Bersih

It's a good thing that I've escaped, isn't it?

It's great that I no longer live in Malaysia, with its corrupt leaders and a regime that is due for change.

I don't feel for those who are left behind.

I'm not Malaysian anymore, after all, isn't it?

Yea, right.

The truth is, with every act of violence, or cruelty, or corruption, my heart bleeds. I feel angry. And hurt.
And yet, pride, at the brave sons and daughters who went out in masses, asking for a electoral reforms.

May we someday see the change we so need.

Admittedly I've often wondered if I shouldn't have been something else other than an endocrinologist. Because, the shameful truth is, I might be a hormone specialist (now, the term specialist is being used loosely) but really I don't like prescribing them.

No, really.

My philosophy is, as smart as we damned doctors think we are, we're not. We often can't medically explain why you may be losing hair, or feel like, or have problems with your erections. Why your penis is short/droopy. Why your bench press limit is maxing out at 200 lbs. Why you can't sleep. (all are real consults I've been asked to see).

And so, I tend to be really conservative- I prescribe a medication when I am confident that a patient is truly having a problem, that the medication will help, and that it will do my patient no harm.
The old adage of Primum Non Nocere has been my cornerstone of practice.

But of late, I've been seen more and more issues to which I cannot ethically allow myself to address. The case in mind was an exhaustive visit with a patient who started off with his personal trainer suggesting that he takes Testosterone to help with his muscle stamina. However because this may be aromatized to estradiol, he also wished to be on an aromatase inhibitor. And to preserve testicular function, requested a 3rd medication in the form of HCG shots.

He called it a cocktail.

Oh man. Is it me, or is it kinda messed up? Maybe I'm just a wimp and isn't ready to do something totally off-label like that. Sure, the physiology of that combo seems reasonable. But has it been studied for use in that context in large scale efficacy and safety studies? Who's gonna speak for the patient who suffers from a stroke or MI from Anastrozole? Who's gonna protect me from litiginous consequences when something untoward happens because I chose to do something that is not standard of care of the medical community?

Also, what's with these TV ads these days promoting supplements that will boost a man's testosterone? These seem to be replacing the weight loss supplement ads these days.

Sigh; life used to be simple, a mentor once said. We used to be doctors. We treat the diabetes and reduce their risks. Diagnosed the thyroid cancers. Correct their hyperthyroidism. Replace their hypopituitarism.

But these days, the practice of endocrinology seems to be going into a very dark, grey area.

Another Buddy Story

We were at at dinner gathering this weekend. It just so happened that at the party was a family whose father recently succumbed to esophageal cancer. But was was more surprising, was that he was treated at our alma mater, and had met Buddy. And so, I was fascinated to hear his wife share his story:

4 years ago, he was diagnosed with esophageal cancer. This, on top of numerous medical issues like diabetes, lupus and heart ailments. He had a wife, and 2 kids. And so, he got bitter. He got angry, and couldn't understand why him.

Why him? Wasn't he already given enough? Why is life so unfair? Why is God doing this?

And then, someone mentioned of a young doctor, a cancer specialist, who was himself battling the same disease. Someone suggested that they meet.

His wife shares that, in that one afternoon, he met up with Buddy for the first time in the Cancer Center. Not as a patient of his. But as peer. As a cancer patient, reaching out to another for guidance. And in that few hours, his outlook changed from being a bitter angry man in denial, to one of acceptance, of someone in awe that if a young oncologist like Buddy who was only starting out in life could face this disease and stare it in the eye and be to accepting and have faith, then so could he.

His wife said that that afternoon changed his outlook 180 degrees. He was no longer bitter. He, someone 30 years older, looked up to Buddy for inspiration.

They shared many emails following that. Apparently stuff that only someone in the inner circle can relate to, someone none of us doctors really understand- the pain, the neuropathy you experience from the chemo, the other side effects.

They were saddened when Buddy passed away last year. They knew he was headed for the same fate eventually; but he faced the adversity with much more dignity, and peace.

I loved hearing that story. I loved how Buddy touched his life and inspired him so much. His family reckons that Buddy was one of the 5 most important people to him during the cancer years. That he mentioned before his passing that he hopes he'd get to meet Buddy again in Heaven to talk again.

They teared up. I did too. But it felt like a wonderful reunion, to be able to share our stories from opposite ends with this one common thread.



True Grit

Many of you would have been uptodate with the news in Malaysia about the hardships that a House Officer has to undergo. The firestorm stems from the tragic death of a young doctor who died from allegedly using medications to fight fatigue.

This was then followed by numerous complaints and letters from HOs, and even their parents (yup, you read that right. Parents) about the inhumane work hours of the trainess.

