Life (and death)...

Seeking Advice

2012-01-31T19:16:00.000-06:00

I'm throwing this out to all you physicians in Malaysia as I haven't a clue to the answer.

Someone I know was diagnosed with sleep apnea and was told he needed to be on CPAP (continuous positive airway pressure), which is pretty standard treatment here.

Except he was quoted a price of RM 10,000.

And when he wanted his polysomnogram report, he was told it was "confidential information" and he cannot be given a copy.

My questions:

1) Does anyone know what these devices may cost (they cost about US$700 to 1200 here I believe) in Malaysia? I'm surprise by the cost quoted (public hospital, too!)

2) Isn't a patient's "confidential" medical records the property of the patient?? Here, we are not even legally allowed to refuse to share a patient's file with him if requested.

Would appreciate any info, thanks!

Instinct?

2012-01-29T14:44:00.002-06:00

Animals, humans included, have such amazing inborn instintcts. Things that these organisms do, without anyone actually teaching them.

Like, how eagles learn to fly. Or how the geese migrate south in winter.

Or, how a toddler learns to pick her nose, and gingerly pops her booger into her mouth like it was a raison.

Yup, that's our pride and joy. And we caught her doing that the other day. Mom shouted in shock, I laughed.

Where DO they learn these things?

I found this hilarious posting on howtobeadad.com. Apparently they contain Vitamin C

Gongxi!

2012-01-25T10:20:00.003-06:00

Happy Chinese New Year!

It's the year of the Dragon- woo hoo. Or rather, sighhh. Because it means my age is now a multiple of 12 (whether it's 24, 36, 48 or 60 I'll let you decide, but I'll tell you that story sometime this week).

Anyway, if you're a Malaysian expatriate like me living outside of Asia, you know it can get pretty damn boring, and it gets pretty homesick too. After all, for many of us we grew up having CNY as the BIGGEST event of the year, one that's filled with all kinds of smells, sights, tastes and traditions. But if you're living in the northern hemisphere, it's cold and white and pretty much nothing else that reminds you of the festival.

And so, we're determined to have Alli experience some of this. We dressed her up in a cheongsam her uncle and aunt bought her, and put on her gold necklace Ah Kong and Ah Ma gave her, and took her to a Chinese festival in one of the local colleges. She got to see her first lion dance (good effort though it was weird to see 4 Caucasian women perform it)(wait, then again I'd bet many Malaysian men would PAY to see that).

And though she was too young to understand it, I told her of some of the traditions and things we'd do. Like:

Having a family dinner on the eve of CNY, then going out to the relatives' for our first angpow hits of the year
Going to the temple for prayers early in the morning, then coming home and getting dressed in our new New Year clothes
As kids, after the open-house crowds had died down (ie I had seen the girls I had crushes on), I'd head out on my BMX with my neighbourhood buddies looking for trouble. We'd have a bag of fireworks, and would look for things to blow up. One of our favourites- freshly made cow-dung. Yes, we have a fierce-looking Sikh guy who'd walk his herd of cows from one area to the other, and inevitably they'd leave a trail of dung. And so, we'd dare each other into sticking a single firecracker into it, and lit the fuse. We never ran fast enough to come home totally clean. There was always some green/black splatter on us, or our bikes. It's a wonder none of us died of E.coli poisoning!
After all that work, we'd be famished and head to each others' houses for snacks, drinks and the all-important gambling sessions. Yes, even parents allowed this, once a year. We'd be playing Blackjack or Cho-tai-tee, with 10-20 cents a wager. It made me feel like a cardshark. But alas, every year I lost. Even to my little brother. The lucky red Superman underwear never worked.
I miss the fireworks! My favourite was the dinky little Moon Travellers; mom and dad would get use a carton and my brothers and I would preciously divvy them up. They were small little things, with only a minimal pop, nothing like the Thunderclaps people eventually used. I loved the smell of the burnt gunpowder at Chinese New Year time.
And of course, the food. Mom and dad always had an open house, and they always catered Malay food (yes, race wasn't as big a deal then, unlike what the idiot politicians are making it to be these days). And always, we'd have rendang which was my favourite even now (despite it one year pretty damn near killing me; remind me, there's another story to be told someday), dumped on a serving of fried beehoon.

Yes, wonderful memories. My buddies and I were just reminiscing that on Whatsapp the other day. The 11 of us, spread over numerous continents and most with kids now. But those were wonderful times. Someday, I hope to show Kris and Alli what CNY is like. And someday, I'm going to show my little girl how to blow up a fresh cow dung!

Manuscripts

2012-01-21T09:47:00.002-06:00

My resident approached me the other day asking for advice on how to write up a case report. It was somewhat timely as my sister had seeked a similar advice recently. I can't claim to be an expert in publishing materials as at my alma mater, the real experts had over 300 first-author papers each, though I've had my hand in this several times. This is what I told him:

Use a cover letter. Even if the author instructions lists this as optional. Take the trouble to find out who the Editor-in-Chief for the journal is, and address it to him/her appropriately. Make it succinct, but explain in one or two lines what your manuscript adds to medical knowledge, or why the case/study is special. Otherwise, a manuscript simply entitled "Chordoid glioma of the third ventricle" gives the reviewers little insight and makes it easy to disregard. Thank the Editor for considering your paper.
Identify potential journals. Not all journals take all types of manuscripts; not all journals take case reports, or medical images, or unsolicited review papers. Do your homework
Know the format. Once you identify your target journals, use the appropriate format. Double-spacing is a given, but know how they like their references cited, or tables and diagrams labelled. If they lists a word-limit, do not exceed it.
Use the proper lingo. Obviously, don't mess up the English. That being said, there is a certain type of lingo that is expected in a scientific publication. Informal language should not be used. No DON'Ts, CAN'Ts, WON'Ts, HE'S. My style is to follow reinforcing statements with INDEED, THUS, FURTHERMORE, rather than SO, OF COURSE.
Don't over-abbreviate. While abbreviations can be used, always start with the full syndrome names and follow this with abbreviations. But do not overdo it. Ie. A 50-yo man with DM 2 presented with SOBOE and ACS...
Do it now! It's true, the passion and motivation for any case or study will fizzle. So, if you are enthusiastic about writing up something and submitting it, do it now! Because if you don't the weeks become months, and then years. Though I'm pretty satisfied with what I've done, I do have manuscripts that ended up in my dusty to-do folder that will never see the light of day. Including that (sigh) 20-page (double-spaced mar)/80-reference review of thyroid nodules that is now 5 years old and is stale and no longer up-to-date. And I'm too lazy to update this. So, do it while you are keen. Otherwise life gets busy and you make excuses.
Use reference formatting software. Do not manually type out your references! That is a lot of work, and you need to modify it to the journal you submit it to. And, if you manually type things out, but decide to add a new reference between Number 3 and 4, you're left with manually relabelling references 4-20! There are numerous programs out there that do the formatting for you. I used Endnote back in my day. It was neat, as from Medline or Pubmed you could directly save the citation (even the .pdf) and keep it in a folder, and then just label it when you work on your Word document.
Don't give up. About two-thirds of my manuscripts were rejected initially. Sometimes it's just a matter of shopping for the right target journal, whose reviewers feel your paper is well-suited to their readership. So, if one journal rejects your paper, look for another. Start with more ambitious ones, the ones with a higher impact factor, and then work down. A mentor once told me, "All manuscripts can be published, if you look long enough for the right journal". (Almost true, though I had one manuscript that in retrospect sucked bad enough that I probably shouldn't have bothered even trying! Ah, that was when I was still a publication virgin).

It's a lot of work. My most hard-earned papers spanned 2 years of my personal work (and 5 years of data). But to get that email, "Congratulations Dr. Vagus, your manuscript entitled X has been accepted for publication...", and then to see your paper in print, is a very rewarding feeling. So, if you are inclined to do research and write papers, it's well worth the effort.

Contraband!

2012-01-15T20:41:00.000-06:00

No, not the movie.
Even better.

Look what I found in the pantry over the weekend. I had the case of the munchies, and went in on my usual exploratory searches. And on one of the shelves, I hit jackpot.

Though I hadn't realized it until a month after they left, mom and dad must have 'imported' this from Malaysia when they visited. I haven't had these in well over 10 years. Not one of those things that would come to mind when I visited Malaysia and went out on a food-hunt. But definitely one of those things I missed.

Ah, the memories of my childhood that each bite brought back. It's a good thing Kristin wasn't a fan; I didn't have to share a crumb of this with her.

Thanks, mom and dad!

Ugh

2012-01-08T19:43:00.004-06:00

Ugh. I feel like throwing up. And so, I have my barfbag beside me right now, in case something comes up the wrong way.

Though we've been together 5 years now, the wife and I can think so differently sometimes. I blame it on my Malaysian heritage.

I made rendang, briyani (from the packs) and roti canai for dinner just now. I made A LOT of it. And much of it we probably could keep for another day, but I didn't think the roti would thaw well. And here's where we digress.

Kristin: Just throw it away, or give it to the dogs. You can always make more.

Me: You want me to throw away my precious Roti Canai*? Never! Here, I'll find some room for it in my stomach.

In the end, guess whose suggestion was the better one? Ugh. I'm gonna need some Tums.

*May replace with (expired) curry paste/ayam masak merah/sambal belacan/etc. Yes, we've had this conversation many times before. Somehow I never learn.

And yet, ask any Malaysian expatriate. Spices and foodstuff from Malaysia are more precious than gold.

2012-01-06T21:27:00.002-06:00

After 9 years.

That's almost a decade. But after 9 years of being in this country, I finally received my green card the other day. It's been a long convoluted road, from a J then H visa and now this.

Though it's a huge relief, and will make travelling with my family much easier, and not having to worry about 'secondary' screens (which is still much better these days compared to the post 9/11 days), getting this was almost a bittersweet moment.

Probably more psychological, since I've called this place home for the last 9 years. Including medical school, I've lived in North America since 1998.

But, becoming a Permanent Resident, also makes it pretty clear (if it wasn't already): This, here, is now home. Here.

No longer Malaysia. No longer the place I was born. The place I grew up with, the place that holds so many precious memories, and still holds so many family and friends still so dear to me.

Though this was not what I foresaw when I started my career here, this was but to be expected when Kristin and I got married and started our family. And though I do consider it a privilege to receive this card, I am somewhat saddened to think about the factors that led me here. The same factors that have led 5 of the 10 other close friends of mine from highschool to seek permanent residence elsewhere, outside of Malaysia. To cause the massive brain drain from Malaysia, the loss of so many young talents. The same issue that comes up over and over again, in a country that found her independence almost 55 years ago: If you are of a different skin color, then you'll always be an immigrant. You'll never have the same rights.

So ultimately, for my family, for my daughter's future, like many of my friends who think about their children's futures, we seek greener pastures. Though this place is far from perfect, this is now home.

The Year That Was

2011-12-31T06:30:00.000-06:00

I can't believe the year is almost over (yea yea, you people in Malaysia are 13 hours ahead of us, I know). This time of the year, I'm sure I'm not the only one who reflects on what has happened in the preceding 12 months.

Much certainly has happened in 2011. For one, after much suffering and time being apart, my wife finally completed her program in nursing anesthesia. After 3 years of 2-hour commutes and weekdays apart, she pulled it off, graduated and joined a group in town. That was probably our high time; I remain so proud of her. Also, our dear Alli has grown so much this year, from sprouting little baby teeth, to learning to walk and then run (and now to climb down the stairs, much to my chagrin), so saying "More!" when she wants more to eat. It's so fun seeing her silly personally starting to show.

Yes, we have much to be thankful for in 2011. However, if I can take a moment to be selfish and ungrateful, taking a step back, 2011 has been a difficult year for many reasons. It has been a year of losses. And the most tragic, was my best friend losing his battle to esophageal cancer after a 4-year batttle that spanned his wedding, honeymoon and his fellowship training to be a cancer doctor. Though we knew that was coming from day 1, knowing this was stage 4 cancer, losing a dear friend is never easy. Especially at such a young age. Nonetheless, we count ourselves lucky that we were able to travel back to Malaysia to spend some time with him and his wife, shortly before he passed on.

And so, I think I'm ready to move on into 2012. Though we can never foresee what the year holds, I hope this year will have fewer tears for all of us.

Have a safe New Year's countdown, folks!

Tragic

2011-12-26T22:23:00.003-06:00

Any accidental death is a tragedy, especially around the holidays.

However this seems heightened when it involves one of your peers, on what started off as a life-saving endeavour.

(CNN) -- Three people -- a surgeon, a medical technician and a pilot -- were killed Monday when a medical helicopter crashed in Florida, the Mayo Clinic said.

The helicopter crashed at about 5:23 a.m. ET about 12 miles northeast of Palatka, Florida, according to Federal Aviation Administration spokeswoman Kathleen Bergen.

The clinic said the helicopter was carrying two employees to the University of Florida in Gainesville to harvest organs when the crash occurred. It identified those employees Monday as cardiac surgeon Dr. Luis Bonilla and procurement technician David Hines.

It's sacrifices and risks like these that I never have to take, that reminds me of what these surgeons and their teams have to go through in the name of helping patients. And in the recent years, there seems to be quite a few of these accidents, probably in part due to the increased numbers of transplants that are performed nationwide.

These guys are heroes.

Our thoughts, prayers go out to the families of those killed in this noble mission. Though I have never met either of them, I know the medical community will mourn this tragic loss.

2011-12-24T07:24:00.000-06:00

One of my patients came by Friday. I was surprised to see her in the waiting room as her appointment wasn't due for another month, but she wanted to bring me this.
A simple jar of homemade apple butter for Christmas.
Sometimes the simplest of things are the most precious.

She wouldn't let me pay her back. But she said I could pay her in hugs so I did (she's 71 so I wasn't worried of any misunderstanding).
Merry Christmas, dear readers.

Sent from my iPhone

Deafening Silence

2011-12-22T23:04:00.000-06:00

My family left today. For my parents, after a month of being here. My brother and sister-inlaw had been here for a week.

With all the commotion and activity and the screaming kids, admittedly it took some getting used to. But then when things settled in, it was heartwarming to see our daughter look up to, and play with her cousins. Or to have my mom and dad teach her the same Hokkien phrases I grew up with. Or have her coo at them. Or simply to share a beer and a nice conversation with my big brother and dad; it's fun in a way, realizing that we're all adults now, and we can have a grown up conversation.

After some migraine-inducing moments with United Airlines (which I won't go into today) they finally caught their flight out to LAX.

And so, for the first time in a month, the house is quiet. There is peace.

Except suddenly it doesn't feel like a home anymore. Like there's something missing. And the silence seems deafening.

I'm sure we'll get back to our own routine, but it'll take a few days. And just a few hours into it, we're missing them already.

Have a safe flight back!

Chaos

2011-12-18T21:06:00.000-06:00

Our home is a madhouse right now.

Utter chaos.

We have family visiting- my parents, brother, sister-in-law, and their two kids. And then there's Kristin, Alli and I. Plus the two dogs. All cooped up indoors because of the cold weather outside.

And so, our house looks like a tornado ripped right through it. One that smells of sambal belacan and ikan bilis.

And yet, I caught myself thinking this over the weekend when we had our (early) Christmas celebration: It's funny how, amidst all the chaos the family reunion brings, one can be filled with peace, warmth and love.

It's been awhile since we were together for Christmas, and though not everyone's here, it's still nice to have family around. And it's so heartwarming to see our daughter play with her cousins, and her grandparents.

Yes, it's easy to forget what this season is really about. It's easy to get sucked into the superficial façade of presents and ornaments and sales. When truly, it's about family.

Season's Greetings, and Best Wishes, from mine to yours. Safe travels.

My Christmas Wish List

2011-12-13T19:30:00.005-06:00

Miraculous scalp hair growth
World peace
To have my patients be cured of their diabetes
A Ferrari 458 Italia Spider (in red, of course)
To have no late-night DKA or thyroid storm consults for the next year
As much as I'm a fan of Vettel, to see poor Schumacher win at least one podium finish in the 2012 season
To get my six-pack back again
To be rid of corrupt politicians (something tells me this will be the most impossible)

Failing of all which, I'd just then humbly ask Santa for a $10 gift card to Caribou Coffee.

Happy Shopping, everyone. Just 12 days to Christmas, Lalalala-lala-la-la.

Difficult People

2011-12-05T18:26:00.001-06:00

It's sometimes hard to deal with difficult people. And though sometimes the rational side of your brain tells you it's not you but them, admittedly I'm guilty of taking things personally.

Today was one of those days, and truth be told, I'm still reeling from that verbally abusive patient I saw on what started out to be a nice Monday morning.

Even before I went him, I heard him yelling at my nurse. And then when you have someone accuse you of being a bad physician, in part because you refused to prescribe antidepressants (when you were consulted to assist in his diabetes management), and accuses you of being rude to the pharmacist (I'm not even sure where this came from), and blames the high cost of healthcare on doctors like you who make him get his other nondiabetic prescriptions from his GP (hence giving him two co-pays), and so generously throws out F-bombs at you as he accuses you of intentionally making his diabetes worse so that you have an excuse to put him on insulin, it's hard to even give a response to any of that.

