Baby Food

So I had this nasty thought while feeding Allison today. Isn't this stuff supposed to look like this coming out of a baby from the other end? And not look like this BEFORE you feed the kid? Probably explains why Alli-cat seems to prefer cake icing.

Money?

I thought it was timely that this article came out in the Star.

Many complain of having to pay for unnecessary tests

PETALING JAYA: A retiree seeking treatment at a private hospital was asked to undergo a blood test, X-ray and an ultrasound therapy. He was referred to three specialists an orthopaedic surgeon, a physician and a nephrologist and was admitted for three days. He had gone to the doctor for his gout.
The retiree, who has no medical insurance, claimed he was
eventually discharged with some painkillers and slapped with a RM2,700 bill.

Timely, as I recently became somewhat disillusioned by an incident involving a private hospital. Someone I know recently underwent evaluation for exertional chest discomfort in a private hospital. Now, I can't claim to be a cardiologist as my subspecialty lies in another area, though I am board-certified in internal medicine, and do try to stay up to date with the current guidelines. And I was surprised, that without even recommending something like a stress test, the cardiologist provided two options: a coronary CT scan, or an angiogram. In addition, he ordered a panel of blood tests including VDRL, hepatitis screen, CEA and alpha-fetoprotein.

Now, this confuses me. While many would agree the cardiac CT shows uch promise as a screening tool, all it would show is presence of coronary calcium and plaque; it gives little information (unless the amount of narrowing is unequivocally significant) on whether the calcium you're seeing on the scan is indeed causing ischemia and hence the symptoms. And an angiogram, on the other hand, was like pulling out the big gun, which is invasive and itself may cause an MI and death in rare causes, to work up a hunch.

Perhaps I'm not qualified to comment. Perhaps it's because I'm not a cardiologist, much less a practitioner in Malaysia where systems differ, but here, the first thing one ought to do is to test the hypothesis that the symptoms are indeed angina, from a lack of oxygen to the heart muscle that is accentuated by exercise. Depending on level of suspicion, and patient variables, this may be as simple as an exercise EKG, stress echocardiogram, or one of the many nuclear stress tests. And if things are suspicious, perhaps the angiogram would then be offered. The CT itself is more of a screen (arguably for the rich) and doesn't tell you much unless it's totally clean. In other words, the test has a pretty good negative predictive value. However this would be rare in the older population where you're bound to find coronary calcium in quite a number of patients and you don't really know if this is the cause of the symptoms. Some studies have found a positive predictive value of only 38% with the MSCT coronary angiography with the 64-row CT scanner.

Thankfully, in this case, the CT was negative and so we could lay the matter to rest. Despite that, I could not understand why this cardiologist recommended Clopidogrel, and switched his statin medication from a cheap generic to a nongeneric brand when his LDL ('bad cholesterol') was 69 mg/dL, with his HDL ('good' cholesterol') being even higher at 73 mg/dL. In my patients, arguably many would be happy with an LDL of 130 mg/dL, or less than 100 mg/dL if you have diabetes, or even if you had vascular disease, less than70 mg/dL.

So, maybe it's an assumption on my part, but the only conclusion that I can come up with, is that this was purely financially driven. And no, I'm not accusing all physicians of all private hospitals of being greedy, but for some of them, you do wonder.

As doctors, yes I admit we have to make some money. We have families to feed, mortgage, loans and maybe even some to spend on 'toys'. Like any occupation, making money is a necessity though in doctors' cases the patient-doctor relationship and sacred trust is a bonus. It's a priviledge that another human being lets you look (somethings literally!) into them, and to share every intimate part of their health with you. You look to the doctor and you trust that he has your best health interest in mind. It's a leap of faith.
But when you get the sense that the doctor sitting across the table is suggesting certain testing based primarily on financial motives, then it really leaves a bad taste in the mouth.

A Decade!

