surgical consult.
The surgeon agreed, and he proceeded to have minimally-invasive parathyroidectomy. His intra-op PTH did drop by 70%, thus with biochemical cure, the surgeon closed him up. His postop Ca was normal so he was discharged home.
A week later, his PCP calls me; he presented with tingling, numbness and cramps- was then found to have hypocalcemia this time. His Ca was 7.1, with normal albumin levels.
Uh-oh. At this point, the index of suspicion should be high for hypoparathyroidism, which is not uncommon after neck surgery, often transient, even if the remaining parathyroids were left alone.Treatment in these cases should include Calcium supplementation, along with activated Vitamin D.
One should order a parathyroid hormone level to see if this is inappropriately low, which would confirm the diagnosis. Also, a Magnesium should be checked in case he had hypomagnesemia, which induces a state of PTH resistance.
His PTH came back 80 (normal 15-65). To my surprise.
"Hungry Bone" Syndrome. 
Haven't seen one of these since fellowship. Since osteoclastic and osteoblastic activity are coupled, after removal of the parathyroid adenoma, the osteoclasts suddenly slow down, leaving the still-busy osteoblasts to take up too much of the serum calcium to lay down new bone, causing the hypocalcemia. Treatment: high dose Calcium and Vitamin D. Should be self limited.

Monday, April 14, 2014

Another Dump

Yup, that's snow.
Yup, it's supposed to be spring.It was a balmy 28 degrees Celsius Saturday. And WHAM, Sunday night we get hit with snow and the temperature drops back down to 1 C.
Gahh. Spring will come. Someday.

Tuesday, April 08, 2014

Spot the cars

I took this picture today when I noticed an able bodied woman walk out of her illegally parked car and walked into this building. While there were at least five empty spots though at the far end of the carpark. And I counted at least two other illegally parked cars.
Could it be then, a reason why this generation will see the highest ever recorded obesity rates?
That, for a lack of a better term, we have become so much more lazy?

Tuesday, April 01, 2014

Patient Satisfaction: A Good or Bad Thing?

I read this article on Medscape recently, which I thought was thought-provoking. After all, I have been on the receiving end of something like this before. It's a bit long, but worth the read:

Editor's Note: 

This article first appeared in the Fall 2013 issue of Keystone Physician, a publication of the Pennsylvania Academy of Family Physicians.
I recently was at the Scientific Assembly of the American Academy of Family Physicians (AAFP) in San Diego, giving a lecture to a large audience of Academy members on respiratory syncytial virus (RSV) bronchiolitis. I mentioned why I thought identifying the RSV virus was important. I stated that if you tell the family the infant has RSV and that there is the expectation that cough will last 1-2 months, this may forestall them going to the ER or urgent care center. In those assembly lines of healthcare, they will be told that their child has "bronchitis" and will receive the inevitable azithromycin script. This will make the parents happy, free the healthcare provider of the need for further explanations, and result in a satisfying visit for the administrators of that facility. The trouble, of course, is that an antibiotic has again been used to treat a self-limited viral infection.
A physician came up to me afterwards and agreed with me but said that he had no choice. He works in one of those venues and is subject to surveys to measure "quality." For him, quality is measured in 2 ways: The first is by getting the patient door-to-door in 45 minutes, and the second is by a Press Ganey survey to see if the patient was happy. Because of these measures, he is forced to abandon his role as a responsible steward of antibiotic use to keep his job and get a bonus.
Another physician in the audience told the crowd that he was able to increase his satisfaction score by 7% simply by prescribing an antibiotic to all patients who call with a complaint of cough, sore throat, or sinus headache. One doctor reported to the media that he had to give Dilaudid® for minor pain because his Press Ganey score was low the previous month.
I believe that this little-known company, Press Ganey, from South Bend, Indiana, has become a bigger threat to the practice of good medicine than trial lawyers. They are the leading provider of patient satisfaction surveys for hospitals and physicians. For the past decade, the government and healthcare administrators have embraced the "patient is always right" model and will punish providers that fail to rate well in these surveys. Press Ganey's CEO, Patrick Ryan, said, "Nobody wants to be evaluated; it's a tough thing to see a bad score, but when I meet with physician groups I tell them the train has left the station. Measurement is going to occur."[1] Obamacare has budgeted $850 million in reduced Medicare reimbursement for hospitals with lower scores.
The mandate is simple: Never deny a request for an antibiotic, an opioid pain medication, a scan, or an admission. One emergency room with poor survey scores started offering hydrocodone "goody bags" to discharged patients in order to improve their ratings. And doctors face the reality that uncomfortable discussions on behavioral topics -- say, smoking or obesity -- come with the risk of a pay cut. If you tell a patient that their knee pain is related to weight, that their smoking is worsening their child's asthma, or that they can't lose weight because of French fries and not a glandular problem, your ratings and pay will take a hit.
Overtreatment is a silent killer. We can overtreat and overprescribe. The patients will be happy, give us good ratings, yet be worse off. We must have the ability to deny treatment for a patient's own good. Patients aren't the best judge of what is best for them. Several years ago, an elderly female patient wanted me to write a prescription for tamsulosin because she got a coupon in the mail. It did not matter that she lacked a prostate.Satisfied patients are not healthy patients. In a paper published in 2012, researchers at the University of California, Davis, using data from nearly 52,000 adults, found that the most satisfied patients spent the most on healthcare and prescription drugs.[2]They were 12% more likely to be admitted to the hospital and accounted for 9% more in total healthcare costs. Strikingly, they were also the ones more likely to die.
We should try to be kind to our patients and take time to understand them, but we must resist these misguided pressures and do the right thing. Sometimes patients have to be told "no," and the leadership in healthcare must understand this. Take heart in the words of Mark Twain: "Always do what is right. It will gratify half of mankind and astound the other."

