T'is probably not a good idea to go directly from the endocrinologist visit for 'Inability to Lose Weight' consult to the McD's 4 floors down.
I hope she at least took the stairs (and no, in my defence I stopped by to drop off a DVD). We pretended to not see each other there (I knew she saw me when she turned away at her table). Obviously I'm making some generalizations here, that 1) This is a frequent occurence 2) Most fast food is unhealthy. And no, the irony of having a fastfood restaurant in the hospital isn't lost on me; I have no say in this matter, unfortunately.

It's true though that excess weight and obesity is the new epidemic. A third of Americans are obese. And while this is probably reflective of numerous factors, it's pretty clear a lot of it has to do with the changing environment. Less physical activity (in part due to the conveniences of daily life technology has given us), more easily accesible high caloric junkfoods, perhaps financial (healthy food is more expensive than fastfood).

Obviously, it's really more complex than this. Nonetheless, there is a tendency as well to find a medical explanation. To find a condition, a disease, that has caused all this weight gain. And (perhaps judgmental of me, I apologize) some denial as well (maybe because of the shift of cultural norms, of what's considered 'good' and what's 'bad' for health). And so, I see at least 5 consults a month to work up issues like inability to lose weight. I suppose it's human nature and I speak from personal experience too; it's far easier to find a disease and to take a pill, than to actually change one's habits. Far, far easier.

And while certain rare endocrine conditions may cause one to gain weight, frustratingly enough for my patients this often is not the case. And yet there is a tendency to blame the 'hormones' for anything. While I see hypothyroidism frequently, often you gotta have pretty pronounced hypothyroidism for a long time to gain a lot of weight. Conversely I've seen a ton of hyperthyroid patients who get mad at me for telling them that they are 'hyper' and not 'hypo', who refuse to believe that a low TSH really implies the thyroid is overactive because they're overweight (I partially blame this on the referring physicians who label patients with low TSH as hypothyroid; yes this is basic medical knowledge but believe me many make this mistake!). And then there's the issue of Cushing's. Every patient I see seems to know about this condition. I can't attest to be an expert on Cushing's, since I'm relatively young (and probably stupid) in my career, but I'll say this: of ALL the patients I've seen for Weight Gain in the last 2 years who have demanded a screen for Cushing's, the number of real cases I diagnosed: Zero. Of the 2 patients I did diagnose with Cushing's, one had a normal BMI, while the other had other clear pathognomonic signs that you could spot from a mile away. And obesity wasn't the presenting complaint.
And yet, I continue to get consults from referring physicians, and from self refers, for weight issues. It turns out to be frustrating for the poor patients, because they wait 2 months to see me, then undergo a series of tests, only to be told the hormones are normal.
Unfortunately, this epidemic will only continue to rise in our lifetime. And I'm afraid I won't have any easy answers to this problem.

Watching F1

I'm ashamed of Allison....

She's a Ferrari fan. Shame on her. The dogs too. Scuderia Ferrari hasn't been the same since Schumacher left. And Alonso's a real prick of a driver.

Me, I'm supporting Red Bull Racing this season. And I'm (still) hoping for Vettel to win. But we all know what happened to him today in Belgium. He's got the skill, and the car to do it. But perhaps in his youth, a wee bit too hotheaded and making too many fatal mistakes.
Alli even laughed when he ran into Button, taking him out.
Bah. I'll have to talk to her about her pick of F1 teams.
At least we had fun watching the race together.

Brilliant! I discovered how to distract the babe. Just hope she doesn't become a tv addict.

-- Sent from my Palm Pre

Good News/Bad News

Good News: A patient today told me my butt looked good in my Calvin Klein slacks.

Bad News: This was a 60 year old man.

The Birthday That Was

I celebrated my 34th birthday over the weekend. And it was special for so many reasons:

• I wasn't oncall this year- I was oncall on my birthdays the 2 previous years. At least now I could enjoy a nice glass of wine
• I was celebrating my birthday, with my daughter in my arms and my wife by my side
• We had good friends visiting us for the first time
• And this was the first time I got to have my birthday dinner with my parents, in, what, the last 9 years?

A few sad truths. After my 30th birthday, these things really don't mean a whole lot. Just another number, another reminder of the inevitable? Also, you realize that while growing old is mandatory, growing up is optional.