I tried to explain my stand on things and tried to make my case, but in situations like this, there was no way he was going to listen.

We both agreed I should never be his doctor again and offered to have a colleague see him from now on.

But deep down, I catch myself wondering, how could our doctor-patient relationship has gone so wrong? For the rest of the day, I caught myself in doubt, of both as skills as a physician, and as a person.

For, as unreasonable as the accusations may be, if someone yells at you loud enough, you can't help but take it personally.

It's on days like these, that you almost wished professionalism and ethics would let you confide in the other patients you see. The patient who have been coming back for years, and with whom you get along, and who seem to trust you. You almost wish you could ask your patients, "How am I doing? Am I treating you well as your physician? Am I taking good care of you?"

But no. We aren't allowed to do that, are we?

And so, you grin and bear it. Life goes on.

2011-12-01T17:25:00.001-06:00

My patient said to me today that she felt lucky that she has such a smart, handsome doctor looking after her.

Never mind that she's

- 86 years old

- Has bad cataracts

- AND, has strabismus

This patient's a keeper!

A Love Letter

2011-11-28T14:49:00.000-06:00

This was a letter I wrote on the behalf of a patient to her medical insurance company. Now, maybe I'm naive enough to think that HMOs and insurance companies, while they do make a monetary profit, is genuinely there to help patients. But sometimes, as when this patient called me up crying because she was told her medication wasn't as necessity, I do wonder. The 'medical reviewer' who looked at her file said there were 'other' options. That she didn't need these pills and so they weren't going to pay for them.

This was my response.

Re: Denial of Calcitriol for PATIENT X

I am writing to appeal your denial of coverage for this patient’s Calcitriol. I disagree with the reason for denial, that this is excluded by this member’s plan.

This patient has post-surgical hypoparathyroidism. As any basic physiology textbook will show, parathyroid hormone is necessary to hydroxylate or activate 25-hydroxy Vitamin D to 1,25-dihydroxy Vitamin D, which is ultimately responsible for gut absorption of calcium. While most patients do not need Calcitriol as a form of vitamin D, in the absence of parathyroid hormone, patients with hypoparathyroidism cannot physiologically do this, even if taking massive amounts of over-the-counter Vit D. Therefore, the ONLY possible option, is Calcitriol. As you should be well-aware, there is no clinically available means of replacing PTH in these patients (the only recombinant PTH available is Teriparitide which is NOT used for hypoparathyroidism).

Not having access to this will lead to hypocalcemia which can be life-threatening. If your company wishes to be responsible any potential hypocalcemic seizures or worse for Patient X, please let us know and we will attach this in our medical records for her. If you wish for a refresher in basic calcium homeostatic mechanisms I would be happy to recommend a medical textbook.

Yours truly,
Dr. Vagus

I must say, I thoroughly enjoyed writing this letter. I had had some other frustrating insurance-related issues, and I happened to have some free time at work, so I vented my frustrations in a creative way. Sometimes I love screwing with these people.

We'll see if things get approved now. Damned greedy insurance companies. Sangchaimosifatt!

Happy Thanksgiving

2011-11-24T09:49:00.001-06:00

Happy Thanksgiving, folks! As we celebrate this holiday, let's take a moment to reflect on all the things we can be thankful for. Things we take for granted. For me, it's my family, and our health. My parents are here with us for this this year which is a bonus.And yes, if you're wondering, that's a turkey sitting in a pail. Will pop her into the oven for the traditional turkey dinner. If you're into roasting turkeys, you'll find that it's all in the brine. Given the amount of time the bird stays in the oven, there is a tendency for the breastmeat to dry out. So, putting the turkey in a salt solution keeps the meat moist. For my recipe, I use a cup of salt, half a cup of brown sugar, ground peppercorn, aniseed and cloves. You can also use apple cider/juice in place of the cold water. Let it soak for a day before the big roast. Give it a try!

Happy Holidays, everyone!

2011-11-23T05:54:00.001-06:00

I just had to share this. No, I did not take this picture, but we saw it on FB somewhere. And with Thanksgiving and Christmas round the corner and some neighbors are already putting up lights, this was the perfect time!

LOL.

Yawn

2011-11-21T08:04:00.000-06:00

I'll admit it.

I've had on numerous occasions been tempting to stop blogging.

Not that I don't enjoy it anymore (I do). Just that, looking back at my posts 5-8 years ago, I realize that now, things are just so.... mundane. Boring. Yawn.

Maybe life as a resident in an academic center was more interesting.

Stories about cardiac code-blues.

Or my culinary experiments.

Or attempts to find me a mate and seeing how desperate I was.

Now that I'm 35, married (happily, of course) and a father, and am out in the boring world of practice, my posts just seem so uninteresting.

Yes, admit it, I know you think so too.

The posts about work. My daughter's diaper colors. My dogs. My bowel habits.

Maybe someday life will get more exciting (not that I'm complaining).

Maybe someday a busty redhead Russian spy is going to drive up my driveway in a Ferrari 458 Italia, wanting to seek my help in trying to prevent the domination of the world by the evil organization SPECTRE.

Maybe someday at work there will be a medical crisis, and in swoops the heroic endocrinologist with a syringe of insulin in his holster, and some Levothyroxine pills in his hands, to save hundreds of the critically ill.

Maybe.

Until then, you're stuck with this.

In a Heartbeat

2011-11-20T07:41:00.001-06:00

We are lucky.

We have our health and each other. It's one of those things, simple no doubt, but we can so easily take for granted.

The last month has been somewhat of a challenge because of a healthscare. Without going into details, you realize though how things can change in a heartbeat.

How things may be good one moment, and then the very next, because of a simple phrase from your doctor like "I'm worried it's cancer..." time suddenly stands still.

I recall this clearly too when my buddy first told me of his diagnosis of esophageal cancer. And with this recent development, it put us almost in a state of dejavu. And I couldn't help but re-live many of those emotions we went through 4 years earlier.

It's like you suddenly stop breathing. And life stops moving. It's a shock, and you're left reeling from the news.

And then, when life resumes, when you finally find the courage to start breathing again, you're breathing a different breath of air.

In my buddy's case, it was as if a virtual clock had started ticking. Him, the oncologist, was most familiar with this. You're talking about 5-year survival rates and median life expentancy.

And so, with every heartbeat then onwards, you are reminded that life has an expiration date. Except this time, as parents we have other thoughts going through our heads in addition. How will our children be provided for? Will we see them grow up? How will life continue?

In this recent healthscare we underwent, I'm glad the news was good, unlike our previous chapter. And so, life is getting back to normalcy. Perhaps it is serendipitous that Thanksgiving is next week. But we are again humbled and reminded, to not take life for granted. And that things may change in a heartbeat.

2011-11-16T06:52:00.001-06:00

We're Off

2011-11-12T06:06:00.000-06:00

Woo Hoo!
Looks like perfect snowboarding weather in Breckenridge, Colorado!

Yes, after a long lapse, we're hitting the slopes. Yea, I know, kinda hard to ski or snowboard living in the amazing flatlands of the midwest.

I took up snowboarding when I was in medical school. It was inevitable:

- Growing up in Malaysia and not having seen snow before

- Having your medical school only 60 minutes away from the Canadian Rockies

- Having a cute Japanese classmate who was into snowboarding (in retrospect, it was stupid to do something just to impress a chick. Learn well, kids)

The wife and I are leaving on a couples' trip to Colorado. The last time we skied/snowboarded was 4 years ago. Thanks to her parents who will be flying in to babysit Alli, this will be our first trip anywhere without our daughter. And, after a harrowing few months at work and some other challenges we've had to face in the last month, plus a stupidly busy call well, this will be a much-needed getaway.

I miss the feeling of the snowboard gliding on the soft, fresh white powdery snow. The contrast between the colors of the winter gear against the whiteness. The laughs and shrieks of people, against the deafening silence of the mountains.

We rented a ski-in-ski-out condo by the slopes, with an outdoor hot tub. We can't wait (ask me again next week if I end up breaking a leg!)

Crossed Lines

2011-11-09T20:25:00.001-06:00

I realized the other day how crossed some lines can be.

I was rounding on some patients on the renal floor, and was talking to a couple of nurses about their patients, getting status updates, things like that. And then I realized that for Mrs. C, the cortisol test I ordered was still pending. It's a test that usually takes no more than a couple of hours, but the nurse wasn't sure why the results weren't back yet. I was in somewhat of a hurry to get to Hospital B where I had another 12 patients to see. And so I said to her nurse, a pretty young nurse in her mid-20s:

"Can I give you my cellphone number?"

At which she gave a half-giggle, and gave me a weird look.

"Errm. I guess so", and proceeds to take out a piece of paper and her pen somewhat hesitantly.

I thought it was the strangest response. Until her colleague asks:

"Is there something you want us to call you with?"

I told them I wanted the test results called in once it came back on the computer. And only after the both of them burst out laughing did I realize that they thought I was trying to pick her up. Bwahaha.

At least my wife thinks I still got 'it' since she was willing to take my phone number!

2011-11-06T20:45:00.001-06:00

Happy Birthday, bud.

Wherever you may be.

Going to the Dark Side

2011-11-01T20:50:00.000-05:00

Ok, after years of fighting it, I relented. I finally walked into the 21st Century, and got myself the iPhone 4 (no, not the 4S). Grudgingly so. Call me a creature of habit, but I don't like change. For that reason, I keep going back to the same restaurants. Keep ordering the same damn dish on the menu. For the longest time I stuck with the same cable TV companies even though they were ripping me off, just to 'keep things the same'. Refused to try out Macs because I was so used to PCs despite all their problems. And so, for the longest time, I stayed away from the iPhones, instead using Nokias (because I was REALLY familiar with them) and then the Palm Treo and the Palm Pre plus. And I love(d) my Pre.

It's a great little device, small enough you could fit it comfortably in your PALM (sorry, bad pun). It's a very ergonomic, attractive little device, with a pull-out keypad for those of us who type like we have bananas for fingers. And WebOS is such a wonderfully intuitive operating system, with simple and very effective user interface. I loved it so much that we even got the HP/Palm Touchpad, knowing that it was no longer produced.

And so, like the many faithful Palm userrs out there, I was saddened to read about HP killing off these products, and the WebOS. Naturally, this is accompanied by ever decreasing Apps for the WebOS, including the loss of my beloved Epocrates (as a sidenote, I was somewhat pleased to read that HP fired their CEO for making all these about-turn decisions). Nonetheless I thought my Palm was in good enough shape that it should last me awhile. I babied my phone. Even to the point of powering down the unit every night to conserve battery life (from those days of using the NiCad battery phones). I kept it in my breast pocket, away from the coins and keys in my pants that might scratch the screen. I thought it would endure.

Until, as destiny would have it, there was a convergence point between a toddler, the handset and solid oak hardwood floors. In a split second, the touchscreen was cracked. And with it, all pressure-sensitive functions of the phone. It became a sleek (cracked) paperweight.

Being oncall in 3 days meant I had to replace the phone with something. Repairs were not an option anymore. At the cellular store, I held out hope that they might still carry some old unused Palms; they did not. I could order one online, except I'd be paying more for a 2 year old model that is no longer in production, compared to a relatively newer iPhone.

Truth be told, I did actually consider it. And the salesgirl actually said she's never seen anyone so attached to a Palm before (you could tell from the look on her face she thought I was an idiot for even considering it). And so, here we are.

I got an iPhone 4. Grudgingly. Sulkingly. I'm probably the only person in the world who's not thrilled to be upgrading to an iPhone. And more so out of objection than stinginess, I chose to not get the 4s.

After all, I already feel like I've lost my (2nd) wife. I'm not going to get Siri to replace her!

Sigh.

2011-10-27T20:40:00.001-05:00

I saw Mr. L the other day. He was one of my oldtimer patients (not in terms of age, but I'd been seeing him for a while). And one of the things he said struck me as an odd, but surprisingly accurate, statement.

"You don't really believe in the stuff you supposedly peddle, do you?"

I had been seeing him for his diabetes for years. And on a more recent visit, he complained of issues with erectile dysfunction and low energy. And so when I offered to check his testosterone levels, he was quite keen on it. Nothing really jumped out on his history; he just occasionally has trouble keeping his erections during intercouse and his libido was a bit decreased. Otherwise, his morning erections, and during masturbation, seemed normal (yes, awkwardly personal, but very helpful questions to ask). He denies any gynecomastia, change in shaving habits. As with many of my diabetes patients, he is obese and has the typical habitus of someone who may have sleep apnea.

As it turns out, his total testosterone was slightly low at 314 ng/dL (normal more than 350). And so we had a discussion about testosterone replacement. He was quite keen on trying something, having seen the numerous TV ads (you know which one I'm talking about; the one with the guy talking to his shadow). And yet he sensed my uncertainty, which I did not attempt to hide.

I belong to one school of thought. The other side of the fence. There is a reason why the normal range for many hormonal tests is wide. They are based on what is deemed to be a normal population, with all our indivdual variations. And the nature of many hormones is that they fluctuate. When it comes to testosterone, there is an age-related decline, as well. And so, it is not too uncommon to have levels sometimes being a bit low. Frequently, blinded studies show little benefit of replacement for many of these borderline patients. However, you'd not believe this, seeing the numerous TV, magazine and newspaper advertisements, suggesting that medication A or B will make you feel like a new man. That if you are tired, or lack the drive you did when you were 20, or struggle with low stamina and weight gain, then it MUST be the low testosterone (heck, maybe I should get MY levels checked. That all sounds like me!). Pharmaceuticals is after all, a multi-billion dollar industry.

While cautious therapeutic replacement trials should be safe so long as things are carefully monitored, I'm of the opinion that the drug companies are already making far too much money, and if someone is not going to feel any better being on their medication, I'd usually discourage things. I'm open to it, but I'd usually not push it. Be it for borderline hypogonadism, or 'hypothyroidism' with a TSH of 5.2, or something similar. Perhaps it is ironic then that a board-certified endocrinologist is much less keen on starting patients on hormone replacement, than many of my general practitioner colleagues.

And so, I left the final decision on whether to start testosterone or no up to him. After checking into the cost of the medication, and looking up some (reputable) medical websites, it appears that he agreed with me. He said no.

Race For the Cure

2011-10-23T07:55:00.002-05:00

We had a fun weekend. Kristin and some of the girls had been training for the Susan G. Komen Race For the Cure 5k run. So, on this beautiful (cool) Saturday morning, 20,000 people converged here to run to celebrate and remember our loved ones, friends, patients, with breast cancer.

Just over US$1 million was raised, but much more than monetary goals, I think this annual international event really raises the awareness of breast cancer and the importance of screening.

It was heartwarming to see so many people there. Clearly, some had lost family and loved ones- many wore names of people they were remembering or celebrating. Many had custom designed team shirts. And I've never seen so many men wearing shocking pink (no, I didn't run- baby duty). Even saw one guy dressed in a pink cow suit with udders for the run.

Congrats, girls! (can you spot them in the finsher picture above?)

Then and Now

2011-10-20T20:16:00.001-05:00

I just had to take a photo of this sign I saw in the hospital. I just had to shake my head; this was a notice to nurses to sign Thank You cards to give to patients. While this might be a nice gesture, I caught myself thinking, Isn't it supposed to be the other way around?

I'm going to make myself sound old saying this, but it did make me ponder about how things have changed in our world.

Then: Patients used to send Thank You cards to the doctors and nurses.
Now: We are sending Thank You cards to the patients to thank them for picking our hospital
Then: If you are injured, you seek the help of a medical team.
Now: I have to listen to this damn radio advertisement every morning when I drive to work: "If you are injured, you need the services of an experienced lawyer. Call XXX"
Then: The doctor would pick the best medical treatment for the patient.
Now: You list out every single option, the pros and cons, and the patient decides.
Then: You make a clinical diagnosis based on a good history and the lost art of the physical examination.
Now: CT abdomen with IV and oral contrast.
Then: If I felt that a patient could not afford medical care, I'd underbill that patient and not think twice about it.
Now: I'd get a formal reprimand from the directors as this might be deemed a case of discrimination, and we might get sued for giving special treatment to a patient over others.
Then: Re@der's Digest magazines were actually filled with good stories, inspirational tales, and fictional writings.
Now: It's drug ad after drug ad after drug ad (the reason I cancelled my subscription, after been a faithful reader since I was 7). It's the same crap on TV too, and I imagine the parents blush when a Viagra ad pops up during family TV time.

Changes for the better, or worse? You be the judge.

Things You Don't Know As A Doctor

2011-10-15T11:48:00.005-05:00

Being someone's physician, you get to see just one side of someone's life. You get to know about their previous ills. You probably understand much of the biochemistry that occurs in their bodies. However, not the more important things in life.

I was reminded of this this morning as I was doing my rounds, and happened to find out that one of my thyroid cancer patients recently lost his battle.

