Thursday, August 31, 2017

Patient Survey

Sometimes you don't know if you wanna laugh, or cry.

Our clinic received our patient satisfaction survey results today, this was a survey conducted by an independent 3rd party, contracted by the hospital for probably a generous sum of money, to do these surveys. Physician bonuses are tied in to how satisfied a patient is. This seems to be the norm these days in the USA.
One comment an anonymous patient put nicely sums it up:
"Dr. X (one of my highly respected partners) knows nothing about Hashimoto's! Doesn't she know when you are taking Armour Thyroid, the goal is to get the TSH as close to 0 as possible?".

And that is why basing physician performance on patient satisfaction is a flawed metric.

I've read of urgent care or ER doctors sending most patients home with a goody bag to keep them happy: either antibiotics, or opiates, or both. And often topped with a serving of work excuse for a few days, and having put them through unnecessary testing.

Sunday, May 21, 2017

Sharing with a patient

Admittedly, that was a first time for me. A patient telling me he was worried about me.
A patient, a guy I have known for 8 years, having treated him for his diabetes, but more recently noted on exam to have a thyroid nodule- one thing led to another and eventually he was found to have papillary thyroid cancer.
Anyways, I know him well enough to consider him a friend. We share stories of our wives and kids, who are about the same age. But at our last visit, he said something that struck a different chord with me.
He said: "Doc, I'm worried about you. I'm worried about your profession."
He had read some articles recently about burnout and depression and suicide rates amongst doctors. He had heard too about the long waitlist to see a specialist in our state (3 months)- because there is a shortage regionally of endocrinologists. He read about how it is so damn complicated now to be a doctor in the USA, not because of medical reasons, but because of the bureaucracy and the paperwork involved. How a prescription generates a 3 page "prior authorization" form that is faxed to me and I have to fill in, justifying to some non-medical clerk in some office why a test or medication is needed. And he/she probably has to follow a script to approve/disapprove my request.
It was a timely question- for that afternoon I was just fuming as I spent 32 minutes on the phone being transferred to 5 different people (yes, that's you, United Healthcare) regarding a prescription I send in. And at the end of the call, it wasn't even resolved. The last gentleman said I should talk to Department A, which was the first person I spoke to. I ended that call with a very unprofessional "Dude, are you kidding me? That was the person I spoke to 30 minutes ago. You guys have to get your act together!" Right before I slammed down the phone.
So yes, Mr. W's statement was timely, and therapeutic. Apparently he wasn't in a hurry, and he was my last patient for the day. So when he asked me how difficult it was to be be a physician, I offloaded on him. Being his physician, I shouldn't have. But I shared some of the frustrations our fraternity faces.
It did make me feel 100% better though I felt guilty that I shared as much as I did.
The truth is, sometimes all it takes is one or two appreciative patients, who do really believe that you have their best health interests in mind, to make all the work seem worthwhile.

Wednesday, May 17, 2017

Always in our hearts and minds

Dr. Tan Tow Shung
November 6th 1978- May 18th 2011

I can't believe it's been 6 years. The time just flew by, the 6 years since you left us here on Earth to be at a better place. In that 6 years, we've all aged but you remain ageless in our hearts, my friend. In that 6 years, our families have grown, our outlook in life has changed significantly. We have learnt much professionally.
But yet, it doesn't seem like that long ago when we were together, as room-mates and best of friends. I remember fondly the simpler days, days without other responsibilities, days when we would hit the Xbox and play round-the clock Halo on weekends. Our hitting the buffets postcall as our comfort food. All that crazy shit only bored Malaysian boys can think of.
I think about life's unfairness. How, you, at the prime of your life and at the start of a very promising medical career, how a cancer doctor can himself be stricken by esophageal cancer. I think about the long hard battle you fought, the times we visited you in the hospital when you had reactions to chemo, or when you underwent surgery. I remember that time when played cards in the hospital family room.
Truth be told, I miss my confidante. I know you're somewhere up there, watching us. But I miss our talks, and your words of wisdom.
It's been 6 years. But we'll never forget you. And till we meet again some sunny day, memories of our friendship and brotherhood will always hold you near to the heart.

Tuesday, May 09, 2017

A Note

I got this in the mail today, coincidentally.
From the spouse of the patient I wrote about the last time.
I wasn't expecting this- but it was sent to my office. And the shameless softy that I am, I'll admit that it made me shed a few tears.