As expected, this was followed by the kneejerk reactions from the authorities, including mandating that hospital directors meet with the HOs weekly to discuss their welfare.

Work-hours. It's a double-edged sword. It's an issue that is arising in Malaysia, but one that has been troubling program directors and residency/fellowship programs for the last 8+ years here in the US.

It's common sense. An exhausted doctor can be a dangerous doctor. How many of us can attest to making a mistake when we are exhausted? As a resident, I've had postcall days that I couldn't remember where I parked my car, and walked home instead. Or when I couldn't remember a friend's phone number. Or what I did with a patient's orders. I remember Buddy's story of how he fell asleep whilst dictating a patient admission note (he had 5 mins of silence that he had to rewind through to resume his dictation!). And you want me to stick that big-ass 18G needle into a patient's belly after I've been awake for 32 hours???

After all, who amongst us would want our family members to be treated by a doctor who's been awake for the last 28 hours? Hell no.

There is data to support that too. Probably also stemming from the pivotal but tragic case of a patient death related to a medical error that was attributed to intern exhaustion. Over the years we have seen numerous publications in the medical literature on this topic, finally causing the ACGME to restrict resident work hours. And thus, when I became a senior resident, our interns could work no more than 30 hours at a stretch, and 100 hours in a week. Naturally, the seniormost people had to pick up the slack.

More recently, the Institute of Medicine published some recommendations to limit things further. This includes

• Limiting the work-week to 80 hours
• Limiting the shift to 16 hours
• Giving protected naps for extended shifts
• And reduced workloads especially for interns

While this sounds fine and dandy, this opens up another can of worms. What then would be the implications of this?

For one, the internship is only one year. It is in that vital, short (well, it felt like forever, didn't it?) year that we learn. We attain the skills to think on our feet. How to make important decisions. How to properly evaluate a patient and formulate a treatment plan. How to balance our time. Prioritize. To be strong, mentally and physically. And it was assuring, knowing I always had a senior to turn to. It is in that short one year, before I am released into the 2nd year of residency at which you are operating semi-independently with no in-house supervision at nights. I learnt a lot in that one year. So, what would be the consequences to the learning then, of cutting the work hours down so dramatically? Will an intern be prepared to fly on his own the following year? And what would happen when the intern who is used to working 16 hours max, goes into the 2nd year and suddenly is faced with longer hours and more responsibility? Is this ex-intern/HO then going to have mommy and daddy complain about the work hours? Are you really going to be able to insert that central line, or do that LP, on your own? Are we going to have an exploding troop of 2nd year green residents/MOs?

An inadvertent consequence many of us foresee then, is that the residency programs will eventually need to increase the duration of their programs.

What about the work? If you reduce one's work hours, how will things get done? Well, when I was the SMuRf (Senior Medical Resident) we did the crap. After all, the restrictions didn't apply to the seniors (do they now?). It would appear this is the case too in Malaysia from what I hear from my colleagues; the more senior MOs end up doing the work.

Another option is to hire more. Have more trainees. Hire hospitalists, mid-level providers, to help with patient care. Which sounds like a good plan until you consider the cost. Indeed, the estimated annual cost of implementing the IOM recommendations was a staggering $1.6 billion dollars.

And so, it's not that simple. You can't just say "Let's cut down the hours, and treat them like Kings".

Though I don't know what the best solution is, I am of the opinion that being a doctor is not meant to be easy. Admittedly I'm probably just being old-fashioned. But the long hours and years mould us to be the doctor, much more than what medical school does for you. I see this as a filter as well, for those who truly were passionate about helping others from those who went into medicine for the wrong reasons.

A career in medicine requires true grit.

And so, if one expects a walk in the park, then that person is going to be sorely disappointed.

You Never Know

Sometimes you never know how a patient sees you.

I had an unexpected encounter recently. My patient was a woman with a history of post-surgical panhypopituitarism for a congenital issue. She also had mild mental retardation, and was always accompanied by a troop of family and nursing home caretakers the 2 times I saw her in clinic.

The first was a pretty long consultation, going over her medical history and ordering the labs. The 2nd visit was to go over the results.

I didn't think things went too well the first time. Her father sat upright, with a stern nonapproving look. He recorded our conversations and did not inform me he was going to do it (it's their legal right, but always a courtesy to let the provider know beforehand). He seemed confrontational, asking many questions and stopping me midsentence frequently. It was an exhaustive 45 mins, and I felt that he must have thought I didn't know anything.

