Our weekend project

Ah, the joys of home ownership:

The neverending chores and projects.

And because our house looked duller than 5 year old faded jeans, we decided to spruce things up a bit. And decided to do some landscaping on the small island of lawn beside the front door.

After about 8 hours of backbreaking labor between Saturday and Sunday, 3 trips to the garden store, generous use of expletives, and about $350, I think we're pretty happy with the results. It was only a small project, and inevitably we'll have more landscaping to do. We're thinking of a stone wall, serving as a planting site for some bushes just under the dining room window out front. And someday, probably next year after we've budgeted some cash for it, to fence up the backyard, add a stone patio and a small firepit. Not that we're both pyromaniacs, but we do love the smell and sound of a campfire.

Formula 1

I admit, even half a globe away, I'm caught up in the excitement.

The inaugural Singapore Formula 1 Grand Prix. I watched the practice runs this morning. Boy was it spectacular.

There's something about the sound of the F1 engines that makes you want to drive like a reckless moron on the streets. That banshee-like shrill of the engine in full rev, pausing only for a fraction of a second as they change gears.

But what makes this extra special is that it's the very first night race in Formula 1. And more than that, having been in Singapore just a few months ago, and having seen the sights and the path the drivers will take in this street race, I'm able to picture this much better, than say, the Sepang circuit.

I'm excited, yes. But I can't say I've been following the races as much as when I was in Malaysia. And I don't recognize half the drivers' names. Sad to say (I know I'm going to get flak for this), I'm still pretty much a Michael Schumacher fan. Too bad he's retired.

I'm probably going to be too lazy to drag my ass up at 6:30 am Sunday morning to watch the race live, but thanks to the wonders of technology, my faithful DVR will record it for me.

(and dear old Kristin won't know what hits her when I watch the race in full volume on my 5.1 surround system )

A Referral

I referred a patient to my alma mater today.

And I have to say, it felt a bit weird. To be calling WFMC, to be faxing in the paperwork TO them, instead of WITH them.

It was a case of Cushing Syndrome. Always difficult, these cases, because lab results are often equivocal, and often contradictory. Case in mind, guy who previously had a normal 24 hour urine free cortisol. I did a 1 mg dexamethasone suppression test which was negative, yet close enough to being positive that it just didn't smell right. And so I repeated the urine studies which this time came back positive. And did a salivary cortisol, further confirmed by the 2-day low dose dexamethasone suppression test I did, with a nonsuppressed ACTH.

His MRI showed a pituitary microadenoma. Presumptive diagnosis: Cushing Disease. Personally, I was confident enough of the diagnosis that I didn't think an IPSS (inferior petrosal sinus sampling) was necessary. But the neurosurgeon wanted that, and it's not something we have readily available here.

So, he's headed up to see if they feel he needs the IPSS, or if they are willing to operate on him based on the data I've collected thus far.

It's a strange feeling sending the patient up. In a way, it's pride, telling the patient that if I was going to have pituitary surgery, it would be by one of WFMC's neurosurgeons' hands. And another, that near-gleeful feeling, reminiscing and telling the patient how the system there works, and the qwerks of some of the consultants there and helping choose a consultant and surgeon for them, based on what the patient wants. And yet, mild anxiety, sending a patient to your ex-mentors and teachers, not as a fellow of theirs anymore, but as a colleague, hoping that when they read your referral letter and see your patient, they go

"Ah, Dr. Vagus did a good job working him up. We taught him well."

And not

"What on God's green earth was that idiot doing?? This patient doesn't have Cushings!!"

I think they taught me well.

I hope.

We shall see when after they are done with their evaluation.

Thyroid biopsies

One of the things I really like at my new practice is that we have 2 ultrasound machines (One, incidentally, I've hijacked and put in my own exam room). Being the product of a modern endocrine fellowship program, my peers and I are probably a lot more adept at doing thyroid ultrasounds and performing ultrasound-guided fine-needle aspiration biopsies, compared to seniors even 5 years ahead of me. Because of an aggressive push by mentors and teachers, and a change in the syllabus of the fellowship programs, thankfully we got a lot more training in this area. I remember the times we practiced on chicken breasts, looking for the little olive hidden somewhere in the flesh. By the time my classmates and I graduated from our fellowships at WFMC, I had already done 84 thyroid biopsies.

It's not too technically difficult to do, but definitely takes practice knowing exactly where to put the probe, and where to stick the needle. I found this video on Youtube; similar to what I do, though I always use the ultrasound for guidance. The numerous publications have made it clear; the diagnostic yield improves greatly compared to palpation-guided biopsies.