It's been a frustrating last few weeks; between the stupid bureaucracy of  insurance, having unhappy patients who are upset at me that I can't fix their obesity/fatigue/sex issues, the guilty of putting patients into financial hardship because of the expensive insulin prescriptions I write. And so, sometimes things like this make all the work worthwhile. Sometimes, all we need is just a few patients who really appreciate us, to make all the difference.

Wednesday, March 08, 2017

Losing Patients

I found out the other day that one of my oldtimer patients Mr. G has died. A 71 year old man I had been seeing for his diabetes and hypothyroidism for the last 8 years.
And then 2 weeks ago, I was informed another, tragically lost her battle with a chronic issue. She was only 24.
I guess I've been working here long enough. 6 years in my previous place, and going into my 9th year here. And so, for something like endocrinology, where the bulk of our cases are comprised of diabetes, a chronic condition that often requires quarterly visits, pretty soon you get to know your patients pretty well.
You know their glucose trends. Their downfalls (for the gentleman above, it was nightly creamsicles). Their fears, their hopes, their dreams.
Like how Mrs. A hopes to retire to Florida, if her husband survives his treatment for colon cancer. How Miss H. is training to be a teacher. How Mrs. T misses her grandkids out East, but isn't able to travel because of her severe CHF and oxygen-dependence, and fears greatly she will never see them before she leaves this world.
You get to know your patients pretty damn well. And truth be told, I've begun to see many of them as friends, even (if I could call them that, as they do pay to see the doctor), or even an extended family member.
And so, when I found out that the two patients had died, I was quite upset. More than I expected the news to affect me. So much so that I called their families during my downtime to convey my condolences and perhaps to share the sadness and grief.

It's true this job sometimes feels thankless. With the numerous dissatisfied patients who are mad that you can't cure their depression or fatigue or obesity. With the piles of bureaucratic crap on my desk- refills, prior authorizations, Medicare forms. The hoops we are made to jump through. But perhaps the one thing I enjoy most in my job is the rapport you do form with some patients. Almost to the point where you look forward to their visits to find out how they are doing.

And so, when you do lose some patients, the sadness (though not comparable to what their family is going through) is real.

RIP. It has been a privilege to have been your doctor.

Saturday, February 04, 2017

Our Trip


In the blink of an eye, this trip is coming to an end. We leave in the next 24 hours. As always, this is the time when I'm torn; part of me is looking forward to returning home- after all the USA is my real home now- and getting settled back into the rhythm of things. And to be rid of this dang balmy heat.
But part of me obviously is saddened to be leaving so much behind. The first is obviously family- my parents, who look a bit more frail every time I see them, and it fills me with so much guilt that I am not able to spend more time with them, my siblings, dear friends, schoolmates from 2-3 decades ago, people who know your deepest darkest secrets and love you despite it all. Leaving behind the food and culture that is familiar to you, the local accent and how it in a strange way relaxes me to be able to speak in Manglish, in our politically-incorrect way.
That all being said, this was probably one of the more special trips back to Malaysia for me. For one, I really wanted my kids and wife to experience the Chinese New Year festivities, with all the noise and in-your-face family chaos. And this they did, from eating the CNY cuisine, my girls playing with fireworks (to my wife's chagrin) and learning to say Kong Hey Fatt Choy. Eating the numerous cookies- the little one loves the 'cupcakes' (kuih bahulu- she would wolf down 5 at a sitting), or learning to appreciate Milo ais (despite the high sugar content!). Simply seeing what their daddy experienced when he was a little kid.
A bonus to coming back this time of the year, is the balik kampung phenomenon; I randomly ran into so many schoolmates in town. That, and the planned CNY reunions we had- I saw people I have not seen for 25 years! How we all have aged- I was embarrassed that I did not recognize a few lads.


It was particularly heartwarming just sitting back and watching the kids interact. How, despite a lapse of several years, my girls just started playing with their cousins from here and Australia, as though they just saw each other yesterday. And watching little Ava hold Ah Ma's hand when I told her she had a bad knee and had trouble walking.
We did make some excursions away too. A short trip to PD- a place I frequented a lot in my youth, and my first trip to Langkawi. This was certainly a different experience from the other islands we've been to: Perhentian, Redang, Tioman, Pangkor. In contrast, this was a huge island- never appreciated the size until now, and a lot more commercialized. The cable car ride and the sky bridge were particularly breathtaking, and despite the complaints I've read about the long queue, we went early in the morning and the lines were quick- definitely the highlight of our trip.


