Monday, May 30, 2016

Of Expirations and Best Before Dates...

Question: Is it safe to consume ikan bilis that expired 4 years ago, or sambal paste from 3 years ago, or rendang mix that expired in 2011?
Affirmative. Affirmative. Affirmative.
As with other few (precious) weekends when I get to play the role of bachelor, when my wife is away visiting family, or at some medical conference, I turn to my vices. And in some ways I wish I could say my life was exciting enough to have secret sex orgies, or drunken escapades, or spending the night in the 'lokap' when I'm a free man, no, what I really do is cook.
As in cook Malaysian food that my kids, wife, neighbors and American friends consider to be more pungent than fermented gym socks.
And because I can't usually cook certain aromatic, spicy dishes, I hoard racks and racks of Malaysian spices. If you're a Malaysian expat living in abroad, you know what I mean. That pack of Bak Kut Teh spices or Rendang paste is more precious than my left arm. 
So when you hoard stuff that you don't usually get to use, the inevitable happens. They expire. But who in their right minds would throw away otherwise perfectly 'good' food and spices from the Motherland??
After all, expiration dates are a government conspiracy. I tell my wife that nothing vacuum packed/frozen ever goes bad.
This weekend, with the missus being away at Boston  with one of the girls, I took the opportunity to make Nasi Lemak.
My wife would rather inhale the air in a small sauna with a dozen flatulent sumo wrestlers than to smell ikan bilis. And with my kid having a peanut allergy, this is a no-no in our household. But with me being semi-alone this week, the timing was perfect.
Except I then noted the print on the packets. April 2012 for the ikan bilis. Ogos 2013 for the sambal paste, and Feb 2011 for the rendang spices.
For a moment, I thought about tossing them and not risking it. For all of 2 seconds.
But then I realized I already have my last will and testament and trust all written up. And life insurance policy in place. And my retirement portfolio has done quite well so far. So the family would be OK without me should shit happen. Literally.
And so, voila:
Nasi Lemak with sambal ikan bilis, ayam rendang, satay sauce. 8 hours later, I'm still alive and kicking. No gastronomic catastrophe yet. I haven't gone blind yet.
Except Ava was getting worried for me, seeing how much I was sweating. The beads of sweat was literally dripping off my head.
In retrospect, perhaps making a spicy dish on a warm 30C day wasn't the best time. But man, it was worth it. And perhaps speaking as someone who hasn't tried it, but there is no way some orgy would be more satisfying that a spicy nasi lemak meal.
Or can it?

Sunday, May 29, 2016

On The Mend

Thanks for the well wishes. The trooper she is, she seems to be on the mend steadily. She had her "permanent" cast placed the other day, And being smaller, and below-elbow, it's proving to be more comfortable. And she was actually excited to be given several choices for color- she picked tie-dye.
The pain is completely gone. Gone enough that we have to keep reminding her to not do anything too physical. After all, my greatest nightmare is to need an ORIF.
And yes, that's a hula hoop she's holding- but that's about all we're letting her do. No slides, climbing, trampolines.
She was initially unsure of how her schoolmates would react. I have to remind myself that they grow so fast- and now she's already to the point where she cares about what others think.
But when she learnt that she could customize the cast, this gave her something to look forward too. 
And so, daddy hot-glued some crystals on it. And because she's always wanted to be a superhero, I put a Batman patch on her sling.

Now she's all set to take on the world. Just don't be breaking any more bones!

Sunday, May 22, 2016

Poor Alli

It's one thing being the doctor.
It's a totally different thing being a father.
I learnt this the hard way a few days ago. Allison had learnt how to use the monkey bars at school, and so wanted to show us she could do it.
Inevitably, when you wage a battle with gravity, gravity always wins. And so she fell, and suffered a distal radial fracture.
While it was not life threatening, it breaks the heart, seeing her cry, and knowing even before the X-rays that the radius was fractured. After all, there was an obvious body deformity.
The X-rays and fluoro told us all we needed to know.

