Happy Merdeka Day!

Happy 54th Birthday, Malaysia.

I wish you peace, and harmony, and economic growth.

I hope that your leaders eventually learn to mature, and make decisions based on what is best for you, and your people. Not for one group. Not for personal greed, or corruption.

I hope that someday, you will become the truly democratic, truly multiracially harmonious society that so many of us want you to be.

I hope society can someday rid itself of selfishness, racism and corruption.

Happy Merdeka Day.

It's a Mad Mad World

Some things are so screwed up.
For one, healthcare and medicine are f*cking expensive. Doctors' visits ain't cheap (and no, I don't get to choose the dollar amount I charge. We just code according to 'complexity' of the case) and the amount that gets charged depends on the health insurance and bureaucratic BS that I don't fathom. Secondly, the medications themselves are overpriced, really. I understand the need to cover costs of R&D. But to be making billions seems wrong.

I guess I'm just irritated with things. I saw a patient the other day for poorly controlled diabetes. She has type 1, a condition that requires lifelong (until someone comes up with a cure) insulin and regular glucose testing to allow for safe adjustments of her insulins. Unfortunately her hemoglobin A1c was 14%, her control hampened by lack of compliance. Except I don't blame her.
Tearfully, she tells me she just cannot afford the glucose strips, and the insulins. She is one of the millions of uninsured Americans. And so, medical care costs a bomb, and she has had to decide what's more important, food/rental or medications.
And so, I squirrelled away whatever free samples I could find in the clinic. And referred her to the social worker. And, hoping the hospital director never finds out, bills her a level 2 (with the multiple issues and her high risk situation, this would have been a level 5). Essentially, something akin to a nursing visit. The last time I did this, I got a reprimand.
Elsewhere in the world, if a doctor, in good faith, decides to undercharge a patient, it's his perogative. Heck, in Malaysia I've had doctors who give courtesy 'free consults'. Here, in this overly civilized country, that may be perceived as a form of discrimination. Why would you give a discount to one patient, and not another?
And so, the hospital and it's lawyers go nuts with these things. And it is very frowned upon, as tragic as the case may be. The hospital does not wish to open itself to any lawsuits.
In my opinion, if we weren't afraid of being sued, healthcare in general would be much cheaper, and the world would be a better place. Without the threat of lawsuits, that may make some idiots be bigger idiots, but I'd like to trust that mankind generally, is good.

If we weren't so careful and afraid of missing somethings, things would be so much simpler and cost effective. Ie, make a medical decision based on the history and the clinical findings and suspicion, and go with it. And not "run other tests to make sure I'm not missing something" defensive medicine that the malpractice lawyers have made American medicine to be, these days. I mean, come on, do all tummy pains require a CT abdomen?

And all that "If you've taken Pill X and have had an adverse effect of Y, call Lawyer Z as you may be entitled to a monetary compensation...". ALL medications have side effects. All of them. You take a pill if you and your physician agree that the benefit far exceeds that. I get pissed seeing the new TV ads for people who had a heart attack while taking a certain pill; chances are without that medication MORE patient would have died from their medical condition.

You tell me, is this not screwed up?

We'll see if I get a call from the director about this case. Frankly, I don't care.

Corndogs, Fried Snickers Bars and BO!

Yup, talking about the state fair. We were there over the weekend; Alli's 2nd (she was 2 months old when we went last year. As usual the crowds were crazy, over a million attendees in the week and the half. Coming from Malaysia, this is always a cultural shock. Deep fried everything, with every imaginable foodstuff sold on a stick. Crowds and crowds of sweaty people wearing wifebeaters, with the occasional whiff of musky body odor.

We discovered too, like her father, Allison loves corndogs. And this is her, posing with a pumpkin, a PUMPKIN, 50 times her weight!

Aside from the usual deep fried candy bars, this year someone came up with the idea of deep-fried butter. I kid you not. And people wonder why obesity is on the rise.

Not that I should be so judgmental; we had the deep fried Oreos, and they were pretty interesting. And I had 2 foot-long corndogs!

Someone please pass the Lipitor.

Century Link: A Study of Incompetence

So, how did I spend my 35th birthday?

Awesome cake and birthday brunch by/with the wife and daughter.

And some vomit inducing moments with our new internet provider, Century Link/Qwest. I swear, the ISPs just keep getting worse. And I have not been impressed. And yes, if you Century Link customer service web crawlers are reading this, feel free to get in touch with me to apologize.