We leave on our ANA (All Nippon Airways) flight tomorrow. We enjoyed the flight in, though in retrospect, compared to our previous flights on Korean, Cathay, Malaysian, Qantas, I felt that this wasn't good value for money. The service was impeccable- but we paid for premium economy seats expecting more perks like lounge access, priority checkin- stuff that we didn't get to experience because of some technical issue- so I'd recommend skipping the premium prices and just diong economy, or trying some other airline. Perhaps better luck next time. I imagine our next trip back won't be for another 2 or more years..... so till the next time, Malaysia, Selamat Tinggal. I shall always hold a part of you close to my heart.

Tuesday, January 17, 2017

Chinese New Year

I read somewhere that the exodus during Chinese New Year is the world's largest annual human migration.
Something the rest of the world have trouble understanding. But to us, it's as simple as "balik kampumg".
This year, I'm especially excited to say that we will be joining the madness.
It has been 2 years since my last trip back (solo- part business as I gave a few lectures). It has been 3 years since Kris and the girls went. And they have never been there for Chinese New Year.
This is important to me. After all, being 1/2 angmoh, being raised in midwest USA where it's pretty homogenous and largely Caucasian, one doesn't get the feel for CNY. You don't get the firecrackers, food, and red being plastered everywhere (except perhaps for Valentine's day). Yes, we've attended a few CNY dos in the local colleges, but it's hard to get into it when the lion dance troupe consists of white guys.
And so, it's important for me to have my girls (wife included) experience what was the major holiday for my family when I was growing up. To feel and indulge in the culture and crazy traditions I grew up with.
Things like the CNY eve dinner. The midnight prayers to welcome the various Gods, with the altar facing different directions every year. The early morning routine- getting up and getting changed into our CNY clothes, the greeting mom and dad and getting our angpows, then the temple, and the open house thereafter.
Getting together with my neighborhood pals- cycling from one house to the next. Having our blackjack and cho-tai-tee sessions, feeling like a big shot betting 25 cent wagers. And, who can forget the fireworks- the Moon Travellers in the early days, graduating to Thunderclap later on.
The lion dance. The irritating but yet comforting high-pitched CNY songs by those Chinese opera singers.
Yup, we will be knee-deep in all that madness. We will be making the 21-hour flight back in the coming days, and spending a few weeks there. My siblings, whom I have not seen for years, will be there too.
Year of the Rooster, here we come!
At a CNY party with Alli 4 years ago!

Friday, January 06, 2017

Just for laughs

Some scenarios from work:

Case 1:
Seeing a patient I've known for years with Kallmann syndrome and anosmia.
Me: "Do you have any sense of smell?"
Patient: "No. Why?"
Me: "Good. I just farted."

Case 2:
Me, teaching the resident physician about Addison's disease and hyperpigmentation (from the ACTH stimulation), and how to look for tan lines to distinguish between pathologic skin color changes versus from UV exposure.
Resident: "What if the patient uses a tanning bed in the nude?"

The right answer would have been to look at the buccal mucosa. Instead, what I told him: "You could spread the buttcheeks out a bit to see if the covered areas are hyperpigmented."

Resident: O_o

My nurses who knew I was kidding, just exploded.

And they say we can't have fun at work. 



Sunday, January 01, 2017

2017

Happy New Year!
I can't believe how in a blink of the eye, a year's ended and another's begun.
2016 seemed to have been a bittersweet year. We've had many good memories, but also lost a good friend to illness, and my daughter broke her forearm (though thankfully in her usual manner bounced right back). Work had many challenges, with me many a times asking if I was on the right career path.
It'll be interesting to see what's in store for 2017. The younger one will be starting kindergarten (surreal!) and we'll be starting the year off with our trip to Malaysia, the first trip for the girls in 3 years. It's also the year I need to recertify for endocrinology- apparently I took my boards almost 10 years ago (!).
I'm also morbidly curious, and cautiously optimistic about the country under the presidency of a businessman bully- but until we give him a chance to do good, it's premature to judge. I'm also still and holding out for the goodness of man, the hope that good triumphs over evil- I'm afraid of what the next major terroristic event or genocide or slaughtering of fellow humans will entail, all done in the name of religion or politics or money. It seems like the news these days spread little cheer. And so, I'm hoping that 2017 will have more happy, inspiring events worldwide, and less selfishness and sadness.
Here's wishing you readers, wherever you might be and whoever you are, a happy, healthy year in 2017/