While I am all for consumer satisfaction, and this includes healthcare, I do think the are numerous caveats and problems with this system. I hear it all the time, from my ER and hospitalist colleagues. From the negative reviews from patients I personally have gotten, for "not prescribing Testosterone treatment because I didn't feel good" (despite having normal levels to begin with). Or because "Dr. Vagus practices based on science only, and didn't want to give me pills to help me lose weight and feel better".  While satisfaction is important, it is also subjective. And in situations of disease prevention, the patient might not necessarily see the end result of our intervention (by not having a heart attack), instead looking at parameters which might not be concordant to our medical goals. In my case as an endocrinologist, it's usually something related to weight, or libido, or hair, or sexual performance, or something like that. And so, if the system evolves into one that rewards physicians based on satisfaction surveys, it's not surprising to have things backfire.
Sure, I could do what that other group of "hormone experts" in town are doing; non-fellowship trained practitioners (some not even doctors) prescribing all sorts of supplements to make one have enhanced libido or sexual prowess, or to make an 80-year old man ripped like good ole Arnie (or that octogenarian you see in the airline magazines). But is that why we are here? Is that what our Oath was about? To satisfy the patient? And not to save lives, or enhance health?
I shudder to think about what kind of healthcare we will end up delivering.

Thursday, March 20, 2014

I got an unexpected message in the office today.
Karen, the daughter of one of my patients, called to let me know she passed away.
Mrs. G was a delightful 89 year old woman with hyperthyroidism from toxic multinodular goiter. My first rule of thumb when dealing with the elderly is, they've gotten so far on their own: don't screw them up!
So, I tend to be more conservative and try the simplest route; be it my diabetes patients or other issues. In her case, we went against the norm and instead treated her with antithyroid medication.
She responded wonderfully, so over the years, I've come to see her just annually. I saw her just 2 months ago at which she demanded I show her pictures of our visit to Malaysia. Which I did.
Her daughter called to say that she passed away from respiratory failure from pneumonia. But wanted to let me know they really enjoyed their visits here, and that Mrs. G really liked me. She also wanted to let us know she won't be coming next January.
It was a bittersweet type of call. On one hand it's nice to know that some patients do appreciate what you do. And having seen some of my patients for years, I do enjoy the social aspects of the visits, too. On the other hand I was saddened to hear of her passing, though her daughter and I agreed that she had led a long and very productive life, and it was just her time.
Goodbye Mrs. G. It was a pleasure knowing you...

Saturday, March 08, 2014


Look what came in the mail yesterday!
Thanks to the goodness of Suanie's heart, she was crazy enough to mail a package of precious, precious Penang White Curry Noodles to a sad, deprived and hungry man in the Midwest USA, in the final grips of the longest winter in memory.
For now at least, this will be more precious than my daughters. I shall have to take my time to savor then. I have to say I was surprised this went through customs.
Thanks, Suanie!!