Just ask my wife and friends who took that picture of me holding my cake in my birthday suit.

(while I was tempted to post that, I figured that would come back to haunt me. So you'll just have to use your vivid imagination, but don't blame me for the PTSD that follows)

Bullshit!

This gets my blood boiling. This guy has made numerous ridiculous calls for banning this or that over the years. But this crosses the line, methinks, since there are medical consequences.

THE Consumer’s Association of Penang (CAP) has repeatedly objected to the proposal to vaccinate all 13-year-old girls from the human papillomavirus (HPV) virus, a sexually transmitted virus because it is unnecessary, unscientific and unsafe.

Despite numerous objections by many quarters, a sum of RM150mil is to be spent annually by the Government beginning this year on HPV vaccinations for an estimated 300,000 girls in the country as protection from only two of the 40 different cervical cancers causing HPV.

HPV is contracted through sexual contact; instead of inoculating our young against a sexually transmitted disease (STD), the Government should focus on prevention by educating them on religious and moral values.

As recipients of a vaccine against STD, ill-informed young girls could be lulled into a false sense of security that the HPV vaccine would protect them against other sexually transmitted diseases.

The risk of cervical cancers itself has been blown out of proportion. It is a known fact that about 90% of all HPV infections are removed by the immune system within two years. This in itself makes the vaccine irrelevant and redundant.

The vaccine itself is highly controversial with an unusually high incidence of adverse reactions and 53 reported deaths in the US alone. This completely unnecessary and dangerous vaccine’s safety and efficacy have never been established in Malaysia.

We urge the Health Ministry to revoke its ill-conceived plan to subject our children to the vaccine. The rakyat would be better off if the money were used to educate our children against early sexual activity as a deterrent to HPV infection (Yea right, with all the baby dumping going on and lack of sex-ed, GOOD LUCK!). With this allocation, campaigns for HPV testing and pap smears as proven early detection procedures can be re-invented and enhanced instead of resorting to the simplistic solution of vaccines.

Since these vaccines only cover some high-risk types of HPV, experts still recommend regular pap smear screening even after vaccination. This only goes to show that screening remains relevant and is undeniably a better method of prevention than vaccination.

S.M. MOHD IDRIS,
President, CAP.

I just had to write in. We'll see if The Star publishes my response in a couple of days...

You know, this thought crossed my mind at work today. I see so many patients, and while I enjoy my work, sometimes it does get to be a bit too impersonal, too formal. But then, when I saw Mr. H today and he was complaining that the nursing home aide smudged his glasses for him, it so happens that I keep a bottle of lens cleaner in my desk. And so, I took his glasses off his face, gave them a thorough cleaning, and put them back on for him. And you know what, it's really the experiences like these that my patients give me, that I enjoy the most.

Not the 'playing the doctor/smartass/expert'. Just the simple, basic, human interactions.

Idle Thoughts

Dad told me this. The most memorable stages in a man's life are:
When he gets married
When he becomes a father
When he becomes a grandfather

While it's going to be a while before I hit the 3rd one, I have to say that I can relate to the other 2.
It's amazing how little Alli has grown. She turns 8 weeks old tomorrow. 8 weeks! From a tiny little embryo to a 9-lb mass of crying drool and poop-making wonder. She even already starting to outgrow some of her onesies.

As much as I'd like to say how tired I am playing the role of the father, really, this cannot possibly compare to what my amazing wife has to put up with. While I was at work, she had to look after, feed Alli. At night, because I was oncall or had to work the next day she would usually not let me help with the nighttime feeding. So, I got to sleep through most of the nights while she either had to get up to feed, or to pump. All this, with the gentle grace of a loving mother. She started school again yesterday (she's finishing up her Masters) 2 hours away from home and gets to come home only on weekends. I can only imagine how tough it is for her, since I go into baby withdrawal after not having seen her in a few hours. All this, and yet that amazing woman manages to write a paper and get her manuscript accepted for publication in a medical journal during her postpartum period!

So hun, this one's for you. You are the most amazing woman I know; I love you!

A Challenge

Sometimes you're just stuck between a rock and a hard place.

I saw my 2nd most challenging hyperthyroid case while oncall last week. The patient was a man in his 30s with Graves' disease.