Thursday, December 08, 2016

How time flies

This will be a soppy post.
There are times when it's surreal seeing how quickly life has gone by. How quickly the girls have grown (how we have grown too, but I'll save that for another day). Take this picture; we took this in front of the Christmas tree 4 years ago:

And in a blink of an eye, they've grown from cute, chubby boddlers (baby/toddler) to little girls. I'm biased obviously; but though I think they're cute as buttons, I'll admit this to you, my dear readers: deep down inside, though I won't admit this to my wife (she wants more kids!), I miss the baby and toddler stage. I catch myself looking a bit enviously at parents with little babies- knowing that there was once I could hold my girls with one hand, all 8 lbs of her. Hearing that baby gurgling and giggling. Or seeing that unsteady toddler waddle.
That being said, I'm also soaking in all in as much as I can, stage by stage. How they go from being 100% dependent on you, to being able to go potty on their own, or dressing themselves, brushing their teeth or being able to make their own breakfast.
And they other day, I'll admit, I was a bit disappointed when the older one, always excited for daddy to paint her toenails, politely declined when I asked if she wanted her nails painted.
And before I know it, time will just breeze by and someday they're gonna break their daddy's heart (and make him proud at the same time) when they leave home for college.
Sniff sniff.

Sunday, October 16, 2016

My first 1/2 marathon!

And so, at the ripe old age of 40, I finally did my first half marathon. If you know me, you know I didn't like running. I did not see this as a natural thing for someone with short, stubby legs. But somehow, being married to Kristin, it's true they say that your spouse changes you. Like how she was almost vegetarian when we first met. And after yet another potluck in my old house, she call home crying to her mom "These Malaysians eat soo much meat!". And now, there are days when she craves for meat more than me.
And so, 2 years ago she talked me into signing up for our first 5k run. Signing up was figurative. More like I was at work and I received an email: "Congratulations, you are now signed up for XXX run....".
After that run, she suggested we train for a half-marathon. She'd done a few of these before. Never I. But today, after having trained for the last 8 months, and actually willingly getting up at 530AM Sunday mornings to go for a 5 mile run before the kids wake up- we finally did it!
It was an interesting experience, to say the least. The way you get palpitations and pumped up for the run. How your gut does some acrobatics the morning of. Certainly gave me a new perspective on things.
Like how the so called runner's trot is real. I called it the runner's rectum. How your gut objects, and causes you to lau sai. Hopefully this happens after the run. But sometimes, shit happens.

Also, never thought much about chafing. I'd heard people joke about it, of using bandaids to cover up your nipples, and using Body Glide to minimize friction and skin irritation. But until you actually experience it, it's hard to understand. By mile 10 my nips were burning like someone stuck cigarette butts into them. And when I stepped into the hot shower just now, my first feeling was agony. However, it could be worse. Just ask this guy.

My wife told me running is 90% mental and 10% physical. She's wrong. I tell her the brain doesn't have much glycogen. It's all physical, dammit. You start the race feeling pumped and excited. With people cheering you on, and you're still full of energy. At Mile 1, you smile and wave at those cheering you on. You see all kinds of hilarious signs, like "Run as though Trump is trying to grab your p*ssy" or "All this running for a free banana doesn't seem worth it". At Mile 6, you're wondering why the mile markers seem to be further and further apart. At Mile 9, those signs you thought funny, don't seem that funny anymore. Mile 10 you're wondering why the hell did you let your wife talk you into this? You're wondering if she's trying to get your life insurance money. Mile 11 your legs feel like dead weights, your nipples are burning and your tummy's cramping. Mile 12 you're thinking where the hell is the Mile 13 marker??? And finally, as you see the Finish Line, you find a last reserve of energy and force yourself to pick up your pace, and force a smile as the photographer snaps your picture.

2:17:53.

After we collected our medals and walked to the refreshments tent, I told my wife: I either have to puke, or pass out. Thankfully, I did neither. But what a day it's been; something tells me this won't be our last half marathon.
(ask me again tomorrow when I wake up to find my legs paralyzed).

