Happy Merdeka Day!

50 years.

That's 50 years of independence from British rule. 50 years we have existed as an independent, sovereign nation.

There is a lot to celebrate. We have come a long way, from those days of another generation. We have grown, economically and developmentally. However, as Malaysians celebrate this historic day, undoubtedly many would ponder. 50 years. 2, for some, 3 generations of families. If so, why on one hand while boasting of how well we're doing, do we still practice archaic, unfair and frankly discriminatory policies? If certain groups have not been able to reach their goal even with favouritism in 2 generations, what makes us think that further affirmative action would do any more good? We often hear of how that 'privileged' group is told to be independent, to emulate non-privileged groups to learn their work ethics, to not rely on biased policies. But no one seems to acknowledge the truth, that by giving one a crutch to walk on, a person will only rely on that crutch even more and totally forget how to walk without it. It's simple; Darwin described it well in his theories of evolution. It's about competition and survival of the fittest. If a species is not allowed to compete, that species will never better itself and will never survive outside its cocoon.

It's a shame, that after 50 years existing as a country, of boasting of a Bangsa Malaysia, that exam papers, university applications, identity cards all contain the mandatory biodata: Race and Religion. It's a shame, that the leaders who on one hand boast of being fair to all races, when threatened by calls to practice fairness and eliminate affirmative action, can pull out a keris (Malaysian dagger) and wave it at the podium during a national political meeting claiming that he will defend his race's rights and privileges with his blood. It's a shame that racial bias tops quality of candidates in many sectors, private and public. It's a shame that as a Malaysian working half a world away in a totally foreign culture, that I've encountered less racism and racial intolerance here in America, than in my home country, and that truly I'm valued by my work and not skin colour.

Apparently, I'm not the only one feeling like this. If the recent 1996-2005 immigration numbers are true, and that 28,527 Malaysians gave up their citizenship, of which 1,720 are Malays, then the obvious question that should come to mind is, why is there just a huge discrepancy between races? Especially when Malays make up over 50% of Malaysia and yet comprise only of 6% in this group . Clearly, something is driving certain racial groups away.

I do miss Malaysia. So very much. I miss the culture. The accent. The food (glorious glorious atherogenic food). The smells, the humidity. The people. I'd even say women, but I can't say that now that I'm engaged, can I? (Oops, I just did, didn't I?)

What I don't miss? The overt racism. Call it NEP, call it privileges. Whatever you call it, it's by definition the practice of racism. Except that it's endorsed by the gomen. Neither do I miss idiots like Kai-ri, who says he's not a bigot while calling Anwar a puppet for the West and for the Jews (firstly, where on Earth did that come from? Secondly, if you don't consider that statement racist then maybe I'm just being high from glue-sniffing).

In many ways I still consider myself a patriot, though a frustrated and somewhat helpless one. Someone who still loves his home country and yearns only for the best for Her. However, one who feels forced away by policies that invoke a strong sense of resentment. And though some may accuse me of being otherwise, I'd argue that a true patriot is one who wants the best for his country as a whole, not one who is interested in safeguarding only his own group's interest.

Happy Merdeka, Malaysia!

Of Men and Fashion

Kristin happens to think I'm colour-blind. And totally oblivious to current fashion trends. I happen to disagree with her. That's one nice thing about wearing suits to work. I mean, a suit is a suit right? How can one go wrong?

Oh how mistaken can one be.

Perhaps it was too early a Monday morning. Perhaps I got dressed in the dark, not wanting to wake the lady up. Perhaps I didn't have my glasses on. Who knows?

I got to work. Felt pretty good, humming a song while walking from the parking ramp to the office. Looked at myself in the reflection off the shiny windows of the clinic. And thought to myself,

What in God's Green Earth was I thinking????

I had a brown plaid sport coat over a green checkered long-sleeved shirt and beige-coloured slacks. And a grey tie with a silver tiepin. Onyx-silver cufflinks. And a navy blue Littman Cardiology III SE stethoscope over my neck.

I looked like the clown from PT Barnum's circus. All that was missing was a red nose and oversized shoes.

So now, I'll have to remind myself to listen to my woman, that

1) White jeans were 'in' only in the early 90's (even if it's Levi's or Guess). I bet even John Travolta is embarassed about his Saturday Night Fever stint.