Prior to his admission, he had been on a course of antithyroid. Unfortunately, he developed a rare but severe case of agranulocytosis, to the point of becoming septic and had needed Neupogen to bring things up. He then developed a stomach ulcer that perforated, requiring multiple emergent surgeries and prolonged TPN.

By the time I was involved in his care, he was fast becoming hyperthyroid again. Steroids did not help, and out of the lack of anything better, we bit the bullet and treated him with Potassium Iodide, hoping to take advantage of the Wolf-Chaikoff effect. Except with no good oral route, we tried something that has been published in case reports to work: rectal SSKI.

When the pharmacist got the order, we got a prompt call: "You want to do WHAT??"

Well, it worked, and dropped his FT4 like a rock. Problem was, iodine works only temporarily, and prolonged exposure eventually leads to increased thyroxine synthesis. And being a pretty sick guy, the surgeons were not too keen on taking him for surgery to remove his thyroid, while radioablation would take months to work. In the meantime his Ft4 crept up from 0.5 to 1.4 to 5.5. He became more and more tachycardic despite beta blockers. I was concerned that if I did nothing, he would go into a thyroid storm.

I had to bite the bullet. Despite his severe agranulocytosis in the past (his white cell count had now more than normalized) I resumed his medications, this time picking Propylthiouracil over the Methimazole that was previously implicated. I told my resident to watch over his labs like a hawk.

I signed off his care to a colleague a few days ago. I pray that in this difficult situation, we made the right choice.

Reunions, and a Wedding

Phew. The last weekend had us driving 12 hours. Drove to WI to meet up with good friends for dimsum, and to see the inlaws. And a bonus was to attend the wedding of a dear friend from fellowship.

This was nice because we got to see some friends we haven't seen since I graduated from the Mothership in 2008. You don't realize how time flies; it literally feels like we just last met up a few months ago, until you think about it and realize, Geez, it's been 2 years, and we're all already board-certified medicalnerdologists and are all out in practice (and thankfully, because of our training, haven't yet killed anyone!).
Yup, this has been a month of reunions. Between this, and meeting up with another buddy from residency whom I had not seen for 5 years, this has been a treat.
Congratulations, Kim & Jeff!

Stories from the Pharmacist

I thought only doctors shared strange stories. But these ones were told to me by our pharmacy resident this week. He also interns at a local retail pharmacy and shared these true encounters he had to put up with:

Story 1:

Irate woman in her 20s, yelling at the pharmacist that the birth control pills "don't work". Naturally he asked if she was pregnant, and she said no. So when asked why did she think they don't work, she yelled back:

"Because these damn things keep falling out!"

Story 2:

Woman at counter, sheepishly asking if Vagisil came in strawberry flavor...

(Apparently her boyfriend found the taste offensive. Ewww. Come on, let the yeast infection clear up first!)

A Privilege

I got to do a hospital consult on Mr. A today. He is a 70 year old man admitted to the intensive care for yet another episode of CHF exacerbation. He was also sick and tired of his automated implantable defibrillator going off. He also has diabetes for which I had been managing as an outpatient.

However by the time I got to him, he had already made up his mind. He was going to have the defibrillator inactivated, and just receive comfort care.

I had a long visit with him, his wife and numerous kids and grandkids. Clearly, he was aware of the implications of his decision. He was adamant that he not be 'coded' should he go into arrest; he knew if he was intubated he probably would never go off the ventilator.

And so, at his request I wrote to discontinue his diabetic medications. It was in many ways a strange meeting- everyone was composed, serious and perhaps a bit saddened, but yet relief was apparent even in his eyes.

And maybe this was a strange word to use, but it really did feel like it was truly a privilege for me, to have been able to share with this patient his experiences in what is probably the last few days of his life. To be able to talk to him, to hear his stories (and, true to his nature, some of his not-so-subtle jokes about the cute nurses and their tight butts)(but I think the nurses and his wife let him get away with that one), to have shared those minutes with him. I was glad it wasn't a busy call day, and I could take my time, not to cure him, but perhaps to aid in the healing of him, and his family. I think on busy days I'm often guilty of not spending enough time with the people I treat, to actually put myself in their shoes, to experience the things the do. So to have had the time today, was nice.

I imagine he'll hang around for another few days. He'll probably even make it till when I sign off the oncall pager to my colleague later this week.

But truly, it is a privilege. Take care, Mr. A.