Saturday, October 15, 2016

The Orion Nebula


Ta-daaa.....
After talking about my telescope set up, I took this picture last weekend. I had to wake up at 4AM to get a nice view of Orion, well before dawn.
And so, in the cold and in the dark, after lugging out 50+ pounds of gear to my backyard, spending 20 minutes just to set up, polar align the mount, then to align the scope, and to power up my laptop, I aimed it at Orion's Belt. Target: the Orion Nebula.
This was a 7 minute stacked shot of the nebular, 1300 light years away from Earth. It's surreal to think; that means what I'm seeing is from 1300 years ago- the photons that left this huge cloud of gas began it's race to us that long ago and is only now arriving. Through the eyepiece it was easily visible though the colors were not clear. But with minimal photo editing, I was able to bring the color out.
As a friend told me, this picture alone is worth the cost of the equipment.

Wednesday, September 21, 2016

Patient Satisfaction

As I did inpatient rounds today, I was struck by something new in the hospital.
Came across numerous phone/tablet charging docks near the elevators, family rooms etc.
These appeared new. All in the name of patient satisfaction.
The newer hot topic in USA Medicine.
That somehow, one of our jobs (as a doctor, clinic or medical system) was to satisfy the patient. Not that I would intentionally wish to dissatisfy them- however it's important to realize that patients are not customers or guests.
The doctor-patient relationship isn't one based on PR; this is not a service industry (though we are here to serve in a way).

So when systems or doctors start to get assessed based on patient satisfaction, this is where things may potentially go wrong. For some years now, more and more systems based their remuneration, at least in part, on how satisfied patients are. This is also becoming a metric for how insurors/Medicare reimburse providers. I know for me, part of my performance bonus is based on satisfaction scores.

The problem is, the patient sometimes not in the position to decide what's best for him or her medically. And may rate a doctor as such. Examples we see regularly:
- The patient who sees a GP for a viral upper respiratory infection- who leaves the clinic mad because he did not get antibiotics
- The patient who goes to the ER, wanting to leave with prescriptions for opiate medications
- The patient who does not want to be discharged despite being medically fit- because he "didn't feel like it yet". (While there are 10 patients in the ER waiting for inpatient beds)
- Closer to home- something I face weekly- the patient with normal testosterone or thyroid or growth hormone, wanting to be put on these hormonal agents for symptomatic benefit
- Or the inpatient I see who just got over his diabetic ketoacidosis, who is mad because he is on a diabetic diet, and feels that he should have unlimited amounts of carbs

Indeed, there are studies showing an inverse relationship- patient satisfaction scores are related to poorer outcomes- higher morbidity or mortality, longer hospitalization, higher cost of healthcare.

And if so why is there such a push to emphasize satisfaction scores? As Dr. Mayo once said, the needs of the patients come first. Not the wants of the patient.

Somehow, in the convulated world of politics and bureaucracy, we lost sight of what's more important. And so, the hospitals are spending more money installing iphone docking stations, provider bigger parking ramps, free valet parking, coming up with extravagant menus for patients. While nurses have a high rate of turnover because they are underpaid. Or the hospital tries to cut costs by forcing formulary medications on patients.

Saturday, September 17, 2016

An expensive hobby

You can probably tell by now. I've am astro-geek. I love all Sci-fi, space, Star Trek, Star Wars etc. I've had this fascination since I was a child. Indeed, there was a time when I wanted to be an astronaut- nevermind that Malaysia did not have a space program (do we, now? Or is it more like a space tourism program?).
One day when I was about 10, I was given a simple 40 mm refractor telescope by dad's boss who got tired of this. Then, it might as well have been the Hubble! You could see the craters on the moon! You could use it to project an image of the sun and watch the sunspots. It was great.
Anyway, life and school and budgetary constraints made me neglect that hobby. The one big treat I gave myself was purchasing a hard cover copy of Hawking's A Brief History of Time (now, if you want a book that will drive you made, go read that).
Fast forward a few decades. I still catch myself looking up, yearning, wondering. My wife knew that. My wife also knew I had a loadful of crap in the garage, including some almost new winter tires I bought for the Porsche which I used only 1 season. It was now taking up space. And playing the little devil on the shoulder, she suggested "why don't you sell your tires and use that money to buy that telescope you've been dreaming of?".
That was good encouragement. I sold the wheel/tire package for $500. And bought the Celestron Nexstar 4SE Maksutov Cassegrain computerized telescope.
Problem was, like any hobby, it starts to become a parasite. It asks for more. And so, over the last 2-3 years, my collection has grown; so has the cost.