2) Men should not wear Capris shorts

3) I should not wear a black suit with a black dress shirt and silver tie. Not unless I'm a magician about to make Lady Liberty disappear

4) Contrary to what I may think, it's not cool to have my pager, cellphone and PDA clipped onto my belt. Especially on the same side.

5) I should not tuck my shirt in when I wear shorts

6) Hard Rock Cafe T-shirts really belong in museums

7) Unless you're the reincarnate of Gianni Versace, you shouldn't wear yellow T-shirts. And there was a reason the gunman didn't miss

8) Wearing tight Renoma undies do no make you look like the models in the ads

Now, naturally, the above is but a generalization. Not all men are helpless basket-cases. Some men are born with that innate sense of fashion and grace. They're also usually gay (another generalization. But it's true for me- my best-dressed friends are gay).

Thank goodness for girlfriends and wives who remind us what slobs we are.

A Tribute

I got word a couple of hours ago; my aunt passed away today. A no-nonsense, tough-as-nails on the outside yet kind-on-the-inside lady, who single-handedly raised her kids after her husband was killed in a plane crash (one of my inspirations to become a doctor, but that's a different story).

Growing up, my brothers and I were monsters, the kind of kids family friends would dread to have visit. We wrecked havoc wherever we went. However, never at Auntie L's place. We were scared shit of her. I remember her admonishing us for drawing on her wallpapers. Or for not flushing after a number 1. Or for running on the bed. Or for slurping my Milo. We learnt to be on our best behaviour whenever visiting Singapore. Over the years though, as we grew older, she became less scary, more motherly, more understanding. I began to look forward to her visits.

We found out about the nonsmall-cell lung cancer less than a year ago. With spinal cord metastasis. She was a lifelong nonsmoker. The problem with being a physician is you know the prognoses of diseases. And you know what metastatic lung cancer means.

Being the tough cookie she was, she kept her spirits up. When we were in Singapore 3 months ago, Kris and I visited with her. In a way, this was a sad affair for me as I had a feeling that we were saying our goodbyes. In some ways this reminded me of the farewell I bid to grandpa before I left for Canada. I had hoped that she would hang around longer, for our wedding in July. And even more, for at least my cousin to see her one last time.

But sadly, this was not meant to me.

Auntie Lian, we shall all miss you badly. Though you portrayed yourself to be a strict disciplinarian, we know better. Inside that tough shell, was a sweet, kindly woman. But though we'll miss you, I'm glad you're finally at peace.

(Mom, Teng, I hope you're hanging in there)

Our humble exam 'room'

One of my passions here is volunteering. One reason why I jumped when they asked for volunteers to treat Hurricane Katrina patients a few months ago.

Somehow, I find this extremely enriching and rewarding. A world away from the complex medicine we practice at work, away from entitled or spoilt patients, away from issues of billing, paperwork, research and other credentials. Just pure and simple man-helping-fellow-man.

Since internship, I've occasionally helped at the Salvation Army free clinic in town. And then, fate, or luck, or whatever you call it, steps in. A friend of mine asks me to help her in establishing the diabetes clinic. She's since left town, but somehow the clinic project falls onto my lap, and I've been the director for the last 2 years.

Doing a stat hemoglobin A1c

Why the diabetes free clinic exists became apparent when I researched for my afternoon presentation 2 days ago. 7% of the US population, estimated 20.6 million people (that's 20,600,000), have diabetes. The estimated cost of care was $132 billion dollars in 2003 (in contrast, Malaysia's gross national income that year was only $121 billion). And unfortunately, healthcare ain't cheap.

The patients we treat are usually uninsured, patients with difficulties making ends meet. A contrast to the wealthy, the VIPs we see at clinic. Mostly citizens, we see also quite a number of immigrants from Somalia, Ethiopia, Asia and the Middle East. It's a nice change of environment as the gratitude, the 'thank yous' are real, and apparent, they come from the heart. They know you are there till 8 pm after a 12 hour day on your own accord. They know you're not judging them on how they dress or smell (well, perhaps somewhat on their diet and smoking habits, but I tell them so). They don't mind that the free clinic does not have proper exam rooms, or lab tests (only semi-expired stat hemoglobin A1c kits).

And, surprising as it may be, I find myself rushing from work to the free clinic feeling tired (after all, I started my day almost 11 hours ago) and yet feel energized when I'm done seeing patients there. A mystery, no?

It makes one thankful for the opportunity to help. For the training, and the ability to use one's skill to touch perhaps not many, but even a few. For the support my workplace has given, from the free medications to even free surgery for our Salvation Army patients who need them.