It was inevitable, the very aggressive kind that he had, but as inevitable as something might be, is still never acceptable in anyone's psyche. And so, when I had some quiet moments between consults just now, I spent some time reading up his obituary. If nothing else, just a private moment to remember him and celebrate his amazing life.

I found out he went to an Ivy-league school, and chaired numerous subcommittees. That he had an interest in the underpriviledged, and was active in social work. Though I had met his wife before, I read that they were sweethearts long before they got married. I read about his kids, that they have twins. I caught myself being in awe of Mr. G's humility- as his physician he never let on to me that he played such a big role in many people's lives.

I recalled too some months ago when Mr. T passed away. My clinic posts the newspaper obituaries of our deceased patients so that we can choose to sign their condolence cards. I found out that he was a World War II veteran, and a prisoner-of-war. That he was an airforce pilot and flew numerous bombing runs.

Or how another patient was involved in the Manhattan project, and the development of the atomic bomb.

No, these things hardly come up in the usual doctor-patient interactions. After all, the have little relevance in the diagnosis and treatment plans. Nonetheless, in the larger scheme of things, these are the events and moments that leave a bigger mark.

Goodbye Mr. G. You fought a short and hard battle- may you find eternal peace now wherever you may be.

To have Type 1 Diabetes

2011-10-08T16:21:00.002-05:00

I saw Andy the other day- he was a new referral for hyperglycemia. Lean, with no family history. His glucose was found to be 455 mg/dL at his primary physician's earlier that day, with a hemoglobin A1c of 14%, so they rushed him in for a visit with the endocrinologist.

I hate being the one to break it to patients; invariably, most patients are initially quite upset by the diagnosis of type 1. To be told that their islets no longer have the capacity to secrete insulin, and to have this disorder for life. To be told that from this moment on, they will need to be on insulin to survive, and to be aware of dietary carbohydrate intake, blood sugars, and all that stuff.

I don't blame anyone for being upset. And I don't blame them too for not quite believing the optimism I show at these visits. I tell them, diabetes does not mean the end of junkfood, or candy, or fun stuff, or exercise. It's just that one has to make some changes to one's lifestyle, and obviously educational empowerment of the patient is key. A lot of learning. But the truth is, with good teaching, and commitment by the patient and health provider, a vast majority of patients have excellent prognosis. They do well.

But the look on their faces tell it all:

"Patients do well?? How can that be? I'll need to check my sugars and take a shot 4 times a day! For the rest of my life??!"

I can understand the patients' scepticism. But, from the other end of the fence, speaking as a doctor, I am humbled as well by the advances we have made in the field of type 1 diabetes. After all, before the discovery of insulin by Drs. Banting and Best in 1921, type 1 diabetes had 100% mortality when it became fullblown. ALL patients died, most never seeing adulthood. In probably the fastest drug developmental program, the first human subject testing occurred in 1922, and insulin came on the market only a year later! Dr. Banting eventually received the Nobel prize in 1923. And now, the situation has completely reversed- with insulin, we expect all our patients to not only live, but live meaningful lives albeit with numerous adjustments to lifestyle.

Imagine if we can someday say this for cancer.

And so, when I do try to be optimistic with these new patients, I do really mean it though I realize we may be looking from different angles.

And I agree with the battlecry of many of my patients still looking out at the horizon for new developments in treatment: Insulin is not a cure.

Someday hopefully we get there. But in the meantime, this is the best we have.

An Interesting Hypercalcemia Case

2011-10-03T20:28:00.000-05:00

I thought I'd share this case I saw not too long ago. The patient, Mr. P, was a 52 year old man who was found incidentally to be hypercalcemic. His serum calcium was 10.9 mg/dL and on repeat 11.2 mg/dL (his albumin was normal, in case you medstudents out there were correctly asking that question).

While the workup of hypercalcemia should include a parathyroid hormone level early on as this may obliviate many other tests if this was inappropriately high (recall that one does not need to have a high PTH to have hyperparathyroidism- a common mistake that I encounter), his PTH was appropriately on the lower end.

So, working along the lines of 'non-PTH mediated hypercalcemia', what is your differential diagnosis, and plan?

(and if you're friends with me on FB and already saw my earlier posting, don't spoil the surprise!)

Signs You're Getting Old

2011-10-01T20:37:00.000-05:00

It's Saturday night, and you find yourself in bed by 8:30 p.m.
You get motion sickness playing on the swingset with your toddler
Your sideburns are greying
You catch yourself choosing to drive the Lexus and not the Porsche on a beautiful sunny day because you're too lazy to work the clutch
When the baby's finally asleep, between sex and going to sleep, you're sometimes picking sleep
You're starting to seriously think about life insurance, writing a will, living revocable trust and things like that
You think driving at 70 mph is way too fast
You walk past a leggy 20-year old blonde bombshell and you catch yourself looking at her mother instead
Your friends' kids call you 'Uncle' or 'Auntie'
You think it's perfectly normal to be getting up at 2 a.m to pee
You're needing to take some ibuprofen for knee pains after running 3 miles on the treadmill
Someone tells you you look good in that tweed jacket

Sighhh. I suppose, as an elderly wise patient once told me, the alternative to getting old is to die young which isn't a good thing either.

My Birthday Present

2011-09-28T20:55:00.000-05:00

Yea, I know, this is a way belated post. My birthday was well over a month ago. But, I wanted to check out the results before I blogged about it.

I love my wife!

The wives out there (no offence) would probably have gotten their husbands birthday presents like socks, or sweaters, or ties or something boring like that.

No, not my Kristin. She bought me a beer making kit! (then again, what about those women who got their husbands a BMW??).

And so, like a mad professor tinkering around in his lab, I couldn't wait to try it out.

The kit comes with all kinds of parts. A big plastic barrel, some plastic beer bottles, and the all-important brewing mix, which contains the hops, spices and for all I know, toenail dirt.

It also comes with a manual, thankfully. I guess this prevents dumb people like myself from fermenting something into methanol and going blind. Anyway, I thought it was pretty straightforward.

All I had to do was to dissolve the brewing mix in water and slowly bring it to boil. And for a personal touch, I added in some orange peel zest.

After that was done, let the mix ferment in the barrel in a cool, dark place. They recommended at least 1-2 weeks, so I left it there in my basement. Except, like a boy on the night of Christmas eve, I kept peeking and checking in on the barrel, which probably didn't help. Then again, I was worried it was going to blow up or something.

After the fermentating, put 2 tablespoonfuls of granulated sugar into the bottles. And if you don't have a funnel you can always improvise with the junk mail you have sitting on the kitchen counter. I guess I must have missed this part in my chemistry classes, but apparently this is the thing that carbonates the damn thing.

Fill bottle up with the beer mix concoction, and leave in in a dark place for another 1-2 weeks. I kept my stuff in a brown paper bag in the basement, completing the picture of an alcoholic!

And waa-laa: Home Made Beer.

I must say, it turned out pretty damn good. Then again, I'm probably biased, and the higher-than-expected alcohol content might have played a role. But I was impressed by the outcome.

Cheers!

2011-09-24T12:54:00.000-05:00

We brought Alli to the apple orchard today. She had a blast feeding the animals and playing in the corn pool!
I love autumm! Despite knowing that winter comes next.

-- Sent from my Palm Pre

Sustainability

2011-09-23T06:59:00.000-05:00

I admit, I'm not very smart when it comes to picking the right approach to my patients with uncontrolled diabetes. I'm still trying to figure things out.

It's a truth; how well a patient does depends in large part to compliance (with some exceptions), with glucometer checking, and proper usage of medications.

And so, from my end, I'm often left totally helpless when a patient comes in for his/her checkups and has an A1c of 14% but NO glucose readings in the past 2 weeks to review. And freely admits to missing 50% of the insulin.

On one hand, I try to tell myself: "They are informed adults- if they choose to not take care of themselves knowing the risks, it is their perogative..."

On the other hand, it makes me, the physician, feel like a failure and a fraud. It makes me feel guilty that they will get billed for this office visit and yet they get nothing out of it, aside from my encouraging them to do better.

And so, I've done things my colleagues have advised me not to. I have my patients email or fax me their logbooks in a couple of weeks so that we have some objective data to guide adjustments of doses. I've even been known to call patients to remind them to send me numbers. So, this inevitably leads to a torrent of emails and faxes weeks later; I sometimes spend hours a day going through these, advising changes. Except this is done in my own personal time; we don't charge for a telephone call.

Sometimes I request for a 2-4 week follow up. Except that my schedule is booked 2 months out, so whenever I ask for an urgent 'work-in' what this usually means is I see them over lunch. Which means the special diet of SpeedLunch+Dyspepsia®, or NoLunch+HungerPangs®.

Sometimes seeing the improved control is gratifying enough. Sometimes, things are no better. But consistently though, I come home exhausted and hungry. And so, I do wonder about the sustainability of this practice. It's not a smart or healthy way for the practitioner, but eventually to keep myself sane I suspect I'm going to have to back off, and accept that some patients just don't want to help themselves and if so, I shouldn't be trying to kill myself helping them.

2011-09-19T20:42:00.000-05:00

It's hard sometimes to not take things personally, methinks. Or maybe I just need to develop a thicker face.

But it's true, for me and many of my colleagues. While we supposedly know that it's just work, when something doesn't fall into place we sometimes take them to heart. It's something I have yet to learn well.

Take today; I received a message that a patient I had seen had a miscarriage. I saw this young lady a months ago for "thyroid dysfunction". Her thyroid labs were perfectly normal, but because she was gaining weight, was fatigued and was losing hair she was convinced her thyroid was underactive. Despite a pretty normal TSH and FT4.

Between that visit and now, she got pregnant, and had a miscarriage. And despite the results, is convinced her thyroid is to blame. She called today, asking to see another endocrinologist for treatment of her 'thyroid problem'.

Being a father, I realize it's tragic to have a miscarriage. Being a physician, the logical side of the brain knows this was not anything to do with her thyroid gland, but there's still a side in your heart that feels a tinge of hurt realizing that a patient may blame you for something.

Indeed, over the years my colleagues and I have had numerous patients switching back and forth. Sometimes it may just be a matter of the physician's personality not being compatible with a patient's. After all, we're all different. While I've 'inherited' several patients in the years, I know I've had a few who requested a different physician follow their case instead. Sometimes, it may be because of something as stupid as my not wanting to prescribe pain medications (when it was their diabetes or hypothyroidism I was managing). Other times, they turned out to be unexpected especially after all the time you've invested making sure you explain things and answer their questions.

Life goes on, and we try to help the next patient.

But every time, like a spurned relationship, there remains a tinge of hurt and disappointment, admittedly.

10 Years Later

2011-09-11T12:55:00.000-05:00

10 years.

It still seems all too surreal, 9/11/01.

What many consider to be the darkest day for mankind in this generation.

On one horrific day, nearly 3000 lives were lost. Countless others scarred and changed forever.

People of all walks of life. All skin colors, religions, political ideology, ages.

I can never fathom how one can plan such a horrible event; I can never understand how one can ever justify killing, let alone that many people. For what? Their beliefs? Revenge?

In some ways, I try to switch off the TV as it shows the many reminders. The haunting video of that United Airlines 175 and AA flight 11 crashing into the towers. I've seen it so many times over the years that it's seared into my brain forever, and I don't need more TV reminders of it. Yet, part of me feels a sense of duty to remember that day, every horrifying event, to remember and respect those who were lost.

They say there are moments that you will remember for the rest of your life. I remember what I was doing when I first heard. I was at Al's apartment in KL- I was teaching in IMU then and was renting a room from him. It was nightime, and I had just taken a shower. I heard him yell, and then call a friend. "Sell your stocks! Someone just attacked the US (in his typical fashion)". I remember being glued onto the TV, and then calling my (then) girlfriend who was in North America to ensure she was OK. I remember going to work the next day, in a daze and shock, that such an attack had occurred, and thinking that the world is forever changed. That such evil, actually existed. I remember the anger and disgust I felt, when I heard numerous people at IMU actually say, "They deserved it..." (the irony, this was supposed to be a MEDICAL SCHOOL, teaching about health!).

10 years after that fateful day. May the world never forget. May we learn to be stronger from it. To be kinder to each other. To be a better people, never mind our race or religion.

2011-09-08T20:44:00.004-05:00

Hey Buddy,

Hope things are going OK. Then again, where you're at, I can only imagine perfection, and that you're at peace.

Though it's been almost 4 months, we miss you terribly. I can't say I go through what your family may struggle with, but you are after all my 'brother'. It's surreal, the realization that you're gone, at least from this physical world. It's difficult realizing that we can't even make a simple phone or Skype call just to chat. Or to confide in my work, or to run a heme-onc case by you. Or just to complain about the wife

I miss those days. I miss the post-call days we went out to stuff ourselves silly. Or when we attempted to play tennis (I'm not sure you could call what we did 'tennis'). The Battlestar Galactica nights.

Funnily enough, one of those things that made me think of you the other week, was Halo. Yup, after a year of sitting in the drawer, I played Halo 3 again. And I couldn't for the life of me figure out why this time round I was having such a tough time getting through the levels. Until I realized, I had a wingman the last time we played. Oh God, how we played. Remember those Sunday 8 AM to 2 PM games? Or when we didn't want to waste a nice spring day playing video games? (and so we brought the damn TV and Xbox outside?).

We had good times, didn't we? I still think of those times, everytime I look at the wall art I have hanging in my study. Yup, the one of two guys playing cards, the one that you claimed "looked gay".
The funniest thing happened the other day. I got a Facebook message from you, wishing me a Happy Birthday. The first thing I thought of was, "Wow, they must have good Wifi in Heaven!". And then I realized your wife had sent me a message but was logged into your account. But still, it was a good laugh. The kind of humor you and I are used to.
It's been 4 months. But know that we miss you dearly still, and will always do. Perhaps the pain and the tears will get better, but we'll never forget you. Till the next time, buddy, be well.

2011-09-05T19:45:00.003-05:00

We took Alli kite-flying for the first time over the Labor Day weekend. Surprisingly, she seemed to enjoy herself. Though after a while she would just toss the reel away and enjoyed watching dad and grandad chase after the kite as it was blown away.
It's amazing how fast kids grow.

Happy Merdeka Day!

2011-08-31T06:51:00.003-05:00

Happy 54th Birthday, Malaysia.

I wish you peace, and harmony, and economic growth.

I hope that your leaders eventually learn to mature, and make decisions based on what is best for you, and your people. Not for one group. Not for personal greed, or corruption.

I hope that someday, you will become the truly democratic, truly multiracially harmonious society that so many of us want you to be.

I hope society can someday rid itself of selfishness, racism and corruption.

Happy Merdeka Day.

It's a Mad Mad World

2011-08-28T08:57:00.000-05:00

Some things are so screwed up.
For one, healthcare and medicine are f*cking expensive. Doctors' visits ain't cheap (and no, I don't get to choose the dollar amount I charge. We just code according to 'complexity' of the case) and the amount that gets charged depends on the health insurance and bureaucratic BS that I don't fathom. Secondly, the medications themselves are overpriced, really. I understand the need to cover costs of R&D. But to be making billions seems wrong.

I guess I'm just irritated with things. I saw a patient the other day for poorly controlled diabetes. She has type 1, a condition that requires lifelong (until someone comes up with a cure) insulin and regular glucose testing to allow for safe adjustments of her insulins. Unfortunately her hemoglobin A1c was 14%, her control hampened by lack of compliance. Except I don't blame her.
Tearfully, she tells me she just cannot afford the glucose strips, and the insulins. She is one of the millions of uninsured Americans. And so, medical care costs a bomb, and she has had to decide what's more important, food/rental or medications.
And so, I squirrelled away whatever free samples I could find in the clinic. And referred her to the social worker. And, hoping the hospital director never finds out, bills her a level 2 (with the multiple issues and her high risk situation, this would have been a level 5). Essentially, something akin to a nursing visit. The last time I did this, I got a reprimand.
Elsewhere in the world, if a doctor, in good faith, decides to undercharge a patient, it's his perogative. Heck, in Malaysia I've had doctors who give courtesy 'free consults'. Here, in this overly civilized country, that may be perceived as a form of discrimination. Why would you give a discount to one patient, and not another?
And so, the hospital and it's lawyers go nuts with these things. And it is very frowned upon, as tragic as the case may be. The hospital does not wish to open itself to any lawsuits.
In my opinion, if we weren't afraid of being sued, healthcare in general would be much cheaper, and the world would be a better place. Without the threat of lawsuits, that may make some idiots be bigger idiots, but I'd like to trust that mankind generally, is good.

If we weren't so careful and afraid of missing somethings, things would be so much simpler and cost effective. Ie, make a medical decision based on the history and the clinical findings and suspicion, and go with it. And not "run other tests to make sure I'm not missing something" defensive medicine that the malpractice lawyers have made American medicine to be, these days. I mean, come on, do all tummy pains require a CT abdomen?

And all that "If you've taken Pill X and have had an adverse effect of Y, call Lawyer Z as you may be entitled to a monetary compensation...". ALL medications have side effects. All of them. You take a pill if you and your physician agree that the benefit far exceeds that. I get pissed seeing the new TV ads for people who had a heart attack while taking a certain pill; chances are without that medication MORE patient would have died from their medical condition.

