I'll start off by saying I really, really wish there were other options. I do. I wish we had the technology, the capabilities, to monitor diabetes and to treat type 1 diabetes without having my patients resort to pricking their fingers 4 times a day, and injecting insulin. Because the other alternative is simple: death.

I really wish we had options. But alas, we don't.

My last patient of the day was a struggle. Strangely enough, they come late Friday afternoons. I diagnosed her with type 1 last month, and she was back for a review, since I was concerned she wasn't accepting it well. Fervently refused the fast-acting insulin so I started her gently with just the long-acting basal insulin to keep her out of trouble.

She complains today that she feels like crap. Has been nauseated the last 2 weeks. Feels tired. Tummy pains. Thirst, urinary frequency. I asked her if she has been taking her insulin.

"Only if I remember it. Maybe 2-3 times a week."

What about her blood glucose?

"My machine's broken. The last 2 weeks it read H1 so I stopped checking."

I gently had to point out that it was working fine, that it had been so 'HI' that the glucose levels could not be measured. I suggested we send her to the ER for urgent evaluation, since she probably was in mild DKA.

She refuses. Also refuses to do more than what she is doing now. Will only give the insulin if/when she remembers, and will NOT start prandial insulin. Despite my gently but firmly telling her she has type 1 diabetes, and once the insulin deficiency is absolute, unless one takes insulin, is not compatible with life. She doesn't care. And what irritates me is she has a husband, and a child at home. Even if she doesn't care about herself, does she not care about her family? I couldn't help but think.

I really wish there were painless, less complex options for my patients. After all, it is easy for me, the doctor, to tell patients they need to stick themselves 4 times a day when I don't even give it a thought how many grams of carbohydrates I'm consuming in that croissant, let alone learning to carb-count and self administer insulin. I really wish there were other options. But there isn't, and though I shouldn't judge, I can't help but get irritated by her selfishness.

I've done what I can aside from spanking her like a parent. I've explained the risks. I've presented the options. I've called and reminded her numerous times at home. I've spoken to her family when they last came with her. All I can do now, is to inform the oncall physician about her eventual inevitable emergent hospital visit. And document everything. She is 25, and she is of sound mind. She'll have to make her own decisions.

Gaaahhh

Water. N-e-e-d w-a-t-e-r.

Actually no. With the humidity, that's probably the last thing I need.

I realized it was a mistake dropping the top on Claudia when I drove home today. The other drivers must have thought I was nuts driving without air-conditioning. If I could have raised the top while driving, I would have done it (can raise it only up to 30 mph). Pride didn't allow me to pull over on the highway, and so home I drove in the sweltering heat.

Trying to convince myself that it was cool and enjoyable. As refreshing as drinking a mouthful of pure desert sand. And to think 7 months from now, we'll be complaining of the total opposite. Minus 39° C.
Shudder. A 78 degree difference between summer and winter. KNNCCB!!!!

Dreams

Sometimes your answers really do come to you in your dreams.

I was the primary investigator in a study comparing two different types of thyroid biopsies, in a population of patients who had both types of biopsies done concurrently. It was a project I 'inherited' from a graduating senior, one who had a pretty notorious reputation for not finishing up what he started. Anyway, I spent about 6 months extracting data, analyzing it and finally wrote up the manuscript. We compared the diagnostic rates of method A to method B separately, so see if method B was really any better than the gold standard A. In the (anticipated) final stage, when I sent my paper to the 2 senior authors to review (you know, the kind of senior authors who don't really say anything or help) one of them suddenly brought up a fatal flaw with my protocol. Apparently pathology frequently just mixes up results between the two; he was concerned the results I had extracted may have been contaminated by the other.

Boy, was I pissed. I don't recall too many times during fellowship when I was as pissed as I was then. I was angry, bitter that I had wasted so much time only to be shot down at the last moment. I was so mad that I had palpitations the whole day, my hands shook. I had a lot of trouble falling asleep that night.

Strangely enough, the answer came to me in my dream that night. I remember it well; I was at work, dressed in my black 3-button suit, and I asked my advisor:

"What I came up with a totally new control group? If the results of A might have been contaminated by B, what if I just looked at the composite diagnostic rate, and compared it to an age-sex matched group who had only biopsy A during the same time period?"

It was so clear I might as well have been there in real life. I woke up the next morning excited. You know, sometimes you have ot drag your sorry ass out of bed at 6 am? Not that day; I leapt out of bed in a hurry, wrote down that idea and then got dressed. I marched right into my advisor's office that morning and laid out that plan.

"You know, that might just work! That's an excellent idea!".

Never mind that I had do find another 380 new patients to make up my control group- at least now my project had a pulse again. 10 months later, my study was finally published (yes, it does take that long sometimes, from the time of first submission to revisions to submissions and then final print).

It's strange sometimes, how answers can sometimes come to you in your dreams.

Some Advice

And so the new medical academic year begins. I see it on the face of the enthusiastic, starry-eyed medstudent who shadowed me today. I hear it in the anxious excitement in my sister's voice as she begins life as an intern. Ah, what words of wisdom can I impart?

