Enough is enough

Today I felt like a parent punishing a child. And I felt like I was going against the motto under which I was trained: The needs of the patient comes first.

But this time I felt that the lesson was necessary. I really do.

This was a 27 year old man I diagnosed with type 1 diabetes 5 months ago. He wasn't happy that I gave him the label. He wasn't happy that I told him he'd be on insulin for life (I can't blame him). His mother reported that he was in denial for a while. And perhaps out of frustration, or perhaps being passive-aggressive, or maybe he had a good reason to: He didn't show up for 2 of his appointments to see me. And skipped another appointment with one of the nurses and diabetes educator. And came late for another 2 appointments.

And so today, he showed up 30 mins late. I was still around though my nurse had already left for the day. And selfishly to an extent, I had a racquetball game to go to. Our clinic policy is if they are 15 mins late without calling then we consider that a no-show, so it didn't have to see him. I could have seen him (perhaps getting to my game late) if I wanted to. But perhaps to teach him a lesson about respecting my time, and not to take up other patients' precious time too (since latecomers almost invariably lead to my seeing other patients late), I refused to see him, and made him reschedule for a future date.

Perhaps it was harsh (and selfish?) of me, but really, he's done it one too many times. It has to stop. And so I hope the next time he comes, he comes on time.

Lucky Number 13

I just got the good news this week.

My 13th manuscript was accepted by the Journal of Clinical Endocrinology and Metabolism, probably something most endocrinologists consider to be the authoritative journal. This will be my first (and last) publication in this journal; my others have been in lower-impact factor journals.

This probably marks the last of my research pursuits from my alma mater, and I'm not sure when, if ever, I'd pick this up again. Yes, I do have a thyroid nodule project in the pipeline but that's been in the pipeline for the last 2 years and I've totally lost all momentum on that (any medical students out there wanting to pick this up?). And I've realized that it takes a lot to do research.

• Research support- a good library database, a good mentor, statistitians, and funding.
• Time- something we had more of in fellowship since research was built into the program. Something some academic centers offer. But alas, to find time to do research in a private-practice setting is probably not feasible. Not when you're seeing up to 20 consults a day.
• Challenge- probably the kiasu guy in me speaking, but I think it's true. Many of us who are in larger academic programs are constantly challenged by peer-pressure. People around you are doing research, are presenting at meetings and publishing in journals. That drives you to perform. I know the peer-pressure was sickeningly stressful initially, but later I've realized that it's driven me to perform more than I ever thought possible. Not that I'm competing with anyone in particular, but it does challenge you to do more. And now that I'm no longer in an academic institution, where now no one publishes and no one cares, I'm ashamed to say I don't feel pushed to publish (well, good or bad thing, I guess).

So, unless I surprise myself, or unless my stale projects get a new lease in life, this will probably be the last paper I'll write. Incidentally, this was a retrospective study looking at whether primary hyperparathyroidism increases the risk of acute pancreatitis. In this study (contrary to most other published data) we found no association.

NICE-SUGAR

The highly anticipated NICE-SUGAR study results are finally published. This study was aimed to answer the ever-evolving question of how 'tight' should glucose control be in the ICU setting? After the Leuven study was published in th NEJM in 2001 suggesting a mortality benefit, many intensive care units adopted their very strict goals, of keeping the glucose less than 110 mg/dL. 5 years later, the 2nd Leuven study (also published in NEJM) did not show a similar finding but this did not seem to deter many people from aiming for such a low glucose goal in the ICU. One reasoning was that the hypoglycemia seen in the intensive group was considered to be under controlled conditions and were 'minor'.

The NICE-SUGAR study seems to blow the earlier findings out of the water: The investigators found that patients randomized to tighter control (glucose 81-108 mg/dL) had a higher 90-day all-cause mortality rate compared to conventional control (less than 180 mg/dL). While the causes of death were similar between groups, the intensive group did have a higher cardiac outcome, suggesting that hypoglycemia may very well be a factor.
Many endocrinologists and intensivists have been holding their breaths anxiously awaiting the results of this highly anticipated study. With these findings, we may very well have to rethink our approach to treating ICU patients. It'll be interesting to see how ICUs worldwide respond to this study.

The 10-Lb Mystery

Here's one of the unexplained mysteries of the cosmos: How can a 12-pound Shih Tzu produce 10-pounds of poo?
It was a nice day, and Kristin and I were planning to have the neighbours over for a block/housewarming party. And because there were going to be kids running around, we didn't want anyone to accidentally fall into poop, and decided to go pick up after Chloe. Only to realize in disbelief how much crap there was. The possibilities? The neighbours dogs have been sneaking over to take dumps? We've been overfeeding our dog? Our dog (like her master) is just full of shit? (or maybe we just haven't cleared our yard for too many days?)