I've seen perhaps 20-30 fracture reductions during medical school and residency. Not a whole lot, since my career path was destined for a nonsurgical route. While I've always felt for the patient in pain, I've never experienced anything like this.
Seeing your own daughter, in so much pain, in so much fear, looking at the foreign white lights of the ER. Seeing the strangers in white coats (not something she is used to, since neither mom nor dad wear white coats to work), poking and prodding.
And then, despite the sedation and pain medication, seeing the orthopedic surgeon reducing the displaced fracture. Despite the sedation, she was somewhat whimpering. And it was sickening, nauseating even, to see your child's distal forearm manhandled, and twisted in abnormal ways to reduce and reposition the fractured fragments. I'm glad I sent my wife and other child out- even I could not keep my eyes dry.
Thankfully, that did not last too long. And so, after a 4 hour ER visit, she went home. With a cast that she will wear for the next 2 months, right into summer vacation, right into her birthday.
She's not happy that she has to miss swim class, or skip gymnastics, or riding her bike, or jumping on the trampoline. But she's being a trouper so far. And perhaps even finding things to look forward to, like how she wants to decorate her cast, or her sling.
Hopefully, this will all be over soon.
But it has me thinking wondering if playsets with monkey bars are secretly sold by companies owned by the American Orthopaedic Association?

Tuesday, May 17, 2016

5 Years


I can't believe it has been 5 years since you left us.
How time flies, my friend. In those 5 years, the world continues to revolve but yet, our precious moments and memories of you become frozen forever.
Down here, much has changed. I've become more cynical, jaded, tired and aged. We now have two girls- you met the older one in your last weeks, remember? She's now in kindergarten, while the other is in preschool.
I miss our conversations; truth is with work and life as a parent, it's hard to form bonds like those we had, when we were relatively young and carefree, and it's hard to find a confidante to fill your shoes. I miss those sessions we would have over a meal, or Halo, complaining about work or life (usually it's me, with your patiently listening). Now, I like to imagine that when all is not well, somewhere up there you're still listening...
I sometimes think about the unfairness of life; of why someone like you would be taken away so soon, so young. Truth be told, I've asked myself many times in the past- why a man like you? Why not someone like me? After all, you'd leave a bigger mark in this world than I ever would. Or maybe that was the point- to teach the rest of us who have much to learn, how to life live and make the most of things.
I remember the time when you told us that you decided to not carry on with chemotherapy. Being the oncologist you were, you knew the odds  even before treatment began. And you knew when you had had enough, and you wanted to just make the most of your time. We both knew the implications of your decision, which was why we made that last minute trip back to Malaysia.
And I'm sure you knew, as I did, when we had dinner at that food court that evening in Penang, that that would be the last time we would ever see each other, at least in this world. Yet, in your usual quite demeanor, you seemed a bit embarrassed when Kris and I gave you our goodbye hugs. You were at peace and perhaps more ready to move on- but we certainly weren't.
You carried yourself with more strength and grace than I ever will know. You never once asked, "Why Me?". And did I ever share with you how I actually met the wife of one of your patients here; someone who was bitter and angry and had trouble accepting his diagnosis, until he found out that his oncologist had stage 4 esophageal cancer, and yet carried on in peace? His wife told me that you gave him newfound peace, that when he finally lost his battle, he was no longer angry.

Buddy- my best friend and confidante, my partner in crime during those 6 years at WFMC, my room-mate, my Best Man, my brother, my Halo teammate.

5 years ago, the world lost a wonderful man, brother, son, husband, oncologist. And yet, you remain near to those whose lives you've touched, never to be forgotten.

I miss you, buddy. Till we meet again someday... here's a toast to you. I'm sure you and our pal Gene are living it up there. 


Saturday, April 16, 2016

Ok, I admit it.
I've gotten lazy.
It's been 3 weeks since my last post. 
Therein lies the issue. Maybe life has gotten to be too mundane. Or busy with the kids. Or perhaps I'm just blissfully happy and have no need to vent out on my blog anymore Smiley. After all, I think that was one of the drivers for my posts:
Complaining about work.
Complaining about being homesick.
And perhaps most of all, complaining about being single (hoping that a girl would fall in love with me reading my blogs!)

It's interesting, a bit embarrassing, and maybe envy-inducing, reading my old posts, those going back 10 years ago when I was a trainee, working at the Mothership under the supervision of the Medical Gods, and seeing all those super-rare cases. Then coming home to a small rented house, hanging out with our community of Malaysian/Singaporean friends. I had a lot more free time then at night, and perhaps a lot of brain-juice and flowing creativity (hah).

I admit I've neglected this. For some reason, I just have less to say. I can't help but notice though I'm not the only one. Many of the blogs I used to follow (still sometimes check it out) are kinda like mine. Lapsed, infrequent entries. Or perhaps stopped completely. Are blogs fads that have passed, perhaps superseded by the newer social media platforms? After all, I vent and share so much more easily on Facebook, and at least I know the people there a bit better. I haven't yet caught up with Twitter or some of the other stuff out there, and it makes me feel old saying that.