You tell me, is this not screwed up?

We'll see if I get a call from the director about this case. Frankly, I don't care.

Corndogs, Fried Snickers Bars and BO!

2011-08-25T19:34:00.006-05:00

Yup, talking about the state fair. We were there over the weekend; Alli's 2nd (she was 2 months old when we went last year. As usual the crowds were crazy, over a million attendees in the week and the half. Coming from Malaysia, this is always a cultural shock. Deep fried everything, with every imaginable foodstuff sold on a stick. Crowds and crowds of sweaty people wearing wifebeaters, with the occasional whiff of musky body odor.

We discovered too, like her father, Allison loves corndogs. And this is her, posing with a pumpkin, a PUMPKIN, 50 times her weight!

Aside from the usual deep fried candy bars, this year someone came up with the idea of deep-fried butter. I kid you not. And people wonder why obesity is on the rise.

Not that I should be so judgmental; we had the deep fried Oreos, and they were pretty interesting. And I had 2 foot-long corndogs!

Someone please pass the Lipitor.

Century Link: A Study of Incompetence

2011-08-21T16:52:00.003-05:00

So, how did I spend my 35th birthday?

Awesome cake and birthday brunch by/with the wife and daughter.

And some vomit inducing moments with our new internet provider, Century Link/Qwest. I swear, the ISPs just keep getting worse. And I have not been impressed. And yes, if you Century Link customer service web crawlers are reading this, feel free to get in touch with me to apologize.

Because the other ISP was steadily increasing its charges over the years, we decided to make a switch. And so last month, July 20th to be exact, we had our DSL installed. A long cable ran from our house, to the back and diagonally across. Why the tech didn't connect us to the nearer box right behind us, I don't know (I think he needed new glasses).

Anyway, we were told the cable would be buried within a week.

And then the weeks came and went. Finally, on week 3, someone came to make the burial. Except this seemed like a bright fellow, and made a new connection to the nearer box so that he didn't have to dig into our neighbours' yards, and buried THAT cable. He said he would contact Century Link to have the service transferred to the new, nearer box instead, and they can then remove the old unburied cable. He suggested I call too, to get things moving faster. And therein lies the problem. 7 tranfers between incompetent customer service reps, with 1 dropped call, and FIFTY NINE minutes later, the last guy finally said, "I have trouble contacting the buried cables department. Can you call back later?"

WTF. And so, to avoid a cerebral hemorrhage from the hypertensive crisis they were putting me through, I decided to give it a break, and see if they would come.

A week and half later, no word. The cable remains unburied. My neighbour's kids have already tripped on it several times (no word on any lawsuits yet). And today, one of the lawnmowers went over it and severed the cable (it was an inadvertent but expected outcome- the damn thing runs across the yards of 3 homes!).

And in this day and age of 'high speed this-or-that', it will be.... taa daahh... 72 hours before someone comes to rectify this.

Strangely enough, things moved a lot faster before I became a customer... but once they had me hooked, things seemed to slow.

And to think this is a telecommunications company. Bullshit.

Maybe I should go back to dialup.

Stages of Life

2011-08-20T06:17:00.002-05:00

Year 1: Milk, food, bankie, sleep

Year 12: Girls are strange. Girls are dirty (hey, it was an innocent, literal 'dirty' then!)

Year 18: I'm cool. I'm the head prefect of the school, and Vice-Chairman of the first-aid unit. And I bet the chicks really dig this pair of white Guess jeans I'm wearing, and this moustache I have on my face

Year 21: Wow, I'm finally an adult (still on an allowance)! I have wheels (a hand-me-down pimped out Proton Wira).

Year 25: Check out those hot 21 year olds!

Year 30: WTF? 10 years of medical education, and I have another 2 years to go before I'm finally done training? And I need to work harder on my papers and get them published!

Year 35 (almost): Hmm. I wonder if that Rogaine stuff will work for me? Or maybe I should shave it all off; why fight it? And oh yea, is it just me, or are women in their 40s sexy? Uh oh, I think I hear the baby crying.

That pretty much sums up the years so far. Yea, I turn 35 tomorrow. Well, technically since I was born on Malaysian-time, I'd be sometime today. I was just sharing these with my wife the other day; it's amusing how one's priorities and thoughts change.

For one, yes, I used to have several pairs of designer white jeans. I thought they were cool. Kinda still do, but my wife has threatened to disown me should I wear them (she allowed me to wear them once on a date many years ago, but that attracted one too many stares). And so the expensive Guess and 501 jeans were donated away. Now I only embarass her in other ways.

For a guy, obviously a big interest in life are the girls. Even now (oh yes, the wife and I are allowed to admire eye candy. See no touch). But it's funny how when I was in highschool, I thought the epitomy of sexy womanhood was a matured girl who was 18. And then it became 21 years of age. And then 28? And now, I catch myself mentioning to Kristin things like, "Check out that woman", and then to realize she's in her 40s or 50s. If you asked me who is THE sexiest woman around after my wife, I'd say Diane Lane. And she's what, 46?

Priorities change. Yes, I'm still working like a dog, probably harder than I'd like to. But at this stage of my life the priority isn't work (it's a necessary evil) or buffing up the CV with publications, or presenting research posters. It's not to dress up and look good and party and impress girls (the only 2 I wanna impress are the 2 honeys still tucked away in bed in my house). It's not money. No, now, more than ever it's family. And I have much to be thankful for.

P/S: If you really want to know what I want for my birthday, it's a 2nd hand (I never get it new) Halo Reach.

The Modern Epidemic

2011-08-17T08:39:00.003-05:00

I saw Andy the other day. One of my oldtimer type 2 patients. And in the midst of the usual banter (this time, about the state fair), he joked about his weight. And then he asked me why this was a bigger problem these days (no pun intended) compared to his parents' generation.

Obesity. It's staggering, the numbers. In some parts of the country, more than 1 out of 3 adults are considered obese, with a Body Mass Index greater than 30. In my practice, many of my patients have a BMI in excess of 50. And it's not only the USA; this is a worldwide phenomenon. And perhaps a greater tragedy is, childhood obesity is becoming much more prevalent. No longer are the lines well-defined: "Type 1 diabetes occurs in childhood, and type 2 occurs in adulthood.." my medical students often quote to me. Not anymore, buddy.

Why is this? There is always an inherent need to find a 'medical reason' for obesity. I see consults for these every week; patients who won't believe their thyroid or adrenals are working fine. "There must be a reason for this. There must be a pill I can take/surgery I can have..."

The reasons are complex. And probably too many for me to fathom. But methinks this is due to the modernization of man. Technologically, but also socially. And unfortunately, what's right as a society may not be the best for its health.

Due to the conveniences of life, we just aren't as active. Believe you me, I'm not referring to things as a 3rd person; I know I am guilty of this too. We just don't move as much.

True, dedicated exercise is great. You know, running, going to the gym etc. However I'm also a firm believer in non-exercise activities. Things that don't require special preptime, or special trips to a facility. Things we can do all the time, during our usual everyday motions. There are numerous studies out there demonstrating this concept. Just any kind of movement, burns calories albeit in small amounts. But as a society, we are just walking, moving around less. We depend so much more on modern automatons. There are escalators everywhere. We use the elevators even to go up (or even down!) a floor. We drive everywhere we go, and walk less. We use the phone to call a colleague and not actually stroll over to their desk (I've called my wife's cellphone from the basement, when I was too lazy to walk upstairs at home!).

Now, not only is the output less; the input is more as well. There tends to be a close relationship between the ease/price of food, and its health value. The cheapest, quickest foods tend to be the least healthy. I admit, the crap I wolf down at lunch every day isn't exactly good for me. As a society, things seem to have shifted to the wrong end of things. How many times have I seen a family with everyone being obese, even the kids, at McDonald's. And the children having 2 servings of fries each, plus a burger and sundae? And I'm just as guilty, having MY Big Mac and fries. Oh, how I wish broccoli and all things green made us fat. And chocolates/fries were full of fiber and protein and vitamins!

But the more difficult thing to admit for me as a physician and as person is, what we do to support some people, may end up backfiring. Some of my patients struggle with weight so much that they have difficulties ambulating, so they instead use a motorized wheelchair to get around. Now, from the civic and societal standpoint, this is great- this offers some people freedoms they would otherwise have difficulty experiencing. But if you looked at things purely from a (robotic) medical view, then this would decrease their activity levels even more, feeding into the problem. And so, both of these views are discordant, and in conflict with one another. In addition, many of my patients feel that they can do longer work because of their excess weight, and apply for disability, allowing them to obtain special benefits, like strategic parking spaces, and a (small) monetary compensation. Again, I see the need for these, but I am also conflicted in saying that these may not help alleviate the underlying medical condition. One can say these in a way rewards the problem.

And so, I wish I had the answers. I wish the CDC, or the NIH, or the government, or Obama, or even Najis did. I wish there was a simple solution to this worsening epidemic. As an endocrinologist, I wish it was as simple as, "Oh yes, you have hypothyroidism, take this pill" or "A laparoscopic adrenalectomy will cure you of your Cushing's and your weight problems".

Unfortunately the answer is probably much more complex than that.

In the meantime, society suffers.

How to make a burger

2011-08-12T18:30:00.001-05:00

So I decided to try my hand at this for the first time. And I have to say, it turned out pretty damn good (caution to the reader: self praise means nothing. Proceed at your own risk).

Start off with ground beef. 85/15 or 80/20 should do it. I woulda gone for the 80/20 but my wife apparently loves me and doesn't want me to die of an MI at 40. So, it's 15% fat it is, then.Other ingredients I added included basil and onions (from our 'garden' Taa Daa!). You'll also need a teaspoonful of salt, garlic.

Finely chop the basil and onions.

Mix the chopped up ingredients with the minced meat. And being Malaysian, I just HAD to add a dash of soy sauce and curry powder. Mix well with your fingers. If you do this after a pangsai session, I've been told the burgers will taste better.
Make apple-sized balls of meat, carefully compressing them to ensure it'll stick together. Flatten them on a platter, and make a depression in the middle with your thumb (so that you'll know when it's cooked- the dimple sticks out)

Grill away on medium heat. It took our grill about 5-7 minutes to cook the patties to medium.

Slice of cheese on the patties while it's still hot to partially melt it.

Serve with some miniscule portions of veggies (we had asparagus) to appease your wife that this is a 'balanced' meal. And then go feed your canivorous side!

Shh

2011-08-10T08:23:00.002-05:00

I just wanted to share this experience from today, which really irritated me.

I dropped Claudia off for her oil and filter change. It had after all been 2 years since the last. The workshop we use offers a courtesy van, so I had them drop me off at work. And in that shuttle, was another 3 gentlemen who needed a ride, too.

Clearly, one of them was a doctor. Probably a surgeon of some sort, as he was in dark blue scrubs. During the ride, he started to make a few phone calls to his nurse. And talked about some billing issues regarding some patients and some procedures. And actually spelled out his patient names to his nurse.

Now, this is wrong at so many levels. For one, it's rude to be yapping on the phone in a shuttle van with others. Secondly, it is simply unethical to be disrespectful of the sacred confidentiality between a patient and his doctor. Indeed, this would be a HIPAA violation and may be an actionable offence.

True, there is more than one 'John Doe' in the city, and he didn't read out in graphic detail his address, or date of birth, or the procedure itself. But come on. Your patients trust you with his secrets, while the others around you expect a certain level of decorum as a member of the medical field.

Even when I'm rounding in the hospital with my residents and students, they all know better than to continue discussing our patient cases when we step into an elevator with other sets of ears. Our topics swiftly change from the insulin dose for Mr. G to what our wives do for a living.

So, to those of you who have been entrusted with this priviledge, remember the sacred oath you took. Be respectful of your patient.

Of Stockpiles

2011-08-07T14:40:00.000-05:00

Every Malaysian expatriate I know does this. You know you do.

Every time I make a trip back, I 'import' a stash of foodstuff into the US. And in fortified pantry of our home, much much more priceless than jewellery, or our legal documents, is my stockpile of Malaysian food.

My precious stash of spices, sauces and pastes from half a world away. A feeble attempt for the tastebuds to experience the homeland. A temporary means of treating homesickness.

And my wife knows better than to mess around with my stuff. She can mess around with my Porsche. My cellphone. The LCD HDTV, or my computer. But this, this is out of bounds.And so, I made dinner the other day. Was craving some Portugese fish curry. And so, I put on my chef's apron, got the fish out of the freezer, and went into the pantry to get My Precious.

Only to read:

I did the only honorable thing. The right thing. After all, I'm a doctor, and health is important to me.

I ate it.

(no diarrhea or food poisoning, so far. Just don't tell my wife about the expiration date)

Time Flies

2011-08-04T19:28:00.002-05:00

I didn't realize the significance of today until I ran into the hospital HR manager today.

"Happy Anniversary!" He wished me.

Oh yes. It was today, wasn't it?

August 4th 2008 was the day I started work in this medical center.

3 years ago. It didn't feel like it was that long ago when I left my alma mater.

Packed up my stuff from that rental I had lived in with Buddy for 5 years.

Drove our two cars and dog here.

I remember when we closed on our home. How we spent the first night sleeping on the floor, because the movers were going to arrive only a day later.

I remember my first day at work. Feeling lost physically, not knowing where to go. Fumbling with the computer system. Still uncertain if I was treating patients right, seeing that that was the first time in my professional life when I did not have to present the case to anyone else for approval.

Time flies. And I do catch myself wondering what's in store for the future...

Split Seconds

2011-08-01T18:55:00.003-05:00

I saw Mr. L for traumatic central diabetes insipidus today. And I was struck by the story my resident told me as he reported the case.

A young father, in his 30s, who had been previously well. And perhaps in a moment of childish fun, decided to fool around on his motorcycle with his son. Without a helmet on.

Young, healthy, promising life. Full of love, laughter.

In a split second, he falls with his cranium hitting onto the solid concrete ground. They say the EMS found his pupils blown, though mildly reactive to light. His GCS was 3. He was airlifted here where he underwent emergency craniotomy a month ago.

Today, when I saw him, he was apparently no better than 3 weeks ago. Unresponsive though breathing spontaneously.

I catch myself thinking, how life can change in just a blink of an eye. In a split second. Life switches from heaven to living hell. One minute, a loving parent enjoying a moment of silliness with his son, and the next his son is sobbing beside his father who will likely never recover. Being a newish father, I can't help but feel so much sorrow seeing Mr. L, someone my age. Feeling sadness for his family, and thinking about the what ifs, and how life might have turned out differently if he decided to, say, play catch with his son instead, or watched TV, or even put on a helmet that day? Or, what if he caught his fall with his arm instead? What if that were me, instead? What could or would I have done differently?

So fragile, life is.

I pray I'm wrong; I pray the trauma surgeon, neurologist and all the doctors on his case are wrong. I pray that someone, Mr. L would get to have more silly moments with his son again.

2011-07-31T10:32:00.001-05:00

Seen at the doctors' parking amongst the BMWs and Mercedes. Love it!

-- Sent from my Palm Pre

Popquiz

2011-07-27T18:26:00.001-05:00

Question: What endocrine gland produces ferritin?

Answer: None.
That was a trick question. Ferritin is not a hormone, but someone should tell that to the doctor who referred a 75 year old man to me who had to drive 2 hours for the consult. As it turns out he's iron-deficient from something else, suspicious for an occult lower GI malignancy.

Transformers 3: Dark of the Moon

2011-07-22T22:55:00.004-05:00

Predictable storyline, check.
Wooden acting, check.
Excessive action scenes with fighting robots, check.
Hot chick, check.

Wife and I went out for date night today, and caught Transformers: Dark of the Moon. And it was my first 3D movie, and I had to say despite the superficial movie plot, I really enjoyed it! If you grew up watching the cartoons, then the movies are going to the a must-see.

And despite the lack of acting experiences, I thought Rosie Huntington-Whiteley did a pretty decent job. Not that Megan Fox is close to winning an Oscar anytime soon. And I have to say, seeing the first 60 seconds of Rosie on the big screen in 3D was nothing short of spectacular (if you've seen the show, you know what I mean). There was a unanimous gasp coming from the moviegoers.

Perhaps it was somewhat of a coincidence too that was watched it tonight, and that men first stepped on the moon July 21st.

(P/S: was that really Buzz Aldrin in the show? If it was, that was pretty damn cool)

Relationships

2011-07-21T09:23:00.002-05:00

Mr. K came to be the other day as a new consultation for his diabetes. I was somewhat surprised, as he had uncomplicated, relatively well-controlled diabetes as reflected by his good hemoglobin A1c. Not the kind of consult I usually see as an endocrinologist. And so I asked him why he was wanting a specialist to treat him and not his GP anymore.
And I was not expecting his answer.

"Because I read in the papers that my doctor was paid $50,000 by the drug companies last year."

