Happy Halloween!

Happy Halloween, folks! Here's Alli in her monkey suit. With her very own banana, too!

Things that make me mad

The next time someone tells me some alternative 'doctor' quack can cure a person of their diabetes and rid them of their medications ought to see the patient in the medical ICU on the verge of death and in refractory DKA (despite being on 15 units/hour of insulin!) because she has the misfortune of believing this guy.

Was on 80 units daily, and then she just stopped everything. Relying only on a combination of acupuncture and natural supplements.
Whoever he is, I hope he has a good lawyer...

I hope she makes it. For her husband and 2 kids. For herself.

Ok, I'll admit it.

It's often easier to pop a pill than to change a habit.

In my case, since Alli came along, our lives have been turned upside down. And unlike the days when I was going to the gym 3 times a week, now I'm lucky if I'm going once a month.

So, my resolution is what I tell my patients: pick an activity that is practical to you. Something that is convenient to do, as for many it's hard to find time to go to the gym or the local pool. So, many of my patients will tell me they walk.

Walking's a good exercise; the problem is it's hard to be objective with walking. A leisurely walk in the mall is not the same as a 3o min powerwalk. So, for many of my patients, my advice is to get a pedometer, and try to hit 10,000 steps a day.

If you've tried it before, you know that getting to 10,000 takes concious effort. To not use the elevators, or call that colleague, but actually walk to where you need to be.

Will let you know if I can keep this up, and hopefully I'll see some results in a month.

Recycling Insulin Bottles

I was impressed when I saw this at work. The things you could do with old insulin vials. This patient was pretty good with his hands and had a workshop in his garage.

Can you tell what these look like?

Words of Wisdom To Myself

I got an anniversary card the other day, congratulating me on my 2nd year being on staff in my respective hospital.

2 years. How time flies. I've left my alma mater 2 years already? And then, I spoke to John, my buddy from fellowship who's 4 hours away, and we compared notes. Now that I'm out on my own, what would I have told myself, that tired but still naive fellow, into his 12th year of medical education, back in 2008? What would I have said to prepare myself? Not that I hate my job now (but admittedly there are some things I don't love, either), but what would I have said?

That the learning never stops.

Geez, you'd think that with 5 years of medschool, 3 years of specialty training and 3 years of subspecialty, that I'd be done with learning. But no. The learning has only begun. Except now, I'm on my own, learning from my patients, from my mistakes. No longer looking up to my Professors for guidance, realizing, partially still in shock, that I'm a Prof myself now, and my students and residents look to me for answers.

That you sometimes don't get to decide who becomes your patients.

Being a subspecialist, I'd like to think that I'm good, no, damned good in some things. My diagnostic rates for thyroid biopsies surpasses many others. I'm pretty confident of hitting a nodule no bigger than 5 mm (if indicated). I've seen about 15 pheos, a dozen insulinomas. There are some things I'm good at doing. But, as I no longer practice general medicine, there are simply some things I don't do well anymore. But inexplicably, I'm still asked to see patients for depression, weight gain, mood swings, skin problems. And all you can say: "I'm sorry, as an endocrinologist there isn't anything I can do for you..."

You realize the innocence of fellowship has shielded you from the harsh realities of the world.

Patients who can't afford their medications and their visits. Overpriced drugs, often peddled by pharma who strolls in to your office in spiffy suits, or supershort miniskirts, while trying to sweet talk you. In the meantime, you know just who is paying for the lunch the pharma rep is trying to buy you: Your patients. No, thank you.

You also shamefully realize that it is a business.

You realize you sometimes will have to disagree with your colleagues on principle. Some may feel that we should never turn away business. But unfortunately (or fortunately?) you were taught to treat patients with a real hormonal disorder, and you learn to despise seeing patients just for the sake of generating revenue, whether or not their GPs were wrong in sending them to endo.

Life doesn't really get cushier.

Yes, the salary's better than a PGY-6. But the hours aren't better. The calls aren't better. The patient loads aren't better. And now, you're made to cover 5 different hospitals all around town, and it's preposterous that some feel we need a monopoly here.

You also get to know your patients.

Now, more than fellowship when you're really staffed by someone else, these are YOUR patients. You are their doctor. And so you learn to share hugs and laughs when they get their diabetes controlled. You share a few tears when they have a miscarriage, or lose a family member. You genuinely get touched, when they make a special trip to the clinic just to drop off a home-made throw for your baby, or some banana bread for you.