Judging by her look, she knows the answer to the mystery. But she's not telling.

Congratulations!

It's official. My sis got her first choice for residency: Internal Medicine at my alma mater. Naturally, I'm very proud of her and know she'll do well, though there will be tough days ahead. At least she'll be only 3 hours away from us.

Not just that, this year, TWO Malaysians got into the same class. MY, one of my blog followers, got in too.

Congratulations to the both of you. This will mark the start of a new chapter in your careers. Make the most of it.

(And a piece of advise to those of you about to embark on post-graduate medical specialization: Eat and sleep and lepak all you want before internship begins. For when July comes, social life as you know it will ceast to exist)

Contraband

Okay, I think I'm a rather 'clean' guy. At least from legal standpoint. The one other time I actually broke the law was when I was driving 110 89 mph in my old Honda (got me a hefty speeding ticket that day). But anyways, that aside, there is something I do illegally, on a routine basis, I'm ashamed to say.

And you know what? Before you go shaking your head and pointing your finger at me, go take a good look at yourself. I daresay 99% of EVERY EXPATRIATE MALAYSIAN I know have at least once indulged in this activity.

The smuggling of contraband out of Malaysia.

Drugs from the Golden Triangle? Pirated software? Tsk tsk. That's for simpletons. Ladies and gentlemen, this is what I'm talking about: Food. Glorious, PRICELESS Malaysian food!

And thanks to Buddy's parents, who snuck in Tow Sah Piah from Penang, who then mailed from Minnesota to me here, I'm in heaven!

Every trip home I make, I make sure I leave plenty of room in my luggage for packs and packs of foodstuff. Though most are processed and probably legit, some such as kaya (coconut-egg jam) probably aren't. Though my own mom wins the prize for BS-ing when the customs officer in LA asked her suspiciously what was in Auntie Rosie's Kaya, and if contained egg. Mom kept a straight face, and said, "No eggs, this is coconut jam".

This, with an obvious picture of an egg right on the container itself. The officer must have been a smart one to not mess with my mom. Don't mess with my mom.

It's true. Ask any Malaysian what they miss most about home, and 'Food' probably ends up within the top 3. I have rackfuls of Brahims and Maggi spices and curry mixes and whatnots. And being priceless, the expiration dates on the packaging is usually ignored. I tell my wife these are merely 'recommendations'. Kristin values her life, and our marriage, and she knows better than to toss my expired Malaysian foodstuff.

So, if you're Malaysian and you're now based outside of Asia, before you judge me, go check out your pantry and I'll bet you have what I'm talking about.

(Psst, wanna trade some year-expired Ayam Masak Merah mix for some satay sauce?)

A Zen Moment

I had a spiritual moment when I was with a patient last week. It was late afternoon, I was tired. Mrs. H was the last patient of the day, intentionally scheduled so because she spoke no English, but rather some Ethiopian dialect, and so the consult was expected to take more time.

We used the language line, a pretty neat service where we use a telephone interpreter. Except these things take forever. And there we were, late Friday afternoon, when I was tired, and crabby. I was trying to explain to the patient what Grave's disease was, and how it may affect the pregnancy. I was trying to explain how I planned to treat this. While using a telephone speakerphone that was neither clear nor picking up our voice well. And as the consult dragged on, I tried to be patient but I admit, it was tiresome. Especially that late in the afternoon and you're trying to get your work done.

And then I caught myself taking a step back (not literally), and looking at this Ethiopian couple, half a world away from their homeland, with foreign and strange-looking people who didn't speak their language. They were probably homesick, and missed their culture. They probably felt out of place. And then for some reason I thought of my mom and dad. And I pictured them in a doctor's office in some foreign land, with some kwailo who spoke some gibberish language. And I thought how if it came to that, I'd want that doctor to treat them kindly, with the respect and patience they deserve.

And with that thought, a sudden peace and calmness came over me. Mrs. H was my last patient, after all, and so we took our time. Ensured she understood every word I said, and I understood hers.

I drove home 30 mins later than I had planned. And yet, inexplicably, felt relaxed and even hummed a tune during the drive, thanking the Guy Above for the gentle reminder of what I'm supposed to be doing for my patients.

It was a Zen moment, and it felt wonderful.