It's handy being able to check out the thyroid in real time. After all, your fingers can only be so sensitive, and you can't really feel microcalcifications or appreciate the microvasculature. And if you've ever tried to read someone else's ultrasound images without real-time benefits of being able to move the probe up or down, you know how difficult it is to know exactly where you are.
It's my 6th week at my new practice, and so far I've done 14 ultrasound-guided thyroid biopsies. It's sometimes complex, deciding who you should biopsy and who you shouldn't. In younger patients with a hypoechoic, irregular nodule with microcalcifications it's a lot more obvious, but if your patient is older and has multinodular goiter with one suspicious looking goomba, but is likely not going to live for another 10 years, sometime it's a judgment call. Not mine, but the patient's. I tell them honestly; worst case scenario they have a focus of papillary thyroid cancer, but it's likely not going to kill them before their natural deaths.
The other challenge is not getting a slam-dunk 'positive for malignancy' or 'benign' report from the pathologist.
If you get a 'nondiagnostic' report (which occurs in 5-10% of cases, a limitation of the procedure) then you're back at square one. Do you rebiopsy? If so, when? Do you just monitor with U/S? Or do you consider lobectomy?
Or, the one I consider the bigger pain-in-the-ass is the 'suspicious' report. Ie, suspicious for follicular neoplasm, or something to that effect. It's a fact. The FNA is a powerful tool, but cannot distinguish a follicular neoplasm from a follicular carcinoma. The distinction is made from histology, evidence of vascular invasion. Something you just don't see with cytology. And you know that chances are, 85% of these suckers are going to be benign, but because of the 15% otherwise, you usually end up having to send a patient to the surgeon for lobectomy. I got one such case today.
Chances are, 32-year old Mrs. F will have a benign nodule. But, we won't know until the surgeon takes out a chunk of her thyroid. A minor procedure, but a surgery nonetheless, and something I wish I wouldn't have to subject my patients to unnecessarily.

But I have to say, it's pretty cool that I have a good friend here, a Malaysian pathologist, whom I'm able to call up on a whim just to discuss the cytopathology reports.

Private Practice

It's a different world, being in private practice versus in academia.

It's probably one of my biggest challenges here, to learn to operate in a different system.

You don't have time for research (maybe a good thing?). Anything you want to do has to come out of your own time. My work from the lab (2007) just got accepted for publication- I'm thinking that's probably going to me my very last publication, unless I can find time to write papers here.

You get a lot less patient time. Something that I don't quite fancy, but I suppose I've been pampered as a fellow. After all, 60 mins for a consult is probably too much. Here I get 45 mins for a new patient and 30 mins for returns. Some of my colleagues do it in 15 minutes. And if I decide to biopsy a thyroid, I somehow have to squeeze the procedure into my alloted time.

You learn to be real succinct and to the point. And yet to be thorough in your clinical notes. Because you realize that how much you get reimbursed has more to do with how well you document your notes, and not what you actually do. If you spent 60 with a patient but don't chart the details well, you don't get paid fully for what you bill.

And here, pharmaceutical reps are actually welcomed. Coming from WFMC, this was a total opposite. Reps were hardly seen on campus, and sponsored activities and drug samples were big no-no's (no offence to any reps out there). Only because the Mother Ship said so. Here, as much as I think the drug companies are making too much money from my middle-class patients, I've given away more free drug samples in the last month to patients with financial problems than I have ever as a physician. You realize that everything has their place; and it's all a balance.

A mentor once told me how 6 years of residency and fellowship never prepares you for the realities of being in practice. How, while the medicine is the same, it's altogether a different world.

How true.

My grand-uncle passed away today.

I got an email from my family last night about how they found him unconscious. Initially though to be a cardiac event, imaging studies apparently showed a large intracranial bleed. A hemorrhagic stroke. The doctors had recommended emergency evacuation, perhaps by burrhole surgery?

Except that there were no neurosurgeons in my hometown, and for some reason, they had trouble getting him transferred to KL for surgery. Something to do with lack of beds I was told. I had to urgently try to contact LP, whose father is a neurology professor in one of the hospitals, to try to facilitate things. Because, if the pressure builds up enough, brainstem herniate results in death.

Sadly, things were not to be. I don't have the details of what happened yet except that by the time he got to GHKL it was too late.

There's always been a generational and cultural gap between my grand-uncle and I. He spoke hardly any English, while I spoke no Mandarin. He was a Chinese-medicine physician/acupuncturist, while I'm an Western-medicine physician. And yet, he was always keen to impart onto me his knowledge of acupuncture. Perhaps, to keep things flowing within the family. Though I'd spent some time observing him at his clinic, it's difficult to learn something new when even the basic concepts are so vastly different.

Secretly, one reason why I enjoyed meeting him was because in so many ways, he reminded me of my late grandpa (his older brother) who passed away 10 years ago while I in Canada for medical school. They were from the same generation, and while my grandpa never lived to see me graduate from medical school, my grand-uncle did. So perhaps it was my connection to grandpa. They both came from the same generation. They dressed the same, looked similar, and in a way, had the same scent.