Because the other ISP was steadily increasing its charges over the years, we decided to make a switch. And so last month, July 20th to be exact, we had our DSL installed. A long cable ran from our house, to the back and diagonally across. Why the tech didn't connect us to the nearer box right behind us, I don't know (I think he needed new glasses).

Anyway, we were told the cable would be buried within a week.

And then the weeks came and went. Finally, on week 3, someone came to make the burial. Except this seemed like a bright fellow, and made a new connection to the nearer box so that he didn't have to dig into our neighbours' yards, and buried THAT cable. He said he would contact Century Link to have the service transferred to the new, nearer box instead, and they can then remove the old unburied cable. He suggested I call too, to get things moving faster. And therein lies the problem. 7 tranfers between incompetent customer service reps, with 1 dropped call, and FIFTY NINE minutes later, the last guy finally said, "I have trouble contacting the buried cables department. Can you call back later?"

WTF. And so, to avoid a cerebral hemorrhage from the hypertensive crisis they were putting me through, I decided to give it a break, and see if they would come.

A week and half later, no word. The cable remains unburied. My neighbour's kids have already tripped on it several times (no word on any lawsuits yet). And today, one of the lawnmowers went over it and severed the cable (it was an inadvertent but expected outcome- the damn thing runs across the yards of 3 homes!).

And in this day and age of 'high speed this-or-that', it will be.... taa daahh... 72 hours before someone comes to rectify this.

Strangely enough, things moved a lot faster before I became a customer... but once they had me hooked, things seemed to slow.

And to think this is a telecommunications company. Bullshit.

Maybe I should go back to dialup.

Stages of Life

Year 1: Milk, food, bankie, sleep

Year 12: Girls are strange. Girls are dirty (hey, it was an innocent, literal 'dirty' then!)

Year 18: I'm cool. I'm the head prefect of the school, and Vice-Chairman of the first-aid unit. And I bet the chicks really dig this pair of white Guess jeans I'm wearing, and this moustache I have on my face

Year 21: Wow, I'm finally an adult (still on an allowance)! I have wheels (a hand-me-down pimped out Proton Wira).

Year 25: Check out those hot 21 year olds!

Year 30: WTF? 10 years of medical education, and I have another 2 years to go before I'm finally done training? And I need to work harder on my papers and get them published!

Year 35 (almost): Hmm. I wonder if that Rogaine stuff will work for me? Or maybe I should shave it all off; why fight it? And oh yea, is it just me, or are women in their 40s sexy? Uh oh, I think I hear the baby crying.

That pretty much sums up the years so far. Yea, I turn 35 tomorrow. Well, technically since I was born on Malaysian-time, I'd be sometime today. I was just sharing these with my wife the other day; it's amusing how one's priorities and thoughts change.

For one, yes, I used to have several pairs of designer white jeans. I thought they were cool. Kinda still do, but my wife has threatened to disown me should I wear them (she allowed me to wear them once on a date many years ago, but that attracted one too many stares). And so the expensive Guess and 501 jeans were donated away. Now I only embarass her in other ways.

For a guy, obviously a big interest in life are the girls. Even now (oh yes, the wife and I are allowed to admire eye candy. See no touch). But it's funny how when I was in highschool, I thought the epitomy of sexy womanhood was a matured girl who was 18. And then it became 21 years of age. And then 28? And now, I catch myself mentioning to Kristin things like, "Check out that woman", and then to realize she's in her 40s or 50s. If you asked me who is THE sexiest woman around after my wife, I'd say Diane Lane. And she's what, 46?

Priorities change. Yes, I'm still working like a dog, probably harder than I'd like to. But at this stage of my life the priority isn't work (it's a necessary evil) or buffing up the CV with publications, or presenting research posters. It's not to dress up and look good and party and impress girls (the only 2 I wanna impress are the 2 honeys still tucked away in bed in my house). It's not money. No, now, more than ever it's family. And I have much to be thankful for.

P/S: If you really want to know what I want for my birthday, it's a 2nd hand (I never get it new) Halo Reach.

The Modern Epidemic

I saw Andy the other day. One of my oldtimer type 2 patients. And in the midst of the usual banter (this time, about the state fair), he joked about his weight. And then he asked me why this was a bigger problem these days (no pun intended) compared to his parents' generation.