• The words 'holiday' and 'weekend' no longer exist in your sleep
• You learn to function on 5 hours of sleep every night
• Your new year now begins in June
• Sleep when you can. Eat when you can. There will be no such thing as 'lunchbreak' anymore
• Learn to keep a straight face when you answer the question "Who would like to see this patient" with "Why, yes, I'd love to!"
• A quote from the fabled 'The House of God' By Samuel Shem: At a cardiac arrest, the first procedure to do is to check your own pulse.
• Learn to kiss ass. Really
• There is no such thing as too much coffee
• Never say no to free food
• Treat the nurses nice; they can make your callnight easy, or a living hell. Speaking from experience: a bag of chocolates as a peace offering does wonders

Another wedding

Phew, we're back. And we're exhausted. We were at another wedding; this time it was Kristin's sister's wedding in Kennebunkport, Maine. We took Friday off and flew in to Boston, then drove a couple of hours to the location.

It was a beautiful wedding, in a pretty location. The weather was great and so they had their outdoor wedding (something about burying a bottle of whisky to keep the rain away, I hear). Kristin was one of the bridesmaids, while yours truly was an usher. Came up with the brilliant plan to charge five bucks for the seats and came home a few hundred bucks richer. Just kidding!

Things went well, considering it rained Friday and Sunday but the sun came out in between. We all had plenty of fun, and got all loaded up on Maine lobsters.

The one interesting thing about this town, is that although it's small, it's a really pretty coastal town, with plenty of water activities. So nice, in fact, that George Bush (senior) has a summer home here and was actually here during this time. You'd see the Secret Service crawling around everywhere you went. And because his home was beachfront, they would patrol the waters periodically too.

And perhaps the most amusing thing, was that this was coincidentally his 85th birthday, so the entire Bush clan came over to celebrate with him. And he's obviously a pretty popular guy in town, so there were plenty of congratulatory banners. They call him 'Skip' (apparently a nickname from school) or '41' (for the 41st president- they call Bush Jr 43).

And so what does one ex-President do for his 85th birthday? He jumps out of a perfectly good airplane!!
Seriously. Go Google this or something. Tandem, of course. Some of the wedding visitors were able to watch him perform the landing.

I usually have no qualms on sharing with patients how little I know.

"I dunno..." is something I say pretty readily.

But a couple of days ago, I had a patient tell me he appreciated me for it. The scenario is fairly similar- some physician refers his patients to me for 'fatigue/dry hair/weight gain/lack of interest/hair loss' just because it has to be related to the hormones.

Often, it's a last ditch effort in that the other doctor hasn't been able to explain things. Sometimes, it's just a convenient punt: The endocrinologist will make all your problems go away.

And so, patients come with misaligned expectations, ones I am not able to live up to. And so I've learnt to make it clear- in the appropriate situations I'll screen them for any endocrine disorders. But if things come back normal, I'll have to gently tell them that while modern medicine has advanced far, there are, and will always be, things we cannot fully explain about the body.

Case in mind, this patient had been referred from one specialist to another, by his family physician who won't even return his phone calls anymore. After I told him his symptoms were nonspecific and something I can't explain from my standpoint, he shares: "I just want to move on with life, not have my doctor lead me on a 7-physician wild goose chase". I was one of the few physicians who didn't promise that the cardiologist/rheumatologist/someone else would solve his problem- I just plain said I don't know. We both agreed that sometimes 'no news is good news' and while we may never explain why he feels the way he does, life has to go on.

But I did appreciate his comments, as he appreciate my honesty.

The Wedding

Emotional.

That's probably how I would describe the wedding. It was a beautiful, emotional event.

My buddy finally married his sweetheart, after a 9 year courtship that spanned medical school, residency, fellowship, 700 miles between then for 6 years, and the hardships of esophageal cancer.

It was a day when not only the love they had for each other obvious, but also the love of their family, friends and colleages for them. They are about the more considerate and kind people you'd ever meet, and it is clear they have touched many.It was special too, to have our 'clan' being so involved in the wedding. I was the best man, with the others acting as groomsmen, bridesmaids, ushers, readers, pianist. It felt truly, like a 'family' event. And it was special too because almost exactly a year ago, Buddy was the best man at our wedding.

I daresay most if not ALL of us were pretty emotional during the ceremony, knowing what these two guys have gone through. Myself, my eyes started tearing up when the couple offered roses to the mothers after they exchanged their vows. Somewhere to my right, I could swear I hear Alan, one of buddy's good friends here, sniffing. Alan, a tough, no-nonsense 6 foot tall American guy.

The reception was pretty crazy fun too. The crowds (fueled by the wine, no doubt) made pretty good use of the dance floor, including these 3 leggy macarena dancers.

Bud's first dance was pretty amazing too, and unlike the rest of us who just went out and danced, it was clear they had a well-rehearsed, choreographed dance to Sinatra's L-O-V-E.
The bastard. Made the rest of us guys look bad.

I have to say too though. I grew up watching American TV and you get the impression that the groomsmen get to hook up with the wild bridesmaids. Well, I have only one thing to say to that.
It's all true! Damn, I got to hook up with this hot blue-eyed blonde bombshell and we had a hell of a magical night! Man, I love being in American weddings. Something about these women seeing other men get married that makes them wanna get a guy. Any guy.
This was the chick I hooked up with (Strangely enough, she bears an uncanny resemblence to my wife. I wonder why?)

