I saw Mr. L the other day. He was one of my oldtimer patients (not in terms of age, but I'd been seeing him for a while). And one of the things he said struck me as an odd, but surprisingly accurate, statement.

"You don't really believe in the stuff you supposedly peddle, do you?"

I had been seeing him for his diabetes for years. And on a more recent visit, he complained of issues with erectile dysfunction and low energy. And so when I offered to check his testosterone levels, he was quite keen on it. Nothing really jumped out on his history; he just occasionally has trouble keeping his erections during intercouse and his libido was a bit decreased. Otherwise, his morning erections, and during masturbation, seemed normal (yes, awkwardly personal, but very helpful questions to ask). He denies any gynecomastia, change in shaving habits. As with many of my diabetes patients, he is obese and has the typical habitus of someone who may have sleep apnea.

As it turns out, his total testosterone was slightly low at 314 ng/dL (normal more than 350). And so we had a discussion about testosterone replacement. He was quite keen on trying something, having seen the numerous TV ads (you know which one I'm talking about; the one with the guy talking to his shadow). And yet he sensed my uncertainty, which I did not attempt to hide.

I belong to one school of thought. The other side of the fence. There is a reason why the normal range for many hormonal tests is wide. They are based on what is deemed to be a normal population, with all our indivdual variations. And the nature of many hormones is that they fluctuate. When it comes to testosterone, there is an age-related decline, as well. And so, it is not too uncommon to have levels sometimes being a bit low. Frequently, blinded studies show little benefit of replacement for many of these borderline patients. However, you'd not believe this, seeing the numerous TV, magazine and newspaper advertisements, suggesting that medication A or B will make you feel like a new man. That if you are tired, or lack the drive you did when you were 20, or struggle with low stamina and weight gain, then it MUST be the low testosterone (heck, maybe I should get MY levels checked. That all sounds like me!). Pharmaceuticals is after all, a multi-billion dollar industry.

While cautious therapeutic replacement trials should be safe so long as things are carefully monitored, I'm of the opinion that the drug companies are already making far too much money, and if someone is not going to feel any better being on their medication, I'd usually discourage things. I'm open to it, but I'd usually not push it. Be it for borderline hypogonadism, or 'hypothyroidism' with a TSH of 5.2, or something similar. Perhaps it is ironic then that a board-certified endocrinologist is much less keen on starting patients on hormone replacement, than many of my general practitioner colleagues.

And so, I left the final decision on whether to start testosterone or no up to him. After checking into the cost of the medication, and looking up some (reputable) medical websites, it appears that he agreed with me. He said no.

Race For the Cure

We had a fun weekend. Kristin and some of the girls had been training for the Susan G. Komen Race For the Cure 5k run. So, on this beautiful (cool) Saturday morning, 20,000 people converged here to run to celebrate and remember our loved ones, friends, patients, with breast cancer.

Just over US$1 million was raised, but much more than monetary goals, I think this annual international event really raises the awareness of breast cancer and the importance of screening.

It was heartwarming to see so many people there. Clearly, some had lost family and loved ones- many wore names of people they were remembering or celebrating. Many had custom designed team shirts. And I've never seen so many men wearing shocking pink (no, I didn't run- baby duty). Even saw one guy dressed in a pink cow suit with udders for the run.

 Congrats, girls! (can you spot them in the finsher picture above?)



Then and Now

 

I just had to take a photo of this sign I saw in the hospital. I just had to shake my head; this was a notice to nurses to sign Thank You cards to give to patients. While this might be a nice gesture, I caught myself thinking, Isn't it supposed to be the other way around?

I'm going to make myself sound old saying this, but it did make me ponder about how things have changed in our world.

• Then: Patients used to send Thank You cards to the doctors and nurses.
• Now: We are sending Thank You cards to the patients to thank them for picking our hospital
• Then: If you are injured, you seek the help of a medical team.
• Now: I have to listen to this damn radio advertisement every morning when I drive to work: "If you are injured, you need the services of an experienced lawyer. Call XXX"
• Then: The doctor would pick the best medical treatment for the patient.
• Now: You list out every single option, the pros and cons, and the patient decides.
• Then: You make a clinical diagnosis based on a good history and the lost art of the physical examination.
• Now: CT abdomen with IV and oral contrast.
• Then: If I felt that a patient could not afford medical care, I'd underbill that patient and not think twice about it.
• Now: I'd get a formal reprimand from the directors as this might be deemed a case of discrimination, and we might get sued for giving special treatment to a patient over others.
• Then: Re@der's Digest magazines were actually filled with good stories, inspirational tales, and fictional writings.
• Now: It's drug ad after drug ad after drug ad (the reason I cancelled my subscription, after been a faithful reader since I was 7). It's the same crap on TV too, and I imagine the parents blush when a Viagra ad pops up during family TV time.

Changes for the better, or worse? You be the judge.

Things You Don't Know As A Doctor

Being someone's physician, you get to see just one side of someone's life. You get to know about their previous ills. You probably understand much of the biochemistry that occurs in their bodies. However, not the more important things in life.

I was reminded of this this morning as I was doing my rounds, and happened to find out that one of my thyroid cancer patients recently lost his battle.