Wednesday, March 05, 2014

Vitamin T

You could call me the hesitant endocrinologist.
After all, I might be a hormone specialist (and I use the term specialist very loosely. Maybe only my wife and mother think I'm special), but I really don't like to prescribe these things unless the needs exceed the risks.
In this case, I'm a sceptic, I'm old-fashioned, I'm cheap.
I ask for the evidence behind the treatment. Good old EBM.
And so, it is a challenge when in the recent years, I see so many men asking for testosterone treatment.
The mild: older men with mildly low free and total testosterone. Studies suggest mild hypogonadism do not need treatment. Most feel no improvement.
The wild: young men in their 20s, who despite having normal testosterone labs, believe their levels should be "higher". Because they work out. Or believe they should be more virile. Or because their personal trainer told them so (I kid you not).
Where do we draw the line? Our lab's normal range is 350-1000. I've had guys say their 450 isn't normal. They should be at 800. I saw a chap whose T was 1200 last week (on replacement), refusing to budge his doses down because he feels good.
The winner in my short career thus far, is probably the very muscular, athletic man I saw 3 years ago- with a total T of 8000. Refused to believe me when I advised him for safety reasons to reduce. Never came back to see this quack endocrinologist, because I obviously don't know what I'm talking about.
And just weeks ago I saw a man who is a professional athlete (apparently is involved even in the Olympics), who had normal levels but feels he should be higher. And when I told him I couldn't in good conscience suggest treatment, his last words to be as he left the exam room were: "Well, if you won't prescribe it, I can easily get it from the gym...".
Why is there a need to justify medically how we feel? Low energy, fatigue, low sex drive, ED, lack of stamina, inability to lift XX lbs of weights?
If I looked at the list of hypogonadism symptoms so artfully advertised by pharma, I personally have 6 of them (don't ask me which).
And so, why do we need a medical diagnosis for what could be life? More importantly, why are we so keen on taking hormonal treatment for a mild low, or even a normal? I imagine a large part has to be the misconception that all fatigue must be low T. And all low T must be treated. If you get treated, you'll feel like a new man. A devious, ingenious scheme of pharmaceutical advertising.
While the risks have been known all this while, the more recent cardiovascular studies remind us this is not to be toyed with. Not just amongst the elderly or those with a history of CAD, but even the younger male population.
And so, while I usually cringe when I see lawsuit ads on TV by greedy lawyers, when the testosterone lawsuit ads started appearing 2 weeks ago, a part of me was somewhat pleased.
Perhaps this will give some caution to pharma to back off on their aggressive direct-to-consumer advertising.

Sunday, March 02, 2014

Jeff Dunham!

As a rare treat to ourselves, Kris and I got a sitter and went for the Jeff Dunham show- Disorderly Conduct. If you don't know, he's the ventriloquist famous for characters like a dead terrorist, redneck, and grumpy old man. Basically, not the kind of performance you'd come to expect from a ventriloquist.
I heard about him way back during my fellowship years, as one of my attendings was in love with Achmed. But only in the last 3 years, when we happened to stumble upon him on the Comedy Channel, did we actually learn to appreciate his humor.
And so months ago, when we found out he was coming to our city, we jumped. Booked the tickets without any hesitation; this would have been my first ever 'concert', by the way.

The show was about 2 hours. Had most of his usual characters, with a new guy. But obviously, the favorite and his opening was Achmed, the dead terrorist.
It was a 2-hour session of gut-wrenching humor, which he somewhat personalized for the Midwest. At times though, it did feel like a sales promotion, with how he was hawking his products, but it was a great show nonetheless. And he seemed pretty down to earth- I didn't feel like our ticket money was going to some spoilt young brat who's doing drugs and egging his neighbors' homes. And though the hall was huge and he was tiny from where we were sitting, it was also projected to the large screen- so it was still nice to be able to see him perform "in the flesh".
Whatever flesh his puppets are made of.
P.S: He's headed to Malaysia and Singapore next month! So catch him if you can!

