Hello, Goodbye

This was a week/weekend of handshakes and hugs. Though in a way, of happiness, for many, it's mainly of some sadness.

The medical academic year ends throughout the USA. Come Monday, newbie, fresh-out-of-medical school grads start their postgrad training (ed's note: unless you have a perforated ulcer, avoid the hospitals for at least 3-4 months). I'm now a final-year fellow (sigh, PGY-6, postgrad year 6, seems so very very long).

With the new, the old has to leave. Thus the topic of this blog. Colleagues, good friends I have known for a year or 5, leave for the next stage in their careers.

Among them, AT, a dear friend and confidante, leaves for her native California. Gene, undoubtedly one of the craziest anesthetists I've met, a real contradiction of a fellow, returns to Singapore where he will terrorize the newbie HO/MOs with stories of his driving his Porsche like a maniac in the snow. Replaced by another 2 Singaporean docs, HS and Kelvin. His departure was preceded by his wife Nat's a few months ago (who continues to torture us with stories of yummy home food).

That's the thing about this training; come the changing of the guards, you're bound to bid some dear friends farewell. Though, you know really, they're going to be in a better place; home.

Farewell, you guys. And till the next time we meet, take care.

GT Girls

I was amused to read about the recent report in the Malaysian papers, about the GT girls' clothes being too racy (pun intended) and being inappropriate for our politicians with high moral values.

Datuk Mohamed Aziz (BN – Sri Gading) asked why the authorities seemed to be reluctant to take action against foreigners when they committed offences in the country.
“Do all men like to look at naked women? There may be some men who like to watch. But are the authorities afraid to take action against foreigners?” he added.

I'm not quite sure what his point was, with that question about naked women. But, ah yes, we all do know what he meant by the GT girls' uniforms, don't we?

For the record, yes, as a man, looking at eye candy is pleasant, but I do think skimpily-clad women holding umbrellas for macho race drivers is somewhat disrespectful and perhaps degrading. But really, that's for the women themselves to decide if they like doing. The larger issue at hand, methinks, is another case of men being unable to control their erections and thus is wanting to exert some control over someone else.

With our politicians' ideas of proper and improper dress codes, you wonder how this issue going to end up.

Or maybe I don't want to know.

It's done. I've formally signed my contract and FedEx-ed it back to my future employers. It's a bit unnerving, coming from a training environment where everything is more or less fixed, and someone's always supervising you, to going out into the big bad world to work.

This is for a nice 7-endocrinologist group somewhere in the Midwest. I've interviewed there twice, and like my future colleagues. The salary's pretty good, and they treat physicians fairly well. And the city's going to be 6 times bigger than this place, which is a bonus. Though the medical center's incomparable to here, it will suffice. Then again, no where will compare to what one is used to.

I had my attorney look over my 15-page contract and compensation offer, and things looked good. And so, there it is. Come August 2008, that will be my new home (if you're wondering why I won't stay here after fellowship- long story. Basically, visa restrictions).

Good News

Dear Dr. V:
It is a pleasure to accept your manuscript entitled "___” in its current form for publication in the journal Thyroid.
Thank you for your fine contribution. On behalf of the Editors of Thyroid, we look forward to your continued contributions to the Journal.

There isn't much that is sweeter than getting an email like that. One of my more important manuscripts was accepted for publication in the journal Thyroid. Essentially, a year's worth of learning in the lab, of an obscure, uncommon disease in Graves' patients. Months of work and reviewing over 50 papers, comes to fruition, though with how it works it'll probably only be published only at the end of the year.

I wrap up my research year in a few short days. It's back to 100% clinical work, being oncall every 5-6 weeks. No more working in the lab, in gloves, under the protective 'hood'. No more Western blots, or experimenting with 3T3-L1 or human orbital cells.

Though not as productive as some of my peers, I think I made good use of my year; submitted 7 journal manuscripts of which 6 have been published or are in press, and one textbook chapter. 4 abstracts for meetings, of which 2 were accepted (will find out about the remaining in a week or so).
Have learnt a lot this year, laboratory techniques, cellular biology. My lab peers have been great, and very very patient, teaching and guiding me. For this, I am thankful.
This was among my work for this year. Thy-1 expression in fibroblasts. Pretty, isn't it?

But I am looking forward to getting back into patient care though. And hopefully, that will help in my preparation for the all-important endocrinology certification exam in 118 days.

New club?

If I didn't know better, I'd have thought that this was a new, trendy modern bar or club or something. Psychedelic colours, modern art, Van Gogh-like geometry.
This is our new Pediatric Center, which held its grand opening today and will open to patients on July 16. The center was designed with children in mind, and its natural themes and features create a calming atmosphere designed to instill a sense of well being and to aid in healing. Funded by a generous $15 million donation, center's opening today included live music, dancers, demonstrations by the nature society and even a butterfly tent.

