Pavlova writes in after my last post:

Your point about medicine becoming a business, can it be happening more prevalently in the US because of the state of healthcare? As most of us know, the insurance and privatisation of healthcare is a strong force in the US while other "socialist" countries like UK, which doctors are paid on a fixed wage and when the healthcare is free, one would have a better opportunity to establish a treatment plan that is based on the patient's best interest rather than the dollar signs?

I can't claim to be an expert. After all, I have no basis for comparison; I've never worked as a doctor in Malaysia or the UK, and I certainly can't claim to be an expert in US medical economics. However, I do think this is an area with no clear answers. For one, I don't think the US system neglects the patient's best interest for profit- rather, while it's true that some doctors may put money above a patient's needs, I think this is thankfully the minority.

On the other hand, a free healthcare system may have repercussions. I remember several lectures by prominent UK professors when they came over to present at grand rounds- they shared that the system there is stretched so thin that they have trouble getting routine bone densities for osteoporosis screening (again, this is hearsay- I never got to work in the UK). Rather, if they suspect osteoporosis they feel it is more cost effective to just treat the patient with a bisphosphonate rather than putting that patient through a scan. Likewise, when I was in medical school in Canada (which has a publicly-funded health system like the UK too) I remember Ben, who had to wait 3 months for an MRI of his knee, because it was for a surgery that was deemed 'nonemergent'. So, if you have a public system, the waiting list ends up being very long because of a lack of funding.

Also, when you have a 'free' system, it encourages patients to take advantage of things. I recall the ridiculously good employee health insurance at my alma mater: employees would not take time off to see their doctors at clinic for minor ailments, preferring instead to just pop by the Emergency Department after work for a sore throat or ear infection. Thus, the ED became overwhelmed and the insuror ended up with a bulk of the bill (since ER visits are always more expensive). Eventually, they had to change their coverage to a less generous plan.

Here, while profits may be a driving force, it also does ironically do some good too; most hospitals have the financial resources to be pretty well-equipped. My current hospital has numerous cath labs, 2 medical helicopters, and numerous top-of-the-line MRI scanners and radiosurgical facilities. True, patients pay a premium for medical insurance compared to some parts of the world, but one could argue that the care they receive tends to be superior, too. Also, over here the fear of malpractice lawsuits indirectly force us to give the best possible care, and probably backfires in the process; the so-called defensive medicine. Ie, the practice of getting more tests than clinically (but not legally) warranted just to make sure we don't miss something. It's one of the issues I have with this place, which is real given the sheer numbers of radio and TV ads everyday, promoting a lawyer's service for any injuries you might have suffered. Take my specialty for example- central hypogonadism (low testosterone) is not uncommon, and in most cases is idiopathic (no clear cause). Yet many professional organizations suggest a pituitary MRI to rule out a central lesion. In my 5 years of doing endocrinology, how many cases of this have I seen? 5 or 6. Out of the hundreds and hundreds of MRIs I've ordered. Practising defensive medicine therefore inevitably jacks up the price of healthcare, and doctors do it not to make money but to make sure they don't miss something that gets them sued.

Also, it's a misconception that we get to bill whatever we like and make more money. We provide care, and we code it according to the level of care we provide (usually dependent on risks, complexity, and there is a pretty strict set of criteria for each). The insurance companies have already pre-negotiated with the healthcare systems to pay a certain amount for every level and the doctors have no involvement at this level. This coverage by the insurance companies (and patients may also pay a small co-pay) is the same whether this is to a private clinic, or a not-for-profit organization like the hospital to which I'm attached (at least, that's how I think it works).

So, I don't really know what the best answer is to things. I don't think I'm smart enough to figure out this problem. But I do think the system isn't ideal, neither here nor there. Here, I despise how it costs my patients so much for care, and for medications. There, while it's great that patients who can't pay still get care, what is the quality of it, and how long do they wait? In many ways Malaysia is similar to the UK's (except we have the option of a private-tier): thinking about my hometown, there isn't even a cathlab for emergency PTCA, so public systems aren't ideal as well.

In some ways, I do catch myself thinking, if you want to have the perfect healthcare system, get rid of 1) the doctors, 2) the lawyers, and 3) McDonald's! That way, you cut down on risk factors, and you get rid of the people who mess up the system (McD: I'm being facetious, obviously. Don't sue me!)

There was a fascinating plenary session about treatment of thyroid cancer today. And therein lies one of my frustrations working outside of an academic medical center, and in the real world. And in some ways, I feel helpless about it.