Volunteer if you ever when the chance. You get more than you give. Really.

Tragic. Just tragic. We got news today of a colleague who was killed in a car crash recently. Though I've never met him in person, I've talked with him on the phone several times because we shared some patients with rare genetic conditions. And he was always helpful and keen to teach the ignorant endocrine fellow about C-E syndrome. Our patients will miss him, as will the rest of us.

A friendly, well-respected medical geneticist, on the way back from a weekend getaway, gets into a head-on collision with another car. His wife and 4 daughters are reportedly in critical condition. All wearing seat belts. He was only in his 40s.

And coming right after that horrible bus crash at home in which 20 died.

It's a grim reminder that life is short, and precious. And very very unexpected. To not take things for granted, nor too seriously. To appreciate the simple yet priceless things in life; the embrace of a spouse, the kiss of a child, time with family. Because you can be here one minute, and gone the next.

I recall one of my favourite quotes in highschool:

I shall walk this path but once. Any good therefore that I can do, or any kindness I can show a fellow human being, let me do it now. Let me not defer nor neglect this. For I shall not walk this path again.

Let's pray for the recovery of those involved in the horrible crash.

Picking a Research Mentor

I don't claim myself to be a seasoned researcher, or a well-published academician. But, I think I've certainly been burnt enough that I thought I'd share my learnings about research. The main thing really, is picking the right research mentor.
I know it sounds obvious, but really, it's not. You have to think about what kind of person you are, how much experience you carry and how independent you are able to work. Then, balance that with how much autonomy you want your mentor to give you.

The Micromanager

A great mentor to start your career off with. Someone who examines everything you do under a microscope, and adds countless grey hairs to your already balding head from the stress he/she gives you. Your manuscript draft that he reviews is typically returned to you full of red (from the track changes function in Word). But someone who has invaluable experience who will teach you about the finer details. An example, my first projects kept crashing and burning, and I had trouble getting them published, because I realized I wasn't learning the art of writing papers and manuscripts, of drafting cover letters or replying to reviewer comments. Until I worked with Dr. W 2 years ago who was instrumental in teaching me the nitty-gritty.

The Invisible Man

This is typically an older, emeritus-professor types, who is close to retirement and who doesn't quite give a dang about how you phrase your manuscript (probably because he has over 100 publications and over $3 million in R01 grant awards). This person typically lets you fly on autopilot, which is nice if you know what you are doing and don't want anyone to be picky about where you place the comma or your style of writing. However, this would not be the person you want to work under if you're new to this and haven't popped your publication cherry. Because you're not going to learn much from this person. Your 25-page draft is typically returned to you with just one line of 'Looks good' or something like it. I learnt my lesson when one of my projects almost crashed and burnt because of a protocol problem that no one noticed (Thankfully I was able to salvage the project by coming up with a totally different control group. Took me a month but the paper's now done and submitted). Yup, don't count on practical advice from this one.

The Newbie

I hate to say this, but even consultants and professors (assistant profs) can be not-well-published. Nothing wrong with this, as academia isn't for everyone. And I'm a newbie too, and would not ever serve as anyone's mentor. These mentors can be overly enthusiastic trying to get you to write cases up for publication, or force their way into your study protocol although they weren't really involved. And the main problem is, while their level of motivation is nice, they often don't have the experience to give you good advise. Which leads to poor quality study designs, or manuscripts. Case in mind from years ago I've spent weeks doing chart reviews for a vague, thought to be feasible project, until the statistician pointed out a fatal flaw in the poorly designed study my mentor came up with for me. Often, they are highly motivated because they want more publications in their names (yours). Another caution- these advisors usually do not have funding, so plan on having no statistician, or artist or research coordinator in your protocol.

The God

This is also another good/bad example of how you can play the game. Once you've established yourself, and feel comfortable writing, and especially if you're in a bigger institution with big names, it's sometimes helpful to tag yourself with a world-expert in a certain field. That way, no reviewer is going to dare reject your manuscript, because of the name your paper carries. It's a simbiotic existence; you get a heavyweight name as your advisor on your paper, he gets a publication for minimal work. This person is similar to the Invisible Man, except that he has perhaps double the number of publications, and has an ego larger than the planet Jupiter. He usually would not micromanage your study, but beware: he knows His name lends a certain amount of credibility, and so he may end up being too fussy with your manuscript in order to not look bad.