Obesity. It's staggering, the numbers. In some parts of the country, more than 1 out of 3 adults are considered obese, with a Body Mass Index greater than 30. In my practice, many of my patients have a BMI in excess of 50. And it's not only the USA; this is a worldwide phenomenon. And perhaps a greater tragedy is, childhood obesity is becoming much more prevalent. No longer are the lines well-defined: "Type 1 diabetes occurs in childhood, and type 2 occurs in adulthood.." my medical students often quote to me. Not anymore, buddy.

Why is this? There is always an inherent need to find a 'medical reason' for obesity. I see consults for these every week; patients who won't believe their thyroid or adrenals are working fine. "There must be a reason for this. There must be a pill I can take/surgery I can have..."

The reasons are complex. And probably too many for me to fathom. But methinks this is due to the modernization of man. Technologically, but also socially. And unfortunately, what's right as a society may not be the best for its health.

Due to the conveniences of life, we just aren't as active. Believe you me, I'm not referring to things as a 3rd person; I know I am guilty of this too. We just don't move as much.

True, dedicated exercise is great. You know, running, going to the gym etc. However I'm also a firm believer in non-exercise activities. Things that don't require special preptime, or special trips to a facility. Things we can do all the time, during our usual everyday motions. There are numerous studies out there demonstrating this concept. Just any kind of movement, burns calories albeit in small amounts. But as a society, we are just walking, moving around less. We depend so much more on modern automatons. There are escalators everywhere. We use the elevators even to go up (or even down!) a floor. We drive everywhere we go, and walk less. We use the phone to call a colleague and not actually stroll over to their desk (I've called my wife's cellphone from the basement, when I was too lazy to walk upstairs at home!).

Now, not only is the output less; the input is more as well. There tends to be a close relationship between the ease/price of food, and its health value. The cheapest, quickest foods tend to be the least healthy. I admit, the crap I wolf down at lunch every day isn't exactly good for me. As a society, things seem to have shifted to the wrong end of things. How many times have I seen a family with everyone being obese, even the kids, at McDonald's. And the children having 2 servings of fries each, plus a burger and sundae? And I'm just as guilty, having MY Big Mac and fries. Oh, how I wish broccoli and all things green made us fat. And chocolates/fries were full of fiber and protein and vitamins!

But the more difficult thing to admit for me as a physician and as person is, what we do to support some people, may end up backfiring. Some of my patients struggle with weight so much that they have difficulties ambulating, so they instead use a motorized wheelchair to get around. Now, from the civic and societal standpoint, this is great- this offers some people freedoms they would otherwise have difficulty experiencing. But if you looked at things purely from a (robotic) medical view, then this would decrease their activity levels even more, feeding into the problem. And so, both of these views are discordant, and in conflict with one another. In addition, many of my patients feel that they can do longer work because of their excess weight, and apply for disability, allowing them to obtain special benefits, like strategic parking spaces, and a (small) monetary compensation. Again, I see the need for these, but I am also conflicted in saying that these may not help alleviate the underlying medical condition. One can say these in a way rewards the problem.

And so, I wish I had the answers. I wish the CDC, or the NIH, or the government, or Obama, or even Najis did. I wish there was a simple solution to this worsening epidemic. As an endocrinologist, I wish it was as simple as, "Oh yes, you have hypothyroidism, take this pill" or "A laparoscopic adrenalectomy will cure you of your Cushing's and your weight problems".

Unfortunately the answer is probably much more complex than that.

In the meantime, society suffers.

How to make a burger

So I decided to try my hand at this for the first time. And I have to say, it turned out pretty damn good (caution to the reader: self praise means nothing. Proceed at your own risk).

Start off with ground beef. 85/15 or 80/20 should do it. I woulda gone for the 80/20 but my wife apparently loves me and doesn't want me to die of an MI at 40. So, it's 15% fat it is, then.Other ingredients I added included basil and onions (from our 'garden' Taa Daa!). You'll also need a teaspoonful of salt, garlic.

Finely chop the basil and onions.

Mix the chopped up ingredients with the minced meat. And being Malaysian, I just HAD to add a dash of soy sauce and curry powder. Mix well with your fingers. If you do this after a pangsai session, I've been told the burgers will taste better.
Make apple-sized balls of meat, carefully compressing them to ensure it'll stick together. Flatten them on a platter, and make a depression in the middle with your thumb (so that you'll know when it's cooked- the dimple sticks out)

Grill away on medium heat. It took our grill about 5-7 minutes to cook the patties to medium.

Slice of cheese on the patties while it's still hot to partially melt it.

Serve with some miniscule portions of veggies (we had asparagus) to appease your wife that this is a 'balanced' meal. And then go feed your canivorous side!