$499 Nexstar 4SE. But oooh, the batteries don't last very long for long tracking/viewing sessions. And so next came...
$20 AC adaptor. Now that I'm viewing, why not take some pictures? Well, I'll need a T-ring...
$22 T-ring for Nikon SLR. But I'm shaking the camera too much. Maybe I should get a shutter release cable
$10 Shutter release cable. Hmm, pictures are so-so. I've read that you can also use video- take a 30 second video of solar system objects, then stack them into a photo.

$160 Celestron Neximage camera. Great shots! Loving the images of Saturn and Jupiter. But dang it, I need a laptop to be portable and to operate the camera.
$300 HP laptop (basic specs- use only for the webcam). Have been quite happy with this. But I wish I had more zoom. Maybe I should get a Barlow lens.

$75 Celestron Xcel 3x Barlow lens. Triples the zoom of your telescope. Have been very happy with this setup. But am wanting to branch out and take other pictures. Maybe I should try taking pictures of the sun. I'll need a solar filter to not blind myself....
$12 Solar filter. What next. I'd love to take DSO (Deep Sky Objects) but my altazimuth mount, as easy it is to use, simply cannot compensate for Earth's rotation. Do I really want to take the next big step and get a larger scope with a German equatorial mount???
(2 years of contemplating later) $1599 Celestron 8" Schmidt Cassegrain telescope with AVX equatorial mount. This thing is huge! Built like a tank and heavy like one too. But very stable, and allows me to finally attempt exposures up to 90 seconds long. But, I need a polar finderscope to properly polar align the mount.
$42 Celestron CG5 polar finderscope. On a good day, I get great shots. But on most days, I'm still getting field rotation and star streaks with shots over 60 seconds. Not getting good shots of faint galaxies and nebulas. How the pros do it is they use a separate scope with an autoguider, hooked to a computer, to guide the main scope with precision.
$340 Orion Magnificent Mini Guidescope package. It's still in the mail- to arrive in 2 days. Alas, when will this parasite stop sucking money out of me??
(I did catch myself salivating over the Starizona Hyperstar lens, which would let you take a 30 second shot of a nebula, in better quality than spending 30 mins doing long exposures. But this would cost $899, and the corresponding Atik camera would cost $1359. So I mentally told them to go to hell)
(for now :P )

Monday, September 05, 2016

Blog Party

One thing I like about our neighbourhood is how we all get along. Quite a few families at our stage in life- 30-40 year olds with kids about the same age. We have numerous gatherings and social events every so often.
And so, one activities that my wife, the unofficial social chair of the block, organized was the block party. This was something she's wanted to do for years, since her family did these when she was growing up. So we decided to hold the very first one, and boy, was it fun.
To close the street completely, we had to do a few things.
- Get signatures of the residents- at least 90% of homeowners have to agree
- Outline a party plan, and seek the approval of the city and fire department
- Rent barricades to close off both ends of the street

Thankfully, all the residents agreed this would be fun, and with that we were off!
We had the block closed off for 5 hours on a weekend; the kids could roam around, bike and scooter up and down the road to their heart's desire, without any parent yelling for them to get ff the street!
We had several bounce houses and carnival games set up. Had a long table in the middle of the street for food.
And Kris even got a sno-cone guy to come and set up a table- that was a  hit amongst the kids, and the adults! We even had sno-cones of the, err, 'adult' variety. Which contributed to a more merry evening.
As a bonus, she had the fire department send a firetruck for a visit. The kids went bananas when the firemen came, blaring their sirens- they got to climb into the firetruck and check out their equipment. We only recently found out that the fire department does this as a community service, and it's nice to meet your local firemen and show your appreciation for the work they do.


Anyway; it was a swell evening, and the first of an annual neighbourhood event, I'm sure.