More Thoughts on Residency

I got this email from J recently. Apparently I have gained some notoriety in my alma mater and some of the students still follow my blog (despite what they said, I did NOT pee in that SGL room!!) :

"What I wanna ask is what are the chances of an IMG from Seremban to enter to for residency program in US? I am currently in sem 4, and I am doing IMU-Seremban"

There is no short answer to this, and certainly the answer will vary for every individual. There will be program factors, and individual factors. And there is something called luck.

Program factors may include:

• Specialty (how competitive, how popular)
• Location (big city vs small town)
• Academic vs nonacademic institution
• Ranking/reputation of the hospital

Individual factors include:

• USMLE Scores (and despite what one might think this is not the only thing programs consider. I've had many readers tell me they were going to give up applying because their scores weren't good)
• Letters of reference
• Research background
• Medical school performance
• Ranking of medical school

Obviously, being a 'young' medschool, the many private medical universities in Malaysia (IMU included) are unheard of. And it's true that to an extent this may affect a candidate's application, since the residency programs may not trust the quality of the product (ie student), or the letter of reference. But having said that, being an IMG does not mean one is inferior. I am very involved in the medical school teaching here, and let me put it this way: There are good and bad IMG applicants; likewise there are good and bad US trainees. I have worked with some final year medstudents here who have impressed me (well, perhaps only 3), while many have induced episodes of spontaneous hematemesis and thoughts of suicide by poking my eye out with my pen.

So, to all the IMG (especially IMU) students out there who are fearful of trying to get into a residency in the USA: Unless you try, you won't know what you might get.

It's a fact: I applied for my residency at Mayo almost as a lark. I needed one more program to complete the list, and didn't think that they would ever even consider my application. But I thought, what the heck, since I had one more spot...

And yes, I know of at least one IMU-Seremban grad who got a residency spot here and is paving the way for the rest.

To those out there nervously counting down to March 19th (Match Day), my dear sister included, good luck with the match, and do look forward as the next few months will mark the start of the next, exciting chapter in your professional lives.

On Personalities

What does one pick when they choose their doctors? The number of letters behind one's name? The reputation of their medical school? How many papers they have published, or how many research grants one holds? How about something as intangible as personality?

One thing I have to constantly remind myself is, in doctoring, as in life, personalities differ.

Some people get along, some people don't. Probably applies to the physician-patient relationship too.

I've 'inherited' several patients from my colleagues, patients who no longer wished to see them. Why, I don't know, and didn't wish to ask. It certainly wasn't a lack of knowledge or clinical judgment, as some of my colleagues are pretty straight-shooters. I've also gotten some pretty positive feedback from some of my patients, here as well as from Minnesota.

However, something tells me I won't be seeing that young lady back anytime soon, the one I saw on Friday. Not that we had a disagreement or anything like that, but just I thought the meeting stayed very cold, very formal and very very guarded. Judging by her body language, I'm not sure if she felt like she trusted me. I can't say I did anything less or more for that patient than for any of the other patients I saw the last month for Graves' disease. But I did spend part of my weekend wondering if I might have done something to have made it smoother?

It got me thinking though about the above. I guess when it comes to finding your doctor, besides the plaques on the wall, the board certification, the experience, personality really does matter. Some personalities get along swell, while some don't quite fit as well. Just as how I didn't like that Mercedez car dealer I was working with last year (which probably became one of the dealbreakers for me in my final car decision) just because I didn't think he understood where I was coming from, I'm sure this is something too that people consider in choosing someone to remain their primary healthcare provider.

Me, I try to use humor to make my patients more comfortable. I also try to remind them I'm human; I have no qualms in telling them 'I don't know'.

And so, I sometimes have to remind myself, that while I'm thankful I get along great with a majority of my patients, and while I'm flattered that some others pick to see me after having seen other providers, I have to accept that there are and always will be patients who think at a different wavelength. And to not get too bothered by that.

It's after all, personal.

A Silly Consult

Okay, I know I shouldn't be making an issue of this especially when economy is bad, and I should be thankful that people are still referring their patients to me...

... but this one really takes the cake.

I got a consult to see a patient. For tachycardia. And the winner? (drum roll please...)

From a cardiologist!!!

Sure sure, some endocrine disorders can cause a sinus tach, but still... sending me a patient with tachycardia without any testing seems kinda silly. I'm tempted to say in my recommendations:

Have patient see cardiology

Dr. Hunk

You know you're a popular hunk of a guy when....

You have two females fighting over your socks. (this was one of my favorite pictures; thought I'd share this. And no, my wife doesn't make it a habit to chew on my socks. And I'm obviously being facetious about the hunk part)