Shh

I just wanted to share this experience from today, which really irritated me.

I dropped Claudia off for her oil and filter change. It had after all been 2 years since the last. The workshop we use offers a courtesy van, so I had them drop me off at work. And in that shuttle, was another 3 gentlemen who needed a ride, too.

Clearly, one of them was a doctor. Probably a surgeon of some sort, as he was in dark blue scrubs. During the ride, he started to make a few phone calls to his nurse. And talked about some billing issues regarding some patients and some procedures. And actually spelled out his patient names to his nurse.

Now, this is wrong at so many levels. For one, it's rude to be yapping on the phone in a shuttle van with others. Secondly, it is simply unethical to be disrespectful of the sacred confidentiality between a patient and his doctor. Indeed, this would be a HIPAA violation and may be an actionable offence.

True, there is more than one 'John Doe' in the city, and he didn't read out in graphic detail his address, or date of birth, or the procedure itself. But come on. Your patients trust you with his secrets, while the others around you expect a certain level of decorum as a member of the medical field.

Even when I'm rounding in the hospital with my residents and students, they all know better than to continue discussing our patient cases when we step into an elevator with other sets of ears. Our topics swiftly change from the insulin dose for Mr. G to what our wives do for a living.

So, to those of you who have been entrusted with this priviledge, remember the sacred oath you took. Be respectful of your patient.

Of Stockpiles

Every Malaysian expatriate I know does this. You know you do.

Every time I make a trip back, I 'import' a stash of foodstuff into the US. And in fortified pantry of our home, much much more priceless than jewellery, or our legal documents, is my stockpile of Malaysian food.

My precious stash of spices, sauces and pastes from half a world away. A feeble attempt for the tastebuds to experience the homeland. A temporary means of treating homesickness.

And my wife knows better than to mess around with my stuff. She can mess around with my Porsche. My cellphone. The LCD HDTV, or my computer. But this, this is out of bounds.And so, I made dinner the other day. Was craving some Portugese fish curry. And so, I put on my chef's apron, got the fish out of the freezer, and went into the pantry to get My Precious.

Only to read:

I did the only honorable thing. The right thing. After all, I'm a doctor, and health is important to me.

I ate it.

(no diarrhea or food poisoning, so far. Just don't tell my wife about the expiration date)

Time Flies

I didn't realize the significance of today until I ran into the hospital HR manager today.

"Happy Anniversary!" He wished me.

Oh yes. It was today, wasn't it?

August 4th 2008 was the day I started work in this medical center.

3 years ago. It didn't feel like it was that long ago when I left my alma mater.

Packed up my stuff from that rental I had lived in with Buddy for 5 years.

Drove our two cars and dog here.

I remember when we closed on our home. How we spent the first night sleeping on the floor, because the movers were going to arrive only a day later.

I remember my first day at work. Feeling lost physically, not knowing where to go. Fumbling with the computer system. Still uncertain if I was treating patients right, seeing that that was the first time in my professional life when I did not have to present the case to anyone else for approval.

Time flies. And I do catch myself wondering what's in store for the future...

Split Seconds

I saw Mr. L for traumatic central diabetes insipidus today. And I was struck by the story my resident told me as he reported the case.

A young father, in his 30s, who had been previously well. And perhaps in a moment of childish fun, decided to fool around on his motorcycle with his son. Without a helmet on.

Young, healthy, promising life. Full of love, laughter.

In a split second, he falls with his cranium hitting onto the solid concrete ground. They say the EMS found his pupils blown, though mildly reactive to light. His GCS was 3. He was airlifted here where he underwent emergency craniotomy a month ago.

Today, when I saw him, he was apparently no better than 3 weeks ago. Unresponsive though breathing spontaneously.

I catch myself thinking, how life can change in just a blink of an eye. In a split second. Life switches from heaven to living hell. One minute, a loving parent enjoying a moment of silliness with his son, and the next his son is sobbing beside his father who will likely never recover. Being a newish father, I can't help but feel so much sorrow seeing Mr. L, someone my age. Feeling sadness for his family, and thinking about the what ifs, and how life might have turned out differently if he decided to, say, play catch with his son instead, or watched TV, or even put on a helmet that day? Or, what if he caught his fall with his arm instead? What if that were me, instead? What could or would I have done differently?

So fragile, life is.

I pray I'm wrong; I pray the trauma surgeon, neurologist and all the doctors on his case are wrong. I pray that someone, Mr. L would get to have more silly moments with his son again.