Saturday, March 28, 2015

LKY

A few days late, but I wanted to leave some thoughts on this.
Being so far away, and ironically being a Malaysian, I still did feel a sense of loss over the recent passing of Lee Kuan Yew. Indeed, part of me was envious that I couldn't be there to pay my respects, reading about this on my Singaporean friends' FB posts. And certainly the huge envy most Malaysians would have, thinking about what a great man and leader Mr. Lee Kuan Yew was, and how things might be/have been if only Malaysia had leaders such as him.
It's pretty damn amazing reading about Singapore's development from a small island settlement to a what it is today. And how it rapidly advanced after its separation from Malaysia, leaving us in its dust while we still, almost 60 years later, struggle with bickering, corruption, racial disharmony. Mention Malaysia here and I'm usually faced with "where is that?" or "Isn't that where they have terrorists?/Is it safe?/That's the country with the plane crashes!".
Mention Singapore, and everyone here knows about it.
Singapore truly has come a long way, and though she isn't without her issues, it's pretty evident that much of her progress can be attributed to LKY. Even if you don't agree with his ways, you can't argue with his success.
RIP, Mr. Lee. You have worked so hard- it is time to rest knowing you have raised a country well.

Tuesday, March 10, 2015

Passport Renewal

So last week the wife and I made a trip to NYC to a date-trip (in-laws offered to watch the kids as we flew out), and to renew my Malaysian passport.
Yes, I admit, though I could probably apply for US citizenship now, part of me is too damn proud to give up my Malaysian identity. I still take pride telling people here I'm Malaysian.
Which is probably why I put up with the tidak-apa crap everyone else does. Which was well illustrated when I was last in Malaysian in November 2013. I knew my passport expired in late 2015 and didn't think I'd make another trip back in the meantime, and tried to get my document renewed.
The Jabatan Imigresen opens I think at 8AM. I was there by 845AM; to my chagrin there was already a long line there. I took a number to wait for my turn to submit my papers.
And waited.
And waited.
In that humid, packed room.
And after 2 hours and having seen the numbers advance only a few digits, I decided to come back. Especially since one of the officers told one of the Ah Pek's off and told him to come back in the afternoon.
When I popped in again at 1PM, it was still nowhere close to my turn.
And so I told them to go to hell, and decided to do it here instead.
Fast forward to now. 
When I emailed the Consulate General of Malaysia at NYC, my emails were answered in a most unMalaysian way- within a few hours. I asked about what documents I needed, and what preparations I needed to undertake.
As it turns out, all I needed were:
1) To complete the Registration of Malaysian Citizens in USA form
2) Passport
3) Malaysian IC (best to have the new MyKad- you'd get a 5 year renewal, versus a 2 year) and a copy 
4) Malaysian BC and a copy
5) US Green Card (not listed on their website, but they asked me to bring mine)
6) US$70

The embassy was located in the east side of midtown Manhattan, walkable from Times Square if you're adventurous. They open at 9AM; we arrived at 930AM and took a number and were attended to within 45 mins. They took my photo on the spot, and my new passport was ready in less than 2 hours.
And best of all, people were FRIENDLY! For one, the Malaysian camaraderie in the waiting room, "Eh which part of Malaysian are you from?" etc. But best of all the consulate officers were actually friendly, efficient, and quick! 
Such a difference from my experience in Seremban in 2013.
Syabas, guys! This is the way to do it. 
If you're looking for info, they are located at 313 East 43rd St, New York 10017 NY
Email: iminych@yahoo.com 

Wednesday, February 25, 2015

Signs Your Kids Are Growing Up

  • Your girl is able to brush her own teeth and doesn't need any help
  • Being able to get herself dressed on her own
  • Telling me she doesn't need me to wave goodbye to her anymore as I drive away from daycare, as she'll have her friends to play with
  • At one time, you stand in the restroom with your daughter as she goes potty to make sure she doesn't fall into the bowl. Now, she goes "Daddy, I need some privacy please"
  • Going from singing lullabies at bedtime (I swear I've probably sung Twinkle Twinkle Little Star over two thousand times in the last 4 years) to reading bedtime stories, to now watching a video on the iPhone of One Direction and having the girls swoon and go "Oooo He's so Cute" at bedtime
  • Being able to tell me the name of a song when she hears it on the radio (when I've never even heard of it before. I guess this is how our dads must have felt hearing New Kids on the Block for the first time)
I'm reminded of the song Butterfly Kisses. To perfume and make-up from ribbons and curls. Trying her wings out in a great big world.
 