Friday, February 28, 2014


A patient made me cry today.
Not that she meant to. But nonetheless it happened.
I was seeing her for Graves' disease. And when we went over her family and social history, she disclosed that she is a widow, at the young age of 35.
I was taken aback, especially hearing that she has 2 young girls, which only made me think of my kids. And so she shared her story of how her late husband, a firefighter, was diagnosed with an aggressive form of cancer in the prime of his life. How, knowing the odds, in his last few months he made an effort to ensure his kids will forever remember him long after he's gone. She talked about the things they did. How, 2 years later his girls still remember him whenever they see a butterfly.
Somehow, we went on to talk about losses. And knowing I had a cancellation after her and was not rushed for time, shared my story of Buddy.
And we talked about love, life, coping. And I couldn't help but imagine how things would be if I suddenly left this world and my wife and girls.
And while she talked about her loss but yet how they try to remember her late husband, at one point she started to tear up, and the tears came rolling down. And unexpectedly, my tears came right out too.
We were both a bit embarassed when I grabbed the box of Kleenex and we both took a couple.
But sometimes, it's unexpected but yet beautiful when patients share these touching stories with me.

Saturday, February 22, 2014

Broken System

No patient should ever have to say: "I couldn't afford to come see you, doc. That's why it's been a year since my last visit".
In the meantime, they've been profoundly hyperthyroid, or their diabetes has been uncontrolled.
I saw several of these patients this week, and it was frustrating, and made me sad. To realize that the system is so complicated, so broken, that we encounter episodes like these.
And who ultimately suffers?
Our patients.
When naive medical graduates first take the Hippocratic oath, pledging to help humanity, none of us knew then the complexities of practice. Medical economics, bureaucracy, medical insurance, medical malpractice, cost of pharmaceuticals.
We just wanted to heal the sick. Simple as that. Not always cure as we do not have divine powers, but always to heal.
But when situations like these arise, truth be told it makes me feel instead that I've signed a pact with the devil.
In the case of my Graves' patient, she looked frankly cachectic, and has lost 40 lbs off her already lanky frame. And while the labs are pending, I know she's going to be thyrotoxic still.
And so, I made her promise that should finances ever become a barrier again, to call me. If I can't treat her in clinic, I can treat her over the phone. And we can minimize the need for labs once we get her levels stabilized.
But it's such a broken system.

Tuesday, February 18, 2014

Wii Fit

After a long lapse, we finally dusted off the Wii Fit and put in batteries. The girls were having cabin fever so I was looking for an activity to do with them.
Except I was unprepared for what came next.
"Oops, it has been 1445 days since you were last here..."
I could swear, I heard a tinge of sarcasm and a snigger when he said that. And the little prick wasn't very nice about my weight gain, either. Apparently, he found the increase to be a bit too much, and he wasn't shy saying it.
And so, ladies and gentleman, I'm officially overweight. Barely, but per BMI criteria, alas, I am.
So, I'm pledging to:
- Hit at least 8,000 steps a day on my pedometer
- Skip the chips at lunch (damn the doctors' lounge and their free chips!!)
- Run 5 km a week (I know, but it's a start...)
- Sell my Wii Fit on Craigslist

Friday, February 14, 2014

Girls vs Boys

Difference between girls and boys, best seen today at daycare dropoff.
Alli and friends: "Oh, I like your pink sweater...".
Boy (holding a toy helicopter): "I call this my Hell-copter. Because when they die, they don't come back...".
I think I'll stick to toenail painting and tutus, thank you very much

Wednesday, February 12, 2014

Bureaucreatic Nonsense, Part 2

I'm sick.
Sick and tired of this bureaucratic BS, really. So consider this Part 2 of my previous post about Bureaucratic Nonsense.
Today, kids, we will talk about formularies.
Formularies are types of medications that are preferred by an insurance carrier, usually for cost reasons. They have been prenegotiated and because of a discount for the carrier, these tend to be preferred for their patients.
Except, many of us wonder if these were made up also for the insurance companies' personal entertainment.
Every new year, we often get calls from patients, sometimes faxes from the carriers, that this year, Insulin X is no longer preferred, and the patients will need to be on Insulin Y. Or statin A versus statin B.
Never mind that they may have been on said medication for years, and well controlled. Never mind that they might have a reported adverse reaction (if you didn't document a good reason, if this occured when under the care of a different provider). Otherwise, they end up paying for this out of pocket.
And so, it's a cat and mouse game when every year, the insurance changes their preferred medications, and we have a barrage of calls from patients or pharmacies requesting alternatives.
And if it isn't a headache enough, this year, several insurance plans have been rasing the headache bar up a notch for clinics: I've been getting letters stating that Medication A is not preferred, with no reference to what an alternative might be. One of the carriers suggest that providers visit the website to look up alternatives. Which takes you to a nonsensical website that asks half a dozen questions about the insurance plans, group number etc.
Which leads me to my suspicion that health insurance carriers really aren't there to help the patient, but to try to discourage patients/physicians from utilizing resources in order to minimize their expenses.
Another phrase that our medical assistants have come to hate, is "prior authorization". PAs are more bureaucratic nonsense that the pharmacy/insurance carrier requires before they approve the medication. And this often takes multiple phone calls, filling of more paperwork, faxing, and waiting sometimes weeks for them to send a letter or approval or denial. And sometimes, PAs are required even if a medication is ON formulary.
Which brings us back to the F word.

