Tuesday, November 30, 2010

Bye, Mom!

Mom left for Malaysia today. After a stay of 5 months, it was sad to see her go as it was when Dad left earlier.
It was a real treat for us that Mom and Dad got to spend these few months with our Allison, to have our daughter be pampered and cared for by the people who cared for me. Alli got really attached to her Ah Ma; you could tell by the way she responds to and laughs with her.
And so, this morning, it was a tearful (ahem, rainy) farewell for us. Mom, Kristin and I just, well, simply put, bawled, while Allison just laughed at the rest of us.
(it didn't make it any easier that Delta messed up her flight itinerary)
Have a good flight back, Mom! We'll miss you! See you next year.

Wednesday, November 24, 2010

I just had to take a picture of my patient's tattoo (with permission of course).
I always suggest insulin-dependent patients wear some form of medic-alert ID in case they are ever found down from hypoglycemia. Some of the younger ones though feel that these tags or bracelets aren't cool enough. So this was my patient's answer.
(I wonder if paramedics are taught to look out for these?)

Sunday, November 21, 2010

One exciting new piece of technology available to people with diabetes is the insulin pump. This has certainly evolved by leaps and bounds from its original prototypes (picture from medscape.com) to the newer devices.

However, as exciting as this may be, the pump requires vital input from the patients. The current ones are not yet closed-loop, autonomous devices. Patients still need to have the ability to count their carbs, and need at least 3-4 blood glucose checks a day. It is a terribly common misconception that the pump is completely automatic and one doesn't need to do anything. That this will magically control their diabetes. In addition, the pumps are expensive and generate multimillions of dollars for the manufacturers. So, I'm particularly selective about the patients I put on the pump and I don't usually recommend this for many patients. The studies have clearly shown, if noncompliance is an issue, getting the pump will only worsen the diabetes.

Unfortunately, methinks because of kickbacks (clinics get paid for every pump they put on), I see more and more patients on pumps, whether or not they are suitable candidates. Patients who have no clue how to count carbs. Or check their sugars once a week. Or have no idea how to operate the device. And amazing as this may sound, some claim they were started not by a diabetes specialist, not even by their GP, but at certain pharmacies in the state (rumor has it that the pharmacy is getting an off-site doctor to write the prescription without even seeing the patients)!

Now the pump is meant to be a personal insulin delivery device, one that the patient manages under the guidance of a practitioner. This is not meant to be managed by nurses or doctors caring for the patient. So, good understanding is vital. It's like driving a car- you need to know how to operate your own car. The problem I've seen more and more of late, are patients admitted to the hospital for other reasons, on insulin pumps. Except some I've struggled with of late have no clue how to operate their devices, or count carbs, and when they get hypoglycemic in the middle of the night, don't know how to decrease the basal rates, or suspend their devices. It gets frustrating to see a patient on consult and to ask the patient for his/her rates but only for them to shrug and say they have no clue, and don't know how to pull it up from their machine. And so this gets dangerous, as even the nurses and other doctors are not trained to manage a person's personal insulin pump device.

And so, maybe I'm just slow to adopt new technologies, but the pump is something I'd offer to my motivated patients who are wanting to find some flexibility in their insulin programs, who are open to learning and are committed to regular glucose monitoring. These patients tend to do well with the pump. However, I tell them that most studies don't show an big improvement in hemoglobin A1c with the pump; the main benefit is that it makes life a bit more convenient for them. But for the others, the ones who forget to take their insulin, or refuse to self-test, or cannot count their mealtime carbs, I tend to discourage them from getting the pump.

Tuesday, November 16, 2010

Of Ranks and Titles

If you've followed my blog long enough, you'd have correctly deduced that I'm an egomaniac. And all my life, I've enjoyed numerous titles and ranks.
In school, I was a member of the prefectorial board, and in my senior year, was elected Head Prefect (that's kinda like Head Nerd). I was a member of the St. John's Ambulance Brigade, a volunteer first-aid organization. I rose from the rank of Private to Lance Corporal to Corporal, then Sergeant, and became the first Cadet Leader of my division in 10 years. I was the Vice Chairman when I left school.
Career-wise, it was Medical Student, then Resident, then Fellow and after 12 years of medical education, Consultant Endocrinologist and Assistant Professor.
But, I have to say, the titles that are most important to me by far, are:
1) Husband
2) Father
If you are a parent, you'll know what I'm talking about. How you can come home after a horribly bad day, pick up your child (never mind if she's crying, or all drooly), and hold her, and suddenly all the stresses of the day just melts away. Suddenly you realize the reason you exist. And you never knew it was possible to love such a little person so much. How, looking at her you see your late grandparents, your parents and yet you know she is going to be a direct line to your descendants, long after you're gone. You see your future, in those precious little eyes. You wonder what those perfect little hands will do and how they will change a world to come. And every single day, every time you see your little angel sleep, as she takes your breath away, you exhale a sigh of thanks to God, for blessing you and your wife with something so magical.