Don't grow up too quick, kids. Because someday I'm going to be giving you away at your wedding. And THIS dad is definitely going to cry.


Saturday, February 14, 2015

Another Phaeo

Phrase that sends shivers up an endocrinologist's spine:
"Biopsy-proven phaeochromocytoma..."
 
Saw my 2nd case of this recently, to my chagrin.
I've seen perhaps 20 cases in my career so far of catecholamine secreting neuroendocrine tumors. But theses should be diagnosed based on clinical suspicion, appropriate biochemistry and radiologic findings.
Never (usually- but will come back to it*) is it justified to diagnose this from a biopsy, as this usually means the physician/surgeon evaluating a patient with an adrenal mass was not considering a phaeo in the differential diagnosis. Or that he/she made the fatal assumption that asymptomatic rules out a phaeo and that lab testing isn't needed- just stick a needle into it.
My first referral was 7 years ago- that patient had a hypertensive crisis in the radiologic suite immediately following the adrenal biopsy. I think the radiologist shat in his scrubs when it happened and it must immediately have dawned on him what the mass actually was.
The second, this patient, had adrenal hemorrhage that required invasive intervention.
 
What I tell residents is this: The classic features of a phaeo isn't that classic after all. All adrenal masses need a biochemical workup, especially before you stick a needle into it.
 
Most phaeos are asymptomatic. And of the symptomatic ones, the most common is hypertension; what looks to be plain old simple essential hypertension. So never assume.
 
(*perhaps the one situation in which I would not blame this on shoddy work is a paraganglioma/extraadrenal phaeo in a weird location- which would be unfair to expect one to consider a phaeo in the differential diagnosis)

Wednesday, February 11, 2015

When you eat too much sugar...

I think I need to stop talking about work when I'm home.
Out of the blue, the little comes up to me and says this:
video
"When you eat too much sugar, you get diabetes"
(strictly speaking it's not true- DM has a lot more to do that eating sugar...)

Sunday, February 08, 2015

Is it unprofessional to pay for a patient's meds?

So last week I did something unorthodox. Even for an eccentric guy like me. Mrs. G has had longstanding refractory Graves' disease. For some reason, resistant to antithyroids (which usually means some component of noncompliance).
And so, push came to shove and we opted instead to refer her to surgery.
As you know, the Graves' thyroid is enlarged and usually very vascular which makes surgery more complicated. And taking a thyrotoxic patient into surgery obviously carries its risks. So a short course of high dose iodine is usually warranted preoperatively, to take advantage of the Wolff-Chaikoff effect; to transiently shut down thyroid hormone production and decrease the vasculature.
I attempted to get her started on this, except she calls me a week before surgery, crying on the phone that she has only a few dollars left to last her for the week and cannot afford the medication. Nevermind that SSKI is relatively cheap.
And so I told her: "Never mind the cost. Just promise me you will take it."
After all, with her paroxysmal a-fib and recent stroke, she needs the thyroid out ASAP.
She did. And so I told her I would pay for it. I called up Walgreen's and called in the prescription, and gave the pharmacist my credit card information.
I saw Mrs. G 3 days ago post-op. She was sore- but otherwise looked great. And her thyroidectomy went smoothly, thank heavens.
In the 7 years of practice, this was the first time I actually paid for a patient's medication, and I'm still partially expecting this will come back to haunt me. I'm half expecting my supervisors to come back with a reprimand, that this is 'not professional', and may open us up to legal action citing discriminatory action, if other patients get wind of it.
After all, I've been cited for crap like this before, like the time I underbilled a patient because he couldn't afford it.
Often, I wish we lived in simpler times. Times when it comes back to two human beings, one a doctor and the other his patient, and that decisions are made just between them. Far away from the attorneys, the administrators, the insurors, the PR department.
To me, it's a simple matter. She needed it. I could help, and I made a judgment call. So what's the big deal?
A doctor and his patient. That's it.