There was a recent report in the papers about doctors being paid consultants for pharmaceutical companies. Either being a spokesperson, or giving lectures on certain drugs to other physicians. That report listed the 20-highest paid doctors in the state. And Mr. K's physician was on that list. And the amazing thing was, according to that report some doctors were paid up to $2 million (remember, this is in addition to the doctors' salaries) (that sum was an outlier- for some patents he owned). Many others were being paid well over tens of thousands of dollars a year, presumably for giving talks.

It's a controversial subject, but perfectly legal.The relationship between doctors and industry. Some being for, while many being against. Some clinics have allow visits by drug reps; some strictly do not. In fact I think even more lenient in Asia where drug companies can pay for your overseas trip to a conference.

The obvious benefits of the relationship are, doctors are able to learn about newer medications. The ability to get free samples and discount coupons to be given to patients in the practice.

Downsides, the concern that this may bias the doctors towards more expensive medications. Conflict of interest. And my personal issue (yes, you can tell which position I take): even if it's just a drug lunch or a cup of coffee, ultimately you know this is coming out from the patient's pocket.

And so, I feel a certain amount of guilt knowing that, really, my patients are paying for the meal the drug rep brought to our office. As such, I avoid these as much as I can (admittedly when I was a resident I had less qualms). And the reps know it too- I'm never very chatty or warm with them- and they try to avoid me too unless they need my signature to leave samples for our clinic.

It's a personal, and yet professional choice. And I no longer give talks that are sponsored by a drug company: I did this just once before 3 years ago not knowing they'd pay me to talk about something I was passionate about- only after I got the cheque did I shamefully realize how things work. And so, while $1000 to give a 1-hour talk about thyroid issues is a nice sum, it's something I'd prefer to do without. And I think it helps me sleep better at night.

For apparently, patients like Mr. K agree with me.

Melting....

2011-07-18T20:24:00.002-05:00

Perhaps Al Gore was right. Maybe there is something to this global warming thing.
44° C heat index!
Phew. At least the humidity is nowhere near Malaysia's and you still hardly sweat. Which means you can wear your boxers for 3-4 days before you need to launder them. Not that I'd do anything like that.
It's hard to imagine with this heat, that 7 months from now on a bad day, the temperature's going to be 70° C LOWER than this. Yes folks, we hit -25° C with windchill not too infrequently in winter.
Stay cool, folks.
Plenty of fluids, stay indoors. And don't do anything stupid like leave your child or pet in the car.

You know the drill.

A Fresh Start

2011-07-12T19:48:00.003-05:00

Ah, July.

Start of the academic year for the US/Canadian medical systems. Where when one was a medstudent previously, is now an intern.

And what it means for consultants like us, is fresh blood (spoken with a Transylvian accent, followed by a sardonic laugh)! New 4th year med students and fresh-faced anxious interns. Which means new entertainment for us (just kidding. Kinda).

It's always interesting seeing the fresh faces this time of the year. Whether it's a fresh 4th year medstudent. Or a fresh intern. Or a fresh fellow (person having completed residency and starting off in subspecialty training).

You see all kinds of characters. Some you like. Some you'd love to work with. Some you'd hate.

There's the very nervous kids. The ones who are trembling so bad when they're examining the patients that you'd think they had a lesion in their basal ganglia (hah, you thought an endo would forget his neuroanatomy, didn't you?). These medstudents/interns tend to be a slight shade of bile green, and look like they were at a funeral. Liable to puke if you pimped them a bit too much with questions on adrenocortical physiology. I tend to buy the medstudents on rotation with me Starbucks; but with these students, I have to be careful about buying them any caffeinated drinks.

And then there's the arrogant SOBs. The ones who act like they know it all, just because they scored a 99 on the USMLE step 1 (which by they way does not predict how good a doctor you'd be). These are the ones who tell you on Day 1: "I'm going to be a neurosurgeon/interventional cardiologist/[insert high-paying subspecialty]". These are the ones I sometimes (shame on me) enjoy watching fumble when I throw out my customary teaching-round questions. Eventually they wisen up and realize that they may need a letter of reference from you, and stop acting like they own the ground you walk on.

Ah, and let's not forget the Beauty Queens/Studmuffins. All medschools have 'em, students who look like they should be modelling for a career instead. Admittedly, some eye candy on rounds, especially when you have a long census, makes work more bearable. And it's always amusing to me (a tinge of envy, perhaps?) to watch the George Clooneys of the medschools schmooch the nurses. "Oh, don't you worry. I'll get the patient chart and bring it to you. And oh, there's some donuts in the nurses' breakroom too; go help yourself.." Oh, if only I was like that in medschool.

There's also the walking dictionaries. The students who know every single factoid listed in every published medical textbook. And they'd be happy to recite it to you too, whenever the need may arise. I have to say, I've found these students very helpful- they're often also very keen on explaining the pathophysiology of things to the patients. And so, when things get busy, I sometimes have my students spend some time after rounds to again go over what is hyperthyroidism, or adrenal insufficiency.

Of course, we next have the eager beavers. Usually medstudents who are aiming for a very competitive residency, and need to get good letters of references. The ones who volunteer to see the next consult, and the next, and the next. Something the other students are only more than happy to oblige. These students tend to carry the most patients. To their credit, often their work is exemplary (for a fourth-year) as well. They'd bring you the charts even before you asked for it. Notes all written in detail. Heck, they'd probably give me a shoeshine and back massage too if I asked for it!

And on the other end of the spectrum, we have the uninterested. Students who couldn't be bothered, and are not hiding the fact that they're bored. They're yawning when you're talking to the patients. They're texting or surfing the next on their smartphones when you're teaching. They don't complete the reading assignments you gave them. I see two subgroups of these students; very unambitious people aiming for residencies even a tadpole could get into, or students late in the academic year after they've matched, and are suffering from a bad case of 'senioritis'. These are the most painful students to work with, and while I've not yet failed anyone yet, one young lady got close to it. When she yet again did not read up on the topic I had assigned her, her excuse which became classic in her medschool after I wrote that on her evaluation, was "It was Mardi Gras yesterday..."

Despite these many personalities though, the best students are probably the ones with a good mix of the above with the exception of the last. And working with these different personalities certainly makes work a lot more interesting. More so when you're now looking at things from the other angle of being a consultant, and not a student anymore.

(And for the record, I was the anxious kid in internship. Especially in the first few weeks of my ICU rotation. I was so uptight that my anal sphincter probably could have crushed beercans. And I had palpitations and insomnia going into call each time).

2011-07-10T08:51:00.001-05:00

Congratulations, you even made it into our local papers!

-- Sent from my Palm Pre

Malaysia: On the Verge of a Revolution?

2011-07-08T20:34:00.003-05:00

Reading all that is going on in Malaysia, I can't help but feel maybe a bit of apprehension for the safety and freedom of the Rakyat, but much more than that, I feel hopeful.

Being so far away from my native homeland, I can't say I understand her ins and outs and ongoing issues in detail anymore; I can't say I understand Bersih's goals 100%, or why some people (politicians aside) claim they have underlying motives. Also being one who isn't paying Malaysian taxes, perhaps I have little right to complain.

Then again, I still consider myself Malaysian. And so I believe I have the right to an opinion...

I'm hopeful that the rally that will happen today (Malaysian time) will bring the much needed change that our nation needs.

For far too long, Malaysian has been controlled, monopolized by one political group. And with monopoly and absolute power, comes arrogance, corruption, inefficiency and ultimately the downfall of a nation as a whole. When rewards are handed out not for quality of work, but for race, or family or friends, or on a 'you-scratch-my-back-I-scratch-yours' basis, then the country suffers.

Malaysians as a whole are just sick and tired of the bullshit that is being churned out and forced down our throats. The unimaginable amount of money wasted on stupid projects, like spending RM 1.8 million to upkeep the official Malaysian Facebook page. Or the RM 50 million to give every Malaysian an email account (when there are numerous free accounts out there). And oh yea, is it just coincidence that this contract was awarded to a family member of one of the leaders? At the same time, roads get more expensive. Goods. Gasoline. Etc etc etc.

We're sick and tired of 'leaders' playing the race card and threatening racial rioting if certain things were not enforced when the truth is they are just trying to drive the Rakyat apart to use certain groups to support their cause. Because they are worried that without their poison, the people are actually deep down just, and fair, and honest, and would like to judge others based on their action, not their skin color.

We're sick of the government twisting things around, and adjusting the law to suit their purposes. Like arresting people who are merely expressing their God-given right to free speech. And to stoop so low as to arrest people for merely wearing yellow (the color of the group rallying for fair and free elections). And then to deny them of legal representation, pulling the ole 'Emergency Ordinance' hat trick. Claiming that the act of speaking up as a group will pose a threat to national security. When in fact, it is a threat to their political power and money. And if it's national security you're worried about, why not arrest that asshole who was waving the keris and making threats to other groups? Or the other asshole who made subtle threats to the Chinese?

This rally is not about race. It's not about personal glory. It's not about a single political group. This is about wanting change, and while it will be some time before the next general elections to see any results, the next 24 hours will be interesting.

To my fellow Malaysian: be safe, and while expatriates like me are far away, our thoughts and prayers and spirit will be with you.

Here's my middle finger to the corrupted out there; may the next elections bring the change that is so much needed.

2011-07-04T08:49:00.001-05:00

Happy 4th, everyone!
Love, from the Jersey shore...

-- Sent from my Palm Pre

2011-07-02T04:05:00.000-05:00

Seen at the mall.
Seriously, does anyone actually use this??

-- Sent from my Palm Pre

Primary Aldosteronism: An Approach

2011-06-28T18:41:00.001-05:00

Someone asked in the chatbox for me to elaborate on why the CT scan isn't definitive in the diagnostic evaluation of primary aldosteronism. This is probably too long of an explanation to fit in there, so I thought I'd write a post about it.

Primary aldosteronism implies that the adrenal(s) is autonomously making inappropriate amounts of aldosterone, independent of the usual kidney-mediated renin-angiotensin system. The evaluation is undertaken usually in one of two situations- the discovery of an adrenal incidentaloma, or in the investigation of resistant hypertension.

In these cases, the first step is to document autonomous aldosterone secretion; we do this by means of a morning serum aldosterone and renin activity assuming that interfering drugs are not in the picture. A positive screening test includes an elevated aldosterone level, typically greater than 15 ng/dL, and an elevated aldosterone to renin ratio. Many of us use 15 or even 20:1. If this is positive, we move on to the confirmatory biochemical test of showing nonsuppressed aldosterone levels despite a good amount of salt in the system. This can be done by oral salt loading and measurement of 24-hour urine Sodium (should be greater than 200) with concomitant high urinary aldosterone (more than 12).

Alternatively, one can do the IV Saline suppression test showing a high (greater than 10) serum aldosterone despite 2 liters of Normal Saline.

(diagram pilfered fromNature Clinical Practice Endocrinology & Metabolism 2005)

At this point, you've documented that the patient is making inappropriate amounts of aldosterone and that the problem lies within the adrenal (ie not a case of renal artery stenosis leading to secondary hyperaldosteronism). However, as it turns out there are several subtypes of primary aldosteronism:

The exam-favorite Conn's syndrome or aldosterone-producing adenoma is often quoted.

However there can often also be adrenal hyperplasia which can bilateral.

(will not really mention the rare glucocorticoid remediable aldosteronism).

And so the problem is although you know the patient has the biochemical pathology, you don't know which adrenal is causing it. And without going into too much detail, as it turns out nonfunctioning adrenal adenomas are not uncommon, while adrenal hyperplasia may often not be visible on CT or MRI. And so, even if you see a juicy 2 cm right adrenal adenoma, you won't know if this is the source of the high aldosterone, or if this was just an innocent bystander while it's really microscopic pathology in the LEFT gland that's churning out the hormone and causing the blood pressure problems. And the last thing you want to do is to have your surgeon colleague remove the wrong gland, only to find out post-op that your patient remains hypertensive and hypokalemic.

And so, if you look at many of the guidelines out there, IF a patient is deemed to be a good surgical candidate, then often adrenal vein sampling for aldosterone (often normalized to cortisol, to correct for the dilutional effect of the converging veins) is required to lateralize the lesion. And AVS is a technically challenging procedure that only the most experienced of interventional radiologists can do skillfully.

The good news is, medical treatment with Spironolactone is usually very successful. So for most of my patients I try to direct them in this route, rather than the surgical. Because the truth is, if it's hypertension that they're hoping to cure, with many patients (first degree relative with hypertension, or prolonged history of hypertension etc) even if the surgeon took out the correct adrenal, they will STILL be hypertensive (though improved). There, a longish explanation for a fascinating clinical problem. I'd direct you to the Endocrine Society Clinical Practice Guideline if you wanted more bedtime reading.

Happy Birthday Alli!

2011-06-24T00:27:00.000-05:00

Now that I'm a parent, I think I understand the phrase "A face only a mother (father) can love". The truth is, every parent thinks their baby is beautiful. Even the newborns. Except they are blinded to another truth: All newborns are ugly. Yup, all of 'em. They're swollen, wrinkly and bruised. Their eyes don't open, or if they do they're cock-eyed and looking in different directions. But yet, the estrogen surges inside you (yes, men make estrogen too, by the way) and you swoon at the sight of your baby, thinking that she is just the most beautiful thing in the world. You hand her around like she's a prize to beheld. You spend big bucks taking professional studio pictures and give them to family and friends.

Blissfully ignorant of the truth.

I know we were. Looking back at the large photo hanging in our hall, the one that was professionally photographed, we catch ourselves thinking, what were we thinking?? We should have waited a few months!But I digress. The months do fly by quickly. And in those 12 magical months, our little potato-looking baby has grown so much, into (what we think; again back to the theory of parents being blinded. For all I know you all might think like she looks like a monkey) beautiful little girl.

Yes, our Alli turns one today! As a parent, it's amazing to see how much your baby develops and learns in that short amount of time. There's just so much fun watching them grow, and learn new things (like how to open drawers and scatter the contents all over the floor).

My dad once told me. A man will have 3 greatest joys: Marriage, being a Father, and then becoming a Grandfather. So true. I'm sure many of you understand this firsthand, while many others will eventually experience this magical journey. Seeing and playing with your daughter at the end of a hard long day, and seeing her light up at the sight of you walking through the door, is an experience that is beyond explanation. And despite the fatigue and stress and of course the evergrowing cost of being a parent, I'm loving every moment of it!

Happy 1st Birthday, Allison! We love you!

Graduation Ceremony

2011-06-17T21:23:00.004-05:00

So tonight the wife and I attended the family medicine residency graduation dinner. It was a pleasure to see the residents I worked with graduate and to be given their wings to go out into the real world.

It didn't seem that long ago when I graduated from residency, until I actually sit down and think about it. 2005. SIX. F*CKING. YEARS.

And so, when Mike asked me for advise on what's in store, I simply said: "Be prepared for a steep learning curve your first year."

Because it's true- what residency and fellowship does is give you the paper knowledge, and hopefully adequate clinical experience. But it never teaches you much about the real-life practical stuff.

Like how to bill/code for a certain level of care you provided.

Or how to run a clinic, or manage employees. Because for the first time, you're not on the bottom rung of the ladder anymore.

How to manage money. Clinic overhead. Lab or transcription expenses.

How to think independently. Really independently for the first time. With no 'supervising consultant' watching over you in case you screw up; no one to catch your mistakes and guide you. It was pretty unnerving to me, having the final say in treatment (well, the patient really has the final say, but you know what I mean).

How to balance work and family.

Life insurance. Disability insurance. Umbrella coverage.

Yup. The first year you'll learn a lot more than you thought you would. But it is also in that year, that you begin to blossom as a physician.

To all the residents graduating this weekend, congratulations. Be proud of what you have achieved, and take pride in your first few steps as a full-fledged physician.

And to all the fresh incoming interns, Good Luck! (that'll be a different story)(tip to patients: avoid teaching hospitals for the next couple of weeks unless you absolutely need medical help!

88 Minutes

2011-06-14T15:45:00.002-05:00

Ok, this has nothing to do with work. But I was watching the 2007 movie '88 Minutes' the other day. Starring Al Pacino as Dr. Jack Gramm, a forensic psychiatrist who incidentally drives around a Porsche 911 Carrera Turbo. The show was pretty entertaining though like most guys (girls too, if you're into these sort of thing) I cringed when his 911 was blown up by the bad guys.
Until I realized something looked very fishy (one of the beauties of a Digital Video Recorder- you can pause and rewind).

Can you see it?

.
.
.
.

.

.

.

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The outer tailpipes of the 911 Turbo is connected to nothing, while the inner tailpipes are connected directly to the fake rear axle!

Yes, I don't expect them to blow up real cars, but I thought this was a pretty glaring mistake they made...