It's strange, that his first wife passed away just last month from complications of a stroke. And it's strange to think that just 7 weeks ago we were having dinner together, and he was saying how proud he was of me. Just 7 weeks ago, when Kristin's dad was having sciatica, grand-uncle graciously gave him a treatment of acupuncture.

My biggest fear, by far, being here and doing what I do, is not being able to help in moments of need, not being able to be with my family in urgent times. This, and another event last week, were just sore reminders of the downsides of being half a world away from my family. It's tough, and I hope every single day my family understands and supports that.

Goodbye, grand-uncle. I shall miss you dearly. Yet, I imagine somewhere in a different world, there is a joyous reunion between two brothers, who have not seen each other in 10 years.

Introducing Claudia...

Finally...

After 2 years, I've finally made my decision. I have been itching to upgrade Veronica (my Honda) for some years now. Some of you may recall my posts about my two top choices: the Mercedes-Benz SLK and the Porsche Boxster. And if you've ever wondered about the results of the poll, most of you readers suggested the Porsche over the Mercedes.Both cars cost about the same. And both beauties are German. But the two cars are worlds apart. I've test driven them several times, every single time I'm torn.

The Porsche 987 (Boxster) is a firstly a sports car. Handles well, and with a mid-engine design, is well-balanced and takes turns as though it was running on tracks. It also emits a strangely arousing, deep-throaty growl, eminating from just the back of your seats. The engine is situated right behind and under the seats- only the mechanic would be able to get to it. Which explains why the Porsche has front AND back trunk space. There's no mistaking the roar of the flat-six engine. And so, one may feel that it is less comfortable, noisier, for long-distance drives. Options cost an arm and a leg. Four hundred bucks for just the color Porsche crest on the wheels? And don't even ask about the Bose sound system, or the hardtop.

The Benz however, is first and foremost, a luxury car, and a sports car second. It's a totally different animal. You see it in the sexy leather upholstery; the shiny metallic parts in the cockpit. This car is made for comfort. The clever Airscarf system (basically a heated airvent on the headrest), the ingenious folding hardtop that changes the coupe into a roadster in 22 seconds. The built in bluetooth and Ipod integration kit. The softer, more comfortable suspension. This is a more forgiving car should you decide to take a 6-hour drive to Chicago. But, a Porsche this is not. It's akin to comparing James Bond to Indiana Jones.

And so, after 2 1/2 years, and after perusing hundreds (I kid you not) of review websites, looking over Porsche catalogs and collecting the Mercedes SLK catalogs from the years 2006, 2007, 2008 and 2009 (again, not kidding) and having too many wet dreams about both cars, I finally bit the bullet.

I bought myself a Porsche Boxster, and traded in Veronica. A tough decision, one I hope I won't regret, but simply put, the Porsche just looks a lot better than the SLK. And it's always been a dream of mine to own a Porsche.

Kristin and I named her Claudia; comes with some options I really fancy- the bi-xenon HID lights, onboard trip computer, Bose sound system, and the bonus, a removable hardtop for less ideal weather.

And yes, yes, I've heard about how the Boxster is the "poor man's Porsche, go for the 911 instead" sphiel, but the short version is, I can't afford a 911, so enough of that. After all I'm an endocrinologist, not a plastic surgeon.

We have a few more months before the snow comes, so I hope we get to enjoy enough with the top down. Soon I'll have to be getting snow tires- I hope this car handles well enough in the winter with snow tires on, otherwise I'm going to need to buy an SUV next!

I pick her up from the dealership tomorrow. Pictures and videos to follow, I'm sure.

First call

I saw this while rounding on patients the other day.

I thought it was pretty funny to have Endocrinology, the cardiac cath lab, the Wellness Center (gym) and the Golden Arches to be on the same list in the elevators.

Ironic, or perhaps job security?

I just wrapped up my first week of call today. While I can't say it was horrid, it was more than I had mentally prepared myself for. I had thought that days of call was over after fellowship, but no. Not only did I have to cover my hospital, I was oncall for 4 hospitals! That meant frequently driving around between hospitals to see patients, and learning the system for different hospitals. I almost had a breakdown Thursday when I was tired and hungry and was dictating a long note on my last consult at 8 pm (started work 730 am that day), only to hit 5 on the phone out of habit (5 was the 'dictation pause' button for the other hospital) only to find out in this hospital, it was the 'end dictation' button. I was promptly disconnected. Frantic, I had to call the operator to speak to the transcriptionists who were very understanding, and promised to merge my dictations.

All week I was on edge, kinda like you're having an anxiety attack, with that tinge of chest tightness, anticipating the pager to go off.

I'm just glad the week's over. It's back to clinic for the next 6 weeks, until I'm oncall again next.

Coming soon to a theater near you....

September 5th 2008