Anyway, I'll still continue to update this with boring, mundane stuff. And the way life is right now, much of it will probably be of my most priceless possessions- my girls (wife included). I'm not even sure if I have any real readers anymore, beside those spambots- feel free to drop me a line if there are real people out there.

Happy weekend.

Wednesday, March 23, 2016

15 years

The wife and I were talking last night, when our university days came up.
And I started off wanting to say that it wasn't that long ago that I was in university.
Until I actually stopped to count, and realized to my horror:
I have been a doctor for 15 years.
FIFTEEN.

15 years ago, I had those letters M and D added to my professional/academic name. Be it a blessing or a curse, it's been with me since.

Holy cow- did the 15 years just whizzed by. After all, between that day (graduation) and now, I've done clinical teaching at IMU in Bukit Jalil, completed my residency in internal medicine at WFMC, followed by 3 years of fellowship in endocrinology, gotten married (twice- but to the same girl thankfully!)(in the USA and Malaysia, lah!), had 2 kids, and have been in practice for 8 years.

It's true what they say about time flying. But it's also interesting to note how I've changed professionally. Sadly enough. After all, ask any keen medical student, and they'll tell you they're going to change the world and help everyone. But somehow along the way, you get jaded, numbed and burnt out from the harsh realities of medicine in the USA: the complexities of health insurance and the skyrocketing cost of care and medications, the greed you sometimes see from industry, the bureaucracy, the lawyers and administrators. And yes, sometimes the patients too- when they argue and fight or are simply indifferent.

But, life goes on. We do what we can. Perhaps less of a spring in our steps, but we have after all taken that oath, and it's one I intend to keep. And the few guiding principles I try to live by:
  • The needs of the patient come first
  • Primum non nocere
I wonder where I'll be in the next 15 years?

Sunday, March 06, 2016

Disney Cruise, Part 2

Ok, this is a bit of an outdated post, but I've been busy (and lazy).
We got back from our 2nd Disney cruise a couple of weeks ago. Again, we sailed on the magnificent Disney Dream ship. It was no surprise that Cruise Critics awarded the Dream the 2016 Cruisers' Choice award. 
We went on this cruise with family last year. And this year, it was a long-overdue reunion with friends from my medical residency days, including one from Malaysia.
The last time we all met up, there was only 1 child amongst us.
Now, well, the picture speaks for itself.
The last time this group got together, it was 2004!

This time, we took the 5 day/4 night cruise to the Bahamas (we did 3 nights the last time). And like the last time, we had a blast. There is always much to do on the ship- plenty of activities for the children: a huge playroom with free child watch, with enough stuff that I had fun there too (I mean,come on, they had a mock up of the Millenium Falcon!!) and the kids spent hours there. Meals were provided in the playroom if the kids wanted to stay, and adults get a "wave" phone that allowed them to text you if your child wanted to be picked up. But the one thing I was surprised by the first time, was the amount of activities to keep the adults occupied. Sports bars, jazz bars, karaoke, games,gym, adults-only pool. And this time, at last knowing the layout of the better, we were able to explore much more compared to the last time.
The first day was spent sailing from Port Canaveral to Nassau, Bahamas.It was a quick overnight sail, with the ship getting into port in the morning. The kids wanted to stay in the playroom so the wife and I were able to explore the island on our own a bit. We got to sample some pretty good rum cake. And the straw market is an easy 5 minute walk from the port- plenty of nice little souvenirs you can get; and they're always open to haggling (I wish I brought my mom!).
We left port that evening, and sailed towards perhaps what is the most amazing part- Disney's private Bahamian island, Castaway Cay. We arrived at about 8AM the following day. It's a smallish island, only about 4 km2- but large enough to give the cruisers plenty of space to have fun and explore. Pick your activities- the two family beaches including one with water slides, the adults only beach, cabanas for rent, water sports, kids' play areas, snorkelling, biking, character meeting. Of all the activities, my wife had to sign us up for the Castaway Cay 5 km run! I suppose it was a good way to burn calories from the amazing food.

Truth be told, the February waters were a bit too cold for me (though the air temp was comfortable). That didn't stop the hordes of swimmers though. After saying farewell to the island, we sailed off- day 4 was spent a sea- and this was the difference between the 3 and 4 night cruise. This was actually a nice welcome- it turned out to be a relaxing day as you didn't have to rush and get everyone ready to disembark for activities. So we just replenished our Vitamin D, laying on the deck on the bow of the ship, and hung out with the other adults in the group.