Makes me wanna be a kid again. I shudder when I think about the Dettol-scented asylum-white kelinik I frequently when I was a child. The hard plastic seats were always too cold.

This, on the other hand, would make a kid WANT to see the doctor. Now, it wouldn't be too shabby working here too; the exam rooms and offices were sweet.

Afternoon Thoughts

I took this picture a couple of days ago. It was a beautiful sunny day, clear blue skies. This airplane was cruising 30,000 feet above me.

I sometimes catch myself thinking. Are there people from my home in that plane? Anyone perhaps flying to or from Malaysia? Wouldn't it be nice if I were there? I wonder if there is anyone onboard, looking down and wondering how it would to live here.

For what it's worth, I'm contend with life here. But I do miss home still. All you people.

This reminds me of a conversation I had with a protégée of mine. "Should I specialize in the US?" She was torn between returning home to Malaysia after graduation, or staying on for post-grad training.

Something I get asked at least several times a month by blog readers.

Unfortunately, I have no magic answer. I wish it was as simple as that. True, the residency system here is geared towards teaching and training. True, you'll get to practice medicine in a way that probably is not possible in Malaysia, unless you work in a private hospital. True, you don't waste time, and get to be, say a consultant plastic surgeon 5 years after graduation. True, inflation isn't half as bad as Malaysia (you can buy a new Honda Accord with 4-5 months' salary as a junior HO!).

But grass isn't always greener on the other side.

The way I see it, when one picks to specialize here, one sacrifices a lot in the name of career. It's possibly one of those life-altering decisions. After working overseas for 10 years, can one ever adapt to return home? And there is a good chance you meet your life partner here; will you ever want to settle down at home then? Will you ever get to enjoy those simple pleasures in life, like taking a short drive to meet with school friends at the nearby mamak? Or go for an evening stroll with mom and dad? Watch your nephew learn a new game?

No, the grass isn't greener on the other side. The truth is, you sacrifice some wherever you go. You'll have things to complain about where you end up. And there will be benefits regardless of whether one works.

So, that question has no one answer. One just has to decide what one wants out of life, personally and professionally.

Excerpt from The Star

Apparently, doctors aren't communicating effectively with their patients, so reports the Friday's Star:So, I found it difficult to muffle my laugh when I had a good look at the Star's report. Talk about ironic.

(cheap thrill, I know. Sorry, Star! We still like you)

Some people say there is no such thing as luck, or fate. This story has made me a believer.

Here, as in most US medical centers, all health workers (doctors, nurses, PCAs, respiratory techs, PT) have to be trained in basic and advanced cardiac life support (BLS and ACLS). We're required to recertify every few years to stay up to date. One of the spokesperson for this program at my hospital is a consultant of mine in endo, Dr. A.L.

Why would an endocrinologist be a spokesperson for ACLS, you ask?

Here's his story, told to me recently.

He was a youngish Scotsman, perhaps in his mid-30's then. Lean, active, keen on research. One of those M.D/Ph.D types. Had just attended our division's annual BBQ/picnic on a Saturday, where he stuffed himself silly like most of us do. Which soon followed with dyspepsia.

Despite it being a weekend, he had experiments going on in the lab. Probably tissue cultures or something similar, I imagine. And so he decided to drive back to work. Now, here, the employee carpark is at one corner of the medical center, connected by a network of long, lonely tunnels. His lab, on the 5th floor of the hospital, far away from the patient-care areas, and certainly vacated on weekends, except for the cages and cages of mice.

And so he parks his car on that late afternoon, and starts walking to the lab. Huffing and puffing from the now-worsening dyspepsia/heartburn. And it so happens that the emergency department was just midway between the carpark and the lab. In the tunnel, not too far from the ED, he falls to the ground. Unconscious. In cardiac arrest, from an acute myocardial infarction ('heart attack'). And it was serendipitious, that at that very moment, an off-duty ED nurse walking out sees him on the ground, and promptly begins CPR and activates the code team.

The code team arrives and immediately begins 'coding' him. However, despite the CPR, medications and shocks, he remained pulseless. And 20 minutes into the code, they are ready to cease efforts and to 'call' the code (ie terminate resuscitation). Not knowing who this young man was. And at that time, someone moves him, and out of his jacket falls his employee nametag.

Dr. A.L.

Seeing it was one of them, the code team hesitates, and resumes resuscitation. Not wanting to give up yet despite knowing it was likely going to be fruitless. And after what seemed an eternity, his pulse returns. And against all odds, he suffered no hypoxic brain injury.

