Happy Doctors' Day!

Happy Doctors' Day, guys.

Yes, March 30th is the National Doctors' Day, proclaimed by Bush Sr. in 1991. To "recognize our Nation's physicians for their leadership in the prevention and treatment of illness and injury...".

Perhaps a day for us too to reflect on things, and to be thankful. To be grateful to have survived the 11+ years of medical education. The 40+ hours of being awake (well, now restricted to 30 or less). The 100+ hours of work a week. The  huge personal sacrifices many of us have had to make. I know many whose marriages could not take the stresses of residency. Or colleagues who had nervous breakdowns. The tears and sweat we have shed. Or having to miss vital family events (my one sore regret was to not be able to attend my grandpa's funeral). Or the humongous financial cost; I have my parents to thank for shouldering my medical education which for many costs upwards of RM 600,000.

Yes, we have been through a lot. And we continue to fight numerous battles. But as I bid this wish to my colleagues, I sadly realize too that many outside our ranks would not feel the same about us. After all, the public's perception of doctors these days is that we're all rich and deserve no other gratitude. That we place money above our patients. That we are all in cahoots with the drug companies. That we think so highly of ourselves. We cannot be trusted, that the advice one finds on Wikipedia or somewhere else on the Internet is more reliable than that given by A Doctor. I realize this reading the public's comments on news websites whenever there is a breaking medical story. You realize that many people out there hate us.

I cringe to think about what many of my patients would think. Do they think I make money whenever I prescribe a (vital) expensive medication? Or that I get a monetary cut when I order a CT scan of the adrenal? Perhaps they think we all sleep with leggy drug reps. Or own stock in drug companies. I don't think I want know.

And so, on Doctors' Day, I shall quietly say thanks to the powers that be and to my family to have let me come so far. I will humbly share the day with my colleagues plodding away at work. No need for fanfare. No need for celebration.

For I sometimes doubt we really do deserve it.

Boutique Doctoring

Admittedly, there are some things I don't like about this job, or specifically, this specialty.

One concept I try to get across my medical students is that hormones, by their nature fluctuate. Sometimes more than others especially in extenuating circumstances. To top that up, while there are MANY tests available, there are good reliable tests, and there are some not-so-good tests. Add to this that there are so many symptoms that the public attribute to hormones that can be nonspecific. Weight gain. Weight loss. Hair growth. Hair loss. Low libido. Erectile difficulties. Mood swings. Lack of stamina. Muscle strength.

Take your pick.

And so, many a times I feel like a boutique doctor.

You know, the kind of physician who hands the patient a menu, and say, "Ok, what tests would you like today?"

And follows that with "What medicines would you like? Something to make you more energetic? Or perhaps you'd like this libido enhancer? Also I strongly recommend this medication to help you shed weight; it's one of our bestsellers!".

Maybe I'm being too cynical and am exaggerating. But the issues (bad, and good I suppose) with modern medicine are that my generation of doctors are taught not to be paternalistic and make decisions for patients; rather I see my job as to provide the patient with the information to make an informed healthcare decision for the better; in addition we now have the wonders of the internet and Wikipedia. Plus, big pharma now is using direct-to-consumer advertising (notice how many more TV and magazine ads we are seeing?).

So, often I have patients coming to see me because the are convinced that they have either Cushing's Syndrome or Addison's or Hashimoto's or Hypogonadism or Carcinoid or whatever else. Asking for a hormonal panel to be tested up the wazoo.

And couple that with the guy whose  total testosterone is a mere 1 ng/dL below normal (with a normal free level) who is demanding to be put on expensive testosterone replacement.

What does one do? Help him make an informed decision. In most cases if they really wanted a therapeutic trial, I hesitantly yield.

Not really being surprised when I see them for follow up 3 months later only to hear that it didn't help them feel better one bit. (though I still fear for the safety of one guy who refused to believe me and at last test had overdose his total testosterone to 5000 ng/dL, the highest I have ever seen. He refused to come back for follow up and has since been getting some Wellness provider to write him the prescription. I hope his prostate isn't the size of a melon).

