I've been at this job for 4 years now. Longer than any other in the past (though I was at my alma mater for 6, it was 3 years in internal medicine and 3 in endocrinology so I didn't keep the same patients for too long).

Long enough to get to know some patients well, well enough to consider them friends. After all, if I'm seeing someone for diabetes every 3 months x 4 years, and sometimes when they are admitted to the hospital, then that adds up.

And so, today I got a call from a patient's daughter. Mrs. P, a delightful 86 year old woman with oxygen-dependent COPD and type 2 diabetes on multiple daily insulin, had passed away in her sleep.

I called her daughter back to offer my condolences. And while it was the courteous thing to do, to call the family, deep inside I really did feel a tinge of sadness.

I remember the last time I saw her, just 2 months ago. She asked to see pictures of Allison. And with a twinkle in her eye prophetically said that Alli's going to be a handufl when she is 2. I remember her wicked sense of humor, and her infectious smile despite her chronically cyanotic lips. And how she trusted no one else to manage her insulins; how she yelled at that poor hospitalist that one time and demanded he "consult Dr. V to manage the insulins" because they were doing a "shitty job" (they weren't actually). 

If there's one thing I like about this job, it's that I get to share so much of my patients' lives. And, if I can allowed to say this, this also means the losses when they pass on.

Rest in peace, Mrs. P. You've had a long, full life. May you be at peace.

I shall miss our visits; I hope I took good care of you whilst I was your doctor. It was my priviledge, really.

Congratulations, Class of 2012

The last weekend was a bittersweet one; we drove 3 hours north to see my sister- after 3 years of postgraduate medical education, she graduates from residency.

Showing much perseverance and grit, she made it through 3 harrowing years, including that character building/destroying internship.

Only to graduate from one of the top medical institutions in the country and arguably the world.

As a big brother, I could only beam with pride as we went to celebrate with her.

But yet, with the end of this academic year, comes the start of another, for her as well as the thousands of medical trainees. The medical students. Residents. Fellows.

And so, this week, she moves to sunny California to continue the next chapter in her professional life, at yet another leading institution. While we are excited for her, a part of my was saddened. Saddened to have my only family here outside of my wife and daughter, to move so far away. And knowing that after she is done with the next step, she moves back permanently to Malaysia.

It was nostalgic and sad too, to revisit the familiar sights and sounds to those of us who have spent 6-7 years at the same Alma Mater, and to relive those memories. To visit Buddy's old apartment, or the same restaurant we must have had at least 100 meals there over the years. To recall the things we, he, had to go through in those final years there.

Yes, this will be a busy week; the thousands of trainees would transition from one program to the next. Often, this will involve physically moving to a different city or even state. Goodbyes are said to classmates, comrades, colleagues and perhaps even soulmates, as paths start to diverge.

As they take one step closer to leaving their academic motherships and to stepping out to the 'real' (medical) world, what advice would I leave these gallant learners?

• Don't lose yourselves. It's easy to lose sight of what's really important in life. We have all had the priviledge of sharing a dying patient's last moments on this Earth: No one has ever said they wished they spent less time with their family. No one has ever told me they wished they made more money, or spent more time at work
• Stay true to your principles, whatever they might be. Whether is is "First do no harm", or "The needs of the patient comes first". And no matter what, stand firm by those principles. Eventhough you may sometimes encounter a patient who attempts to threaten or bribe you to do something that goes against what your beliefs are
• There will always be patients who will frustrate you. Or deceive you. Or talk or cry too much. While you might not have the answers for their ailments, they are still people. And everyone deserves at least respect
• Yes, out in the real world, you finally get to make real money. You finally start to pay off your loans, or are able to afford a mortgage, or to save. But never let that guide your actions. You are a doctor, and you priority is the health and wellbeing of your patient. Not how many tests you can put him through, or how many patients you can see in a day
• It's OK to not have the answer. The 3-7 years of post medschool training might have taught you much, but it's not going to teach you everything about the human body. It's humbling to admit, but doctors really don't have all the answers.
• It's also OK to be afraid. The first time you treat a serious problem with no real supervision. To realize, "I'm it?? I don't have to staff this with my consultant? I AM the consultant?"
• The learning never stops. I hate to admit this, but after 2 years of college and 5 years of medical school, and 3 years of residency and 3 years of fellowship, the learning ain't done. Medicine is dynamic, so should you. But don't fall into the trap of feeling the need to read every journal. Find a few that is relevant to your field, and peruse it periodically. Thrash the rest
• We are in the business of saving lives. Unfortunately, there will be some patients you will lose. Some, perhaps even because a decision you have made as his doctor. But remember, you are not God. You cannot win all battles. And there is a huge difference between losing someone because of the wrong decision, versus losing someone because of neglect or malpractice.