Nothing makes you feel old like realizing you graduated from medical school 10 years ago.
ONE DECADE AGO!
Geez. I realized that a week ago when I was congratulating my med students. I told them about how my graduation was that spring morning when it hit me. Holybegezeez! It was May 2001! I remember how proud we all were (and perhaps a bit surprised!) that I made it through medical school, in a foreign country (I was a big-time mommy's boy and had a homesickness problem. Who knew, huh?). I remember how it felt when it came time for the Faculty of Medicine graduates to take the Hippocratic Oath:

"....WITH PURITY, HOLINESS AND BENEFICENCE I will pass my life and practice my art..."

And just like that, our lives were changed forever. With the 2 little letters stuck behind our names, M.D., we became Doctors. It didn't seem like that long ago, but in a blink of an eye, here I am.

Perhaps it was just a matter of coincidence that this trip back to Malaysia, I found my old graduation cap hidden away in a dusty cupboard and decided to bring it back with me to the US.


Geez. 10 years. If that seems like a long time, here's something for you starry-eyed med-students to ponder. I started medical school in 1996. 15 years ago! (that's the picture above, the smallest class in the history of the medschool). Between medical school + residency (specialty training) + subspecialty, it took me 12 years! So, as I've said many times before, I don't think being brainy is all that important to get you through medical school. Sure, having the grades help get you INTO medschool, but once you're in, it's pure stubborn-ness and perseverance that gets you through things.

Good luck!

Stages of Grief

They lied. The psychology books in first year of medschool (gawd, that was 1996!!) talk about the five stages of grieving.
Denial, Anger, Bargaining, Depression and Acceptance.
And though I can't say the extent of grieving we are doing comes anywhere close to what my Buddy's family must be going though, our hearts and minds are in a bit of a disarray now. And it's nothing like that damn Kübler-Ross model of grieving. Instead, we seem to be going randomly between these stages:

Depression and sadness- and bawling our eyes out, thinking that he's really gone. That we'll never see him again in this world, share stories, do fun stuff.

Reminiscence- of all the fun, crazy things we did. Still cracks me up thinking of the time we made a waterbomb with some dry ice and plastic bottle (blew up so loud that we went hiding in the basement, fearful that the cops would come!). Or the time we were baking in a small room with the heater on full blast because Idiot Buddy read somewhere that warmth made fireflies blink more (apparently not)(and we were that close to popping them into the microwave to warm them up more!).

Guilt- why did I not call him more? Why did I tell myself I was going to call him after I went off-call? Why didn't we spend more time in Penang when we were visiting?

Bitterness- about why him? A gentle, kind soul. A religious, wonderful man, a doctor just beginning his family and career. I catch myself asking: Why not me? He's much more of a better man that I could ever hope to be.

Peace- knowing that he's no longer suffering. And that he's in a Better Place. That he's Home, and someday we'll meet again.

Gratitude- that though he lived a short life, that I had the honor to have known him as well as I did. To have shared so much.

It's interesting how one's mood goes quickly from one to the other. But with every passing day, it gets a bit easier. And I catch myself smiling thinking about my friend somewhere up there, probably laughing his butt off that the rest of us have to go to work on Monday. His funeral was Saturday morning Malaysian time. I hear it was a touching affair, with many loved ones sharing beautiful stories. I hear the church was packed. And Buddy got the best seat in the house from up there.

In Memoriam

We Shall Miss You

Dr. Tan Tow Shung

November 6th 1978- May 18th 2011

He was a giver. If there is one word I'd use to describe my buddy, that would be it.

Born and raised in Malaysia, he begun his amazing career as a Healer at the International Medical College. From there, he went on to graduate with his M.D. from the prestigious McGill University in Canada, before landing a position at the world-famous Mayo Clinic. There, he would spend the next 7 years of his life training in internal medicine, followed by a fellowship in hematology and oncology.