And at the same time hating the idea that I am contributing to the exploding cost of healthcare and the billion-dollar pharmaceutical profits.

CPAP Dealer

This is a follow-up to my earlier post seeking information on CPAP (continuous positive airway pressure) devices. A family member of mine was recently diagnosed with sleep apnea and so we had been trying to track down a reasonable distributor for this.

Thanks to a link from Palmdoc, we ultimately settled on this company, Erickg Sdn. Bhd. , a company that is located in KL. I just wanted to share our experiences in case there are others out there who are looking for someone to work with.

I have to say, the experience has been somewhat of a pleasure. I communicated with a Steven, one of their product executives, via email. Though we are half a world apart, he provided me with timely and very helpful information about the various options. Eventually, when my dad did contact him, he was very professional and helpful and patiently explained things. He took the time to go over things, something I always appreciate for my patients and more so my family. He was able to help my dad understand things well, and provided good follow up to ensure things were working well after he gave my dad a loaner set to see as a trial. He even offered to drive 45-mins to our house (at a cost) though my parents eventually opted to drive to KL instead.

The prices were decent; more than the cost of CPAPs here in the USA, but certainly MUCH less than the RM10,000 quoted by one of the ENT specialists my dad saw. The obvious bonus was, apparently, this is covered by the government for pensioners.

So there you have it. My dad's sleeping a lot better, healthier. And if you're in the market for a CPAP device, consider checking them out. And no, this is not a compensated-advertisement.

Priorities

I thought this was an interesting response in The Star today, to a complaint by family of a patient of the air-conditioning failure and the slow rate of repair work. Written by the Director of the Serdang Hospital:

I REFER to “Hot times at Serdang Hospital (The Star, March 15).  

The failure in providing a comfortable environment in Hospital Serdang is caused by a technical malfunction in the computer system controlling the Building Automated System for the air-conditioning system.

As such, priority is given to critical locations such as Accidents and Emergency Department, Operating Theater, Critical Wards, Imaging and Diagnostic Department, Invasive Cardiac Lab, Urology/Nephrology Clinic, Labour and Delivery, Obstetrics and Gynaecology, Administrative Office, Central Sterile Supply Department, Pharmacy and Day-Care.

Maybe it's just me, but between uncomfortable patients, and Administrative Office, it's interesting for the hospital Director to put priority on the latter, no?

Vacation

We had a busy week! After my, ahem, visit with the endoscope, we had the rest of the week off and spent the week out of town with the in-laws (though it was fun for me to whine to everyone about how I started my 'wonderful vacation' on a clear liquid diet, then being on a bowel prep and getting a tube shoved up my ass!)

It was a special treat as my brother-in-law and sister-in-law flew in from out East with their baby and we got to see him for the first time.

It was an especially meaningful weekend- our daughter (and my nephew) was baptized on Sunday, and even her great-grandparents got to join us for the event. It's something Kris and I want for her- to have a good relationship with God, and this was the first step of hopefully many to come.

Thankfully, she behaved herself pretty well in church, so long as she got to hold her special blankie. And she loved the attention the elderly people gave her!

And best of all, she got to spend quality time, almost the whole week, with Kristin's family! Though they're not quite as far away as mine in Malaysia, she doesn't get to see them much so this was a nice treat. It's amazing how fast she is growing and it was fun to see her interact with them. I can't wait though for my family to come visit again hopefully later this year to see our little girl. In the meantime, thanks to the wonders of technology, she is able to see both sets of grandparents on Skype often enough.

When Bad Things Happen

I love having the honor of sharing so much in my patients' lives. When they get married. Have babies. When their thyroid cancer is in remission, or when they've done a great job controlling their diabetes. It really is a priviledge, something not all jobs offer.

However one thing I continue to struggle with is when things go bad. Because, you're dealing with people's health here.

When you find horrible multi-level metastasis.

Or when they develope a tragic cerebral thrombosis during surgery.

Or when they suffered a car accident related to hypoglycemia from insulin overdose.

Or when they develop a major adverse effect of a medication you prescribed.

