WTF?

I did a presentation to my division this week on a mystifying case.

It was one of those WTF cases. Ie, you start off thinking the patient has one thing, order a test and when the results come back you go What The F*ck????

It was a nice lady in her 40's who was seen here previously for primary aldosteronism some years back. Although her adrenal CT clearly showed a 1.2 cm nodule on one adrenal, the other was 'lumpy' as well and so she underwent an adrenal vein sampling. Which didn't quite lateralize enough for the surgeon to want to operate (2.3:1). And so, I see her 5 years later for follow-up.

Doing well on spironolactone. Her doctors back home did a CT, and then a PET (for unclear reasons) which showed some uptake in the adrenal, as well as one side of the thyroid.

When I saw her, she didn't quite look right. Big nose, maybe. Big hands too, maybe? Or maybe it was just the typical Midwestern habitus?

It was one of those cases when you ordered the tests to 'cover your ass', so to speak. We thought the PET thyroid abnormality was from Hashimoto's (she didn't have a palpable nodule), but to be safe we did a thyroid ultrasound. And because we entertained the thought of acromegaly, though however unlikely, I decided to check an IGF-1.

A panel of tests, a thyroid ultrasound + FNA and MRI later, it turns out she has (in addition to primary aldosteronism) acromegaly from a GH-producing pituitary macroadenoma, and papillary thyroid cancer.

Our thyroid surgeon took out her thyroid gland, and 6 days later our neurosurgeon did a transphenoidal resection of her pituitary adenoma. She left the hospital a day later; last I heard she's doing well and will be coming back to see me again in a few months.

But for the life of me, I'm stumped. I'm sending her to see the medical geneticist when she next returns to see if this is possibly Carney Complex. By conventional criteria, she does fulfil the requirements but something just seems very unusual here. Nonetheless, it was a fascinating case.

My hero

It's all about perspective.
I'm pretty content with life in general. I'm wrapping up 6 years of training at one of the premier institutions here. I have a job secured after graduation that pays a very comfortable 6-figure salary. I get to write presciptions. I've had the unforgettable unexperience of coding patients, and even bringing some back to life. I get to play the newest ultrasonography machines that cost more than my car, and stick needles into patients' necks, and get paid for it. I've published. I'm house and car-shopping. I'll be marrying my dreamgirl in 132 days. Life is pretty good.
And then I read Kenny Sia's blog about becoming a judge for a Malaysian model search reality show. Suddenly I'm green with envy. The last time I was asked to judge something was for a high-school skit of guys in drag.

With witty humor, skills in photo-editing, and presumably some special coconuts, this guy is truly a celebrity blogger. Perhaps weird coming from a 31-year old internist/endocrinologist, but this guy is my hero.

Okay, maybe I'm being facetious. Well, kinda.

Cold, cold Minnesota

There is no gentle way to put it. So pardon my crudeness. But really, today I was afraid my nuts would freeze and fall off like some over-ripe durians. My cremasteric muscle were working so hard that I think my gonads were retracted to somewhere deep within my thorax. One reason why I hate this time of year. Unlike in Malaysia, when January/February brings the anticipation and excitement of Chinese New Year, fireworks and angpow, here it's just the coldest time of the year. The season after Christmas, when the pretty holiday decorations and lights have been taken down, but the snow keeps coming. Compare that to summer, when trees are green, BBQs are out, and the women are running around in bikinis.

Before I experienced my first winter in Canada in 1998, I never really understood how boogers can freeze. I mean, Calvin (of Calvin and Hobbes) was just being ridiculous, right?

Wrong. Boy was I wrong. The 'wonders' of winter a Malaysian boy had to discover. Your boogers DO freeze when it's cold enough. And they get rock hard. You could probably shape and cut it and mount it on an engagement ring and she wouldn't be the wiser. Oh, and that shock your lungs experience when you step out on a cold day such as today and inhale your first breath of the winter special. Your lungs almost go into a coughing fit (not unlike how one feels stepping off the plane in Malaysia and take the first breath of the humid air, actually). Or how sitting on cold leather car seats feel like sitting on nails (thank goodness for seat warmers). Or how the air is so dry in the winter that you nosebleed, your skin itches, and there's so much static electricity that you shock everyone/everything you touch, and you see sparks when you comb your hair in a dark room. Speaking of static electricity, this reminds of Nawi, a buddy of mine from Malaysia who went to medical school with me in Canada. Being the typical kampung boy, he liked to walk around our student dorm in his sarong and shirt. Sometimes, he'd even go commando. And then one day, he went to the laundry room to use the washer. As he unloaded his laundry, his body came into contact with the metallic washing machine. Unfortunately, because he was commando, the part of his body that came into contact was his most, err, anterior part. His wee-wee. And so he discharged from the tip of his manhood through the thin sarong cloth to the washing machine, and experienced a minor jolt to his nether regions. I found him doubled over, hand on his crotch, uttering unmentionables. I doubt he ever went commando in his sarong again. He's now a surgical registrar in east Malaysia- someday I'll tell the story to his kids.
Anyway, enough digressing. It's cold. Oh, what I'll do for a hot bowl of Asia laksa right now...