Sunday, February 01, 2015

Snow Day


We are in the midst of another snowstorm. About 12 inches so far and it's not going to end for another 7 hours. So we are all huddled in, under our blankets and sipping on hot chocolate.
That being said, sometimes there's nothing prettier than a nice snowfall.
Everything is white and pure again. Sounds are numbed by the snow, and all you hear is the soft rustling sounds of snowflakes falling, and perhaps distant sounds of snowblowers. Tree branches are frosted white, and there's a thick layer of icing on our patio furniture. The squeaky sounds of footsteps, of the rubber soles against the slippery snow.
It's was something I could not fathom, coming from Malaysia, of how instead of needint to mow the lawn, we use gasoline powered snowblowers to clear the snow. How driving in snow feels, or how you can sweat underneath all that gear, but yet to have your face freeze because of the direct contact with the cold.
This blizzard ends at 9PM tonight. Thankfully, we have nowhere to go this lazy Sunday afternoon. I hear over 2000 flights have been cancelled so far. So, we're just going to stay lazy and enjoy the day.
Stay safe, folks.

Friday, January 23, 2015

Doctor Shooting

Those of us here mourn, and are shocked by the recent events in MA.
A vascular surgeon is shot to death in the very hospital he works in, by a family member of a patient.
It is shocking- however perhaps I'm just too cynical- but it was inevitable, bound to happen someday. After all, guns so part of the American culture that there are about 300 million guns in the United States. That's about one for every man, woman and child.
Undoubtedly this is fueled by the 2nd amendment, the "right to bear arms..." which people quote as though it was the bible, and a God-given right.
Adding to that is the industry's lobbying, the NRA and the mantra of "guns don't kill people, people kill people..." (yea, but people with guns kill more people).
The rationale is that we need guns to protect ourselves from other people with guns. Genius, and the whole place becomes the Wild West.
And so, people are walking around packed. Despite what the signs might say on the entrances of facilities: No guns allowed. After all, if it's concealed, who's going to know?
In my very clinic, we've have at least 3 patient encounters (not including those in law enforcement who came in armed because they carry a gun to work) where patients proudly showed off their guns to their doctors, thinking it was cool. One of my colleagues promptly walked out of the patient room-good for her.
So, with so many people carrying firearms in this country, it does not surprise me that tragedies like these occur.
Human beings have their limits; we all will someday snap if put under enough pressure. In this case in Boston, it was apparently related to the shooter's mother's death, and presumably he put the blame on the doctor. But doctors do not have absolute power over the human body, and we will fail some patients, especially in a high-risk specialty such as surgery. I've certainly pissed off many patients in my short career so far, whether it's because I refused to prescribe opiates, or weight loss pills, or when I tell them they need to lose some weight, or when they're upset by the high cost of medications. It's scary enough that some patients may harbour ill-will and blame towards the doctor when something goes wrong- but to come in and shoot him?? Well, the system makes it so easy.
It makes it so easy for someone to carry a firearm, that tragedies, accidental or not, will continue to happen.
Like that toddler who shot her mom in Walmart because she got into the mother's handbag and found her gun.
Or that man who shot another in the theater, because he thought his life was "in danger" when someone threw popcorn at him.
Or that police officer who shot that kid carrying a toy gun, because it looked real
Or that kid who shot another at a party, because he found a gun in the house.
I'm all for freedom- and many say this is a freedom that is given to them. But where does it stop? We all have a right to protect ourselves- but do we all need to be packing guns. Or an assault rifle? People are passionate about the 2nd Amendment, that it's a right- however the very word "amendment" means a change in a document- so yes things can be changed, if there is political will to it.
Will it ever happen? Never. I see it in how charged people are about their guns. How the NRA fuels this fire. Heck, I see it in friends with 5-6 guns and assault rifles who clearly see their gun collection more so as a hobby, a pride and joy, than a safety necessity.
Such scary times we live in.
RIP, Dr. Davidson.

Tuesday, January 06, 2015

Greetings from the Icebox

Wednesday, December 24, 2014

Merry Christmas!

I saw this on the neuro floor of the hospital today.
 
Yes, I had to round on Christmas eve, but at least I get to sign out the pager to my colleague in the afternoon.
I'd say this was pretty creative of the healthcare staff.
And I do like how the hospital is decked out in holiday decor (without racist Isma and Perkasa idiots tearing down they don't accept).

 
And I guess I shouldn't complain. After all, I get to go home and be with family when the day is done. I can't say the same for my patients- they have to stay in a foreign, strange place, with strange food and smells and sounds, with strange people poking, prodding and waking them up.
So I thought it'd be fun to dress the part. I wore a Santa hat and reindeer tie for rounds yesterday and today.
And I thought it'd be a lark for the endocrinologist to be giving out candy canes to patients (see what's poking out from my pocket?).

(Don't sue me: I figured it's only 11 g of carbs and shouldn't mess up anyone's blood glucose too much!).
Merry Christmas, everyone. May this be the season you are filled with love, with family and loved ones near, or at least near to our hearts. In these times of madness in the world, let goodness and kindness prevail.

