Surprise Surprise

Allan (not his real name, duh) had his surgery Friday. The surgeon made a courtesy call to let me know post op that he was doing well. He also called to give me a hard time:

"You saw this guy for a problem with his nuts, and you diagnosed him with thyroid cancer??? WTF???" (this surgeon is a friend of mine)

Yea, I was surprised, too. Tip to the medical students out there: Don't neglect your physical exam.

I saw Allan initially for hypogonadism (probably related to an old testicular injury) over a month ago. As always, you do a good exam, which includes checking the family jewels in these cases. Now, as an endocrinologist I always also check the thyroid, but was unprepared to find a pretty decent-sized but previously undiagnosed thyroid nodule. It was pretty hard too, clinically suspicious, so I had him return a couple of days later and performed an ultrasound and fine-needle aspiration. The sonographic features were fairly classical- hypoechoic with increased vascularity and microcalcifications, so I wasn't overly surprised when the pathologist called me up a few days later and gave me the report: papillary thyroid cancer.

I saw Allan in the hospital while he was recovering. He looked great and I assured him that I expected him to do really while though we would need to monitor things closely in the next several years. Gave him a gentle reminder that in all probability his smoking probably puts him at greater risk than that 1.1 cm focus of thyroid cancer that now hopefully has ceased to exist in his body, but we will know at follow up.

But yes, neither one of us did expect to start off seeing a patient for a problem with the nuts and to end up with a problem at the other end of the body.

Hah! 30.6 mpg! And they said Porsches were fuel-thirsty animals. Eat your hearts out, Toyota Prius (erm, not really, this isn't any basis for comparison)(and dear readers, never take cellphone pictures when car is in motion- I was at the lights).Okay, granted, this was unusual in that I did a lot of highway driving this week. And was so very light-footed that 80-year old grannies were probably faster than I was. And the traffic was pretty good so there wasn't a lot of stop-go traffic, and drove with the top up all week. Still, call me frugal, but 30.6 miles per gallon highway on REGULAR, not premium gasoline for a Porsche Boxster has gotten me pretty impressed (yes, premium gasoline is recommended but the car does come with a knock sensor that supposedly adjusts to the octane rating, and I've checked out the forums and no one's had any problems yet, and I've done 89 octane for the last year). I suppose it's a good thing I didn't get the Boxster S.

But don't get me started on being frugal with gasoline- you'd never believe what a couple of Asian college students would do to stretch their money. I remember those college days when Alvin and I would car pool and we'd literally drive in the smouldering 29° C heat of equatorial midafternoon Malaysia with the air conditioning off, just to maximize our mileage.

Being Professional

Being a doctor requires a person to sometimes have God-like traits sometimes. One includes one to not be judgmental. I was involved in on and for obvious legal repercussions will be vague.

I was asked to care for a patient who was involved in the manslaughter of a person.

Though I believe I acted professionally and provided the best medical care possible, deep inside me, I couldn't help but feel bitter for the family who lost a loved one over the weekend because of this patient's inactions, and also ironically for this patient's family itself who has to now forever live with the scars and the social stigma. I felt for the victim, who was almost my age, who had a family to support, whose family was now left with their hearts ripped out. I thought about my wife, my parents, my siblings, and how it would be if something had happened to be because of someone else.

As a doctor, you bite your tongue and try your darnest to not let any actions show your personal opinions as you talk to the patient and ask about their medical history and perform the physical exam. And as you examine the patient, you realize that you are touching the hands that caused the death of another human being just hours ago.

And so, I did the best I could, as a doctor treating his patient. As professionally as I could. God help me.

Horror

Horror is:

Coming home after making rounds in the hospital to find out in the bathroom that you left your fly open.

I got one of the weirder calls tonight oncall.

It was the hospital PR director.

"Uh oh. Someone must have made a complaint about me". Seriously, that was my first thought.

And then the egomaniac kicked in: "Someone must have given me a big compliment".

Seriously, those were my first two thoughts. But no. Apparently a television newscaster wanted to interview an endocrinologist regarding a recent event. And so she contacted the hospital who called the oncall endo: Mua.