We know that for the most part, patients with differentiated thyroid cancer have excellent prognosis. There is also ample published data from my alma mater that adequate surgery is virtually curative in stage 1 and 2 patients; there is virtually no survival benefit of additional radioactive iodine ablation. Hence, the bias I picked up from there is, low risk patients do not usually need ablation. However, the sonographers there are amongst the best in the world, and if there is disease in a node, they call it. And the surgeons do a good job with the surgery. I131 should not be used as a technique to 'clean up' tumor burden left behind by the surgeon because of inadequate pre-op evaluation. I know, this might be a somewhat debated topic, but the 20-year survival data they published is hard to argue against.

Problem is, outside of large centers like that, you realize you have no control over what someone else does before they consult you. And when the endocrinologist is consulted only AFTER surgery, and when they didn't even look at the lymph nodes before and during surgery, you realize sometimes your hands are tied. And if the radiologist has the blatant honesty to say they don't trust their techs to look at the the cervical nodes, even if you could have, how much weight would you put on cervical sonography? (admittedly I'm not sure if they were also motivated financially to suggest a CT scan for all my cancer patients rather than the cheaper ultrasound). Are you really going to take the risk of not ablating that patient?

In that sense, I miss working in an institution where everyone communicates with each other, and are all in agreement of the best plan of care. In the meantime, I guess I can only do my best and hope I'm guiding my patients in the right direction.

Boston!

Yes, I finally got here after a hair-raising/frustrating flight out. You know it's not good when the pilot starts the day by saying :

"Looks like we're a little low on hydraulics, so we'll have the mechanic come and top it up" only to overhear the mechanic say later:

"I don't know if it's just low, or if it's a leak. There's fluid all over the place!"

Needless to say, whether they topped it up or stuck a piece of gum to plug a leak up, my flight out took off, albeit 50 mins late. Thankfully I was OCD enough to plan for longer transits and I made my connecting.

Anyway, Boston is as I remember it. This would be my 4th visit here (all for meetings, come to think of it). Big, bustling with activity and traffic. Parks, water. And very very expensive. I balked at the US$42 hotel parking sign as the shuttle dropped me off.
I'm reminded that although I talk about being bored in the Midwest, we are really very content and I'm at heart a small-town boy.

I went out for some Chinese food at the food court near the convention center and hotel, which turned out to be pretty good. I just had to share what I found in my fortune cookie:

Kinda prophectic, no?

P/S: Guess what I got for dessert? Double Irony: Tubby endocrinologist carrying a bagful of Dunkin Donuts glazed donuts while attending an endocrine conference!

Off to Boston!

Geez! Done with call, finally (except I start another week in 2 weeks!). But I'll worry about that later; right now I'm just glad to be done. I leave on an early morning flight tomorrow to AACE 2010. And for a nice change this time, I shall be going purely as an attendee, a 'tourist', no presenting research posters. Not that that was a big deal, but it always keeps you on edge and it's hard to relax and concentrate on the meeting when you have this thing hanging over your head. Come to think of it, after having done about 18 posters and 2 oral presentations, this will actually be my very first meeting when I have absolutely nothing to present!!

It'll be nice to meet up with my Mayo colleagues, and some old friends who are based in Boston now. And, if I can find time, I have to hit that Malaysian restaurant in Chinatown!

Happy Birthday, Chloe!

One spoilt-rotten dog:

Chloe turns 2 this week. And don't ask how we know; she loves Culver's frozen yogurt.

2 Lectures and Oncall

Phew.

What a week it's been. Except my weekend isn't over yet- oncall till Wednesday. And on top of that I had 2 lectures to present at meetings. Gave a lecture on thyroid nodules at the Physician Assistants' Society meeting, and did another on intraoperative glucose management at the nursing anesthesia meeting today (I grumble about it, but I'll grudgingly admit that I like giving lectures though I wish it took less time to put together a presentation).

Anyway, a bit of a cheap thrill, but after the lecture this morning, I saw this car in the parking lot of the hotel, and just had to snap a picture.

This was the very first time I came upon the Porsche Panamera in the flesh. This is Porsche's first attempt at a 4-door sports sedan. I've only read about it and seen it on TV, and the styling's been pretty controversial; the longish, bulbous back does seem to give the car strange proportions.

But I agree with the reviews I've been reading about though: pictures don't do the car justice. It looks fugly 2-dimensionally, and it does look a bit better real. Just a bit; now it's just plain ugly, not fugly anymore.

Then again, to it his own; this car is many times more expensive that mine.

I'll admit it, blogging seems to have lost some of the appeal. A lot of it probably has something to do with how I'm out of residency/fellowship in an extremely hectic academic center, and so things are more 'boring'. After all I no longer run codes, or put in central lines. Admit it; my entries in the last couple of years is so much more ho-hum and yawn. You can say it.