We got back to port about 6AM the following day. After an early breakfast, we disembarked early at about 8AM to do some exploring in Orlando. All in all, it was another great cruise, and it was especially nice to see some old friends.
Would I sail Disney again? Hell, yes. Maybe not next year as the budget probably won't allow, but in a couple of years, perhaps.
If you're planning to do Disney, some words of advice:
  • If you want to explore the pool, choose an early boarding time
  • You'll need to pack a daybag, as your luggage will be brought to your room only many hours after you board. Obviously, you'll need swim gear if you intend to use the pool while waiting around- but it's a good idea to actually be wearing your swim suits under your clothes when you board. The last cruise, there was a long line for the ladies' restroom so the girls had to wait to get their suits on
  • You'll have a choice of first or 2nd dining for meals- with younger kids, I'd say the first dining is best- you get to have your dinner and catch the shows after that. And the shows were excellent- don't miss them
  • Consider using travel agency for booking. We used Dreams Unlimited- fares were the same as the Disney website, but very helpful agent, and they give freebies, as well as onboard credit ($100 this time, and $250 the last cruise- so it's really a rebate).
  • Plenty of websites with room suggestions- check it out. Very helpful times. We got a deluxe verandah room with balcony- on the port side of deck 8. I thought this was a great location. Port side is where they dock on Castaway Cay; but if you want a view of the beach from your room, then pick starboard.
  • I think this changes depending on wind conditions- but the two times we sailed with them the fireworks on Pirate Night was towards starboard, so not visible from our room.
  • Alcohol is pricey. Yet, they allow you to hand carry alcohol onboard if you wish- check out the website for limits.
  • If you have young kids, bring their pirate/princess costumes- great photo ops for Christmas cards.
  • Likewise, if you intend to give the girls a treat and send them to the Bibbidy-Bobbity Boutique, dress them up in their princess dress and then take them there- you'll save a huge bundle having them do the hair package only, but yet they'll already be in their dress. They'll feel like real princesses for a few days!

Sunday, February 14, 2016

Happy Valentine's Day!

I saw this on FB today. Sorry, the endocrine geek in me could not resist.

Happy Valentine's Day!

Saturday, February 13, 2016

John Cena

One of my patients broke his leg the other day. A 27 year old man with type 1 diabetes who also has cognitive disabilities. Had a hypoglycemic episode and fell down a flight of stairs and unfortunately fractured his right tibia. I saw him a few days after his surgery, and he was in some pain, and crying because he wanted to go home to his bed.
He happens to be a a huge fan of WWE. This was obvious in the years I have seen him in clinic- he would always come in his WWE cap. To him, John Cena was God himself. And so, yesterday, I dropped by his hospital room to drop this off.

                                                     
Sometimes, it's fun to get to know your patients. Despite all the frustrations of this job, perhaps the greatest joy is getting to know your patients and feeling like you're a part of their lives. He was still yearning to go home, and was still in some pain, but the smile he flashed when he saw this was priceless. The nurses later told me they hadn't seem him eat so well since he was admitted (though not necessarily a good thing with his diabetes :) )
Ava even drew him a picture/get well soon message. Note the bleeding from the right leg.

Sunday, February 07, 2016

Happy New Year!

Happy Chinese New Year!
Another year, another CNY.
Can't believe it's already 2016. And can't believe it's another CNY. Well, it's not hard to forget living in the relatively culturally secluded Midwest, where there isn't much festivities.
Year of the Monkey. None of my kids are monkeys, though they certainly act like one sometimes. However, my late Ah Kong was a monkey. Until his final years when he was showing some dementia, he was always soft-spoken, gentle, and serious; not the kind of personality the horoscope would suggest.
This is always the time of year when I yearn for home (yes, this is home now, but you know what I mean) the most. When you get a flood of memories, the traditions your family has. The things you'd do, even if you didn't understand why. Traditions you know will die with you, as you plant your new roots in a different land, on which you will make new traditions for your kids to pass on- but not the kind of traditions you grew up with. Bittersweet, but alas, to be expected raising kids here.
However, the standing plan currently, if budget and time permit, is for the family to spend Chinese New Year 2017 in Malaysia. It's ambitious, and with Allison in school now, we'll have to take her out. And the ticket prices will be horribly expensive. But it's important to me that my children at least see and experience a Malaysian Chinese New Year with my parents at least once, so that they'll somewhat understand what their daddy did during his version of 'Christmas'. Thankfully, my wife understands this is important to me. And so, 2017, we'll be there.
In the meantime, here's wishing all you readers, family, friends, loved ones, a Happy and Prosperous New Year, and may the Year of the Monkey be filled with silly laughter and happy memories.