Number 18

2011-06-10T17:49:00.004-05:00

This past call, I dealt with the 2nd sickest pheo patients in my career (yet). This would have been my 18th pheochromocytoma patient.
Mr. K presented to the ER with pleuritic chest pains. During the workup which included a CT chest to rule out a pulmonary embolism; that caught a glimpse of his adrenals which contained a 6.6 cm heterogenous mass. Aside from the chest pains, he was pretty asymptomatic, with reportedly a history of benign essentially hypertension well controlled with an ACE-inhibitor.
When I saw him in the hospital, I reviewed the function of the gland, but also assured him that most masses are nonfunctioning though the sheer size of the tumor probably will necessitate adrenalectomy eventually. He looked great, and was normotensive. We also started biochemical testing then, though I'm often hesitant to initiate testing in inpatients as the probability of a false positive increases.
I was called that night by the nurses because they had trouble with his blood pressure. 'Trouble' was probably the understatement of the year. So fluctuant was his BP, that they transferred him to telemetry. One minute his BP was 90/50, while the next it was clear up into 240/120s. Even on the arterial line. My pretest probability for a pheochromocytoma went from 'low' to 'almost definite'.
In the outpatient setting, treatment of pheochromocytoma begins with adequate hydration as although patients may be hypertensive (caveat: most patients are NOT hypertensive) they tend to be intravascularly dry. I also tell them to tank up on salt (one of the 2, well maybe 3 conditions in which an endo might tell you to take MORE salt. Can you guess the other 2?). Alpha blockade is started first (classic medschool exam question) and while there are numerous you can pick from, I start with the shorter acting Phenoxybenzamine. The shorter duration of action allows for better titration of doses. My personal goal is to see a systolic drop of 15 to 20 mm Hg on standing with no reflex tachycardia though you may also pick an absolute BP goal. Once the patient is adequately blocked, a beta blocker is then started. For select patients, we add a 3rd line agent a few days before surgery: Metyrosine, to deplete adrenal catecholamine levels, that is if you can get your hands on it.
For Mr. K, by the time I got to the hospital, his primary team had decided to intubate him for respiratory distress; his blood pressure remained mostly high though these were peppered with marked drops. In these situations, regular alpha blockade would not be fast-acting enough. Throughout the night, we resorted to Nitroglycerin and then Nipride, Nicardipine and finally Phentolamine. For the next 24 hours he remained fluctuant, at times with his BP so high that many of us feared he would stroke out, while at other times his BP was so low that they had trouble feeling a pulse. It was touch and go for the 5 days he was in the ICU though things eventually stabilized enough that he was extubated and we transitioned him to the usual Phenoxybenzamine and then a beta blocker.
And so, when I saw him in clinic 2 days ago for follow up, I could not help myself but to give him a big handshake and a hug- he was out of it for most of the time in the ICU, but his family was there and they knew how worried we were. It was with a great sense of relief to see Mr. K walking and talking normally, cognitively intact.
He's not out of the woods yet obviously. But I'm pleased by his progress and the level of his alpha and beta blockade. He's probably pretty well-prepped for surgery which will happen in a week. And God willing, things should turn out well.
Post-op, it's necessary to reassess things biochemically as there is a chance of metastatic pheochromocytoma- patients should undergo repeat 24-hour urine catecholamine and metanephrine testing. If biochemistry remain abnormal, then imaging for metastatic disease is necessary, whether you use MIBG or Octreotide or some other scan.

Some experts suggest that the biochemistry be done annually for life. At the recent meeting I attended, some actually advocate genetic testing in ALL pheo patients (not just paraganglioma) as the incidence of familial pheo appears to be much higher than what the 10% rule suggests.

Will keep my fingers crossed that Mr. K sails through surgery, which he should. We had him see a very skilled surgeon and he's young enough that I don't anticipate any problems.

And so, that was my 2nd scariest pheo patient. One of these days, I'll tell you about my SICKEST patient.

Shopping

2011-06-06T05:53:00.001-05:00

The meeting is going well. My brain has expanded a bit since Day 1, from all those lectures (or maybe from all that food?). Anyhow, I ran into some Malaysian endocrinologists at the meeting. Yes, how I ran into them with 10000 attendees, I don't know. But I do have a bad habit of chatting people up when I hear a familiar Malaysian accent.
It was their first visit to the US. And they heard I was somewhat familiar with Boston, their question was "Eh, where is good shopping, ar?"
Which got me thinking. When Malaysians come to the US, they shop like there was no tomorrow because 'things are cheaper here'. I know that's what my family does. But when overseas Malaysians like myself head back to Malaysia for a visit, WE go on a shopping spree because we think things are cheaper there.
So which one is it???

-- Sent from my Palm Pre

Boston

2011-06-03T10:21:00.000-05:00

See you in Boston!

Headed for the 2011 meeting of the Endocrine Society. And it's a bonus that Allison and Kristin get to join me (we have family there). We'll also get to meet up with some old classmates from my alma mater.

Plus, it's a bonus that our hotel is only 2 blocks from the Malaysian restaurant there!

2011-06-01T10:53:00.001-05:00

While I'm still unsure of where I stand on this matter, I am however amazed and awed by their gallantry.

Japanese seniors volunteer for Fukushima 'suicide corps'
The group, consisting only of retirees age 60 and up, says it is uniquely poised to work at the radiation-contaminated plant, as the cells of an older person's body divide more slowly than a younger individual.

In times of crises, the Japanese can certainly rise up to the challenge. If this was, indeed, a suicide mission, is it not logical then for the elderly to volunteer?

(I suppose medically this makes sense as well, cancer risk increases inversely proportional to the age of the patient at radiation exposure, no? Ethically, well, I don't know what would be the right thing to do)

Let's hope the matter can be resolved soon.

Baby Food

2011-05-31T19:54:00.001-05:00

So I had this nasty thought while feeding Allison today. Isn't this stuff supposed to look like this coming out of a baby from the other end? And not look like this BEFORE you feed the kid? Probably explains why Alli-cat seems to prefer cake icing.

Money?

2011-05-29T13:05:00.006-05:00

I thought it was timely that this article came out in the Star.

Many complain of having to pay for unnecessary tests

PETALING JAYA: A retiree seeking treatment at a private hospital was asked to undergo a blood test, X-ray and an ultrasound therapy. He was referred to three specialists an orthopaedic surgeon, a physician and a nephrologist and was admitted for three days. He had gone to the doctor for his gout.
The retiree, who has no medical insurance, claimed he was
eventually discharged with some painkillers and slapped with a RM2,700 bill.

Timely, as I recently became somewhat disillusioned by an incident involving a private hospital. Someone I know recently underwent evaluation for exertional chest discomfort in a private hospital. Now, I can't claim to be a cardiologist as my subspecialty lies in another area, though I am board-certified in internal medicine, and do try to stay up to date with the current guidelines. And I was surprised, that without even recommending something like a stress test, the cardiologist provided two options: a coronary CT scan, or an angiogram. In addition, he ordered a panel of blood tests including VDRL, hepatitis screen, CEA and alpha-fetoprotein.

Now, this confuses me. While many would agree the cardiac CT shows uch promise as a screening tool, all it would show is presence of coronary calcium and plaque; it gives little information (unless the amount of narrowing is unequivocally significant) on whether the calcium you're seeing on the scan is indeed causing ischemia and hence the symptoms. And an angiogram, on the other hand, was like pulling out the big gun, which is invasive and itself may cause an MI and death in rare causes, to work up a hunch.

Perhaps I'm not qualified to comment. Perhaps it's because I'm not a cardiologist, much less a practitioner in Malaysia where systems differ, but here, the first thing one ought to do is to test the hypothesis that the symptoms are indeed angina, from a lack of oxygen to the heart muscle that is accentuated by exercise. Depending on level of suspicion, and patient variables, this may be as simple as an exercise EKG, stress echocardiogram, or one of the many nuclear stress tests. And if things are suspicious, perhaps the angiogram would then be offered. The CT itself is more of a screen (arguably for the rich) and doesn't tell you much unless it's totally clean. In other words, the test has a pretty good negative predictive value. However this would be rare in the older population where you're bound to find coronary calcium in quite a number of patients and you don't really know if this is the cause of the symptoms. Some studies have found a positive predictive value of only 38% with the MSCT coronary angiography with the 64-row CT scanner.

Thankfully, in this case, the CT was negative and so we could lay the matter to rest. Despite that, I could not understand why this cardiologist recommended Clopidogrel, and switched his statin medication from a cheap generic to a nongeneric brand when his LDL ('bad cholesterol') was 69 mg/dL, with his HDL ('good' cholesterol') being even higher at 73 mg/dL. In my patients, arguably many would be happy with an LDL of 130 mg/dL, or less than 100 mg/dL if you have diabetes, or even if you had vascular disease, less than70 mg/dL.

So, maybe it's an assumption on my part, but the only conclusion that I can come up with, is that this was purely financially driven. And no, I'm not accusing all physicians of all private hospitals of being greedy, but for some of them, you do wonder.

As doctors, yes I admit we have to make some money. We have families to feed, mortgage, loans and maybe even some to spend on 'toys'. Like any occupation, making money is a necessity though in doctors' cases the patient-doctor relationship and sacred trust is a bonus. It's a priviledge that another human being lets you look (somethings literally!) into them, and to share every intimate part of their health with you. You look to the doctor and you trust that he has your best health interest in mind. It's a leap of faith.
But when you get the sense that the doctor sitting across the table is suggesting certain testing based primarily on financial motives, then it really leaves a bad taste in the mouth.

A Decade!

2011-05-26T08:57:00.000-05:00

Nothing makes you feel old like realizing you graduated from medical school 10 years ago.
ONE DECADE AGO!
Geez. I realized that a week ago when I was congratulating my med students. I told them about how my graduation was that spring morning when it hit me. Holybegezeez! It was May 2001! I remember how proud we all were (and perhaps a bit surprised!) that I made it through medical school, in a foreign country (I was a big-time mommy's boy and had a homesickness problem. Who knew, huh?). I remember how it felt when it came time for the Faculty of Medicine graduates to take the Hippocratic Oath:

"....WITH PURITY, HOLINESS AND BENEFICENCE I will pass my life and practice my art..."

And just like that, our lives were changed forever. With the 2 little letters stuck behind our names, M.D., we became Doctors. It didn't seem like that long ago, but in a blink of an eye, here I am.

Perhaps it was just a matter of coincidence that this trip back to Malaysia, I found my old graduation cap hidden away in a dusty cupboard and decided to bring it back with me to the US.

Geez. 10 years. If that seems like a long time, here's something for you starry-eyed med-students to ponder. I started medical school in 1996. 15 years ago! (that's the picture above, the smallest class in the history of the medschool). Between medical school + residency (specialty training) + subspecialty, it took me 12 years! So, as I've said many times before, I don't think being brainy is all that important to get you through medical school. Sure, having the grades help get you INTO medschool, but once you're in, it's pure stubborn-ness and perseverance that gets you through things.

Good luck!

Stages of Grief

2011-05-22T14:03:00.001-05:00

They lied. The psychology books in first year of medschool (gawd, that was 1996!!) talk about the five stages of grieving.
Denial, Anger, Bargaining, Depression and Acceptance.
And though I can't say the extent of grieving we are doing comes anywhere close to what my Buddy's family must be going though, our hearts and minds are in a bit of a disarray now. And it's nothing like that damn Kübler-Ross model of grieving. Instead, we seem to be going randomly between these stages:

Depression and sadness- and bawling our eyes out, thinking that he's really gone. That we'll never see him again in this world, share stories, do fun stuff.

Reminiscence- of all the fun, crazy things we did. Still cracks me up thinking of the time we made a waterbomb with some dry ice and plastic bottle (blew up so loud that we went hiding in the basement, fearful that the cops would come!). Or the time we were baking in a small room with the heater on full blast because Idiot Buddy read somewhere that warmth made fireflies blink more (apparently not)(and we were that close to popping them into the microwave to warm them up more!).

Guilt- why did I not call him more? Why did I tell myself I was going to call him after I went off-call? Why didn't we spend more time in Penang when we were visiting?

Bitterness- about why him? A gentle, kind soul. A religious, wonderful man, a doctor just beginning his family and career. I catch myself asking: Why not me? He's much more of a better man that I could ever hope to be.

Peace- knowing that he's no longer suffering. And that he's in a Better Place. That he's Home, and someday we'll meet again.

Gratitude- that though he lived a short life, that I had the honor to have known him as well as I did. To have shared so much.

It's interesting how one's mood goes quickly from one to the other. But with every passing day, it gets a bit easier. And I catch myself smiling thinking about my friend somewhere up there, probably laughing his butt off that the rest of us have to go to work on Monday. His funeral was Saturday morning Malaysian time. I hear it was a touching affair, with many loved ones sharing beautiful stories. I hear the church was packed. And Buddy got the best seat in the house from up there.

In Memoriam

2011-05-19T05:49:00.001-05:00

We Shall Miss You

2011-05-17T20:01:00.009-05:00

Dr. Tan Tow Shung

November 6th 1978- May 18th 2011

He was a giver. If there is one word I'd use to describe my buddy, that would be it.

Born and raised in Malaysia, he begun his amazing career as a Healer at the International Medical College. From there, he went on to graduate with his M.D. from the prestigious McGill University in Canada, before landing a position at the world-famous Mayo Clinic. There, he would spend the next 7 years of his life training in internal medicine, followed by a fellowship in hematology and oncology.

For 5 of those years, we lived together in a small rental. They say it's hard to find a room mate you can live with for too long- for some reason that didn't seem to apply to us. We did almost everything together, to the point that our friends thought we were gay and were a couple (I was desperately single then, while he was in a long-distance relationship for 5 years and so his then-girlfriend was not often seen). Among our favorites were the hours of Halo (and then Halo 2) on the Xbox and the customary post-call buffet dinners when we would wolf down pounds of food at Golden Corral and complaining about the stupid admissions the ER sent up to us. People called us the Malaysian Triad (there were 3 of us). We regularly hosted BBQs and dinners for visiting Malaysians and Singaporeans. And, as boys usually do, got into our own mischief, making fountains with Mentos+Coke, or little bombs with dry ice and water.
Despite all the fun and mischief, he was an extremely bright person, scoring 99s in his USMLEs and acing the internal medicine boards. As a physician, he was warm, caring and astute and was a master in clinical medicine. I remember that patient we both shared- he was asked to see him for severe anemia of unknown etiology; he quickly and accurately diagnosed hemolytic anemia from his prosthetic valve. I saw the grateful patient post-op, who had nothing but praise for my friend.

As a friend and room mate, he never complained about me getting the better room, and the parking space. He was always giving. His love for his eggs and omelettes were legendary- Kristin even gave him an egg fridge-magnet when we moved away. And no one made a better mojito than he. We had one too many merry parties thanks for his concoction.

Why God chose to allow a 29-year old the cancer doctor to develop esophageal cancer, a wonderful human being, I'll never understand. But in those 4 years that followed, my buddy and his wife taught us much about personal strength, love, faith, sacrifice, and in the final months, grace. I'll never forget how he kept his diagnosis of adenocarcinoma hidden away from everyone for several days, because I was about to take my endocrinology board exams. Knowing, as a cancer specialist, that Stage 4 disease is like a death sentence for most. But yet, he kept it bottled, just because he didn't want it to affect my exam performance.
In those 4 years, he made the most out of life. He reminded us, the 'family' there, of the true meaning of friendship. He brought us all together. We were blessed, that when Kristin and I got married he was willing and able to be my Best Man. And then, a year later, we were honored that they wanted us to be their Best Man and Bridesmaid. And despite the shadow hanging over them, that was the most heartfelt wedding I had ever seen. It was as if they had not a single care in the world, as they uttered their vows. There were numerous teary eyes when Tow Shung and his wife started their first (choreographed, too!) dance as a married couple. Despite the chemo, and the radiation. Despite the odds. Living life to the fullest.
We were fortunate that just last month, we were able to visit him and his wife in Penang, and had a good several days. We talked. We reminisced. We laughed. And for that moment, it almost seemed that things were back to normal. To the days before the illness. We had a good time.

Tow Shung,

You were my friend, my buddy, my room mate, Best Man and my Brother. You fought a good, long battle. Thank you for teaching me about what friendship means. For helping me survive the most harrowing years of my professional career. For seeing me through the thick and thin. For the years of fun and brotherhood.

Though you are no longer physically with us, I know you're still with us, and you're in a better place. I know you are at peace now; know that we will never forget you. And though I don't know when we'll get to meet again, I know the day will someday come. That we'll get to share a few glasses of your wonderful mojitos. Till then, buddy, cheers.

Rest in peace; we will miss you.

A Request for Prayers

2011-05-16T06:28:00.001-05:00

I fear it's begun.
It pains me to say so.
Please pray for my buddy.

Congratulations, Class of 2011

2011-05-13T19:59:00.002-05:00

Today was the last day of medical school for my MS4s (and all the other medstudents in North America, too).

The very last day of their lives as a medical student, or clinical clerk, whatever they call it. They were euphoric, almost to the point of being manic, on rounds today.

For good reason I guess. They survived the first of many gruelling chapters (and though many of us thought that medschool was the tough part, bwahaha, you realize it's a cakewalk compared to what's to come).

But being cheeky, Jeff, one of my students asked:

"So Dr. V, how are you going to manage rounds without us?"