A part of it too though, is how I do feel that after 8 years, I've lost a big part of the anonymity. Probably my own asking, knowing how much of an egomaniac I am, but many of you out there probably know me personally, or know where I work, maybe even where I live. And therein lies the problem. There are some things you think and wish you could vent out, kinda like that 5-day old impacted stool that is just waiting to explode into the porcelein bowl. But sometimes you know it's just going to backfire, like how that explosive diarrhea ends up spraying your bottom with tiny brown droplets.

Take today at work, for example. There are so many things I wish I could say, hiding behind the cowardice and anonymity of the worldwide web. I wish I could say I hate my job, except I don't, well, not most of it anyway. I wish I could say I felt that I was making a big difference in my patients' lives, but on some days, I really don't. Without going into detail, it does sometimes feel like you're seeing a patient for the sake of seeing a patient, not because your training, knowledge and skill offers some measure of assistance to the person across the room looking for help. But no, don't ask. We all know how saying too much comes back to bite you in the ass. Admittedly, I have been tempted to start a splinter blog. Kinda like Dr. Jekyll and Mr. Hyde. A more public, happy blog, and a darker, more sinister b*tching blog. Just to get things out of my system.

Except with email, facebook and a blog, I'm not keen on getting started on something else.

Oh well. In the meantime, I'll vent to my wife, and drink some happy juice.

Cheers!

JDRF Walk

I'd call this a resounding success: thousands of walkers showed up for the annual JDRF walk to raise funds for juvenile diabetes. I have to admit, this being my first year I wasn't expecting such a crowd, but yet they came, and in droves. All wearing their specific team T-shirts, some corporate, some family honoring a specific member (presumably someone with type 1).

It was refreshing, seeing so many people walking for one cause, to fund research into a cure for type 1. Perhaps it's easy for me to forget as the endocrinologist, but I did see some thought-provoking posters that the organizers had put up:

"Insulin is NOT a cure..."

'Tis true. We, the practitioners, use insulin so frequently, signing praises of how well it works, and how when Banting and Best discovered this, they saved the lives of millions (since until insulin was discovered and given exogenously, type 1 was 100% fatal). But it's easy to forget that for the patient, we are merely treating their condition, not curing them. But for a disease like diabetes (type 1 or 2, for that matter), cure is a strong word that we never use. Maybe someday, one can only continue hoping for the countless this affects.

Until then, we'll keep plodding and walking on...

Now someone get me some oxygen!

An interesting consult

I was reviewing notes for one of my nurses (we supervise several nurse practitioners) and almost burst out laughing when I read the following.

He ate at ABC and reports having 5 slices of french toast, pancakes with syrup, 2 beers, 2 shots of Jack and then was called to have his appointment with cardiology for pre-angio work up for ischemia. His sugar after that was found to be 580 mg/dL and his angiogram was cancelled and he was referred to endocrinology instead...

Not that I was being cruel or that it's a laughing matter, but sometimes some things are not unexpected. At least this patient was being honest with his story.

So I spent the night with the wife yesterday. In case you didn't know, she's doing her clinical rotations now and is out-of-town on the weekdays, only home for the weekend. But because I had today off, I decided to drive over (about 2 hours away) to spend the night with her. A bonus was I got to meet up with a buddy and his wife from our residency days. Never mind that that was back in 2002 (gawd, that makes you feel old).

Maybe I'm getting soppy. And maybe the rum has something to do with it (I had two shots tonight), but I did catch myself wondering who those who did long-distance relationships managed to pull it off. My wife (and baby) is only 2 hours away from me, and I get to see her every weekend, but as it is, I'm already missing her like crazy. Just having her around, her infectious, almost cackling laugh. And I miss feeling Shim (the baby) move; we've noticed that she gets pretty active at about 5 pm (and it's a pretty amazing feeling, feeling your baby move). But yea, just 2 hours away, and I already feel the way I do; I do wonder who those who are in long distance relationships do it, like my sister. As it is, we have a tough time Sunday nights when Kristin has to drive to XY to prepare for the week. And the dogs know it too; they mope for the next after hours after she leaves (they really do!).

Anyway, I'm babbling. I do miss her, and thankfully she gets home the day after tomorrow. I can't wait.

So I attended a friend's wedding today. Not just any wedding; it was my first gay wedding. Now, I admit, that's one thing I can't comprehend 100% seeing that I'm not gay, but I do know this:

It's clear they love each other. And maybe because I'm simple minded and don't like to get into the whole religion/ethics/morality argument, but if one human being loves another as much as the way I love my wife, if two souls can have such a strong spiritual bond and bring each other such immense joy, then they belong together. Never mind skin color, religion, language or even if they are of the same gender. They belong together.

Congratulations, John and Larry!

(P.S the camera on the Palm Treo sucks. I need a new phone)