It's not an easy next step. And the journey is probably far from being over. But for now, take a moment to reflect on how far you have come. To remember those without whom you could not have made it. And take a moment to recognize your work, and be proud of yourself!

Happy Birthday, Princess!

I can't believe our troublemaker Princess turns two today!

2 years!

2 years ago this day, we were blessed with the most precious little thing. It didn't seem that long ago when, I was seeing my 8:00 AM prolactinoma patient, when my wife called me from the hospital: "I'm 4 centimeters and fully effaced. Get your butt here stat!"

Fatherhood is such a beautiful, strange experience. You hold your daughter, and think to yourself that no one else in this world could possible have as much as you do, not because you have more material wealth, or fame, but simply because of that little person you are holding.

You feel like you are the most blessed person on Earth.

I'm sure all fathers feel like that of their children. So it's true; the most priceless of things, aren't things at all.

Happy 2nd Birthday, our precioud little pumpkin!

It's the truth that the cost of healthcare is skyrocketing, and Medicare (and private insurances) is spending astronomically higher amounts of money for its members. While this is probably multifactorial (in no small part due to Medicare fraud methinks, but I shall blog about that some other day), on a week like this I couldn't help but wonder how much us doctors contribute to that when we don't stop for a moment to think.

This has been a particularly frustrating week, as I seemed to have a disproportionately higher number of what I consider to be inappropriate endocrine consults. I was averaging about 3 consults a day of medical issues unrelated to what I can help the patient with. These included:

• High CK levels- 8x above normal and having proximal muscle weakness. Suspecting polymyositis, and suggested he sees rheumatology, the people who actually treat this
• Depression
• Fatigue- with the usual normal TSH levels (and Vit D)
• High Total T4 in pregnancy (but normal TSH)- even my 3rd year med student could remember that TBG levels are increased in pregnancy hence the TT4
• Anemia (low MCV, ferritin, with complains of melena)- Dear Doctor, your patient has a GI bleed!
• Neck pain- apparently this patient's doctor mistook the left sternocleidomastoid for the thyroid, or something

I hate to be judgmental of my peers as I don't think I'm all that bright myself. But I caught myself wondering if this was from perhaps the lack of better ideas (maybe the GP was at the end of the rope) or just poor medical knowledge. Or maybe the patient insisted on the referral.

Unfortunately, I'm not business-smart; I don't appreciate seeing patients for the sake of making money- I consider myself oldschool- I want to help patients with real hormonal disorders.

Consider this- a Level 4 Consult (99244) has a reimbursement fee of $168. This would be the norm for the patients we see.

A Level 5 (99245) gives a reimbursement of $218. If we are dealing with a high risk situation, or if I am required to review/order radiologic tests then we typically mark it a Level 5.

(And no, that's what the system charges- not what I take home per patient)

And so, can you imagine what this must be costing the whole damned system if one single specialist is 'wasting' $500-600 a day seeing unnecessary consults? Clearly, this must add to the healthcare economic burden. And what about the cost to the patient? They have a copay and thus don't pay the full amount; but what about the emotional costs when they have their hopes up only to find out you cannot help them? Or to have them drive 2 hours to see you for hypothyroidism only for you to say that their TSH was 1.12 and FT4 1.3 (normal) just 5 days ago? 

This is one reason I miss working at an academic center. There seems to be more careful thinking rather than the kneejerk "Refer to XXX to check for YYY". Like, if an internist was considering a diagnosis of Cushing's, he'd order the test and if abnormal only then would he refer. Or, rather than sending your fatigued patient to the endo to see if the thyroid was working fine, do the test first as many people with fatigue will not have hypothyroidism.

Instead, I've been horrified by some of the clinical notes I've seen as part of my consults. Like having a GP refer a patient to 3 different specialists to 'rule out' 3 different things all from the same clinic visit! Whatever happened to the art of being a doctor?

And so, as much as I enjoy my work, there are times when I do get frustrated with how the system can be so flawed.



Priceless!

Happy Father's Day!

If I have seen further it is by standing on the shoulders of giants

In this case, that giant would have been my father (and mother). If I have accomplished anything so far, it would not have been possible without the love and nurturing of my parents. And now that I'm a dad myself, about to celebrate Father's Day with my family tomorrow (oooh, I wonder what they got me? ), I can't help but worry sometimes that I might never be able to do as good a job as he did.