Thursday, February 04, 2016

Sick Day

I took my first sick day this week.
I just couldn't take it anymore- my head was pounding, I had a runny nose and congestion, and a sore throat. And so I asked the clinic to cancel my afternoon.
It was my first sick day in 14 months.
Strangely enough, there was no pride that it's been that long since I last called in sick.
Instead, I felt horrible for a few reasons.

For one, I felt an immense sense of guilt because I knew that would be pissing a long line of patients off. Patients who have waited 2-3 months to see me, especially the very-anxious new consults for a variety of issues they or their PCP felt was urgent and hormonal. And so, to cancel would mean rescheduling and waiting another few months. Who would not be miffed?

The second reason that I felt bad though, was just the sheer madness of the situation itself. I'm not proud that I have a 'clean' record of not taking time off for illness. Instead, I'm ashamed of it. I'm perplexed that we function in a world where either patients or doctors see it wrong, to be ill and to take time off for themselves. We see it unforgivable to make a patient reschedule- the very people who are often themselves on sick leaves to come see the doctor. And yet, for some stupid reason, we think so highly of ourselves that we think our immune system is s resistant to influenza, parainfluenza, rhinovirus, coronovirus, strep or whatever else germs are out there. Perhaps the M.D. degree hanging on my office wall had antimicrobial properties. But no; we are human too, and we do get sick. So why do we find it so difficult, why does the system make it so difficult, for us to acknowledge that, that often we go to work if we are ill, if we think it's mild and not too infectious?

Indeed, I posted something on my blog years ago- results of a survey asking if people preferred their sick doctor to still see them knowing that they might be infectious, or have their doctor reschedule the appointment and wait another few months to see them?

The results- most polled that they still preferred to see the sick doctor.

Tuesday, January 19, 2016

When Breath Becomes Air

After waiting a few weeks for this, I finally received it yesterday.
When Breath Becomes Air, a book by Dr. Paul Kalanithi, a Stanford trained neurosurgeon who was diagnosed with metastatic lung cancer during his residency.
The first part of the novel is about his early years, and his foray into the world of medicine. He shares his experiences during residency, and having gone though this myself, at many levels this hit close to home.
The 2nd part is about his struggles after his diagnosis. As a doctor and surgeon. As a husband, And later on, as a father. This too, hit close to home.
It was an easy read. It was a difficult read. It was a good read.
I couldn't put it down- and so I began reading the book at 6:30PM, and finished it at 10:45PM. By the end, I was a mess. I was quietly crying in bed as my wife and kids slept.
For one, this brought back all kinds of memories, experiences I have always been ashamed of, but could relate to. I remember the torture, the sheer exhaustion, as an intern. I remember the times when I could not take it any more, and had to go into the bathroom during rounds to just sit down and cry for a few more minutes, before I could go on with work again. We all start off human, but the truth is the training kills off part of the soul, part of the human side. Paul shares a story of how his colleague wished a patient had metastatic pancreatic cancer just so his Whipple's would be cancelled, and she could get some much needed rest; of how when she realized what she was thinking, she just broke down in shame. I can certainly relate to that. No matter how we try not to lose our humanity, sometimes you are so beyond exhausted that you think the unthinkable. I remember having had those days; when the nurse calls to tell you that your patient died overnight- the first thought that comes is that of gratitude, so that you have one less patient to round on, and you get perhaps another 15 minutes of precious sleep. I remember having that exact reaction- moments thinking that, that I started to cry uncontrollably in the oncall room because of the sheer shame I felt, even having that thought cross my mind. No, I've never ever told anyone those thoughts, until now. In a way, I'm relieved that I wasn't the only one cruel enough to think that, and I'm glad that was a phase of my training that is well behind me.
The 2nd part was difficult for me to read too, for obvious reasons. We've all lost patients, family, loved ones. And the person that obvious comes to mind was Buddy. After all, he could have written a book like this. Indeed, a now-stalled dream of mine once was to write a book about him- and though I have a few stories in my hard drive, the momentum is lost and the stories will instead be committed to the heart and mind. Anyway, this could have been his story though perhaps being a medical oncologist and not neurosurgeon, perhaps the work-related stories less dramatic. And instead of Stanford, we were at the other premier medical center. And instead of lung cancer, it was high grade adenocarcinoma of the distal esophagus. Paul died at 36; Buddy at 32. And though I would have loved to share his story on print, the reality is the stories will die with us, those of us who had the privilege of knowing him, and spending those last few precious years with him.
I remember how he broke the news about his cancer. I remember the chemotherapy sessions, the many hospital admissions for intolerable emesis and dehydration. I remember the discussions we had about sperm banking before the chemotherapy would kill his chances of fathering offspring. I remember being in awe of his apparent strength, his peace, despite the unfairness of having an uncurable cancer, with a dismal prognosis that as a cancer specialist he was only too aware of. I remember when Buddy asked me if he should marry his sweetheart, knowing very well that he would make her a widow. I remember asking myself, asking God, why him? Why Buddy, who was such a talented, wonderful human being? I remember asking the obvious: Why not me? It's a question I sometimes ponder still. Why him, and not me? He would have made such a positive difference in so many lives. Buddy was such a better human being, a doctor, than I would ever be. God, I miss him; but reading Paul Kalanithi's books brought back a flood of memories of my friend. And in a way, it was comforting reading Paul's words as it seemed to give me some insight into Buddy's psyche.
This would be the last I'd ever see him alive. We both knew; it was pretty obvious the way we said our goodbyes. He passed away a months after we visited him.