I did a 5 min phone interview (unpaid, and unrecorded, of course). I doubt much of that material will see light of day, but that was certainly one of the more interesting calls I've ever gotten while oncall.

My Exciting Weekends

Sometimes when people ask, "What did you do over the weekend?" I'm almost afraid to answer.

Perhaps people think we're out clubbing? Or out racing the Porsche on the track? Perhaps to some exotic high society event?

Erm. No. Mainly spend my weekends doing yardwork. Yup, you heard that right. You see, growing up I never understood why people voluntarily did yardwork, or mowed the lawn. I saw that as something boring, old people did (sorry, dad!)(then again, perhaps this is a sure sign of aging for me). And then, once you own your first home things change. You want things to look presentable, even pretty. You take pride in your property (ie kiasuism).

Weeds don't belong on your yard (and we all know how those damn weeds grow like, well, weeds), and so the weeding seems to be neverending. And, dare I say this?- I find housework pretty relaxing. Your mind is free to roam and wander and you go about in your ahpek singlet and shorts and slippers (something my wife reminds me isn't exactly considered cool here in the US, or probably anywhere else), go on your hands and knees, and just pull out those weeds. Little else can give a man so much power, as to be able to determine the destiny of the common weed. Then again, you rip one out and another zillion takes its place a week later; I imagine the roots contain millions of dormant pupae that are awakened when their host is being exterminated?

One other really fascinating boring thing we've taken into is growing our own garden. Not a lot of produce this year this this was our first attempt, but we have a pretty good crop of cherry tomatoes, sweet basil, thyme and oregano going. It's pretty cool to be able to just walk out to the deck, pluck what we need, and use our own stuff in our cooking; for some reason it tastes sweeter and feels more rewarding. Never mind that these things cost just, what, a dollar, in the stores?

Some weekends we do try to take advantage of the local fares and festivals that are going on. Take the corn festival in a nearby town last weekend, where they basically bring corn by the truckloadfuls, steam them, and you get as many as you want. Complete with fair food, music entertainment and stalls selling trinkets.

So there you have it, an idea of the exciting things Vagus does on his weekends. Perhaps it's a sure sign I'm getting old(er) but sometimes I do enjoy these simpler things in life.

And I'd much prefer this, than next week when I'm oncall.

The Rule of 10's

I suppose it was about time.

I saw this case recently, of a patient with a history of phaechromocytoma (UK-spelling intentionally used). This was resected over a decade ago, and she was then lost to follow up. Has been doing well, totally asymptomatic. And then someone recently decided to do some screening tests. Her serum metanephrines were through the roof.

When I saw her, I repeated the test along with a 24-hour urine study, since these are often prone to false positives. Again, over 10x above normal. An MRI abdomen was negative, so I ordered an MIBG scan which came back positive for multiple mets to the skeleton.

Phaes are rare; they say most practicing physicians may see only one in their careers. Yet, despite the rarity of this, all exams seem to contain at least one phaeo question. And all medical students know the Rule of 10s for phaeos: 10% bilateral, 10% in childhood, 10% extraadrenal, 10% metastatic.

This would have been probably my 12th case in my career. Simply by probabilities I suppose it was time I saw my first metastatic case though I have been dreading this day. I will not have much to offer this patient though I am hoping that a bigger, academic medical center may have some experimental trial they can enrol this patient in.

The Hot Wife

So I found myself in an interesting situation. It was a case that went in a convoluted direction and I'll spare you readers the details. But I was seeing this patient who was initially sent to me for evaluation of hypogonadism (low testosterone); he had presented to his primary physician complaining of low libido. He came back to me to review results, this time bringing his wife along for the meeting.
Now, she was a fairly striking woman probably in her late 30's, who dressed well too. As we were talking about the numbers and the effects a patient may experience, Mr. P burst out, obviously frustrated by his symptoms:

"Come on, Dr. V. Look at my wife! Don't you think she's hot? Shouldn't I be more turned on?"

Now, is there ever a proper answer to that question?

(I took the coward's way out and didn't answer the question- just told him treatment should help with the sex drive)

Difficult Patients

I do believe most patients out there are sincere and want to help themselves. But out there, I am certain, are too the people who take advantage of the system.

