Monday, April 29, 2013

Patient Art

A patient of mine came in with his arm in a cast.
I asked him what happened, but before he could answer I was paged out of the room.

When I came back, this is what I saw.
Pretty self-explanatory.
The "crap" was a nice touch. I would have used more choice language.
And they say patients have no sense of humor.

Wednesday, April 24, 2013

Clearwater, Florida

After a long lapse since our last vacation, we took a short trip to Clearwater, Florida. Just a 4 day trip, but this was also a good warm-up for the impending Malaysia trip- good to see how the girls would put up with the flight.
Well, this was my first trip there. We wanted a beachfront hotel; location was the priority, not the room. And so we stayed at the Hilton Clearwater. It was an older hotel; its age was apparent from the outside though the rooms were modernized and tasteful if not a bit small. If you were unlucky enough, you might get a room facing the ventilation system- section of the hotel which was something of an eyesore. Thankfully we got a harborview room.
The beach, now that was something else. Long stretches of soft white sand. Right outside the hotel. It was easy to get to the beach, and back.
We loved it. The kids spent hours playing on the sand. Kris and I got to relax, and also went out on the jetski.
It was fun, right up to the point when she asked, "Are there sharks in the Gulf of Mexico?". I told myself I could swim faster than her if one ever came for us!
This was Ava's first trip to the beach. One we hope to duplicate in July when we go to the Jersey Shore. And again in November when we make our family trip to Pangkor.

One extra bonus was our visit to the Clearwater Marine Aquarium. It's resident Winter inspired the movie Dolphin Tale, and it was exciting enough for Alli to see some of the resident dolphins, and the other marine wildlife. But it was a treat to be able to see Winter as well.
Though the facility was small, and does not at all compare to the larger aquariums out there, and the cost adds up pretty fast, considering this functions primarily as a marine rescue facility, it was pretty entertaining for the kids, and the money goes to a good cause.
After a fun 4-day visit, and what felt to be a never-ending flight, we're home, just in time for me to start call this week.
Oh well. At least I have some tan lines to remind me that we had great trip before work resumed.

Friday, April 19, 2013

Winds of Change

Though I'm far away from my native Malaysia, every single day for the last 15 years I've been away, I have checked the local news. I wonder about her ongoings. And I have to say, like many Malaysians, have become more disillusioned about her leaders.
The circus that is going on in the recent weeks and months is a testament to how far some groups will go to retain absolute power.
And with one of the main opposition groups possibly off the ballots and its leaders possibly needing to go on the ballot of its ally, some are concerned if this will lead to confusion especially amongst those less aware of the recent events.
Some might also say they would never vote for a candidate under the PAS ballot.
Indeed, growing up, the Chinese have often seen PAS as a radical group.
But perhaps one of my good friends put it best: "Maybe this will show the real spirit of muhibbah in Malaysia".
Voting for a candidate not on the basis of skin color, or race, or religion. Instead, voting in the hopes that this candidate will have honor, honesty and integrity. Voting down corruption. The Chinese and Indians (and of course the Malays too) willing to back up PAS simply because of the dream that someday, we will be rid of the corrupt.
Malaysia, though many of us may be far away, I have high hopes for you.

Monday, April 15, 2013

I usually don't take offence at what a patient might say.
Today was an exception.
I saw a 62 year old woman for the first time- she had seen my colleagues in the previous months for her diabetes. She came in with no glucose logs (she hadn't been testing). She had not been taking her diabetes meds. Indeed, her blood pressure was 160/90 mm Hg; she had also deferred her ACE-inhibitor, and had refused treatment with a statin for her LDL of 168 mg/dL as well.
Not surprisingly, her hemoglobin A1c was 9.8%. And so, I urged her to consider changing her ways, and to take her prescribed medications.
To which she said, "I wonder how much commission you make prescribing these medications?".
I was rudely surprised at that question.
I firmly answered: "Nothing. We make zero dollars prescribing a medication".
Unlike some parts of the world, here we doctors prescribed and the meds are picked up only at the pharmacy (plus the medications she was supposed to be on are generic, anyway).
So I gently but firmly told her that if she wasn't willing to take our advice, and thinks we have ulterior (financial) motives, why was she choosing to come for her 3 monthly visits anyway? What good were these visits, if she didn't heed our advice?

Friday, April 12, 2013

34 years!