You never really get used to all that respect.

Really. I've been a doctor for 9 years. And yet, I'm still uncomfortable with older patients and colleagues calling me Dr. Vagus. I may have the paper qualifications, but they have much more life qualifications and experiences. I don't think that makes me more of a person than they are. And truth be told, I miss being called by my first name. I've love it for my nurses or patients to call me by name.

Sometimes, you're it.

Whether you like it or not. What should be done for that patient with the metastatic pheochromocytoma? Or the Stage 3 follicular-variant papillary thyroid cancer? What about that patient who has resistant hypoglycemia despite having had 4 amps of D50 and being on a D10 drip? You might not be 100% certain, but at least with the training you've had, you're 90% sure, and in the hospital you are probably most qualified to handle the case. And so, trust your instincts, trust your gut. That 12 years of training has to be worth something, right?

And sometimes, you have to flex your ego muscles.

You have the qualifications. You are a doctor, a subspecialist. You know what you're talking about (usually!). The damned insurance companies don't, and often neither do their medical directors. And so, if they are refusing to pay for that echo as part of the pre-op evaluation in your acromegaly patient with the striking edema, it is up to you to stand up to them and say, "Acromegaly can cause cardiomyopathy; I am concerned about this patient's ability to safely undergo surgery. Would you like to be responsible for this patient's death on the table?". After all, you're it. You're the patient's doctor, and you're his advocate. No one else. He belongs to you, and you to him. You will have to look out for his interests above everything else.

New Hair Growth Formula!

I did it!
I was able to regrow my hair!

And it works too. Using an all-natural non-medication technique!!

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. Now I just have to sell this new look to the wife.
Wish me luck.
(I don't think she'll take the bait)

Therapy

You know, sometime life gets you down. Maybe I've been reading the global news too much. All the craziness in the world:

• The economy here, and how my patients have to pay through their noses for their medications.
• The war in the Afghanistan. Or the fighting between Israel and Palestine.
• The racial discrimination in Malaysia.
• The senseless killings in Mexico.
• The accident victims in Indonesia.
• The starving families living in poverty.
• Some of my patients to whom I have gotten quite attached: Mr. H who is dying of lung cancer. Mrs. Y, an elderly dear who tries not to cry everything she comes in to my clinic accompanying her husband who is withering away from Alzheimer's. Mrs. L who had that miscarriage.

Why can't we all just get along? Never mind skin color, race, religion, language? Just, get along?

Sometimes, you pause to catch your breath. You sigh and take a deep breath, except you can't ever inhale enough. You feel the burdens of the world on your shoulders. You feel helpless at all the hate and suffering going around. And you ask God, whether to you it's Yahweh, or Buddha, Allah, or simply The Guy Above: Why? What is the meaning of life? To suffer and learn?

And then, you look at the face of a child. Your child. You see her almond eyes. Her hair. You smell her skin as you hold her. And then, the miracle happens: She smiles at you. And just like that, all the troubles of the world, whether it's depressing news you just read on CNN.com from half a world away, or 10 miles away in the office, just melts away.

If you are a parent, you know what I'm talking about. If you are not yet one, then this is just nonsensical babble that until 4 months ago I would never have understood. You thank God for the miracle of life that He has brought to you.

Alli must have magic powers: How on earth did she make things flow UPWARDS against gravity?

Mind you, this was with her sitting up in her childseat.

Hair Loss

Out of jest (and okay 50% out of frustration, I admit), I told a patient,

"You know, if you really wanted to see someone for hair loss, you probably shouldn't have picked an balding endocrinologist".

Seriously (and someone please tell me, why do those GPs send their alopecia patients to endo?). Ok, when I was a kid, I had so much hair some people thought I was a little girl. And in highschool, my trusty follicles were lush enough that I sported the then-popular Tommy Page hairdo (why is it that if he was American and such a hit, why has NO ONE here ever heard of him?).

And then 2 years ago, I got married. Still had plenty of hair. I realized this looking through my pictures from fellowship and reminiscing the good old times. And to my alarm, in a short span of just 2 years, my hair has been rapidly thinning to the point that, well, you get the point.

Is it the marriage? Or the high-stress job?? Perhaps the 'warmer' climate in this part of the Midwest?

A badly angled picture, especially with the flash, shows my scalp in all its glory.

