You never know

Sometimes you never know how a patient sees you.

I saw K today for follow-up of her diabetes. I last saw her over a year ago; she is a 20-something year old woman on an insulin pump for her type 1 diabetes. In the past, I've always had the sense that she was not too interested in what I had to say. I wasn't sure she actually followed my insulin instructions. And so, when she waited that long to come back I just assumed she didn't want to be here.

Turns out she and her husband moved north, and she had been under the care of a different endocrinologist. Except she didn't like her and didn't think their personalities matched.

And so today she drove 4 hours to come see me (with another 4 hours home).

And said she didn't think the new endo cared about, or listened to her as much as I did. Said she missed the great care our clinic provided to her over the years.

I was flattered- and on a crazy busy day with quite a few other uninterested patients, this was refreshingly very encouraging words.

And from her, of all people; I would not have thought!

I can't believe how fast these kids grow.
Monster 2.0 is now 7 months old. And looking back at Alli's old pictures, we are reminded of the wonders of genetics- their resemblance to each other is clear (or maybe it's because infants all look the same?).
That's Alli in the picture frame.

My Precious

My parents will tell you that a long LONG time ago, before I was dumb enough to want to be a doctor, my original ambition was to be an astronaut.

Yes, an astronaut.

It all started with two books my dad bought for me when we were up in KL for something-or-the-other. I remember being captivated by some books I saw in a bookstore and made a hell of a fuss over it. Spaceflight and Astronomy. Dad relented and got the the books, and I was hooked. I remember lovingly wrapping the books in plastic wrap.

I devoured them, and then reread them over and over again. And read whatever I could on space, astronomy, even UFOs. I was fascinated by all things related to the cosmo (I still am, but practicality prevails).

I remember the ecstasy when my dad's ex-boss gave me his old 50x zoom refractor telescope. I spent countless hours moon and stargazing. I learnt to pick out the constellations, and could name spacecrafts. Learnt how to rig the telescope into projection the image of the sun and sunspots (NEVER look directly at the sun, if ever you're dumb enough to think about it).

When I was older, I eventually founded the astronomy club in highschool (but sadly left for college before they eventually purchased their first telescope).

Oh the dreams I had.

But sadly, that was before the time Malaysia had a pseudo-space program and there was no such thing as buying a seat for yourself on the next rocket to orbit.

And so this silly boy went into his other calling instead.

But after a long lapse, my wife talked me into taking up this hobby again. Perhaps it was her way of getting me to rid our garage of junk.

"You can buy your telescope if you get rid of your tires. Maybe this is something you and the kids can do..."

So, I finally sold my 5-year old hardly-used winter tires. After all, since that first year I haven't driven the Porsche in the snow.

And with the extra change I got, I bought a telescope.

Nothing too fancy, but a Nexstar 4SE 4" Maksutov-Cassegrain reflector telescope. As tempted as I was to consider the 5" or even 6", I couldn't bring myself to blow $800 on a hobby I haven't pursued in over 15 years. Who knows, maybe I'd get bored after 5 mins. So I don't expect this to be hardcore, and probably isn't going to be too helpful for deep-space observation or photography, but it's a start. And I got a 8-24mm eyepiece to go with it.

It's on transit now, and I expect to get it this week. But admittedly, like a boy anxiously waiting for Santa on Christmas eve, I've been looking out for the UPS truck every night.

Except, this is a boy with a Visa and astronomy gear is not cheap and he's going to have to show a lot of restraint.

Will let you know how things pan out. But I'm excited. And maybe something I can change my job!

Har Mee!

 

I was ecstatic when I found this in our local Asian store!

Malaysian prawn noodles. And while it was nothing close to the real stuff, it was pretty damn good (then again it's been 2 years since our last trip back).

Problem is, the smell of shrimp really puts my wife off. So I'm going to need to find some extra strength mouthwash next

Job Satisfaction

I read an article the other day of a survey of practicing doctors. This included questions related to job satisfaction, salary, and if one could do it again, would they pick the same specialty.

I wasn't terribly surprised with much of the answers for endocrinology. Close to half of those surveyed stated they would have picked a different specialty. Many reported a lack of satisfaction with the work.

Though this field deals with all kinds of hormonal disorders, due to the current health climate, most of our day is spent seeing people with diabetes mellitus.

Because diabetes is one of the unique conditions where direct, hands-on self-management by the patient is vital to success, endocrinologists have very little control over outcomes.

It's a concept scary to many patients: You want me to self adjust my insulin doses? Why can't you just tell me how much to use? (Because I see you only every 3 months but in the meantime, if your glucoses are consistently out of your goal range, it needs to be adjusted periodically. And because I am not there when you are eating; so you need to count your mealtime carbs to properly dose the prandial insulin).

I liken it to driving. You can't tell someone over the phone how to drive. You provide them with the teaching. And then when they are on the road, they are required to turn left, or right, or brake or speed up, based on what they see real-time.

And so, to do well when one is on multiple daily insulin, regular glucose self-testing and relatively independent self-adjustments are necessities. It's a tiresome and expensive process, unfortunately. But it works, and until technology evolves, this is the best we have.

Herein lies a tiresome phenomenon I see repeated daily. Patients very frequently walk in with no glucose data, and very frequently missing their insulin shots. Often they just shrug their shoulders, or smile guiltily. Or some who test and have been consistently hyperglycemic for the last 3 months but have not increased their insulin.

It's a pleasant enough visit- I enjoy seeing my patients again, hearing about their family. Professionally though it is frustrating; hemoglobin A1c 9%, 8%, 9.2%, 9% over and over again.

And I imagine many are like me; I don't see patients as dollar signs walking in my door- rather (believe it or not) I do want my patients to do well, to remain healthy despite having diabetes. And so, I know I for one do personally take it as a sign of failure on the healthcare team's part, when things remain uncontrolled.

Despite reminders, numerous visits with the doctor and the diabetes educators.

There are days when I come home beaming because I feel that I made a difference; but there are often days when I come home feeling like I did nothing.

One factor is obviously cost and inconvenience. Another however, which is the real silent killer, is the lack of urgency. When a doctor tells a patient "You have cancer", or "you had a heart attack", people jump. They know it's dangerous and something needs to be done.

When you tell someone their diabetes is badly controlled, many ask: So what? Why do I need insulin if I feel good now, never mind my bloodtest? Uncontrolled diabetes is the leading cause of blindness and kidney failure, and a major contributor to heart disease. The disconnect is that we are talking about the future. It's not a tangible risk.

But the greatest tragedy is once the complications set it and they start to worry about it and try to get things under better control, the damage is done. You can prevent it from worsening, but you can't undo it.

Thus, am I surprised that many endocrinologists find a lack of satisfaction in their careers? No. It reminds me of some good friends, great patient people, who surprised me when they quit practicing medicine to join a pharmaceutical company. Maybe it was the hours. Or maybe they just got tired working with patients.

No, I can't see myself doing that; I love the patient interaction too much and would hate to give that up. Have I been tempted to do something different? Definitely.