• Like that patient who is on 'disability' because of her diabetes; I asked her what she did over the weekend and it included a pretty physical camping trip. And yet, for reasons unclear to me she was able to talk her family physician into certifying that she was 'disabled' and is collecting benefits while leading a fairly active life
• Or that patient who got irate at me and had her husband call to yell at my nurses, because I wouldn't write a letter to her employer because she wanted to wear tennis shoes to work. Reasoning: She has diabetes (no neuropathy) and her regular dress shoes give her blisters. She wasn't too taken by my suggestion to get better fitting shoes.
• Or that patient who wanted me to be a witness in a lawsuit blaming his one-week-use of Zyprexa in causing his type 2 diabetes. He said nothing of his underlying BMI of 44.
• Or that diabetic patient who talked me into writing a letter giving her a couple of days off work because she was unwell. She didn't have a family physician, and I was silly enough to agree to write that letter until she found herself a primary care provider. Next thing I knew, she thought she was still too 'unwell' to go to work on day 3 (because her blood pressure was 144/90) and urgently called my office to have me issue another letter with a new date reflecting her extra day or otherwise she would be fired.
• Or that patient with Graves' who wants to work half days for the next 6 weeks while the Methimazole took its time to work. She's too stressed out to work full days, apparently.
• Or that patient who has since recovered from her hip surgery 7 months ago, yet still really enjoys parking in the disabled parking spots.

While I do try to sympathize and offer the best help I can, and try to see each patient with an open, nonjudgmental mind, sometimes when you run into a few bad apples who so take advantage of the system you get jaded, and can't help but to be a bit cautious. So now, when patients bring in all these papers, unless I've gotten to know them well I'm more inclined to politely tell them no.

Health Reform?

Certain catch phrases seem to be in-vogue. Last year it was 'bailouts'. Now, it's 'Health Reform'.

Pavlova asked me the other day what I thought of a government funded healthcare plan, and what I thought of Obama's proposals.

I guess I'm still undecided, frankly speaking. One reason being, although I should be more aware of what's going on, I haven't really kept up to date with the proposals he has.

In concept, a national healthcare plan sounds good. We eliminate the problem of the uninsured, or the underinsured. God knows this is a problem in this country- just last week alone I was lamenting to my nurse about how frustrating it is for my patients to not be able to afford their meds. I had 3 patients last week alone make a conscious decision to drop some medications just to 'stretch things'. As a doctor I felt helpless except to listen to their woes, and perhaps to offer them samples. And I know when I was running the free clinic back in MN, we never saw any lack of patients.

The problem with a centralized government funded plan, is how this would affect care for everyone else. Think about it; if as it is you sometimes have a waiting list to see a specialist or to have a procedure done, how would you feel if suddenly you double or triple your wait time, when suddenly everyone was in line?

People here always say, "If Canada could do it, why not the USA?".

Well, I remember Ben, a friend in medical school who needed knee surgery- he waited 3 months just to get the MRI scan because it was 'elective'. How would people feel about it? Also, many are concerned that if you are not concerned about paying for your care, would this lead to abuse of the system? Perhaps this is ungrounded, but I know we saw a version of this where I used to work- the employee health coverage was so good that people started going to the ER for coughs and colds, just because it was more convenient to do it rather than to take time off during office hours to see a physician in his office.

Furthermore, as a friend put it recently, just taking an objective step back and thinking about it: If someone who pays $100 a month for insurance and the other person doesn't, how can you expect to provide exactly the same level of service to both? Let's not talk about medical necessity, but about the other elective or nonurgent concerns; same type of hospital room? Same wait time for a consultation? Same access to imaging? How would such a system survive? Would you bankrupt the system giving the most excellent care to both groups? Or do you bring the level down enough to be financially viable and have the payers complain about having to share his room with 3 other patients?

Perhaps Obama's recent proposal for a two-tiered system may very well be a solution. I know we in Malaysia complain of a two-tiered system, but this may address some of the potential problems people anticipate. After all, Canada's federally funded system is not without it's problems. And while I have never worked in the UK, I've certainly heard plenty of complains about the NHS.

Honestly, I have no answers. I just know the system seems broken currently, and I do what I can to give good care to my patients.