I found this in my album the other day. Yup, that's me in the back seat, with my older brother. Me, with the same stupid grin. And yes, I'm aware I look effeminate as a kid.
Gosh, that was the home in which I grew up (mom and dad still live there. I still call it 'home' despite us owning our house here- guess some things never change).
Anyway, it's surreal finding these, and then realizing that 34 years later my kid has the same stupid toothless grin. This was Alli 1.5 years ago. Before she grew fangs with which she devours everything.
These pictures were taken 34 years apart.
Except she's a lot cuter than dad way (digression: does ANY parent truly think their kids are ugly?).

Wednesday, April 10, 2013

In a follow up to my previous post about physician burnout, I read this on Medscape recently. As a specialty, we are not doing the worst- ER and Critical care are up there which isn't too surprising given the high-stress job and the long hours.
What I found surprising (and yet not surprising) was that family medicine was up there at number 3.
And then when you look at the causes that the surveys pointed it, it kinda made sense. The top reasons many feel burnt out is the bureaucracy, and the hours spent at work.
Speaking from personal experience, I know the amount of time I spend on paperwork drives me crazy.
Each day I try to squeeze in time between patients to fill out:
  • Prescription refills
  • Prior authorizations (a taboo word for our MAs)- filling out questionaires for the insurance carriers explaining why my patient needs insulin, or calcitriol, or Pill X or Y.
  • Diabetic shoe prescriptions. This one boggles my mind; I'm not a podiatrist. Medschool, residency and fellowship do not train us to decide who needs diabetic shoes and who doesn't. I haven't the foggiest idea if they need "Plastizole inserts" or widened shoes. For that I trust my podiatry colleagues. But for some stupid reason, the Feds have determine that it is the endocrinologist that needs to sign the forms. Even if the podiatrist deems it necessary (but yet in a brilliant ploy- also recently determined that I cannot bill a foot exam if their feet have already been checked by the podiatrist within the last 6 months- but yet they need an endo to examine the feet within a 6 month period)
  • Letters stating why my patient with diabetes on basal-bolus insulin need to check their glucose more than 3 times a day (I don't know which genius sits on the Advisory Commitee for Medicare, but EVERYONE on basal bolus insulin should be testing 4 times a day or more to be safe!)
  • Forms to testify why my patient can do this, or can't do that. From driving, or certain physical activities, to just plain working
  • Letters stating why my patient needs that pituitary MRI
Between my medical assistant and I, we spend 1-2 hours a day on these. So yes, I'm not surprised. I imagine the family doc would have much more than I do
Appears though that other factors were at play. Money being one of them (personally I am not complaining though with the changing climate our office has taken a huge hit in pay in the last fiscal year). Interestingly, the Affordable Care Act  and EMR were listed as number 4 and 5- this certainly has been causing a lot of angst and concern amongst my colleagues. And while many would be surprised by EMR (Electronic Medical Records) as the use of electronic records is supposed to make things better for patient care and physicians, the truth is many systems are prematurely jumping on the bandwagon to tak advantage of the federal stimulus package. And so what happens is medical systems adopt a poorly designed EMR that adds little to patient record keeping (aside from some quality improvement parameters) but instead churns out patient notes that lists 3 pages of diagnoses, medications but has nothing useful at all when it comes to the clinical impression and plan of care. I see this every day, since our system adopted an EMR- I get more asking the patient why they're there to see me, than to read the referral notes that were sent to me. Not to mention learning a new EMR, especially for physicians who are not computer-saavy (but are otherwise excellent clinicians) can be particularly harrowing. I know of at least 3 internists in the area who retired early because of this; they were spending 2 hours every night trying to catch up on documentation.
Anyway, I thought this was an interesting, thought-provoking piece of news. And as if to add more headaches/bureaucratic crap, I received notification from the American Board of Medical Specialties just yesterday that they're changing the way we do our Maintenance of Certification (MOC)- something about needing to do some MOC activities every few years (in addition to our CME requirements every 2 years) and on top of the exams every 10, just to maintain certification. Geez. Something tells me these activities have costs involved, too.
And people wonder why physicians are getting burnt out.
Dear medical student readers: if there is anything I want you to learn from this, look at the first diagram- and consider training in pathology, psychiatry or ophthalmology if you want to be happy!

Saturday, April 06, 2013

Magic Treatment

This is a true story- I didn't make this up.
A young man went to one of my colleagues complaining of erectile dysfunction. Apparently, he was wanting to get a prescription for the little blue pill and testosterone.
He was going on about his total inability to get an erection, whether it was stimulated or physiologic (morning erections).
After the history taking came the exan. By my colleague, a dainty blonde young woman. At which time, he spontaneously sprouted a huge erection.
Needless to say, he didn't get the medication. And my colleague left the room a dark shade of red.