Thinking perhaps, that because they preround on my patients they make rounds a lot shorter. I almost felt guilty popping his bubble when I told him that rounds without any medical students or residents are at least 50% quicker.

I ask the relevant questions. Examine what's necessary. Write the orders. Off I go.

So, while it's intellectually stimulating and perhaps fun having a troop of students on rounds and going over topics on the fly, like adrenal incidentalomas, or DKA management, it's true that medstudents NEVER help make rounds speedier.

I reminded Jeff of the 11th Law of the House of God: (if you haven't already, go read the book)

"Show me a medical student who only triples my work and I will kiss his feet.."

To all the 4th years/almost-doctors out there: Congratulations, and Good luck in your residency!

Pills Pills Pills

2011-05-09T20:36:00.005-05:00

I had a conversation with my dad the other day after he saw his doctor. Some changes were made to his blood pressure medications. However, he did not recall the names, nor the doses.

Which got me thinking about how frequently I see this on the other end, as the treating physician. Patients who have no clue what they are taking, besides "A round yellow pill, and a square blue one...". I've had to, on occasions, call the pharmacy to verify their medlist. And while PDA or online pill identifiers are available, taking that 10 mins to look up your pills means I have 10 mins less to discuss something else with you.

In the world of medicine, especially geriatric medicine when a patient may be taking upwards of 12 different types of medications, I can certainly understand how overwhelming and confusing medication names may be.

Plus, the people who actually name the pills give them such tongue-twisting megamulti-syllable names. Ah, if only medications were called Blood Pressure Pill A, and Diabetes Pill 2.0, life would be so much simpler.

But no. We call meds Gorillastatin or Kombimetforglitazone or something fancier.

Having said all that though, one tip I share with many patients, and my dad, was:

It's always a good idea to know the names of the medication you're taking, the dosages and the indication.

Keep a folder somewhere with all your medical information. Health history, previous medications, current medications, allergies. Previous test results, names of doctors.

After all, we all keep a file of our bills, car and life insurance information. Contact details of ex-girlfriends (oops).

So why not our health?

Plus, this helps your other doctors understand what you're already taking, while minimizing the risk of medication duplication or interaction, and the risk of side effects.

Update this folder regularly, and carry a miniaturized version in your wallet, and bring it to all health visits.

Your doctors will thank you for it. But much more importantly, you will be a much safer patient.

Medical Treatment of Primary Hyperparathyroidism

2011-05-04T20:35:00.003-05:00

Finally!

The FDA finally approved the use of Cinacalcet for primary hyperparathyroidism. This is a relatively common condition in which one (or more) of the parathyroids become overactive and thus raising calcium levels. While most patients are asymptomatic, in severe cases, left untreated this may lead to premature osteoporosis, symptomatic hypercalcemia (the medstudents amongst you would know the phrase I'd bet: Bones, Stones ....) and kidney stones.

While the only curative treatment is surgery, most patients are mild enough that this can be safely monitored conservatively.

The problem is when patients clearly have indications for surgery, but yet they are poor surgical candidates. Minimally invasive parathyroidectomy is not a big deal, generally. Generally. But when you have an 80-year old who's had a 3 vessel bypass and still angina symptoms, then the rules change.

The many I struggle with are elderly patients with severe hypercalcemia and osteoporosis, but yet, because of underlying vascular or lung disease and their advanced age, places them at higher risk for surgery itself. And being a firm believer of Primum Non Nocere (First Do No Harm) I'm not too sure the treatment is worth the risk.

Fortunately, this is where Cinacalcet comes it. It's a calcimimetic which lowers PTH and hence calcium levels; it treats the problem pretty well.

Unfortunately, for the longest time this wasn't FDA approved (it's not an experimental drug- it's been used a long time by the nephrologists for secondary hyperparathyroidism here. Also been used for primary HPT in Europe for awhile). So until it received this indication for use, the insurance companies consider its use in my patients to be 'off label' and hence won't pay for the drug. When clearly, it's a drug that works, and is safer than surgery for some patients. They'd rather my 86 year old female patient undergo general anesthesia and surgery. I've had that argument with numerous 'medical directors' of the insurance companies before, and the answer is always the same: We won't pay for it.

You wonder if their primary interest is the patient's wellbeing.

Anyway, with this welcome indication for Cinacalcet, it should be a thing of the past. It's good to have an alternative to surgery when you have a high-risk patient.

A Yearning

2011-04-30T07:21:00.000-05:00

Ok, this is a juvenile post by a spoilt boy. But hey, it's my blog and I don't feel like talking about work. Take 2.5 weeks of vacation, and you know the shit's waiting for you in the office when you return is inches deep, you know how it is. So, no, this isn't about work.

I'm missing her.

My Claudia, from Stuttgart (Germany). A 2.7L flat-6 with a beautiful wail when you hit 3000 RPM.Replaced instead by Allison, from Iowa. A 18-lb 4-V (mitral, pulmonary, tricuspid and aortic, mar), screaming, poopy-making machine.For obvious reasons, I haven't had much of a chance to drive my car. It's a 2-seater, with passenger airbags; so while I've been almost tempted enough to even call the cops to find out if it's legal to have a carseat up front when you only have 2 seats, I know it would be irresponsible of me to drive her to daycare with this. And so, ah, the very exciting CRV.

I feel like a bad 'husband'. There she sits, in the garage. She was my daily driver the first year I had her (even in the winter!). Now, I've hardly touched her more than twice in the last month, though I've given her yearning glances more than once. The warming weather only makes the temptation worse. I'm missing the feel of the wind in (what's left of) my hair; the smooth-shifting short-throw gears, the acceleration as I drive onto the freeways.

And so, until Kristin starts working soon, I'll likely be doing daycare duty.

(and before you accuse me of being sexist and giving my cars female names, my wife calls her car Lucy).

2011-04-27T21:10:00.002-05:00

I was heartbroken by the events I heard about today. I saw Matt for follow up of his diabetes. I had known him for the last 2 years, and we've had a pretty good relationship. He has worked hard all his life, and for the last year he had been planning his retirement. He was excited at the prospect of finally slowing down, and spending time on carpentry, his hobby. I last saw him in January.

Today, his outlook was completely different. He seemed saddened, almost tearful. 2 months ago, his wife of 33 years was diagnosed with metastatic colon cancer. She had undergone surgery, and just yesterday had a portacath placement in anticipation of chemotherapy. Unfortunately, she developed a pneumothorax, and required hospitalization and a chest tube.

He shared how they had dreams to travel. How his wife was so guilty that she actually apologized to him because she ruined his retirement plans. About how this was not a priority for him though he would have to work indefinitely, to keep their employer-subsidized health insurance to pay for her treatment. Knowing how much he was looking forward to retirement, I know this must not have been easy for him.

There wasn't much to do for his diabetes; I just made some adjustments to his insulin pump. But I spent the next 10 mins just listening to him, letting him share his emotions, his fears. I listened as he was telling me in other words how much he loved his wife, and how afraid he was of losing her. I had to keep from tearing up.

After he left, I sent some flowers to his wife's hospital room. And said a little prayer for them.

Sometimes, these things just tear you up inside.

Back at Work

2011-04-25T19:47:00.003-05:00

Day 1 of work after having been gone for almost 3 weeks. As it turns out, one of my patients today had a multinodular goiter.

And thus I learnt-

Never a good idea to consume a tall Starbucks White Chocolate Mocha prior to performing a thyroid fine-needle aspiration.

(It was good stuff, actually. And no, there were no complications and I hit the nodule I wanted to. But still, the trembly hands probably did not instill confidence. By the way, did you know that that drink contained 470 calories, 63 g of carbs, and 150 mg of caffeine??? Damnnn...)

A Study

2011-04-24T10:11:00.005-05:00

Now that I've completed my data collection, I intend to submit my manuscript soon. This is one of the most spectacular medical studies I've been involved in. So, I plan to submit this to the most prestigious of journals. With such high quality material, I'm 100% sure this will be accepted by Nature or Science. Heck, even NEJM isn't good enough for this. The results are sure to shake the scientific world.

My manuscript shall be entitled:

"The effects of a Malaysian diet on body weight and composition: A 2-week prospective study"

Objective: Malaysian food has typically been thought to be lacking in nutrients and was traditionally thought to be a poor source of energy. We sought to investigate this and to dispel any myths regarding the unhealthiness of the Malaysian diet.
Methodology: This was a prospective study of 2 weeks duration involving a large number of subjects (n=1; however because the study subject was an outstanding male specimen, this was deemed adequatedly powered to show a statistically significant difference). The patient was subjected to no less than 4 meals a day of Malaysian food of his choosing, limited only by stomach capacity and postprandial nausea. Western and non-ethnic foods were omitted from our study. Body weight was measured by a single Weight Watchers digital scale, and data regarding intake/output was captured using a specialized digital-ink-wood fiber papyrus interface (ie pen and paper). Data was analyzed by using the t test or Wilcoxon rank-sum test.
Results: In the 16 days in his native land of Malaysia, the subject consumed 85 meals (mean daily 6 ± 2). He experienced 2 episodes of traveller's diarrhea, both of which were minor and did not require decreasing the frequency of meals. At the end of the study duration, he gained 2.3 kg (p<0.01).
Conclusion: Contrary to public belief, we have shown that the Malaysian diet is rich in nutrients, and should be employed in a malnourished population.

My next project:

"Prevalence of depression in subjects deprived of Malaysian mamak food".

The trip back

2011-04-22T10:44:00.008-05:00

Goodbyes are always difficult, but it was nice to have family and a group of friends come and see you off. And as always, mom's tearducts got a bit hyperactive (and after 13 years too!), especially when Alli was waving Bye-bye to her. But, we finally made it. 31 hours total, with the 4 flights and 3 layovers. This time round, though the journey was long, Alli did a lot better. She didn't fuss at all, and seemed to enjoy the ride. She slept most of the way, which allowed us to finally enjoy the facilities, and perhaps a glass or two of champagne.

And though this sounds weird, I swear I'm not making this up: The satay served on the plane is pretty damn good. So good that I'd say it's even better than the stuff from Kajang! (except Kajang satay tends to be fattier- which also adds to the flavor, and the atherosclerosis).

It was so good that I had 3 plates of this. Hey, I figured if this is going to last me for a year or two, why not indulge?

As the plane headed to Taipei, we flew over the city, and I thought I'd share this shot I took:

Hope I get over the jetlag before I start work Monday.

My hope for you, Malaysia

2011-04-20T08:08:00.000-05:00

We leave for the US in a few short hours. Am hoping the babe will behave herself on the long flight back (she did pretty OK flying here, only from Taipei onwards did she fuss). Not sure when we'll next travel back since long journeys with an infant is more challenging.

I am reminded again this trip, as previous, though deep in my heart I'll probably always call Malaysia 'home', every visit I make, things seem more and more foreign. That I find more and more issues that only make me more certain that my decision to immigrate was the right one.

At the heart of my concerns, is the evolving and progressing racial issues. 15-20 years ago, perhaps I was blinded or shielded from all this, I never saw race being as big an issue as it seems to be today. The Lat cartoons of Ah Kow, Ali and Raju of yore captured those sentiments well. We played alongside each other, made good friends and never wondered why our names, skin color were different. No one ever question the others' patriotism, or belonging in this country. No one ever accused the other of being an 'immigrant'. No one ever told me to 'Balik China' until college.

These days, the tone seems completely different, in large part methinks is the fault of hot-headed or ambitious politicians who play up the racial card to win support, and the system itself. The major political parties are racially drawn. Schools (and indeed some universities) are racially divided. Certain jobs. Housing areas. Affirmative action policies that clearly have failed (it doesn't take a genius to see that if a program hasn't achieved its targets in 40 years, it's never going to. Also, it's a simple Darwinian concept; providing a crutch simply makes a group depend on the crutch and selects against the stronger).

Time and time again, the Chinese and Indian put up with subtle threats if they question too much. Threats like "Don't test our patience", or "Remember May 13th?" or waving a keris.

This seems ironic, as we have been independent for over 50 years. 50 years that one would think would give a country, its people and its leaders some maturity of how a progressive and modern society works. Instead, we seem to be going backwards, with the younger generations becoming more and more suspicious, entitled and perhaps bitter, of the other races. Younger generations using the term 'pendatang' (immigrant) on the others, when the truth is we all were born in the same country and are citizens (and this particularly stung when I had a KID, no more than 16, direct that statement at my parents a couple of years ago at a nearby park! A kid, who has not been around for even a third of the time my parents have).

People often ask me if I've encountered racism in the United States. The truth is, I've experienced more of that here, in my native country of Malaysia, than being a foreigner there. There, you are respected as a person, based on your contributions to society, not on your skin color or religion.

And right alongside all the policies that clearly remind us that we are different, and are not seen as equals, the politicians are spending taxpayer money promoting the concept of 1Malaysia. That seems contradictory, don't you think? In addition, if you can't see each other as equals in your own country, how do you expect to perform in a global setting?

And so, as we prepare to leave 'home' again, I do leave with this hope for my Malaysia. I do hope that her people will tire of the retarded rhetorics of the politicians with their own agendas. That Malaysians truly will see that we're all really not that different after all, and that what defines us is really our actions, rather than the amount of melanin in your skin, or what term you use to call God. I hope that we will again learn to respect and admire and take advantage of our differences, rather than use them to drive us further apart. I hope that her people will learn to ignore or even punish the leaders who play the race card, rather than flock toward them seeing them as their saviours. I hope that leaders will be chosen based on their abilities, not skin color (and for that matter, get rid of corrupt and greedy leaders in a speedy fashion). I hope that we will strive to better Malaysia for the good of Malaysians, not just for the Chinese, or Indians, or Malays, or whatever else race.

Perhaps you may say these are ambitious dreams that will never happen. But you know, I believe that humans, society, evolve for the better. And so, while I'm not holding my breath that things will change soon, I am cautiously optimistic that Malaysians will eventually succeed in seeing each other as simply that: Malaysians. Nothing more. Certainly nothing less.

Till the next trip, farewell.

2011-04-18T21:27:00.004-05:00

So this trip is almost done. 16 days just breezed by, and we leave for the US soon.

We got to meet up with my buddies the other day, good friends from primary school. It's always interesting, how some friendships, despite the distance and time, still holds strong. It feels like I never left these guys, when in fact I last saw them well over a year ago. It's interesting how you just catch up on where you left off previously.

Though this year, it was also somewhat weird that the number of kids were starting to outnumber the adults.

I also took Kristin to my old high school. It's unreal, finally realizing that we left in 1993. That's almost 20 years ago! It was a treat to run into some teachers I recognize, though they seemed a lot scarier back in those days.

We're ready head back. We've done enough travelling. We were able to meet up with the people we wanted to see (well, most of them anyway. Some plans didn't work out, disappointingly). And I've certainly had enough of the heat (that, and the 5 day headache I've put up with).

Snow, here we come.

Textbook Chapter

2011-04-16T21:35:00.001-05:00

Finally, it's out.

The book in which I authored one of the chapters. The publisher sent me a copy of the book the other day right before I left. It's always gratifying to see your work come to fruition. Except these things sometimes take too long. Not that I have a ton of publication experience, but journal manuscripts take at most 4-6 months to be published from the time they accept it. Textbooks on the other hand...

This marks my 2nd textbook chapter. My first was some very dry EBM-type garbage that would put an insomniac to sleep (hah). This project was more appealing to me when I was invited to contribute. I wrote this in the 2nd year of my fellowship, back in 2007. And this is only coming out now, 4 years later. I was beginning to wonder if it would ever be published.

If you're ever looking for a book with scary bedtime stories/pictures, go check it out!

(and no, my dears, I don't get a single cent. The work was done out of professional/academic courtesy)

Back!

2011-04-15T08:04:00.000-05:00

So, after a long 8-day roadtrip to Ipoh, Pangkor, Penang and Cameron Highlands, we're back in Seremban to unwind before we leave in 5 days. The road to Cameron was windy, so windy that we both got carsick. And so, I showed my wife the traditional Chinese way of treating nausea: Dried sour plums.

She loved it.

Driving back, we saw quite a few of these. I just had to ask Kris to take a picture of this. Why would anyone in their right mind who was driving be checking Twitter for traffic conditions??? Is this where taxpayer money is going to?

To say goodbye

2011-04-13T10:20:00.003-05:00

Medical school provides you with the basic scientific knowledge you need to become a doctor. The 6 years of specialty and subspecialty training gives you the experience and the confidence to go out in practice. But despite all the difficult cases you have to face being a doctor, the one thing no medical school or residency ever teaches, is how to say goodbye. Especially to one of your own. To family.

This has been a long, hard battle for Buddy these last 4 years. One that he has fought with much grace and fortitude. However, because things were still progressing, a few months ago he made the decision to cease his chemo. And so, the primary purpose of our trip home this time was to see Buddy and his wife. Where we go from here will be uncharted territory.