And so, admittedly I was hoping he wouldn't show up with her the 2nd time round. But no, the same troop came: patient + father + sisters + nurse. And so, not surprisingly the same thing: the recording, the many questions, the look. THAT look.

We went over the results, and formulated a treatment plan.

As they were leaving, her father shook my hand, but I was unprepared for what he said loudly, well within earshoot of my staff: "Thank you, Dr. V. You really ARE the best!"

(When he opened his mouth to speak, I was kinda expecting something like: "You damn quacks don't know anything, do you?")

Sometimes, you really never know how a patient perceives you.

People have told us many times that Allison looks like me. I never believed a word of it; indeed, I thought that if she looked anything like me, she'd have trouble finding a boyfriend. Until I came across this picture of me on my first birthday, bawling. Yes, I had antisocial traits and didn't like parties. And it struck me how my daughter looks so much like me in that photo from 34 years ago. With the same curled lips.

The little miracles of life.

What do you think?

Ties

Some ties might be stronger than you think sometimes.

I attended the Malaysian night last weekend, organized by the huge population of Malaysian students at one of the universities here. At the start, the national anthems of the USA were played, and people asked to join in.

It was the first time in perhaps 18 years that I actually sang the Negaraku (well, not counting those nights when I ran out of lullabies to sing to Alli to put her to sleep!).

And, in an unexpected moment of nostalgia and patriotism, I teared up.

I really did.

I guess some things will never change. I may be a permanent resident here now, and despite my disgust of the extent of corruption and racial politics being practised, I will always be Malaysian.

(also demonstrated by the amount of nasi impit and satay sauce I was inhaling at the dinner!)

Communicating

It's amazing how things have changed.

I remember the days when I was in medical school in Canada (holy shit- it has been over 12 years??). Staying in touch meant: writing a letter (yes, with a pen and paper- remember that?), sticking a stamp on it and sending it off. Wait 2-3 weeks for a reply from mom/dad or friends. When I felt generous, there was the telephone with a calling card I had saved up for.

Email was in its infancy (at least for me). Some friends had it, some didn't. And I didn't have broadband and couldn't afford dialup.

Now, things are different. I catch myself in awe seeing this every weekend.

Thanks to the wonders of the internet + Skype, my daughter is able to see her Ah Kong and Ah Ma in Malaysia on a weekly basis. Or her Grandpa and Grandmom in Wisconcin.

Here's Alli, trying to get a piece of Ah Kong's breakfast!

No, it doesn't replace the physical closeness, but it's still amazing to be able to do that, and to have them talk and watch her run around, or stuff toast into her mouth, or jump on the bed.

I'm excited to see what technology will allow us to do in the next 12 years. And the day they're selling Star Trek's food replicator at Best Buy, I'll be the first in line (provided they have an extensive Malaysian menu!)

Bad Apples

Admittedly there are going to be bad apples in every barrel. And I have to admit, I have an inherent bias of the law profession, as many of my experiences with lawyers stem from them asking me to be an expert witness for the plaintiff in some (often unfounded) lawsuit (which I kindly refuse).

But I was particularly mad when I saw Mr. J yesterday. He was an 79 year old man with pretty decently controlled diabetes for the last several years. Did so well that I told him I could see him just once a year. And so, I was surprised to find his hemoglobin A1c suddenly higher than his norm at 9%; after all, he has never had a higher-than-7 reading in the 4 years I have known him. Until he told me the reason; he stopped taking his diabetic medication 5 months ago. Without discussing with me, or his GP. The reason was, this poor elderly man was scared out of his wits by the 5 or 6 lawyers who called him out of the blue, asking him to join them in a lawsuit against the maker of his medication.

You probably know which one I'm referring to, after some studies associating bladder cancer to this drug. Though 'association' does not equate a causal relationship. And as what I tell all my patients: All drugs have potential benefits and risks. What about the thousands of patients with nonalcoholic steatohepatitis whose livers benefited from this medication? But never mind- it's a decision I let my patients make, if they choose to remain on it.

What I was particularly mad about, was how these greedy lawyers were hounding my patient. He had received calls, from no fewer than 5 different lawyers, in the last 8 months. And because a patient's medical history is strictly protected information, it's clear that someone has been doing something illegal: someone in his chain of healthcare was sharing with these law firms the names and phone numbers of patients taking this medication.

There'll be bad apples in every barrel. Indeed, we all know of even bad or unethical doctors. But this seems to take it up one level.

After much discussion, Mr. J resumed his meds, and we plan to see him back in 3 months- hopefully with his diabetes under better control then. But I suggested to him that the next call he gets from a lawyer, he should challenge them and ask how they got his information.

For someone needs to be accountable for this.