Buddy's wedding weekend

And we're off to the wedding.

Buddy's long awaited wedding, at which I'll be standing in as best man.

This truly will be a magnificent event- after 6 years of a long-distance relationship of 700 miles. Symbolic of their love and devotion and strength, in the face of cancer.

Pictures to follow- for now I have to pack!

I laughed myself out of my chair seeing this on MMR (referenced to failblog.org). Thought I should share it.

A Tale of 2 Patients

I had a couple of DKA (diabetic ketoacidosis) admissions this last week while oncall.

The first was a 27 year old woman, a professional in a large firm here in town. Presented with DKA and newly diagnosed diabetes, fairly classic for type 1. She was visibly upset at the diagnosis, but after a day of grief, decided to take charge as what she is used to doing at work, do research and was keen at learning how to administer insulin and how to adjust. I discharged her after 2 days and expect her to do very well.

The 2nd case, a lady I've seen 9 out of the 10 call weeks I've been oncall. A 31 year old with diabetes so poorly controlled she's already on hemodialysis and has had 2 coronary stents. She literally comes in with DKA once every month; spends a day being unconscious in the ICU, then when she recovers, becomes one of the meanest and most demanding patients I've known here, screaming at nurses and doctors for not letting her eat a cheeseburger or go out to smoke, while she was still in DKA. She smokes, does drugs and binge drinks. These have been factors in her usual DKA admissions. I saw her sick like stink in the ICU a few hours ago, barely conscious, with an anion gap of 30. I told her a couple of admissions ago, that DKA carries a mortality of 2-4%- if she tries hard enough eventually she's not going to make it. That's 1 in 25 admissions. Tonight, I fear she might be really testing things.

As a physician, you try to be objective and heal. You try to not be judgmental; after all you know no one is perfect. You try to be patient, to not get mad at the patient. But at times like this, you sometimes can't help it but to think that sometimes some patients just don't try enough.

And yet, you know that even if the patient doesn't want to try, you have to try your darnest to help heal the patient. And you pray that God has enough mercy to let your patient get through this, if only just one more time.

Perhaps she'll learn this time.

Disgust

Truth be told, I felt disgusted with myself today.

I saw Mr. L back for review of labs. I saw him a few weeks ago for evaluation of gynecomastia (that's man-boobs, for you non-medical folks) from hypogonadism. I had reviewed his referring doctor's notes, some test results and an MRI scan of the pituitary. I had ordered a few other tests.

Anyways, he was a jovial, if slightly embarassed, 20-year old. He also had no medical insurance. And he mentioned that he got a bill for $850 for my consult and that he was arranging for financing.

I was shocked. Shocked by that amount. But also, shocked and mad at this country's state of medical affairs.

True, I provided the care he deserved, and I billed according to the level of complexity involved. From the physician side of things, that's about it- I don't get to decide how much to charge him, I don't get to decide how much out-of-pocket a patient pays (that's all regulated by some higher power, presumably the feds). Almost all my patients have insurance, so they pay only a small copay. Unfortunately, this man had no such thing, and bore the entire brunt of the medical bill.

So when I saw him back today, I did what I was told not to do; coded the visit with the lowest possible code, something equivalent to a nurse visit.
A few months ago I had asked my supervisor: I had been told it is not up to me whether I can no-charge a patient, even if they have financial difficulties. That simply opens up too many doors for risk of patient discrimination; i.e. why did I give free treatment to one patient and not another.

But it did get me mad thinking- is this how much a patient has to pay out of pocket to see a subspecialist if he doesn't carry any insurance? What are things coming to? Why IS healthcare so expensive? To feed us, the greedy doctors? To pay for the freebies the pharma reps throw at us? To pay for malpractice insurance to protect against unreasonable lawsuits? R & D?

I'm not sure I have the solution to this problem either. People here ask why the US can't adopt the socialist health system of Canada. I recall how some patients had to wait months just to get an MRI for an elective surgical procedure. Ditto for Malaysia- the poor still get healthcare, but at the cost of convenience, time, and arguably, quality (of meds, infrastructure, not doctors).

Somehow the simple code of the doctor treating the patient has gotten way too complicated. You see it in how we do all kinds of scans and tests 'just to make sure' (don't want to miss something and get sued later). You see it in the TV ads looking for patients to join the law firms in a class-action suit against a medication that has saved countless lives but undoubtedly had some side effects. You see it in cities which no longer have obstetricians, because the cost of malpractice insurance is simply too high (some places cost more than a new Ferrari F430 every other year). You see it in clinics that no longer give out free samples to the 99% of patients who need it, for fear of the 1% with ulterior motives who may use that against you.

In that regard, I miss the days when I saw patients at the Salvation Army free clinic. It was simple healthcare, repaid with nothing more than a $5 donation if the patient could afford it, or a handshake if the patient couldn't. I wish I had the time and energy to get back into volunteering.

Yes, I do feel disgusted with myself today.