For 5 of those years, we lived together in a small rental. They say it's hard to find a room mate you can live with for too long- for some reason that didn't seem to apply to us. We did almost everything together, to the point that our friends thought we were gay and were a couple (I was desperately single then, while he was in a long-distance relationship for 5 years and so his then-girlfriend was not often seen). Among our favorites were the hours of Halo (and then Halo 2) on the Xbox and the customary post-call buffet dinners when we would wolf down pounds of food at Golden Corral and complaining about the stupid admissions the ER sent up to us. People called us the Malaysian Triad (there were 3 of us). We regularly hosted BBQs and dinners for visiting Malaysians and Singaporeans. And, as boys usually do, got into our own mischief, making fountains with Mentos+Coke, or little bombs with dry ice and water.
Despite all the fun and mischief, he was an extremely bright person, scoring 99s in his USMLEs and acing the internal medicine boards. As a physician, he was warm, caring and astute and was a master in clinical medicine. I remember that patient we both shared- he was asked to see him for severe anemia of unknown etiology; he quickly and accurately diagnosed hemolytic anemia from his prosthetic valve. I saw the grateful patient post-op, who had nothing but praise for my friend.

As a friend and room mate, he never complained about me getting the better room, and the parking space. He was always giving. His love for his eggs and omelettes were legendary- Kristin even gave him an egg fridge-magnet when we moved away. And no one made a better mojito than he. We had one too many merry parties thanks for his concoction.

Why God chose to allow a 29-year old the cancer doctor to develop esophageal cancer, a wonderful human being, I'll never understand. But in those 4 years that followed, my buddy and his wife taught us much about personal strength, love, faith, sacrifice, and in the final months, grace. I'll never forget how he kept his diagnosis of adenocarcinoma hidden away from everyone for several days, because I was about to take my endocrinology board exams. Knowing, as a cancer specialist, that Stage 4 disease is like a death sentence for most. But yet, he kept it bottled, just because he didn't want it to affect my exam performance.
In those 4 years, he made the most out of life. He reminded us, the 'family' there, of the true meaning of friendship. He brought us all together. We were blessed, that when Kristin and I got married he was willing and able to be my Best Man. And then, a year later, we were honored that they wanted us to be their Best Man and Bridesmaid. And despite the shadow hanging over them, that was the most heartfelt wedding I had ever seen. It was as if they had not a single care in the world, as they uttered their vows. There were numerous teary eyes when Tow Shung and his wife started their first (choreographed, too!) dance as a married couple. Despite the chemo, and the radiation. Despite the odds. Living life to the fullest.
We were fortunate that just last month, we were able to visit him and his wife in Penang, and had a good several days. We talked. We reminisced. We laughed. And for that moment, it almost seemed that things were back to normal. To the days before the illness. We had a good time.

Tow Shung,

You were my friend, my buddy, my room mate, Best Man and my Brother. You fought a good, long battle. Thank you for teaching me about what friendship means. For helping me survive the most harrowing years of my professional career. For seeing me through the thick and thin. For the years of fun and brotherhood.

Though you are no longer physically with us, I know you're still with us, and you're in a better place. I know you are at peace now; know that we will never forget you. And though I don't know when we'll get to meet again, I know the day will someday come. That we'll get to share a few glasses of your wonderful mojitos. Till then, buddy, cheers.

Rest in peace; we will miss you.

A Request for Prayers

I fear it's begun.
It pains me to say so.
Please pray for my buddy.

Congratulations, Class of 2011

Today was the last day of medical school for my MS4s (and all the other medstudents in North America, too).

The very last day of their lives as a medical student, or clinical clerk, whatever they call it. They were euphoric, almost to the point of being manic, on rounds today.

For good reason I guess. They survived the first of many gruelling chapters (and though many of us thought that medschool was the tough part, bwahaha, you realize it's a cakewalk compared to what's to come).

But being cheeky, Jeff, one of my students asked:

"So Dr. V, how are you going to manage rounds without us?"

Thinking perhaps, that because they preround on my patients they make rounds a lot shorter. I almost felt guilty popping his bubble when I told him that rounds without any medical students or residents are at least 50% quicker.

I ask the relevant questions. Examine what's necessary. Write the orders. Off I go.