He take his endocrinology board exams a few months later, passing with flying colours and proceeds to become one of the foremost world experts in thyroid cancer.

A series of events led to that fateful outcome. Had he passed out 3 mins earlier (in the carpark) or later (in the lab) , or had the nurse not seen him in the lonely tunnel, he would have been dead.

Sheer dumb luck? Fate? Do you believe?

And are you ACLS-certified?

Coffee, Tea or me?

For those who wanted to know, this was the topic of my presentation at the meeting, a case series of 4 patients with osteosclerosis from fluoride toxicity associated with tea consumption. The presentation was well-received, and I had numerous questions from the audience since this is extremely rare in the USA. However, fluorosis appears to be endemic in some parts of the world, probably related to high tea consumption and fluoride levels in drinking water. This generated an interesting discussion at the meeting because some amongst the audience came from these endemic areas and had some experience as well. We published this in a journal this month. I've included the abstract:

Acquired osteosclerosis is a rare disorder of bone formation but an important consideration in adults with sclerotic bones or elevated bone density results. In such patients, malignancy, hepatitis C, and fluorosis should all be considered when making a diagnosis. We describe 4 patients evaluated at our Metabolic Bone Disease Clinic from May 1, 1997, to July 1, 2006, whose bone disorders resulted from chronic fluoride exposure due to excessive tea intake.
Three of these patients had toxic serum fluoride levels (>15 μmol/L). Although the clinical presentation of the patients varied, all 4 had an unexpectedly elevated spine bone mineral density that was proportionately higher than the bone mineral density at the hip. Other clinical features included gastrointestinal symptoms such as nausea, vomiting, and weight loss; lower extremity pain sometimes associated with stress fractures of the lower extremities; renal insufficiency; and elevated alkaline phosphatase levels. Readily available, tea often contains high levels of fluoride. Obsessive-compulsive drinking behaviors and renal insufficiency may predispose to excessive fluoride consumption and accumulation. The current cases show that fluoride-related bone disease is an important clinical consideration in patients with dense bones or gastrointestinal symptoms and a history of excessive tea consumption. Furthermore, fluoride excess should be considered in all patients with a history of excessive tea consumption, especially due to its insidious nature and nonspecific clinical presentation.

Some interesting numbers:
Recommended adult intake: 3-4 mg fluoride/day
Fluoride content of regular tea: 2-6.5 mg per liter
Fluoride content in jasmine tea: >200 mg per liter
So, something to think about the next time you order that 3rd glass of teh tarik.

Phew. I'm tired. Something to do with the 8 a.m-630 p.m talks (though my brain shuts down at about 2 pm, so I'm not sure why I stay till so late). Nonetheless, we're having a good time here in Toronto, academically and socially. I'd estimate about 8,000 participants at the conference, with many excellent presentations.
Somewhere along the way, we also managed to have fun. Went up to the CN tower (again), the tallest free-standing structure in the world. Though the kids jumping up and down on the glass floor while I was standing on it didn't particularly thrill me. It was a loooong way down.
I did my oral presentation today. Public speaking- not exactly my favourite. I'd sooner run around the conference hall in a pink g-string than to do public speaking (I asked, but they wouldn't let me). Still, it went surprisingly well; the hall was pretty full and people weren't snoring, at least none that were audible. My case series was well-accepted, and according to my colleagues I handled the questions from the floor well. So now, thankfully I can relax and enjoy the next 2 days in Toronto. One additional bonus, was that I actually met some fellow doctors from Malaysia! There were 2 research posters, one from a group in USM, another from PMC (Yes, Dssraj, your DEAN and I talked about you!), so that was a source of pride. Rumor has it that there is a hot Malaysian drug rep somewhere here too, but my eyes have been gourged out by my fiancee, and so I haven't noticed her. Not trying to be funny, but it's true, many drug companies intentionally hire people who are visually attractive! It was apparent how many of the hundreds of pharma reps in the exhibition hall looked like models (male and female). See Palmdoc's posting on this subject.
Neways. More when I get back to Rochester. Ciao.

Endo 2007!

Will be away for the next 6 days for the annual meeting of the Endocrine Society, in Toronto, Canada. Have been there several times in the past, though not for a meeting. Should be a fun time, especially with the wonderful food there. 11 of the 12 fellows from my program will be going along as well to present our research (I'd hate to be the one remaining fellow in town who will be oncall and taking all patients!).

Knowing my KPC nature, I'll be looking out for people from home. Will be doing an oral presentation on Monday; if you find yourself there, look me up!