The Type A

A variant of the micromanager, except this person gives less practical guidance, and pushes you harder. Also, be wary of changing deadlines- "Don't worry, the abstract is only due in 4 months" easily and without warning morphs into "You need to submit the 21-page manuscript in a month. And oh, I think you should write up a grant proposal for this and try to get some funding. Also, I've decided to expand your study's primary outcome". If you survive this one, you can expect high-quality publications in respectable journals. But plan on lots of caffeine, aspirin and Valium. And do make sure your 18th floor office windows are locked, in case you develop any temptations to jump out.

The Bully

I had a mentor like this in medical school. I cringe when I recall my experience with him. This is a person who is a very established researcher, well-published, IQ over 180, but totally lacks any interpersonal skills. He is a mentor by force; he has no ability nor desire to teach and guide.The only reason he's agreed to take on someone is because the head of department probably forced him to because it's in his contract, because he is after all employed by a teaching institution. Don't expect to learn much from this person. He's happy if you're invisible and leave him alone. He cares only for his lab animals, not you.

Stay far far away.

I don't know why, but I found this extremely funny. In fact, funny doesn't quite cut it. It was farking hilarious. I squirted raspberry sorbet onto my white dress shirt.

Breastfeeding wave hits Putrajaya
By SIM LEOI LEOI
PUTRAJAYA: Twenty-three mothers breastfed their babies for a full minute at the Putrajaya Hospital today, in an attempt to create a new record in the Guinness Book of World Records.
The mothers were part of the "Global Breastfeeding Wave" - a worldwide campaign to get mothers to breastfeed their child for the first month. To take part, the mothers had to breastfeed for a full minute at 10am.

Now, don't get me wrong. I think breastfeeding is important, and the health benefits are clear. I think countries like Malaysia need to be more open to this, to encourage it more. But I don't think an attempt to get into the Guiness Book of Records for the most number of simultaneously breastfeeding moms really does anything, except to make us a laughing stock. Always wanting to get into some book of records for some stunt.

At least my colleagues and I had a good, hearty laugh. I'll be expecting an attempt soon for the highest number of people peeing into the same squatting toilet.

Addendum (update Aug 14th):
Seems I'm getting a lot of flak for this. Thanks to bulletin boards like so. I'm not sure why people are thinking that I have something against breastfeeding moms. I thought it's clear I support breastfeeding. Read my lips: I found the use of this to get into the Book of Records funny, get it? Nothing personal. I find it funny here too, and in Canada or wherever else they do it.

I'm rather irritated though by the language in this mommy's breastfeeding bulletin board, that amongst other things I should be decapitated and thrown out of the country along with my family (and I thought moms were supposed to ensure kids used the proper language. Omigosh). Or how some of them came to the conclusion that I think US is better than Malaysia, or US this, US that bla-bla-bla. Maybe it was me, but I thought some of the comments in there were blatantly racist.

All I can say is, before you ketuk me, perhaps you can take a step back and see what I found amusing. And I never hope to see any talk about beheading someone again in a bulletin board as lovingly named as susuibu.com

I'll let the rest of you readers be the judge (and my lesson learnt: never piss off moms).

Primum Non Nocere

To the patient I couldn't help the other day.

I'm sorry we couldn't help you. I know you don't quite believe what I said and I know your personal opinion remains strong. Though you leave frustrated and disappointed, I hope you at least trust me that what we suggest is what we think is best for you. Your best interest was my only priority.

After all, our first rule is Primum Non Nocere- First Do No Harm.

One reason this was a busy week, was an exceptionally high number of hypo_glycemia patients we saw this week. I saw 4 myself, all post-gastric bypass. The high volume is undoubtedly from the many publications my colleague has on this topic, creating a major (crazy) referral bias. My 2nd publication on this topic should come out in Endocrine Practice this month. The referral bias lends itself to another problem which I shall not go elaborate too much, but let's just say when patients are coming from as far as Alabama and Texas, they expect to see you, get the mixed-meal test (fully expecting positive results), CT and/or ultrasound, then the calcium stimulation test, then the surgeon, then have surgery, and be discharged all within a week. Granted, it's expensive to fly in and stay in town, but you can't rush these things. And this leads to high expectations.

The fundamental issue with hypo_glycemia is one needs to fulfil Whipple's triad: 1) Documentation of low serum glucose (less than 50 mg/dL), 2) Concurrent symptoms of neuroglycopenia, 3) Resolution of symptoms with glucose treatment.