Wednesday, August 17, 2016

A New Decade

I'm afraid.
In a few days it'll be my birthday. 
A. Whole. New. Decade.* see footnote
For the sake of sanity, let's not go into details about which decade, but lets just say I'm not a teenager anymore.
It's kinda surreal. After all there was a time in my life I thought being 24 was "old".
And now, I find myself referring to twenty year olds as "those kids".
And you slowly have to acknowledge the signs that you're no longer a spring chicken. Things like how you develop random joint aches. Or how your hair thins and your children always draws their daddy with short spiky hair in their drawings- all 5 spikes. Or how you've gone from finding grays on your scalp, to finding gray nose hairs, to finding gray pubes. How you find plaid jackets and bow ties fashionable. Or how you think 50-something postmenopausal women to be more attractive than a 21 year old. And how your idea of driving too fast is 76 mph.
Yes, folks, it's that time.
And I'm not sure if I'm just going to wake up that morning to find my scalp totally clean ala Jean-Luc Picard (minus the charm).
A long time ago, I had some pipedream goals for this decade of life. Things like being married and having my own children. Owning a Porsche 911. Having more than 20 publications. Having more than one million dollars in my retirement/investment portfolio.
Hah- most of them will remain pipedreams for now. But here's to the next decade* of life....

* though to be mathematically accurate, the next decade actually starts the following year. Just as how the new Millenium began not in 2000, but 2001, or how we begin counting at 1, not zero. But what's the fun in that?

Sunday, August 14, 2016

Of DRGs and BS

I was frustrated recently by the system and how in some situations it fails the patient.
I was asked to see a hospital consult recently. 78 year old man found to have an incidental thyroid nodule.
It was a 3 cm hypoechoic solid nodule with some microcalcifications on sonogram. The team had already ordered an FNA to be done- results came back suspicious for follicular neoplasm.
Traditionally, with this result, the next step is surgery, as you've exhausted the capabilities of the dainty 25G needle of the FNA- cytology alone cannot differentiate between a follicular carcinoma versus an adenoma. Often, our surgeons would do a lobectomy and frozen section; and if there is no cancer they would leave the intact lobe behind.
Now, with the option of using molecular markers, there is potential for second-tier tests to restratify the nodule into a benign versus suspicious nodule- if it comes back the former, then the patient is spared from surgery as it has good negative predictive value. In a case like this- elderly man with comorbidities who is a higher risk surgical candidate, this would be a good test to try to avoid surgery.
And so when I saw the patient and read the pathology results. I was curious as to why they did not run the additional test. I called the pathologist up to enquire. Frankly I was quite put off by his answer.
This was a Medicare patient, admitted for chest pains. His DRG would not cover the 2nd tier test which means they will end up forking out the cost of the test itself. So it was felt to be unjustifiable.
WTF?
The DRG. Diagnosis Related Grouping. Essentially, it you are admitted for condition XYZ, Medicare pays the hospital a set amount. Anything else on top of this, regardless of length of stay, the reimbursement is the same. A system to incentivize hospitals to not to do too much of keep the patient too long. But in situations like this, backfires on the patient.
My initial thought was- if that was the case WTH did they even biopsy this in the first place? It could have been done as an outpatient. I was a bit miffed that it seemed that the bottom line superseded proper patient care.
And so, I'm left with choices I don't like:
a) Consult a general surgeon for thyroid surgery- something I try to avoid for elderly patients with thyroid nodules as there is a good chance the nodule is no longer clinically relevant. The risk of surgery arguably may be higher than the risk of leaving a small speck of differentiated thyroid cancer in the neck
b) Attempt a 2nd biopsy as an outpatient with the molecular markers- something I do routinely in clinic- but it seems illogical to put him through a 2nd procedure, and it's certainly not the recommended step in a case like this, as the concern is the 2nd FNA might not procure cells from the same location accurately enough to reassure even if the 2nd set of results came back OK
c) Leave things be. Which I'm most tempted to take- given his cardiopulmonary comorbidities. Indeed, when I see clinic consults for nodules, I ask myself if this patient is likely physically fit enough for surgery- if he/she is not in good health I often try to dissuade FNA. After all, if the test isn't going to change my management, why run the test?
And so, I'll be seeing him for follow up in a few weeks. But yet another clear example of why a needlessly complicated system, coupled with money-minded administrators, end up failing the patient.
Sigh.

Saturday, July 30, 2016

Milo

So, the question is: Should I or shouldn't I? I know it's 2016, but as someone once said, precious food contraband from home should never be wasted. They never expire. Or maybe I said it.
Anyways, if this ends up being my last post, you'll know what happened.