Tuesday, February 04, 2014

Fairy Dancing


I just had to share this. We took this video of the girls dancing in their tutus to their favorite fairy show.
Though I grumble about it in public, the truth is it's fun being a dad to girls, and having all this girly stuff around. And I'm getting pretty good at painting the toenails, too!

Tuesday, January 28, 2014

3 More Days!

3 more days to Chinese New Year.
While the excitement is palpable in Malaysia and perhaps even in social media, admittedly it's not much celebrated here.
However, I take pleasure in wishing my Asian patients "Happy New Year"; apparently the cultures overlap much amongst groups- my Vietnamese and Filipino patients tell me they celebrate the same festival, too.
And so this weekend, we're getting together some people for our own CNY do.
And, funnily enough, something I've taken for granted growing up- I actually PAID money to download Chinese New Year songs from Amazon.
Yea, me. Dr. Banana- someone who can't speak a word of Mandarin, who can't understand the words of the songs. However, someone who still finds great comfort hearing those mildly irritating, upbeat songs sung by kids.
We also have our CNY wall hangings ready to be put up. And a stack of (very old) ang pows to fill.
By this time back home, we'd be getting our new year clothes out, and ready to be worn for Day 1. And my brothers and I would be excitedly dividing up our stash of fireworks, to be used on the first night.
Oh, the excitement.
What about you? How are YOU preparing for CNY?

Sunday, January 26, 2014

Bacon Cupcakes!

I just had to share this.
In my mind, there was no logical existence for it, unless perhaps a devious creation by the makers of insulin.
A cupcake laced with, and topped with.... bacon!
It seemed like such a weird, illogical and contradictory combination that I just had to try it. The salty, crispy bacon against the fluffy mild sweetness of the cupcake, and the creamy, sweet cream cheese frosting. And surprisingly, while my tastebuds got a bit confused (not unlike when I tried chocolate covered potato chips), it was pretty damn good!
But alas, it doesn't take a genius to figure out its nutritional value, or lack of it. Which explains why my job exists.

Wednesday, January 22, 2014

Back to Memory Lane

This is something I've been meaning to post for months since we got back, but as usual, kids take up all your time. Something I was keen to do the last trip back to Malaysia was to show my kids places their dad went to. And so, one morning, we drove to my old kindergarten with Allison (Ava was too young, so we left her with grandparents). The headmistress was kind enough to let us visit, though having a kwaipoh roam the yard was somewhat disruptive to the kids having classes methinks!
Being in preschool now, Alli had some inkling to what kindergarten was. However, with how different the systems are between the USA and Malaysia, I think she found it hard to fathom (my wife too, I think). The huge class sizes. The relatively spartan conditions. The dirty toilets, with the squatting potty, no less.
For me, it was certainly a trip back to memory lane. It is the same building, at the same location I went to 30 years ago (WTF??? Really, 30 years???). And though the memories are mostly long gone, I do remember much.
Like where my classroom was (yellow class, with Ms. Janet as our teacher). I remember where the toilet was, and how even then, I hated to take a dump outside of home (I remember the day when I did have to take a dump and my kindergarten sweetheart Salina happened to walk in on me!). I remember Sports Day; I think I won a price in the tube race. I remember the biscuits they used to serve at break time- I loved those chocolate wafers (to my delight I can find them here) and those pea-sized biscuits with the sugar frosting on top. I remember the ?ivy plant in the back, and how we used to pluck the leaves and stick it to our forearms. I remember the concert night (or whatever they called it, but I remember it as the concert). When we all dressed up and performed on stage; I remember dad buying me and Hon Hui a bottle of Yeos strawberry drink. And I remember the damn lipstick they put on me for the performance!
Anyone find me?
But perhaps my fondest memory, now that I'm a dad, is my Ah Kong. I used to be the most homesick kid in the world. I had screaming, howling, crying escapades whenever my parents dropped me off (actually carried on until Standard 1!). Anyway, after some unsuccessful drop-offs, they got desperate, and finally talked my grand-dad into coming to kindergarten with me.
As in, staying there the entire class! I remember how Ah Kong would sit on the bed outside my classroom while I was in class. That must have been for at least 4-6 hours each time? I remember how nervous I got whenever he stepped out of view.
I don't remember how long he had to do this, but it was certainly long enough that I remember this fondly.
(sidenote: Don't you think it's ironic that having been such a homesick boy, I ended up settling down farthest from Malaysia amongst my siblings?)
Yes, Alli and Ava will have their own experiences here in the USA, experiences that will be foreign to me still. But I'm glad I was able to take her there for a visit.