I have much to learn, but I love being a father.
(ask me again in 16 years when she's a teenager and her cellphone bill includes $150 of text messages!)

Sunday, November 14, 2010

A Funny Story

I almost died when I heard this last week, as was relayed by one of my nurses.
A middle-aged couple at clinic seeing one of my colleagues for thyroid cancer. As he went into the treatment plan, the wife listened intently while the husband seemed restless.
And then he blurts out, "I don't see what's the big deal with needing the radioactive (iodine) treatment. You just rub some cream on the thyroid, and it'll go away."

The wife's reply was classic:
"You dummy, that's the hemorrhoid, not the thyroid!"
Needless to say, he shut up for the rest of the visit.

Wednesday, November 10, 2010

Advice from an Old Fart

One thing that I keep telling the trainees working under me is, take your time, develop your own style. I think it's important, because many of them get so confused why we all do things a bit differently. Picking this medication instead of that. Doing this. Not doing this.
Because truly, as much as the practice of medicine is a science, it's also a whole lot of art. And I think professional personalities can differ as much as our social personalities.
For example, as a physician, I consider myself a minimalist. I'm not a big fan of using the newest medications just because they're out there, because as we all know, new=expensive, and usually lacks the clinical outcomes data the olders meds have. And I've become very skeptical of Big Pharma, and what their hot-rep-in-a-miniskirt tells me about their new wonderdrug.
Also, I tend to be a realist. Yes, I do try to get the hemoglobin A1c down to less than 7%. But the truth is for some patients it really doesn't matter anymore that they're slightly above goal. The very old, those with multiple comorbidities and who are likely more at risk of hypoglycemia. Those who won't have the life expectancy to see any possible benefits in microvascular risk reduction of lowering the A1c. So, sometimes rather than starting an 80 year old on insulin, we agree to just 'chill' and watch things conservatively (now this might come back to haunt me in a pay-for-performance scheme where the doctors are reimbursed purely based on numerical goals, without considering the individual patient. Methinks this will force providers to be too aggressive, with resultant hypoglycemia complications in many patients).
Likewise, if I see a 78 year old with a thyroid nodule, I'm likely to not suggest a biopsy, because I really don't wanna know what's in there. Even if that 1.2 cm nodule harbored some papillary cancer, it's highly unlikely surgery will prolong his life since he will almost definitely die of other causes like a heart attack. Conversely, a patient that age will likely have a higher surgical risk. So, if I think I'm unlikely to suggest surgery anyway, I ask the patient, Do you really want to know?
This is in contrast to some of my colleagues. Biopsy every patient with a nodule. A1c MUST be under 7% (or 6.5%, depending on your beliefs).
So I give my students and residents this advice. I think it's important when they're at that malleable stage of their careers: "Don't do what I do". Or what Dr. X or Y does, for that matter. Don't blindly follow without understanding.
Instead, read the literature. Review the guidelines, and the studies that support them in the first place. And then, based on your take of things, make your own treatment decisions. Because at the end of the day, you'll have to justify your decisions. And saying I'm picking this insulin because that's what Dr. V likes isn't going to inspire a lot of confidence.
So, to you students and residents and fellows out there, take your time, do your reading, to figure out just what kind of doctor you'd wanna be.

Sunday, November 07, 2010

Chick Magnet

They say babies, especially at weddings, are chick magnets.
Well, I have only one thing to say to that.
Then again, a picture speaks a thousand words.

Friday, November 05, 2010

It Works! (Kinda)

I wasn't expecting this (anymore) but here it is: So I got a cheque from Google Adsense! Excited as I was, it was more that I received something from Google, rather than the actual sum.
I added Adsense to my blog, oh, 4-5 years ago? Never heard a thing about it, never got any follow up. And so, like the many hoaxes/conjobs out there I thought the getting-paid-for-advertising thing was too good to be true.
Except, sending this to me 5 years later, and to the wrong address (my old address- but still ended up with my sister who forwarded it to me), is a bit ridiculous. And truth be told, at this point I'd rather not have those irritating ads on my blog. Except it's been so long, I don't remember my username and password and so I can't rectify the mailing address, or even delete it. They claim to not even have my email when I clicked on the 'forgot my password' link. And my email to Google asking to cancel my Adsense went unanswered.
Oh well. Thanks, Google!

Tuesday, November 02, 2010

Gaaah, why do they have these in the doctors' lounge??
It's calling out my name...

-- Sent from my Palm Pre