Monday, December 22, 2014

Signs You're Getting Old

This crossed my mind when I looked in the mirror this morning. And no, I'm not 'fessing to any of these.
  • You are finding grey hairs. Grey nose hairs
  • You look in the mirror when you first get up, and for a fleeting moment you see your dad
  • You refer to those twenty year olds as "those kids"
  • Your favorite cars on your Cars.com iPhone app are minivans and electric vehicles
  • The damn drug companies start sending you laxative samples (I still have a dozen boxes if anyone wants any!)
  • You see a hot 20+ year old nurse, and the first thing that comes to mind is "Hmm, I wonder how her mother looks like?"
  • You think getting up to pee 1-2 times at night is normal
  • You're afraid of getting a new computer eventhough your current is on the brink of death, because you're secretly afraid of Windows 8
  • Your optometrist is giving you 2 years before you'll need bifocals (that sonofabitch)
  • You think bow ties and plaid sport jackets look nice
  • Your eyebrow hairs are starting to curl
  • College student-types call you "Uncle"
  • Your bowel habits are as regular as the cesium atomic clock
  • Between Playboy magazine and Consumer Reports, you'd pick Consumer Reports any day
  • You use 'Jaws' from the original 007 movies to illustrate the phenotypic changes of acromegaly. Only be to met with blank stares and questions of "Who's Jaws?"
Oh well. As a mentor once told me, the only way to avoid getting old is to die young.

Wednesday, December 17, 2014

Priceless

I admit, I'm one of the millions of Facebook users who are ungrateful, who use the social media site without paying, but complain about its privacy policy, data mining practices and the stupid intrusive advertisements that put up on my wall. Your know, the "related links" ones.
But this one wins a prize.
 
This was priceless; there was no better ad in response to the post above it.
Maybe they're not that stupid anymore.

Sunday, December 14, 2014

Farewell, Elaine....

I found out a patient of mine passed away 3 days ago.
I had been seeing her for the last 5 years- and it's something I've really come to enjoy in my field- the longitudinal care we provide and so we really get to know some patients, and even get attached to some of them (This would be in contrast with the role of a hospitalist, or ER doc, who provides on-demand care).
Anyway, she has type 2 diabetes, but was a dear little old lady, with dementia. I also see her son and cousin as their endocrinologist. And at the visit with her cousin, he shared the sad news. She wasn't feeling well that day and wanted to rest. But she never woke up.
She was 89.
She finally got what she wanted. She lost her husband a long time ago. And despite the dementia, remembers him well. And everytime I see her, she would grumpily say that "old people have no business being alive for so long. Why wouldn't He just take me now?".
And I would tell her "Elaine, it's just not your time..."
She lived alone in a trailer home before her son made the difficult but necessary decision to put her in a nursing home 10 months ago; she was the lady Kris and I brought a birthday cake to last year.
I shall miss her, seeing her spunk, her dry sense of humor, and hearing her stories (stories she had told me a dozen times before but doesn't remember).
But at least she's finally at peace, and she'll celebrate Christmas with her husband, finally.
Farewell, my dear... I hope I took good care of you while you were here.


Saturday, December 13, 2014

Congratulations!

So our 'foster' son graduated today. We 'adopted' several students from Malaysia who are in the university here, if nothing else to help out in the initial transition from Malaysia to the American way of life. Thinking back to my culture shock leaving Seremban for Canada 16 years ago, I thought it would be nice to have someone from 'home' take you in, and so we have been doing this for several years.
Anyway, today, we attended the graduation ceremony of one of our students. He has been here for several years, and it has been satisfying seeing him bloom from a shy, quiet person into the man he is now.
Yea, I know, that makes me sound aged, but it was really neat to see him walk up to collect his hard-earned degree. And Kris actually even teared up a bit.
In fact, this university is apparently popular amongst Malaysians, and there was some pride on my part, watching the many Malaysians graduate.
His folks flew in for the graduation, coming from a small town in Malaysia and being in the USA for the first time. And so we've been hosting them for the last several nights since we had some extra rooms. That being said, the glitch is they speak little English while my Hokkien and Cantonese is bad enough to make my ancestors turn over in their graves and cringe. But we got along great, and it was amusing seeing Kris communicate with them.
They leave tomorrow for a long awaited vacation before their long trip back to Malaysia.
Congratulations, guys. May this be the first step in a fruitful and fulfilling journey.