It's a good book. It was a real tearjerker for me. And perhaps in part because I am now a husband and father, it was particularly poignant that the book was completed posthumously by his wife because he took a turn for the worse unexpectedly. It made me think about how things would have been if I was in his shoes, at this stage of my life.
Ultimately, it's a book about faith, strength and love. I'd highly recommend it.

Saturday, January 09, 2016

Why You Shouldn't Let Your Kids Play with Siri

So a word of caution to you parents out there with iPhones. The girls like to take our phones and talk to Siri. They find it hilarious that she can actually talk to them. They love to say things like "Call me Cinderella" etc. It's kinda cute actually.
I didn't think much of it, until I got this work-related email.
Addressed to Pretty Princess.
Obviously, this is visible only to the receipient- but I guffawed when I saw it.
I think I'll keep the nickname.

Wednesday, December 30, 2015

The Force Awakens

OK, I had to blog about this, right?
Whaddaya think? OMG, right?

I was blown away. Granted, I'm a scifi geek and I love Star Trek and Star Wars, and know enough about them that I wasn't going to be like that girl who went to the Star Wars opening night wearing a Starfleet uniform.


But geekiness and blind loyalty aside, it was a great show. Much better than the previous 3, with no stupid characters like Jar Jar, or corny lines. It was new and foreign enough to feel like a new movie, but yet had enough connections to keep it in the Star Wars family. And it doesn't leave you hanging completely as Episode 5, but does leave you in a bit of suspense at the end.

My goosebumps came out and hairs stood up on the back of my neck when the Star Wars theme came on. And it was a bonus that my 5 year old is into it too, and jumped up and smiled ear to ear when the show started.


The lightsabers. The X-wings. Millenium Falcon. The banshee-like screams of the TIE fighters. OMG OMG. I'm hyperventilating.

It was a great movie, and it's going to be a long wait till Episode 8. I'm not going to give away any of the plot- just go watch it and expect to have a great time. I know I will, for the 2nd time.

Saturday, December 19, 2015

Perspectives

So the 5 year old hands me this. A picture she drew for daddy:

Smiley
I was like, erm, thank you. 
But how to you respond to your daughter who draws you that? All I could think was, maybe she's old enough that I shouldn't shower in front of her anymore.

I innocently ask her. "What did you draw?"

"I drew a giraffe for you, daddy. Can't you tell?"

Oooooooooo. Smiley


I guess I had my head in the gutter. Now I see it.

