Secrets I Wish My Patients Knew

• Our coding/billing is dependent on complexity and risk. So, we get paid more by your insurance for higher risk situations. But having said that, I would rather have your diabetes be well-controlled and make less, than have patients with uncontrolled hyperglycemia.
• Yes, it's probably your fault (not for all patients obviously, but 90% of the ones referred to me) that your diabetes is badly controlled. You don't check your sugars, and miss your insulins. But would it surprise you to know that as your physician, it makes me feel like a failure? I really do want to help, but I can only do so much without your support.
• I really do wish my patients and my staff would call me by my name, not Dr. So-and-so. That's an academic title and says nothing about one's capabilities as a person. I may have had more education than some of you, but many of you know more about life than I do and so the respect you give me is often overstated and undeserved.
• I take no pleasure putting you on medications. I do so only because the research has shown that it improves your health down the road, whether it means you'll live longer, or decrease your chances of kidney failure. And no, I don't get any perks from the drug companies (see my earlier post about my sentiments for Big Pharma).
• I might be a doctor, but I am a person. I am a son, brother, husband and father.
• I really do want to help my patients. But when you come to me for your 3-monthly visits and bring no glucose logs nor even check yourself, and yet your A1c remains above 10%, I'm at a loss. In fact, I'd rather you not come, but reschedule to a week when you CAN bring in some numbers for us to review together. Without numbers, we're adjusting blindly and that can be dangerous.
• I might be an endocrinologist, but I don't have all the answers. I can't tell you why you're tired, or are losing hair (tell me when you figure this one out!), or have mood swings, or can't sleep.
• I'm old school. I like the cheaper generics whenever possible. Don't ask for the newest drugs just because they're new. They're also more expensive, and lacks the longer track record than the older guys.
• I know I'm sometimes late; I'm sorry. It's often because of the guy before you. Having said that I do wish you were on time. We have patients come 15 mins early so that my nurse can reconciliate your medication list, and get the vitals and bloodwork started. But when you come in 15 mins late for your appointment, you're really 30 mins late, and the rest of today's patients end up waiting for your delays.
• I don't always go by the rules. Yes, the guidelines recommend that your LDL be below 100, or that your A1c below 7%. But for some of you it probably doesn't matter anymore. So, I'm probably not going to be aggressive and start my 92-year old patient whose A1c is 7.3% on insulin, because, damn, if you're 92 years old, you've done well on your own thus far, and don't need a doctor trying to fix what don't need fixin'. Likewise, I'm probably not going to start you on some expensive 2nd-line cholesterol medication just to lower your LDL another 10 mg/dL.
• We're human too. We make mistakes, hopefully not big ones. But when I do, I feel horrible about it. But yes, I believe in honesty and I WILL tell you if I messed up.
• If I treated you for gestational diabetes, I REALLY do like it if you bring your baby for your postpartum follow ups!
  

Sometimes, you can't please everyone. I freely admit to my patients, "I'm not smart enough to figure everything out!". As a subspecialist, we're hopefully very good in some specialized areas of medicine, but that also means we have the blinders on, and aren't very good in things outside our field of practice.
And so, the challenging issue is that sometimes, patients come with preconceived notions and are convinced something is wrong with their hormones.
I've studied in this field for 12 years. I still have trouble understanding and describing exactly what a hormone is; how these people all just KNOW their hormones are off is beyond me.
And so, the other day I saw a patient with a list of symptoms (yes, she brought a list) that had over 20 lines. And it was obvious she has done some reading, for she basically went from one gland to the other- "so could this be my thyroid? What about my pancreas? And my parathyroid?". Despite her normal thyroid labs, she was keen on getting on thyroid hormone because she had trouble losing weight.
So I spent the better part of my consultation with her going over the labs that had already been done (and were normal) trying to reassure her. I went over how the labs (indeed the clinical picture) did not suggest there was a problem. I knew as she left that she wasn't satisfied, and was not surprised to later read her negative comments that she sent to admin.

"... bad doctor, said he practices using SCIENCE only..."

Coming from my alma mater, I actually took this as a compliment. I pride myself as someone who is cautious, who practices evidence-based and research-based medicine. There are practitioners out there, who use medications purely for symptom relief without scientific merit (using thyroid medications for weight, or Prednisone for low energy etc). I demand proof, that a test is reliable, and that any medication indeed does benefit my patients and do not harm them (and I demand proof that the newer more expensive medications are better than the cheaper generics ). I'm a scientist, and so my work is based on scientific data.

And so, to accuse me of practicing based on science, would make my mentors proud. For, there are other places to go to to find a quack.

Graduation

Congratulations, hun!

My wife graduated with her Masters in Anesthesia yesterday.

Words can't express how proud I am of her. Not only did she take upon this 3-year program with gusto, but she also did it in spite of the weekly driving (she had rotations in out-of-town hospitals for pretty much a year, some as far as 3 hours). And, despite her seniors telling her "You can't possibly start a family during this program, it's impossible..." she worked throughout the pregnancy (she was intubating a patient when she went into labor, incidentally) and took only 6 weeks of maternity leave in order to graduate in time with her classmates. She balanced her time between work/study, being a great mom to Allison, and a wonderful wife to a whiny husband. AND, on top of that she found to time to write and publish a medical paper!

Congratulations, honey! We're all so proud of you!

Update on the Pheo

I know, I know, I've slacked off. Haven't blogged for a week.

Combination of having been oncall for the week (I hand off tomorrow) and picking up the virus of the week from daycare.

But, one thing that did cheer me up was seeing my 62 year old pheochromocytoma patient doing well post-op.

She had an uneventful laparoscopic adrenalectomy today. The final pathology is pending, but both the surgeon and the pathologist agreed it looked classic. A good outcome is always a big relief- and stems from good teamwork between the endocrinologist, surgeons, radiologists, primary care provider, and of course the patient. And it was a good teaching case for my 4 medstudents and 1 resident too: all were surprised she was asymptomatic, and had none of the classic symptoms the textbooks all tell you about.

I started her on alpha blockade with Phenoxybenzamine 3 weeks ago. And told her to go nuts with the french fries, as most pheo patients are intravascularly volume depleted, contrary to what one might think. And so, water and salt loading is necessary.

And since she is from an hour away, she had been a real trooper visiting her GP twice a week for supine and standing blood pressures, and faithfully reported the results back to me. And, despite the cost of the meds, and the debilitating side effects, increased the doses every few days. And when she was ready, we started the beta blockade. She responded so well that I suggested we go ahead with surgery now, to which she wasn't keen for not wanting to miss out on Valentine's Day with her husband. I promised her I'd bring her chocolates.

Though she was still groggy and in some pain when I saw her in the ICU just now, she tried to sit up to give me a hug. And she remembers my promise to her.

I'm going to have to bring her some chocolates tomorrow.

A small price to pay, to see a patient do well.

Results

Bastards. All of you.

Well. 46 of you.

Results of my beard/moustache survey is out.

Apparently most of you (almost 80%) side with my wife. Something tells me she paid you off.

My First Angpow!

Gong Xi Fa Cai

Happy Chinese New Year, everyone!
Hopefully the year of the Rabbit brings you luck, prosperity, wealth, and a little less snow. Incidentally, I saw this on failblog today. We're getting hammered by the white stuff. My wife's 4WD got stuck in our driveway on her way to work!
It's surreal, the difference between here and Malaysia- I'm watching a live feed of the festivities from home, and to see all the red jars of cookies, mandarin oranges, to hear the banshee-like scream of the bottle rockets, followed by the loud bang that comes after that, makes me fell like I'm back there. Technology is a wonderful thing.The only thing missing is the smell....