And, as much work as parenthood is, the smiles and hugs and kisses from my daughter make it all worth it.

To all the dads out there, especially mine, Happy Father's Day!

Oncall

Oncall for the next week. It hasn't been too busy, with a patient list covering only 2 (of a possible 5) hospitals.

And then, early this morning, I was rudely awakened by a loud beeping. I look at the time: 1:31 AM.Uh-oh. A call at this unholy hour- what can it be?

Diabetic ketoacidosis? Severe hypoglycemia? Thyroid storm? My mind went over the possibilities as I called the operator.

"Good morning, doctor. It is a patient call..." as she proceeded to put me through. Must be someone with glucose issues, I thought.

"Good morning; this is Dr. V. What can I do for you?" I asked.

"Yes, I see Dr. X (one of my colleagues) for testosterone. Anyway, I am having bad insomnia and restless legs. What can I do about it?" said the voice on the other line.

The things I was tempted to say, but didn't. Amongst the possibilities:

• Oh yea? Well, thanks to you, now you're not the only one awake
• Would you like me to sing you a lullaby?
• Maybe I can prescribe some insulin. I'd bet you'd be unconscious if we drop your glucose to less than 20 mg/dL
• KNNCCB!!!
• Take some Benadryl. About 2 liters of it.

But no. I diplomatically said: "Call your family doctor. This is not an endocrine issue...". The problem with being accessible to patients who really need us, is that sometimes this service is abused. Thankfully, this doesn't happen too frequently.

Anniversaries

I can't believe it's been another year.

It's our 4th wedding anniversary- it's unbelievable how time just flew by. I can't believe that it was already 4 years ago, when we did our double wedding- our first here in the USA, and then the 2nd in Seremban, Malaysia. It was somewhat of a whirlwind, with the long flights and with her entire family flying in for the Malaysian wedding.

But what a wonderful 4 years it has been. And though things seem to be whizzing by, and though I can't wait to see what else life has in store for us, I'm not wanting to rush and miss a moment of it.

Happy Anniversary, honey. I love you!

On a similar note, we celebrate too Buddy and his wife's anniversary. He was the best man at our wedding, and almost exactly a year later, Buddy and his sweetheart got married (their wedding a day before our anniversary). After a prolonged long-distance courtship they finally got married on a beautiful Spring day. After a long battle with cancer, he passed on a few weeks before their 2nd anniversary last year; however this will be a day so beautiful that none of us would ever forget.



Happy Anniversary to you guys, Buddy (We took the liberty of sending your wife flowers to remember this day. Don't worry- you can pay me back when we next see each other)

To Judge

Doctors shouldn't judge.

That's not our job. We are here to diagnose diseases and treat patients. To cure sometimes, but to heal and comfort always.

But I'm only human. And admittedly, sometimes patients piss me off.

On one hand, the hospital is overflowing, with patients in the ER waiting for beds on the floors to open up.

On the other hand, I have patients like Ms. Y who comes in to the hospital every other week for yet another episode of diabetic ketoacidosis that was induced by a combination of noncompliance with her insulin, and drug abuse.

And the minute she is medically stable, she sneaks out of the wards for a smoke. Or strolls across the street for McDonalds. While refusing to be discharged because of her "abdominal pains" necessitating multiple doses of opiates. All at the expense of you and I, the American taxpayer.

This makes me mad; while I do think that Medicaid is an invaluable program that benefits many people, the frustrating thing is that there are also many out there who take advantage of things. And no longer feel the need to be responsible for their own health anymore.

And in the meantime, not only are we footing the bill, in moments such as these, other patients who could really use the bed suffer.

Boys & Girls

Psst. Here's a secret: I love having a daddy's girl.

Yea, I know, it takes getting used to initially; all the pink in the house. Dolls, barrettes, ribbons. Kissing little owies. Singing her to sleep while waving bye-bye to her fishes. Drawing flowers on the sidewalk with chalk.

Especially coming from a predominantly male household, this took some getting used to. And it's only gonna get more interesting with another baby girl on the way.

But I'm loving it. And I was reminded of the differences between boys and girls when I was there fixing dinner for Alli, only to look outside to see my neighbor's 3 boys chasing a little bunny rabbit with their BB guns!

I would have gone out to stop them if their father wasn't there, taking shots at the poor bunny.

It probably wasn't all that different when my brothers and I drove our parents (and neighbors) up the wall when we were little.

I'll take girls anyday. I'm sure having girls will turn into a nightmare when they hit their teens.

But for now, I'll stick with the pink ribbons, thank you very much.