Saturday, December 05, 2015

Ornaments


We put our tree up last weekend. And though there was a time I would have liked to have a uniform, clean, coordinated tree, in the recent years I've learnt to appreciate my wife's family tradition of getting trinkets and ornaments from events, people, places and adding them to the tree; putting them up certainly evokes certain memories.
Take this angel. A simple crystal angel sitting on a bell. I've had this for over 10 years now, but I remember where it came from. It was a nice gesture from a patient I was seeing in the hospital, who had a prolonged stay because of complications from a diabetic ulcer that ultimately led to his foot being amputated. He wasn't happy at the prospect of being in the hospital, but he was particularly disappointed that he couldn't take his wife out for their 50th wedding anniversary. And so I bought them a cake and brought it to them (ironic since I was dosing his insulin!). He was appreciative enough, and knew I happened to have to round for Christmas that year, and gave me this. He called me his personal angel- not something many patients say to me since many see us as the doctors who put them on insulin shots.
That was many years ago, and though I've forgotten his name, I still remember which part of the hospital his room was, and our interactions.
As I look at our tree, it's also now beginning to be filled with ornaments related to our girls, or trips we've taken. Never mind that it's not a uniform color- I'll take my memory-laden tree with its ornaments.

Monday, November 23, 2015

A Hypogonadism Consult

I had an interesting consult the other  day. Again, one of the many, hordes in fact, of men coming in for a testosterone prescription. And I admit I'm jaded and I've begun the stereotype. This was the classical young man, meathead type with biceps bigger than a treetrunk. He could have been a body double for the incredible hulk. Proud that he bench presses 200 lbs.
And yet, feels that he needs to be on testosterone. Admits he 'juices' up frequently too (a word I learnt not too long ago) with crazy shit he was getting from his gym- androgens, to which they often add aromatase inhibitors to prevent gynecomastia, and HCG to prevent the resultant testicular shrinkage. What a crazy world.
Anyway, like many before him, this chap refuses to accept that his blood test showed his testosterone to be normal. And so he was here for  some 'medical testosterone'.
"I'm young. I should be on the higher range of normal!".
They all say that. Never mind that the total T was in the 600s already.
And he was most convinced of this for two reasons. That he has peaked with his weightlifting. And that he has 'erectile dysfunction'.
As an endocrinologist, I do go into a bit of detail when taking a history of ED. So I asked him what that meant to him. He was very concerned because a few years ago he could have sex about 5 times. And now it's only about twice.
A. SINGLE. DAY.

Talk about feeling inferior. This chap's definition of normal was having sexual intercourse 5 times a day. And he is concerned that he is now only interested or able to do it 2 times a day.

I wasn't sure if I should laugh, cry, hit my head on the wall, or go on my knees and kowtow to him. 5 times a day??? Teach this padawan, O Master.

I was professional and held my composure. And did all I could to explain to him the normal endocrine physiology of the reproductive system, the risks of unnecessary testosterone use and the medical guidelines. I'm pretty sure he left unconvinced.

In the meantime, I feel like I need to go to the gym more.

Tuesday, November 17, 2015

The Nonbelievers

I have to admit, I have an inherent bias.
And how it came to this I don't know. After all, I hated Evidence-Based Medicine (EBM) in medical school. I had a bully of a mentor, a lab-based cardiac physiologist with minimal people skills, who bluntly told me, "Your question was so stupid I'm not even going to try to answer it...." (digression: I'm not a model teacher- but I swore I would never speak to a student/resident like that ever. Words do scar). Anyway, I spent all of medical school fearing the word 'research', and hating everything EBM.
I went into residency with the same sentiments, feeling stupid, ignorant and inferior when you are in the company of the world's medical greats. The world-famous researcher clinicians whom patients travel the world over to see. Classmates who compare not only how many publications you have but what impact factor the journal that accepted your manuscript carried.
Research. Ugh.
And then something kinda slowly happened. After all, you do get brainwashed training at the same institution for six years. And not that I consider myself a brilliant researcher, but at least I learnt some of the ropes. I learnt what it takes to write a paper, analyze a study, even perform experiments (I got to play with human orbital fibroblasts, yay!). And I popped my publication cherry. And became a scientist. I still consider myself one- after all, a doctor is a person of science, and as dynamic as science can be, we too need to evolve and learn, don't we? And so, it's interesting how I went from that hater of EBM in 1999, to one who looks at The Evidence, to guide his clinical judgments. Not only the conclusions of the study, but also to try to pick apart the study to see if he agrees with the findings. After all, the goal of an author is to get the study published, and one often learns to present the data in the most compelling way; so you can't always take things at face value. And so, yes, I'm a believer of EBM, I think we all should be.
That being said, I've realize that the world doesn't see things that way. For some, EBM remains a bad word, one that is controlled by Big Pharma who makes things up to fool doctors and ultimately patients, all in the name of making money. And I've realized that once a person chooses to not believe, there is no amount of data you present that will be accepted, that they always will view things with a generous serving of skepticism. That big pharma bought you/CDC/FDA over- never mind that the basic concept of EBM is that you learn to critically appraise and make your own decisions.
This is perhaps more worrisome when the person you're trying to convince is a medical professional. I ran into this situation when discussing a case with a surgeon, when he (in my opinion) was over treating a patient with an unjustified therapy based on an unproven diagnostic test (which incidentally enough, is something he owns too).
And so sometimes, there is only so much you can do. And sometimes, you just have to take a step back, and agree to disagree. But secretly you hope the patient takes your side, because the data really doesn't show that that treatment is necessary.