So, while it's intellectually stimulating and perhaps fun having a troop of students on rounds and going over topics on the fly, like adrenal incidentalomas, or DKA management, it's true that medstudents NEVER help make rounds speedier.

I reminded Jeff of the 11th Law of the House of God: (if you haven't already, go read the book)

"Show me a medical student who only triples my work and I will kiss his feet.."

To all the 4th years/almost-doctors out there: Congratulations, and Good luck in your residency!

Pills Pills Pills

I had a conversation with my dad the other day after he saw his doctor. Some changes were made to his blood pressure medications. However, he did not recall the names, nor the doses.

Which got me thinking about how frequently I see this on the other end, as the treating physician. Patients who have no clue what they are taking, besides "A round yellow pill, and a square blue one...". I've had to, on occasions, call the pharmacy to verify their medlist. And while PDA or online pill identifiers are available, taking that 10 mins to look up your pills means I have 10 mins less to discuss something else with you.

In the world of medicine, especially geriatric medicine when a patient may be taking upwards of 12 different types of medications, I can certainly understand how overwhelming and confusing medication names may be.

Plus, the people who actually name the pills give them such tongue-twisting megamulti-syllable names. Ah, if only medications were called Blood Pressure Pill A, and Diabetes Pill 2.0, life would be so much simpler.

But no. We call meds Gorillastatin or Kombimetforglitazone or something fancier.

Having said all that though, one tip I share with many patients, and my dad, was:

It's always a good idea to know the names of the medication you're taking, the dosages and the indication.

Keep a folder somewhere with all your medical information. Health history, previous medications, current medications, allergies. Previous test results, names of doctors.

After all, we all keep a file of our bills, car and life insurance information. Contact details of ex-girlfriends (oops).

So why not our health?

Plus, this helps your other doctors understand what you're already taking, while minimizing the risk of medication duplication or interaction, and the risk of side effects.

Update this folder regularly, and carry a miniaturized version in your wallet, and bring it to all health visits.

Your doctors will thank you for it. But much more importantly, you will be a much safer patient.

Medical Treatment of Primary Hyperparathyroidism

Finally!

The FDA finally approved the use of Cinacalcet for primary hyperparathyroidism. This is a relatively common condition in which one (or more) of the parathyroids become overactive and thus raising calcium levels. While most patients are asymptomatic, in severe cases, left untreated this may lead to premature osteoporosis, symptomatic hypercalcemia (the medstudents amongst you would know the phrase I'd bet: Bones, Stones ....) and kidney stones.

While the only curative treatment is surgery, most patients are mild enough that this can be safely monitored conservatively.

The problem is when patients clearly have indications for surgery, but yet they are poor surgical candidates. Minimally invasive parathyroidectomy is not a big deal, generally. Generally. But when you have an 80-year old who's had a 3 vessel bypass and still angina symptoms, then the rules change.

The many I struggle with are elderly patients with severe hypercalcemia and osteoporosis, but yet, because of underlying vascular or lung disease and their advanced age, places them at higher risk for surgery itself. And being a firm believer of Primum Non Nocere (First Do No Harm) I'm not too sure the treatment is worth the risk.

Fortunately, this is where Cinacalcet comes it. It's a calcimimetic which lowers PTH and hence calcium levels; it treats the problem pretty well.

Unfortunately, for the longest time this wasn't FDA approved (it's not an experimental drug- it's been used a long time by the nephrologists for secondary hyperparathyroidism here. Also been used for primary HPT in Europe for awhile). So until it received this indication for use, the insurance companies consider its use in my patients to be 'off label' and hence won't pay for the drug. When clearly, it's a drug that works, and is safer than surgery for some patients. They'd rather my 86 year old female patient undergo general anesthesia and surgery. I've had that argument with numerous 'medical directors' of the insurance companies before, and the answer is always the same: We won't pay for it.

You wonder if their primary interest is the patient's wellbeing.

Anyway, with this welcome indication for Cinacalcet, it should be a thing of the past. It's good to have an alternative to surgery when you have a high-risk patient.