Wednesday, December 10, 2014

I Won Something

Omygod I won I won I won!
Not sure what I won since I didn't submit anything, but this text message must be real right???
Perhaps someone out there, some random philanthropist out there, must recognize my genius.
Anyway, let me know what happens if anyone calls the number above to claim the prize on my behalf. Fully invite all the readers to spam that number.

Sunday, December 07, 2014

A starry-eyed premed student shadowed me the other day. And as much as I tried to show her to ropes, I felt guilty showing her the realities of practicing medicine in the USA.
Not only do doctors need to know and treat disease states, our roles have evolved in not-so-ideal ways to include other duties.
Like how the insurance companies expect me to know what is on their formulary drug list (ie what is preferred, or cheapest, for their members). Not only is this confusing enough as every company has a different preferred list, but the same company often changes in the new year. So this year they prefer Insulin A, but next year it's Insulin B, or C. In the meantime, when the new year comes along, we get faxes from the pharmacy or calls from the patients, that their med is no longer preferred.
Like how I spend at least 2 hours every week performing paperwork (not inclusive of charting since this isn't paperwork anymore, being on EMR). Signing prior authorizations, or writing letters explaining why that patient with thyroid cancer and increasing thyroglobulin levels need an iodine scan. Or why a patient needs to be testing his glucose 4 times a day.
And yet we play the unenvious role of defense lawyers. How it's no longer about clinical suspicion. Or simple trust. Like how when the patient tells me she isn't pregnant and I send her for a scan, the radiologist still wants us to do a pregnancy test, "just in case". Because her word isn't good enough, in case they get sued. Or how pretty much everyone who walks into the ER complaining of a tummy ache gets a CT scan. And you wonder why the USA spends more money per patient than anywhere else in the world, with nothing to show for it.
Or how I feel like I'm reduced to a secretary or record keeper. Needing to do stupid items to "meet meaningful use". To have my clinical notes explode into 4 pages, when I have only 2 paragraphs relevant for the referring physician- only to fulfil some quality measures that some bureaucrat with the IQ of a snail has decided to be important.
It's true that medical school and residency only teaches you so much. That in the first year of practice you really do have the steepest learning curve; when you actually come out into practice on your own, no longer shielded by attendings.
And so, after the half day of shadowing, I hope I didn't put the student off medicine. However it is true that being a doctor is getting way too complicated these days...

Friday, December 05, 2014

Apparently I'm constipated. Just received a huge carton of samples in the clinic. Addressed specifically to me.
Well, you can't say I'm anal retentive anymore...

Wednesday, November 19, 2014

Some Pictures

As promised, here are some pictures of the trip. We flew in from Dallas, TX to Sydney, on what I'm told is the world's longest nonstop flight- on the Qantas Airbus 380. A butt-busting 16 hours 55 minutes! Thankfully the girls did OK.
Spent a few days touring the sights of the beautiful city (though I was struck by the high cost of living, something I wasn't expecting).
From there, we flew the 4 hours to Perth to see family, before flying back to the USA 1.5 weeks later (only to get stuck in the airport, but you already knew about that).
 




What I can't understand is, EWWW. Placenta cream, and for $36??

Tuesday, November 18, 2014

Back!

Phew. The weeks just rushed by.
We got back to the USA 3 days ago. Barely made it home though; the irony was it took us less time to travel from Australia to the USA, than it did to get back from our port of entry to home.
Thanks to the reliable US airlines. In this case, the wonderful United Airlines.
We wait, and wait and wait.
While watching the sign go from Delayed 5 mins, to 15, to 60, and eventually CANCELLED. All because they were "waiting for a part from the warehouse".
Yea, try having a flight get cancelled at 1045PM, with 2 cranky kids, when you're jetlagged after a 20 hour flight.
Thanks, United Airlines.
 
And it didn't help that when we did get back, they misplaced our bags, which needed to be delivered the following day.
 
KNNCCB.
 
Anyway, I'm glad we are done with travelling for now. It was wonderful to be able to see mom and dad and my brother's family. To watch the kids interact. Australia and her beaches were also breathtakingly beautiful (and I'm not even referring to the bikini-clad women).
 
Anyhoo- it was back to work yesterday. And start oncall tomorrow. What fun. Hope you're staying warm, people. For us, it was 20C last week, and -12C today.

Thursday, November 06, 2014

The Trip Thus Far

We're having a blast so far. Five days in Sydney and now in Western Australia to see family.
More when we return but here's some pictures from the trip so far.