These last few days, we were able to meet up with him and his wife, and caught up on things. Shared memories of the good old days, when we were roomates for those 5 crazy years. Did so much together that for the longest time, many thought we were gay and were an item. We reminisced of the time we played with Coke+Mentos . Or the many Malaysian potlucks we hosted, or the Halloween pumpkin carving sessions we did.

Tonight, we had dinner with him before we left for the journey south tomorrow. And though unspoken, it's pretty clear what we were thinking: Is this goodbye?

Where will the road lead us next? No one knows. How would metastatic esophageal cancer behave in a 30+ year old? But it was difficult seeing him suffer from the pain. It seemed almost too much of a coincidence that Boyz II Men's "It's so hard to say goodbye to yesterday" came on the radio in the restaurant as we were wrapping things up. Kris and I could not keep our eyes dry as we got up to hug them and bid them farewell.

I catch myself wondering why life seems so unfair. Why is it that I get to go on with my life, and start a family, while they've had their lives put on hold while they fight this battle? I feel a tinge of guilt, with a dash of anger and bitterness.

What's next? Who knows.

But if there is anything inspiring in all this, it is the overwhelming amount of love and faith surrounding them. Their love for each other. Of their families and friends for this wonderful couple. Their faith. And if there is one thing I'd ask of you, regardless of your beliefs and faith, is to say a little prayer for him and his family.

Stories from the Twilight Zone

2011-04-12T03:36:00.003-05:00

HO#1: The bloodbank did not have any blood to send up for this patient.

MO: How can that be? No blood at all?

HO#1: No, they said completely zero. They even confirmed it with a +.

MO looks at the chart to verify. Written on the chart was O+.

MO: Patient is low on Vit B12. Please order this for the patient.

The next day:

HO#2: The pharmacy did not have any Vit B12. But I took care of the problem. I gave the patient 2 doses of Vit B6.

We met up with our buddies in Penang for lunch. I almost died when my friends shared the above real-life stories. It would have been hilarious, had it not been true. These 'doctors' should not be out running around in our public hospitals treating patients.

2011-04-08T07:51:00.002-05:00

Here we are, on the island paradise of Pangkor with beautiful white sandy beaches, and here I am, sitting in the kiddy pool.

(not that I'm complaining; had the time of my life with my little one)

An Industry

2011-04-05T20:41:00.002-05:00

Day 3. So far so good. Had a case of Mamak Malady (ie diarrhea) already, but it's all worth it for sure. Poor babe though- the heat/jetlag seems to be really affecting Alli and she's having a tough time sleeping and staying asleep. Naturally this means mom and dad too.

As always, it's a great feeling being home. And I sometimes do feel weird calling this home, since technically our home is in the USA now. But, one can always have two homes, no? Plus, introducing Alli to family and friends here has been great. Though we'll have to make another trip when Alli's bigger- she won't remember this trip. I've had many sentimental moments, telling her "This is where I slept as a child" or "This was my Ah Kong's room" or "This is where I used to get haircuts" etc. One of my joys has been sharing stories of my childhood with my daughter. I imagine all parents do that. Because, as importance as our futures are, it's also vital to have a sense of your past. And I'd like Alli to know where her dad's roots stem from.

Anyway, I digress. Something I wanted to blog about. And yes, before you go around condemning me, I'll be the first to admit: I'm a hypocrite.

You see, I was surprised, or perhaps shocked is a better word, to see the sheer number of ads in the newspapers for private medical schools. And it'll seem like I'm a bastard for saying this, as I'm a product of a private medical school too. But I do still (naively?) consider the field and the practice of medicine and healing, to be sacred work. It's not just a profession, but it's a lifestyle, a passion, and an art. And no, not that I think I'm so damn smart that I got into medical school and all, but I do find it concerning that there are so many 'alternative' paths to becoming a doctor. Seeing so many ads promoting medical schools only seem to cheapen things, especially when many of the ads promote how economical the programs cost, with no hint on the academic requirements for entry.

Yes, I'm being awfully judgmental and jumping to conclusions, but seriously of the (at least?) 7 ads I saw in the papers, with many of the schools not even having had any graduates yet, of the many foreign schools of which some where not even WHO-recognized, I do question the quality and reliability of the medical education. Granted, I have not had the pleasure (or displeasure, as some of you have commented in MMR) of working with grads from these schools, so I have little basis for my concerns.

It's clear, this is a multimillion-dollar industry, one that is also driven by the lack of medical school positions in public universities and coupled by the unfairness of affirmative action. So, the motives for the sprouting of these private medschools is pretty clear- everyone's out to make money. And when a country as small as ours boasts of so many medical schools locally (more than Canada!), plus the numerous others in other countries aggressively recruiting Malaysians, you have to wonder what will happen a few years when the hospitals are overflowing with HOs who don't get the training and experience they need, before they are let out into private practice?

Who suffers?

The patients.

Leaving on a jet plane

2011-04-02T06:13:00.002-05:00

Woo hoo.

We leave for the airport in 6 hours. And so we're now at that paranoid phase.

Did we pack this? Is our bag overweight? Will we miss our connecting? Is Alli having a fever?

It's been a year since I was last in Malaysia- for Kristin the last time she was there was our wedding, 3 years ago. So, we're both excited about this but truth be told, because of all the craziness in our schedules, the excitement for trip didn't really hit us until yesterday.

We start the first of 4 flights at 2.50 pm local time, Saturday. We arrive in KL at 11 pm Sunday, Central time.

32 hours.

Bring on the wine!

See you guys soon!

4 days

2011-03-30T21:55:00.002-05:00

4 days.

In 4 days, we start our long journey to Malaysia. Admittedly, for the first time, I'm nervous- travelling with a 9 month old, on a 20+ hour flight, might just be a challenge.

Before I was a father, I'd always give parents of little babies the evil eye. I'd be thinking, "Your baby had better not be bawling the entire journey", or "What idiot brings a baby on a plane trip?". Not that I'd ever say anything.

Yes, I was a pretty selfish SOB.

But now that I'm a father, I feel a sense of guilt- taking poor Alli on such a long journey, but also guilt towards my co-passengers on Saturday's flight. I'd be hoping that my daughter remains the angel that she is, and keeps the fussing to a minimum.

Yes, in 4 days. This was a relatively last minute trip. We had planned to travel back to Malaysia next year. But, as it turns out, a good friend isn't doing too well with his chemo. We miss them terribly, and hope to bring some cheer to him if nothing else. And we didn't want to wait a year.

And so, in 4 days we start the long journey back to the Land of Satay, Nasi Lemak, Teh Tarik, Char Kuay Teow, and Secret Videos of Politicians Having Sex (if you're Malaysian, you'll understand that last one!).

Of being flatulent

2011-03-26T21:38:00.002-05:00

Bad: Farting in front of your patient

Worse: Farting in front of your patient whilst performing a thyroid biopsy

Alas, it happened to me the other day. I almost died; it was one of those "I didn't see it coming" situations. Thankfully the patient and my nurse both pretended they didn't hear it. Or maybe neither weren't sure who did it. But it got me thinking though. What excuse can I give the next time I accidentally let one out in front of a patient?

It was the nurse (I write her paychecks, so she wouldn't dare challenge me, would she?)
That's just the sound of the needle aspirator.
It's normal for your ears to pop or hear things when I stick the 25G needle into your neck. It's just an auditory hallucination.
That's the sound of the ultrasound's cooling fan.
Sound? What sound? I didn't hear anything.
That was just my stomach.
That's just gas escaping from the thyroid as I prick it.

Then again, if it's a smelly fart, there's probably no way around it. What excuses can you come up with?

A Challenging 'Disease'

2011-03-22T19:50:00.002-05:00

Mrs. L kept me busy all week on call. A patient with type 1 diabetes, and like many others, pretty brittle. Has been in the hospital for 7 weeks now, from complications of GI surgery.
Despite stable doses of insulin, her glucose levels would swing wildly, from very, very lows, to very very highs, with no clear change in intake, or insulin.
Over the weekend, she was transferred to the ICU for septicemia. Ultimately her blood cultures grew all kinds of weird bugs. But during the emergent transfer, when the nurses were packing up her stuff, they found a bag stashed in her room.
A bagful of medicines, insulins, syringes, even meth. Many dirty needles. The surgeon then confronted her (and I'm glad this was a no-nonsense, pig-headed, God-complex surgeon) and got it out of her. While the medical and surgical team have been trying to help her, she was doing drugs, and also injecting all kinds of things into her, even deliberately contaminating needles with fecal matter, and pricking herself. She was also alternating injections of insulin and dextrose into her IV port, which probably explains the swings.
Munchausen Syndrome.

Munchausen syndrome is a type of factitious disorder, or mental illness, in which a person repeatedly acts as if he or she has a physical or mental disorder when, in truth, he or she has caused the symptoms. People with factitious disorders act this way because of an inner need to be seen as ill or injured, not to achieve a concrete benefit, such as financial gain. They are even willing to undergo painful or risky tests and operations in order to get the sympathy and special attention given to people who are truly ill. Some will secretively injure themselves to cause signs like blood in the urine or cyanosis of a limb. Munchausen syndrome is a mental illness associated with severe emotional difficulties.

Munchausen syndrome—named for Baron von Munchausen, an 18th century German officer who was known for embellishing the stories of his life and experiences—is the most severe type of factitious disorder. Most symptoms in people with Munchausen syndrome are related to physical illness—symptoms such as chest pain, stomach problems, or fever—rather than those of a mental disorder. Reference: clevelandclinic.org

I've seen perhaps 5 or 6 of these in the last 10 years. Always difficult to prove, unless you catch someone red handed. After all, how can you confront someone and accuse them of lying? Though that gal I saw in residency was making it pretty obvious when her skin abscesses grew enteric bacteria, but these occured ONLY in areas of her body where she could physically reach (frontal body, trunk, none in the back).
Always a challenge to treat- as doctors we are trained to treat the medical problem at hand. With care and concern, medicines, invasive therapy. But that is always with the assumption that the patient's on your side. But how do you treat someone, when that someone is working against you, trying to sabotage things?

Matched!

2011-03-18T20:43:00.002-05:00

Not me. My students.

Yesterday was Match Day, the day when all the medical students applying for a US medical residency find out there they go next academic year. A very stressful yet exciting time, one that marks the end of a chapter (of being a student), and the start of a new chapter (well, still a student of sorts, but you have a Dr. in front of your name). The 3 to 8 years of specialty training that follows.

This year, a record 38,000 applicants applied for 26,000 positions of residency. If you're interested, the Match Statistics can be found here. 6% of US medical students were unmatched compared with 50% of International Medical Graduates who did not secure a position. Encouragingly, there were more students matching into primary care medicine this year, a vital area that has frequently been neglected because many (wrongfully methinks) see it as not being glamorous enough.

And so, like someone who has years of wisdom to impart on his 4 students doing their endocrine rotation, what did I leave my students with:

Learn to find your own way. Your career is only in its infancy; at this malleable phase of your life, don't learn to imitate someone for the sake of imitation. Don't do this because that's what Dr. X does. Or use that medication because it was Dr. Y's favorite. Or be conservative or aggressive with your treatment goals, just because.

Rather, read the literature and make your own conclusions about how you wish to treat your patients. Because medicine is as much an art as it is a science. And though I became a 'Doctor' that fateful May 10 years ago (OMFG, has it been that long???), I have yet to master either. Take a step back, and ask yourself, what is the right thing for THIS patient?

And, ah, oh yes, be nice to the nurses. You might have the title, but they have the years of experience. If they tell you they're worried about a patient at 2 am, get your ass out of your callroom to evaluate the patient, otherwise the next overhead page you hear might just be a Code Blue. And, if you piss off the nurses, they can make your life hell.

3 of my 4 students matched (the 4th had to go through the scramble- a very stressful experience- but last I heard he was able to get a spot finally).

Congratulations, guys!

Poll Results

2011-03-16T19:44:00.002-05:00

So here are the results.

I must say I'm not too surprised- about half of you preferred to go ahead and see the doctor, eventhough he may be sick and is an infectious risk. If it were me, I'd probably vote the same too.

On the receiving end though, I did feel pretty shitty that day, and was really feeling ill. So, I wouldn't have been able to give good care, not when I was having shaking chills and running a high fever. So, it wouldn't be fair too to expect the sick doc to work; everyone needs their sick days.

But one of you readers did ask though: don't we have colleagues who can cover for us? Alas, only to a certain extent. When patients are already needing to wait 4-6 weeks to see a specialist, it usually means the manpower is lacking enough that there isn't a redundant/extra person just sitting around waiting for someone to fall ill.

So, it's one of those things; in an ideal world, I wish I didn't have a job that doesn't allow for sick days without making me guilty and penalizing my patients.

Thanks for your two cents.

2011-03-13T09:52:00.003-05:00

Why is it that everytime I'm oncall, I have this strange urge to poke my eyes out with a pencil?

Anyways, more when I sign off Wednesday.

Right now, our thoughts, prayers go out to the people of Japan, and indeed, the people of the world.

Tremulous times, these are. And with already so many natural disasters, we really don't need any more man-made problems like all the unrest going on in Libya.

Sick Day

2011-03-07T11:25:00.004-06:00

And so I'm home sick today. Probably thanks to the munchkin; she has been graciously picking up and sharing whatever bugs there are in Daycare. I've never fallen ill so many times before; just last month I took my very first sick day, in my 3 years of work since I joined my group. And now, just 4 weeks later, I'm down with some crud again.

And truth be told, I felt horribly guilty calling in this morning to tell the office manager to reschedule the patients. For one, I've had a terrible headache since yesterday, I ache, am running a fever of 102.8 F and my throat hurts like the devil. The bed has been very accomodating today, though I feel horrible knowing that some patients waited 6 weeks for an appointment with me, and many probably took a day off planning to drive in to town for the visit. And so, this always gets me thinking:
What would patients prefer? Would someone prefer to just see the physician, knowing that although the illness may be contagious, it's not anthrax? Because, as someone on the receiving end, I'd be pissed if I took the day off to see the dentist, only to have him cancel on me.
Or, would patients prefer to reschedule and not risk seeing a physician who may not be on top of his game because he feels crummy, and risk picking up whatever cooties his nostrils may transmit to his hands, and then to you?
Humor me. This is a legitimate survey and I'd really like to know.

Create your free online surveys with SurveyMonkey, the world's leading questionnaire tool.

Secrets I Wish My Patients Knew

2011-02-27T06:10:00.001-06:00

Our coding/billing is dependent on complexity and risk. So, we get paid more by your insurance for higher risk situations. But having said that, I would rather have your diabetes be well-controlled and make less, than have patients with uncontrolled hyperglycemia.
Yes, it's probably your fault (not for all patients obviously, but 90% of the ones referred to me) that your diabetes is badly controlled. You don't check your sugars, and miss your insulins. But would it surprise you to know that as your physician, it makes me feel like a failure? I really do want to help, but I can only do so much without your support.
I really do wish my patients and my staff would call me by my name, not Dr. So-and-so. That's an academic title and says nothing about one's capabilities as a person. I may have had more education than some of you, but many of you know more about life than I do and so the respect you give me is often overstated and undeserved.
I take no pleasure putting you on medications. I do so only because the research has shown that it improves your health down the road, whether it means you'll live longer, or decrease your chances of kidney failure. And no, I don't get any perks from the drug companies (see my earlier post about my sentiments for Big Pharma).
I might be a doctor, but I am a person. I am a son, brother, husband and father.
I really do want to help my patients. But when you come to me for your 3-monthly visits and bring no glucose logs nor even check yourself, and yet your A1c remains above 10%, I'm at a loss. In fact, I'd rather you not come, but reschedule to a week when you CAN bring in some numbers for us to review together. Without numbers, we're adjusting blindly and that can be dangerous.
I might be an endocrinologist, but I don't have all the answers. I can't tell you why you're tired, or are losing hair (tell me when you figure this one out!), or have mood swings, or can't sleep.
I'm old school. I like the cheaper generics whenever possible. Don't ask for the newest drugs just because they're new. They're also more expensive, and lacks the longer track record than the older guys.
I know I'm sometimes late; I'm sorry. It's often because of the guy before you. Having said that I do wish you were on time. We have patients come 15 mins early so that my nurse can reconciliate your medication list, and get the vitals and bloodwork started. But when you come in 15 mins late for your appointment, you're really 30 mins late, and the rest of today's patients end up waiting for your delays.
I don't always go by the rules. Yes, the guidelines recommend that your LDL be below 100, or that your A1c below 7%. But for some of you it probably doesn't matter anymore. So, I'm probably not going to be aggressive and start my 92-year old patient whose A1c is 7.3% on insulin, because, damn, if you're 92 years old, you've done well on your own thus far, and don't need a doctor trying to fix what don't need fixin'. Likewise, I'm probably not going to start you on some expensive 2nd-line cholesterol medication just to lower your LDL another 10 mg/dL.
We're human too. We make mistakes, hopefully not big ones. But when I do, I feel horrible about it. But yes, I believe in honesty and I WILL tell you if I messed up.
If I treated you for gestational diabetes, I REALLY do like it if you bring your baby for your postpartum follow ups!