I don't know how my other colleagues deal with this. I'm not sure if this happens only to me; but when things go wrong, it hits me at a very personal level. It gets me wondering if I should have prescribed something else, or explained things better to a patient, or advised better, or referred to a different surgery or radiologist. I wonder if there is anything I could have done to have prevented it. I spent weeks thinking about the case.

They say that everyone has something that keeps them up at night. Well, when bad things happen to my patients, this is the thing that keeps me up at 3 AM.

National Colorectal Cancer Awareness Month

March is the National Colorectal Cancer Awareness Month.

Colorectal cancer is the 2nd leading cause of cancer deaths in the USA, with over 50,000 deaths annually. And while some people may present with symptoms of changes in bowel habits (constipation with bouts of diarrhea) or blood in stools, most are asymptomatic until advanced stages. As such, it is recommended that screening colonoscopies be started at the age of 50, younger if there are other risk factors like family history or inflammatory bowel disease.

And to generate more awareness, yours truly decided to get his arse scoped today. Yup, no kidding. Well, also because of a family history of colon cancer. I started my screens at the age of 25, and this would be my third.

Many of my patients are fearful of the procedure. Worried about the pain/discomfort. Well, personally, there's nothing to it. Thanks to a generous dose of Midazolam and Meperidine, my friendly gastroenterologist had me out like a light. Or at least I don't remember him shoving that damn endoscope up my butt. Last thing I remembered prior to the procedure was getting worried that I wasn't yet sedatic/amnesic and he was already lubing up the endoscope; I actually said to him "Erm, I don't think your nurse has administered the Versed yet".

"We'll fix that". True to his word.

The worse parts are probably the 'ancillary' stuff. For one, I was suffering from a clear liquid diet for the last 36 hours, and having to take the ghastly 4-liter tank of laxatives (while my dear sympathetic wife and daughter happily chowed down hot dogs, chicken fingers and other snacks all weekly). I was starving all weekend! And after you take the stuff, just make sure you have a nice collection of magazines to keep you occupied when you're on the toilet. You're gonna need it, trust me.

So there, it's not that bad an experience. Though with the Midazolam, there was much I don't remember. Like how I kept asking the doctors and nurses the same questions every 2 minutes. Also, my wife tells me there was a bombshell of a nurse who looked after me in recovery but I don't remember anything about it. And thankfully my colon was clear, aside from the copious amounts of flatus which I'm blaming squarely on the gastroenterologist's insufflation.

So, if you're over 50 years of age, or have a strong family history of colorectal cancer, do yourself a favor and schedule a colonoscopy. It could save your life. It did my dad's. 

A Dream

I got an email from Buddy the other day.

Yup, my best friend who succumbed to esophageal cancer last year.

Some stupid spam-mail, presumably because someone had hacked into his account. But yet, I caught myself smiling reading the email. Who knows, perhaps this was a sign from him? Perhaps this was his way of reaching out?

I found myself thinking, “Boy, you must have good broadband up there, buddy!”

Strangely enough, probably because of the email, I dreamt about him that night. I dream we spent an afternoon hanging out. Doing the normal stuff we used to. Going out for a meal, chatting. And in that dream, we spent the time reminiscing the wonderful years of friendship we’ve had, the fun and the mischief we got into. We were thankful for the friends around us. It wasn't the kind of dream where we just relived the past. No, in that dream, we both knew he had passed on, but was only visiting for a short while.

I told him how much we all missed him, and how big of an impression he left in our lives. I tearfully told him how sad it was for Kris and I to say goodbye that night in Penang when we left, knowing very well that that would be the last time we would see him in this world. But Buddy, in his usual stoic way, said that he is doing well. And told me to tell the others to not worry about him. That someday we’d meet again, but until then to go on living and making the most of our lives.

I woke up with my eyes wet that morning. It was as though we had again said our goodbyes. But that was a wonderful dream, to be able to talk to him again. To share how life was for us. To share my troubles and insecurities and things I don't get to unload to many. To just have my Buddy back again, even for just a moment.

God, I enjoyed that dream. Whatever that might have meant, whether or not that was a sign, Buddy, we miss you.