Saturday, July 23, 2016

CGMS

About 20% of my diabetes patients have type 1. And as any patient or physician will know, this can be more challenging than type 2 in many ways- for one a person is completely dependent on exogenous insulin to survive. For some, this insulin-glucose-meal-exercise relationship can be very precarious and brittle.
And to make things worse, over time, many lose their protective senses and have hypoglycemia unawareness. Not being able to rely on symptoms to warn you of low glucose- palpitations, tremors, sweating. The first sign of low sugars might very well be loss of consciousness and a seizure.
Many of my patients try their best- they test their glucose all day. They carry glucose tablets, glucagon at home and at work, medic-alert ID. But sometimes, that might not be enough.
Last month, I lost perhaps my 5th patient in the 8 years I've been here to hypoglycemia. Mr F. was a 52 year old man with very brittle diabetes. He was prone to episodes of diabetic ketoacidosis or hypoglycemia, and was a frequent visitor to the emergency department. It was clear that he would benefit from having closer monitoring with a continuous glucose monitoring system (CGMS). However, these things are very pricey, and while it might be partially covered by some insurance, there is still a huge cost to patients. And his insurance unfortunately did not cover this.
One morning his wife came home and found him unconscious in the living room, drooling and having some twitches. She called 911 and have him a glucagon shot. When EMS arrived, his glucose was 23 mg/dL. He was brought to the hospital, but despite treatment, did not regain consciously. The neurologist felt that he suffered irreversible anoxic/metabolic brain injury. He passed away a week later, in hospice care. I felt his family's pain, after having been his doctor for 7 years, and seeing him struggle.

And so, thinking about him, and many other patients like him, yesterday marked a big step for continuous glucose monitoring devices.
The FDA advisory panel recommended allowing Dexcom to change its label- from a device meant to be used to supplement glucometer data, to a a nonadjunctive use.
The concern has always been if measuring glucose continuously from interstitial fluid, is accurate enough to be relied on for insulin dosing, versus blood glucose. And the truth is, when the earlier generations of CGMS came out they were unreliable, and a hassle to use. I remember seeing a few during training and thinking, "Who would pay to use this?".
This has evolved to very sleek, reliable (somewhat) and frankly, life-saving devices. And they are not too uncomfortable- I wore one for a few weeks to get a sense of how it feels.
The major hurdle for many is cost; and though it might be covered by insurance, there is still a significant out of pocket cost. In addition, Medicare does not cover these at all, so for my older patients, this is not a viable option. One reason has been it was felt to be "experimental".
If the FDA grants it full approval, it would mean they acknowledge that though it's not a perfect device, it's good enough to not have to prick your finger 4-6 times a day to get glucose data (you still need to do so twice a day for calibration). And hopefully, this will lead to eventual change- better coverage by insurors and more accessibility for patients.
Sadly, this will not come at least for a year I'd imagine- it takes time for insurance companies to change their policies. And it will come too late for Mr. F. But I hope this will make a difference for many others.

Wednesday, July 13, 2016

Dumb...

Bell

Get it? Dumb Bell.
Ok, this is a geek post.
As you probably already know, I like space. No, I'm not claustrophobic- but I like all that is related to astronomy.
I'm a Trekkie. I'm a Star Wars fan. All manner of Sci-fi.
One of my favorite books is Stephen Hawking's A Brief History of Time (now, how's THAT for a bedtime story?).
Anyway, I've had my telescope for several years. It's a 4" Celestron Maksutov Cassegrain scope with computerized goto altazimuth mount. I love it. It's given me hours of viewing pleasure. But the mount has always been limiting me to solar system photography- while it tracks the stars, it does not rotate along Earth's axis.
So this year, with the blessings of the wife, I upgraded to an 8" scope with an equatorial mount. And took a deeper (much more expensive) step into astrophotography.
Meet Big Brother....


I still have much much more to learn about deep space objects. But I was particularly proud of this one. 
This was a picture of the Dumb Bell Nebula, or M27. A planetary nebula 1360 light-years away in the constellation Vulpecula. So the light took over 1000 years to hit the camera's sensors.
It was a 20-minute stacked picture at ISO 800.
Sleeping 4 hours that night and feeding the mosquitoes in the backyard was worth it.
More to come in the future.