Sunday, January 19, 2014


Just when you thought it was safe to come out (after all, the snow had pretty much melted, and it was 8C!), winter comes and plays a cruel joke. We get a huge dump of snow, with whiteout conditions. Stories of 30-car pile-ups on the interstate. It took us 80 minutes to drive 12 miles home.
But, if there is one thing to enjoy out of this, this was the view from my office the next morning:
Sun dogs.
No, not an actual dog. But that bright, rainbow colored ring around the sun. Diffraction of the sunlight into its spectral components by the ice crystals in the air. Or something like that.
See, winter isn't all bad.
Oh, who am I kidding? I miss Malaysia!!

Friday, January 17, 2014

Bureaucratic Nonsense

Had to fight off hematemesis today when I received a letter from a patient's insurance.
Mr. X has type 2 diabetes, and at his last visit with me two months ago, had complained of erectile dysfunction. His usual screening labs were negative and so we discussed the option of phosphodiesterase inhibitor therapy. He was keen on trying sildenafil, so I sent in a prescription.
He also had a history of coronary artery disease, for which he received 2 stents 9 years ago. He was prescribed sublingual nitroglycerin to be used only as needed if he had more chest pains. Which he never did since his intervention. But, like the obedient patient that he is, he kept refilling the nitro prescription his cardiologist gave him, "just in case". We discussed the side effects and the potential major interaction between these two agents, but felt that since he has never taken the nitro in the 9 years he has had a prescription, it would be OK taking sildenafil as needed.
And so, this started a bureaucratic roller coaster which is still in mediation. His insurance company said "No", because an astute clerk had noted nitro in his medlist. The fax had a number the physician or patient could call to appeal the denial, and to review the case with a medical reviewer.
Now, I can understand the concern seeing Viagra and nitro on the same list, so I called the 1-800 number to review with a pharmacist reviewer. And I clearly explained that although nitro is listed on his medlist, it is a PRN (as-needed) medication, one he has NEVER used in the 9 years he has had this. And I explained that the patient is aware never to take both medications at the same time. The pharmacist seemed understanding, and agreed it was OK and promised to relay this to the people who approve these things.
A week later, I receive another fax. No. Because your patient was noted to be on nitroglycerin.
Which prompted me to write a letter this time, again explaining that the nitro was a formality- though he was prescribed this, he had NEVER used it. While on the other hand his erectile dysfunction was significant enough to be causing quality-of-life issues. Explained that the patient is aware of the interactions. I signed and sent this letter off to Insurance Company From Hell.
And then today, I receive another letter. "Your appeal letter cannot be processed because you are not an authorized representative of the patient".
What the frak??? I am the prescriber, and by that alone, I am a representative of the patient. And if I wasn't authorized to be speaking for the patient, WTF did you send me those two faxes anyway??
Anyway, I was required to get the patient to sign a 4 page form, stating that I am indeed an authorized health representative for him.
Never mind that I've been his endocrinologist for the last 3 years.
And people wonder why they say that medicine would be a lot cheaper and simpler without insurance companies and lawyers.
Somehow, I'm not holding my breath that this will be approved.
(Next, I'll vent about formulary changes in the new year!)