It's a fact that serum glucose can drop below 50 mg/dL in normal, lean healthy subjects, and therefore presence of symptoms at the same time needs to be well documented. In the case above, my patient had symptoms at a glucose level of 91 mg/dL, and she's trying to talk me into sending her to pancreatic surgery. She's convinced that 90-100 mg/dL is too low for her. I would not be acting in her best interest, if we took out part of her pancreas, based on available data.

The next step once this has been documented, is to know what the c-peptide and insulin levels were to ensure this was insulin-mediated. Once shown, imaging should be the next step. Because no study has 100% sensitivity, we tend to do a CT, ultrasound, and sometimes endoscopic ultrasound (no head-to-head comparison, but thought to be the most sensitive of all) if the first test was negative.

If nothing clear lights up to suggest insulinoma, a selective arterial calcium stimulation test is usually the next step, to regionalize the problem. 0.025 mEq/kg of calcium is injected into the vessels feeding the pancreas, while insulin levels are measured in the hepatic vein to look for doubling or tripling of insulin.

Only in well-defined cases, do we consult the surgeons. And even then, treatment is not always surgical, as nesidioblastosis may recur and so we reserve that for the refractory, severe ones.

My personal total is now 18 patients, probably the highest amongst the fellows in my division, since I have an interest in this condition. Something that occurs less then 6/1,000,000. Perhaps because of the bias, I must say though that I'm unnerved at the number of bypass patients I've seen presenting with hypoglycemia. Some are clearly not real, and yet there appears to be something, from the altered anatomy, that causes their symptoms that are not glucose-mediated. The ones that are real, what IS the best treatment? Beats me... just 2 years ago when I drafted my manuscript on this subject, we thought surgery should be firstline. Now, with the recurrences we see, I don't think so anymore.

It's a challenging medical mystery. Why this happens. How to treat it. Why patients feel the way they feel. Made more challenging when they come with preconceived notions that they will definitely have surgery.

(if I seemed vague about this condition, it was intentional due to the rarity of it and not wanting anyone to Google my blog. But if you have a medical background you probably know what I refer to. Reference here)

It's Friday!

In the world of endocrinology, people are divided into two factions. In some places, less so, but this rule applies probably worldwide. You're either a diabetologist, someone who has an interest in primarily diabetes, or an endocrinologist, someone who is keen on everything else (And then, in a crazy place like this, people are differentiated further into diabetes, lipid, thyroid, bone, or adrenal/pituitary)

I must say I belong to the latter (endocrinologist). If I had to pick an area (really, outside of a really academic institution, this isn't feasible) I'd consider myself a thyroidologist. That's been my area of research, and primary area of interest. Diabetes, sure, I could handle. After all, in my world that's going to be the bread-and-butter, but that's not where my passion truly lies.

Workwise, I've seen a fascinating number of cases this week. I've been coming home pooped, but yet intellectually stimulated. From pituitary apoplexy to autoimmune polyglandular syndrome type 2 (Addison's disease and premature ovarian failure) to adrenal incidentalomas to 4 hypo_glycemia patients (of which two are real, after gastric bypass, which brings my personal total to 18). And I diagnosed papillary thyroid cancer in one patient and biopsied two benign thyroid nodules too. And while I was mostly lost and overwhelmed 2 years ago, it's now become fun when I'm the PGY-6, senior fellow, and I actually know what I'm doing half the time (as compared to <10%).

And it's a good feeling to be pretty adept at FNA biopsies of the thyroid; these days my consultants just stand a distance away and let me handle the probe and needles.

Yup, it's been a fascinating week. But still, I'm thankful it's Friday. Time for rest (Anyone seen the Simpson's movie yet?)

We're okay. So far, everyone I know wasn't involved. The I-35W bridge over the Mississippi collapsed just over 3 hours ago. Estimates have 2 4 6 fatalities and 28 41 hurt thus far, though reports are trickling in that many more were killed. This happens to be one of the major interstate highways, and this happened at rush-hour, 6.05 pm. Over 100,000 cars travel over this bridge daily. They estimate over 50-100 vehicles were on the bridge when it collapsed.
Though an hour away and a safe distance from here, this was a highway I've travelled on numerous times. And, on a whim, I was this close to driving up to Minneapolis after work today.
Our thoughts and prayers go out to the victims, families and gallant rescue workers and divers trying to search for survivors, or extricate the bodies.
More news here.