Holiday Party

We had our belated department 'Christmas Holiday Party' over the weekend. Except Christmas has long been over. But still, it was fun to mingle in a totally different manner. The consultants were less stiff. The clinical assistants and secretaries were less formal with us. We got a pretty good band this year. Amazingly they were only in their late teens-early twenties. Did a great job with improvisations, pulling some of us up onstage for dialogues.

With my lab research mentor and her husband.

And no, I wasn't telling jokes onstage. Though the organizers made me do unspeakable things. Like demonstrate to the band how one uses the orchidometer to measure testicular volume (after all, we're all endocrinologists here!). No live patient though. And no, that bulge in my pants was not, erm, me. That's what you get when you carry the device in your pant pocket.

Like I said, t'was a fun night, though sad to think that this would be my last department Christmas party here. Sometime during a lull, Dr. H, who has been one of my strongest supporters here (he wrote me the nicest letter of recommendation I'd ever received for my job application) came up to me, gave me a hug and said he was going to miss me. And some of my clinical assistants said they same.

Friday Night Rambles

Friday wasn't a great way to end the week. I saw an out-of-towner and diagnosed him with thyroid cancer. He also had money problems, and really wanted only the bare minimum done. In the midst of preparing him for surgery, I had a disagreement with my consultant and the surgeon, who wanted some tests and consults done which in my opinion were unnecessary.

Which wasn't a big deal, and profesionally I still disagreed with him, but you have to do what a surgeon wants you to do if you want him to do what you want him to do (to operate on your patient).

But I came home a bit upset, and in a way, irritated at myself. Wondering if I was really cutting corners because I was trying to spare the patient the burden of the expensive tests and neurology consult? Or was I really that sure that those weren't necessary before I sent him to surgery? The surgeon had implied the former. Which may have been true- the patient's mother pleaded with me to not perform any expensive tests; maybe I started off biased. Maybe my judgment was impaired because of what the patient wanted, and not because of what was in his best interest.

Needless to say, I came home doubting myself.

Which got me thinking (really, the topic of my post today): I wonder what patients would prefer?

Would patients prefer to think that their doctors are infallible, mightier-than-thou, always confident Healers? What would patients think of a physician who is, simply put, human? Someone who has good and bad days, someone who doesn't have all the answers, someone who, heaven forbid, feels stupid on a bad day?

I caught myself wondering this when I was talking to Kris last night. We've always been taught to be professional, to show empathy but to show no emotion. To be confident.

But, I wondered what my patient would think had they known I disagreed with the surgeon, and such was left with some doubt? That I left work feeling, simply put, dumb?

Would they make a connection with us, and realize we're only human? Perhaps even strengthen the patient-doctor relationship? Or would that only jeopardize it?

Someone once told me, a surgeon who doubts himself is more dangerous than one who makes the occasional mistake. Perhaps it's true in the fast-paced, life and death world of surgery. But does that apply to everyone else?

Food for thought, but perhaps a big too heavy for a weekend.

P.S I Love You

Okay, if you missed this the last time, here's another confession. I sometimes do enjoy chick flicks. If you look at my DVD collection, on one end, you'd find movies oozing with testosterone and action, like Top Gun, Blackhawk Down, and the Tom Clancy series. At the other end of the cabinet, sits Love, Actually, My Big Fat Greek Wedding and Bend It Like Beckham.

(The Vivid movies I keep under lock-and-key somewhere else!)

And so, Kris and I had a dinner date on Friday. Nice Italian restaurant, some Riesling, and then a movie.

P.S. I Love You.

Omifarkinggawd. If that wasn't a tearjerker, I don't know what is. Without giving anything away, it's a story about love, death, finding one's way again and letting go. In that order.

Maybe it was that time of the month for me. Maybe it's been a rough week (haven't had a weekend off in 2 weeks). Maybe my abstract dateline's been putting me under pressure. But holy cow, what a tearjerker. And folks, I'm not talking about those dainty moistened red-eyes type. This was the all-out tears-rolling-down-your-cheeks-like-your-brains-were-liquifyeing sort. I felt so dehydrated by the end of the movie I had postural dizziness. And Kris found 2 mountains of salt on her seat from the dried tears.

And we weren't alone. The theater was packed with couples, no doubt guys grudgingly going to this movie to please their better halves (ahem). There were sniffles and even sobs, galore. I know this tubby 50+ bearded man behind me was trying to suppress his sniffles.

Can't say the movie reviews were excellent. But we thoroughly enjoyed the show. Hillary Swank was good (and hot, too). And the rest of the night Kris kept trying to get me speak in an Irish accent whilst wearing my boxers with suspenders. So, if you're a sucker for punishment, go watch this show. You might find a tender side of yourself you never knew.

And I hear chicks love snags (Sensitive New Age Guys).

My New Year's Resolutions

We did a New Year 2008 Countdown at a buddy's place. 2 bottles of champagne, 1 bottle of sparkling non-alcoholic wine for the kids. We were set. And then age sets in. By 10:15 pm, the grown-ups were yawning (the kids were having a blast with the PS2). And so we decided to do a New York Countdown: we counted down live with the masses of people in Times Square (so it was 11 pm Midwest time). By midnight, we were all home and in bed.

• To do a better job keeping in touch with friends afar
• To not sweat the small stuff
• Before I say anything out of frustration or anger, to really ponder about it first
• To work out more
• To complete my pending manuscripts before I graduate

Then again, never have had too much luck with resolutions. What's yours?