The morals of story:
1) If you want to keep your hair, don't get married (I know Kristin has a thing for bald men. I suspect that when we're asleep, she's secretly plucking out my hair, a few every night)

2) If you're seeking treatment for thinning hair, don't be asking for advice from the guy who obviously has less hair than you. Believe you me, if I had the cure I'd be the first in line

Well, maybe not. I'm not sure I'm really all that bothered by it. One of these days, I keep tempting myself to shave it all off...

I'm not ashamed to admit it:

I love taking long hot bubble baths.

Especially after a long week of work.

The kind where the water's so hot you could probably hard-boil eggs in them (come to think of it, I probably did!). With some cheap scented bath soap, and the jets churning up the bubbles.

And the radio playing, tuned to Delilah (yes, I know I'm shameless).

A good book (usually Road & Track or Car & Driver). And a glass of beer. Ahh. Yup, this washes away all the pain. Until the next stretch of call 3 weeks later.

The Etiquettes of Making a Referral

I won't claim to be an expert in how one should order a consult for a patient. But speaking as someone on the receiving end, I've learnt that there are some things that make a consult more challenging. And so, if there is something I could ask for when physicians send me their patients, they would be:

• Be specific. Are you sending the patient to me for hyperthyroidism? Osteoporosis? Don't just put on the consult request: 'Thyroid issue' or 'Hormonal imbalance'
• Along the same lines, don't add a list of issues just because the patient is coming my way. Because we have limited time for the patient, it helps for me to know what exactly you want me to address. Don't send the patient here for 'Diabetes/hyperlipidemia/hypothyroidism/weight gain'
• SEND your clinical notes or lab results. If you send nothing, I'm often forced to do my own set of labs. If this has already been done, this is a redundant cost to the patient. Also, it's only polite to send your notes over before I see the patient. It helps no one for me to see a patient and to have absolutely no idea why they're here
• Don't promise the patient anything I can't deliver. The ones I know I disappoint are the patients who are sent my way for 'Weight Gain' or 'Fatigue' and have been told by their physicians that the 'endocrinologist will be able to help you...'. Unless there clearly is an endocrine issue, I'm not sure I can live up to those promises
• I'm a subspecialist. I don't practice general medicine anymore. So, just because I've seen your patient doesn't mean that I'll be taking over his opioid medication management, or prostate meds
• Check before you send the patient over, if we're 'in-network' for the patient's insurance. Though it may be revenue for me, I really hate it when patients end up paying a lot out of pocket. I'm not here to make their lives more difficult for them

Venting

So I'm oncall again, and whining. And so, here it goes.

I did not become an endocrinologist to:

• Figure out why the orthopedic hardware you implanted failed (yes, this was a real consult from an orthopod)
• Drive 12 miles to a hospital to see a patient for a history of hyperprolactinemia 5 years ago, who is admitted for cardiomyopathy. Her menses are regular and she denies any breast discharge. And you couldn't even be bothered to at least check a Prolactin now before you put in the consult? Are you really a doctor? I expect more from my medical students.
• See patients for the sake of seeing patients. To not "turn away potential business even if it may not be endocrine in nature". I'm sorry if I disagree with your philosophy. I'm here to help patients who have endocrine disorders. I'm not smart enough to figure everything out.
• Figure out why your patients have trouble losing weight, or gaining weight, or are losing hair, or have mood swings, or are depressed, or tired. Seriously, before you put in a consult for a subspecialty, think: are there any lab abnormalities or clear endocrine pathology that justify the consult?
• Cover all the diabetes patients in all 5 hospitals in the city, even the simple ones. Considering there is a 20% prevalence of diabetes in middle-aged patients, there are at least 250 patients currently in the hospital with diabetes. Learn to look after your own patients, and if you need help, I'd be happy to assist.
• Also see clinic patients while oncall. And take nightcalls from all the nursing homes in the city, and from any patient at home. While many calls are justified, there is only so much one person can do. And when you get 11 pm calls like "I just came from a wedding and did a lot of dancing, and now my foot hurts. What should I do?" you discover you have an endless supply of exotic words you'd like to use (but can't).

In many ways, I miss my alma mater. I miss working in an academic institution where the consults seem more reasonable, and it's not all about numbers and keeping your revenues up. I miss having an hour for consults (real consults) when you can really get info from patients. Or more time with your diabetes patients to really explain how to adjust their insulins.

There, I've vented. Time to get back to work. And no, you may not leave a comment this time. I know, this is my childhish vent. As my friends say, I'm lucky to have a job in these economic times...