Sunday, November 01, 2015

Patient Satisfaction

There is much talk about the importance of patient satisfaction. Of how some hospitals and physicians are reimbursed in part based on how satisfied patients are, the much-hated Press-Ganey surveys. After all, we do want our patients satisfied, don't we?
Do we?
Proponents say, patients are clients, customers. Keeping them happy should be a priority.
But is this truly the relationship physicians and patients should have? After all, in situations like this, the 'customer' isn't always right; the patient doesn't have the background knowledge to know that's best for him or her. Studies have shown that higher patient satisfaction is associated with more adverse outcomes.
I'm sure this is a struggle all physicians across all specialties face. I hear this coming from ER and primary care colleagues of how patients leave disappointed if they are not prescribed antibiotics for a viral syndrome, or opiates for pain.
This week alone I encountered three situations myself where patients left obviously disappointed and upset.
Two patients with no background of thyroid problems who were upset because I would not prescribe thyroid hormone treatment for their fatigue and inability to lose weight despite claiming to be on a diet and exercising. One already had a TSH that was undetectable while on exogenous Levothyroxine, refusing to discontinue treatment.
Another patient, a woman, who left upset because I would not prescribe Testosterone treatment for her dry skin! Because according to her extensive research (on Google) skin dryness if from Testosterone deficiency; after all if a person makes too much, you get oily skin, acne, right?
I have to say, a part of me blames the referring physician. It gets my blood boiling, wondering where how the heck these people got their medical degrees. It's not surprising that a patient leaves unhappily, when your GP promises that this hormone specialist will fix your problems, and gives you the impression that your troubles are indeed from a hormonal imbalance. And then you wait 2 months to see this person, who then says no to treatment but bills you for the visit.
So, no. I do wish to try to satisfy my patients, but my view is a patient is not a customer in the classic sense; he/she does not have the medical background to really know what's best for his or her health.
As how my patient ominously ended my session with her after I counselled her on the risks of unnecessary hormonal treatment: "I'd rather have a stroke than continue to be fat..."
Is this going to be the future of healthcare?

Sunday, October 11, 2015

Farewell, my Malaysia

My flight out departs in a few hours. And truth be told, I miss my wife and kids terribly, and a large part of me can't wait to see them.
Another part will miss what will always be one of my homes- Malaysia.
And I find myself doing what I usually do in the days preceding my departure. I try to capture as much as I can, to bring the memories back with me. This usually means my shooting of random pictures.

Such as the beautiful chaos of the pasar malam. 

Or how motorcycles snake in and out of traffic, often carrying little kids, or sometimes even 3!

I'll miss the KL skyline. Even if it was haze and smog-covered this trip. But thankfully, this night when I was up there for dinner, it cleared up enough for me to snap this picture.

My mom found it amusing when she saw me take this picture. It was just a reminder of simpler times. And it was something I wanted to show my family- they are so used to getting coconut milk from packs that one never wonders about how we get the milk. The girls have never seen a machine like this.

Yes, it's all random stuff. But it's the weird, simple, random stuff that makes Malaysia truly Malaysia. I've had a busy week- giving lectures to 3 groups in 3 different states (all pro bono, mind you). The last group I met with were medical students early in their careers. Asking me the age-old question- should I go overseas to study/specialize?
Well, it's a difficult, subjective question to answer. There will be goods and bads. But the one bad will be, you will be leaving a culture, a people, a language, a cuisine, a climate that is so familiar and near and dear to you, to live in a foreign land. No doubt with time, that land becomes home as it has for me, but some things will always remain foreign. And so, you will make sacrifices, and when it's your time, you may find yourself doing as I do- taking pictures of quaint coconut graters because it reminds you of your childhood.
Farewell, Malaysia. You have not lost your charm, though many of us abroad worry about your future. Here's to hoping that the Rakyat will rise up above the disease and rot emanating from her politicians and bigots, and bring her glory days of peace and harmony and muhibbah back.