It was inevitable, the very aggressive kind that he had, but as inevitable as something might be, is still never acceptable in anyone's psyche. And so, when I had some quiet moments between consults just now, I spent some time reading up his obituary. If nothing else, just a private moment to remember him and celebrate his amazing life.

I found out he went to an Ivy-league school, and chaired numerous subcommittees. That he had an interest in the underpriviledged, and was active in social work. Though I had met his wife before, I read that they were sweethearts long before they got married. I read about his kids, that they have twins. I caught myself being in awe of Mr. G's humility- as his physician he never let on to me that he played such a big role in many people's lives.

I recalled too some months ago when Mr. T passed away. My clinic posts the newspaper obituaries of our deceased patients so that we can choose to sign their condolence cards. I found out that he was a World War II veteran, and a prisoner-of-war. That he was an airforce pilot and flew numerous bombing runs.

Or how another patient was involved in the Manhattan project, and the development of the atomic bomb.

No, these things hardly come up in the usual doctor-patient interactions. After all, the have little relevance in the diagnosis and treatment plans. Nonetheless, in the larger scheme of things, these are the events and moments that leave a bigger mark.

Goodbye Mr. G. You fought a short and hard battle- may you find eternal peace now wherever you may be.

To have Type 1 Diabetes

I saw Andy the other day- he was a new referral for hyperglycemia. Lean, with no family history. His glucose was found to be 455 mg/dL at his primary physician's earlier that day, with a hemoglobin A1c of 14%, so they rushed him in for a visit with the endocrinologist.

I hate being the one to break it to patients; invariably, most patients are initially quite upset by the diagnosis of type 1. To be told that their islets no longer have the capacity to secrete insulin, and to have this disorder for life. To be told that from this moment on, they will need to be on insulin to survive, and to be aware of dietary carbohydrate intake, blood sugars, and all that stuff.

I don't blame anyone for being upset. And I don't blame them too for not quite believing the optimism I show at these visits. I tell them, diabetes does not mean the end of junkfood, or candy, or fun stuff, or exercise. It's just that one has to make some changes to one's lifestyle, and obviously educational empowerment of the patient is key. A lot of learning. But the truth is, with good teaching, and commitment by the patient and health provider, a vast majority of patients have excellent prognosis. They do well.

But the look on their faces tell it all:

"Patients do well?? How can that be? I'll need to check my sugars and take a shot 4 times a day! For the rest of my life??!"

I can understand the patients' scepticism. But, from the other end of the fence, speaking as a doctor, I am humbled as well by the advances we have made in the field of type 1 diabetes. After all, before the discovery of insulin by Drs. Banting and Best in 1921, type 1 diabetes had 100% mortality when it became fullblown. ALL patients died, most never seeing adulthood. In probably the fastest drug developmental program, the first human subject testing occurred in 1922, and insulin came on the market only a year later! Dr. Banting eventually received the Nobel prize in 1923. And now, the situation has completely reversed- with insulin, we expect all our patients to not only live, but live meaningful lives albeit with numerous adjustments to lifestyle.

Imagine if we can someday say this for cancer.

And so, when I do try to be optimistic with these new patients, I do really mean it though I realize we may be looking from different angles.

And I agree with the battlecry of many of my patients still looking out at the horizon for new developments in treatment: Insulin is not a cure.

Someday hopefully we get there. But in the meantime, this is the best we have.

An Interesting Hypercalcemia Case

I thought I'd share this case I saw not too long ago. The patient, Mr. P, was a 52 year old man who was found incidentally to be hypercalcemic. His serum calcium was 10.9 mg/dL and on repeat 11.2 mg/dL (his albumin was normal, in case you medstudents out there were correctly asking that question).

While the workup of hypercalcemia should include a parathyroid hormone level early on as this may obliviate many other tests if this was inappropriately high (recall that one does not need to have a high PTH to have hyperparathyroidism- a common mistake that I encounter), his PTH was appropriately on the lower end.

So, working along the lines of 'non-PTH mediated hypercalcemia', what is your differential diagnosis, and plan?

(and if you're friends with me on FB and already saw my earlier posting, don't spoil the surprise!)

Signs You're Getting Old

1. It's Saturday night, and you find yourself in bed by 8:30 p.m.
2. You get motion sickness playing on the swingset with your toddler
3. Your sideburns are greying
4. You catch yourself choosing to drive the Lexus and not the Porsche on a beautiful sunny day because you're too lazy to work the clutch
5. When the baby's finally asleep, between sex and going to sleep, you're sometimes picking sleep
6. You're starting to seriously think about life insurance, writing a will, living revocable trust and things like that
7. You think driving at 70 mph is way too fast
8. You walk past a leggy 20-year old blonde bombshell and you catch yourself looking at her mother instead
9. Your friends' kids call you 'Uncle' or 'Auntie'
10. You think it's perfectly normal to be getting up at 2 a.m to pee
11. You're needing to take some ibuprofen for knee pains after running 3 miles on the treadmill
12. Someone tells you you look good in that tweed jacket

Sighhh. I suppose, as an elderly wise patient once told me, the alternative to getting old is to die young which isn't a good thing either.