Saturday, July 27, 2013

The Malpractice Report

I read this report on the other day.
It was a report of data obtained from a survey of physicians in the USA. And some of the numbers and the responses, frankly, were just depressing, scary and discouraging. Maybe I'm too idealistic- deep in my heart I think that most doctors put their patients' best interest as a priority, and that no one hopes for any bad outcomes. And perhaps mistakes happen, and when they do, perhaps a lawsuit is just.
However, seems that many more, are not.
Some of the findings: 40% of those surveyed have been named in a lawsuit. And contrary to my impression, the specialities most frequently sued were not the procedurally-inclined, but internal medicine and family medicine (perhaps also because there are more primary care docs...). And this is where it starts to get sticky:
Nature of the suits include "failure to diagnose" or "failure to treat". I will humbly admit to all my patients that doctors are not Gods. We are not know-alls. And sometimes, perhaps limited by normal test results, there are some things we might not be able to pick up. And within this, repondents gave examples like: "There was a fetal demise at 19 weeks. Prior to trial, it became apparent that the mother (patient) was using cocaine." or "The patient had a complication after a laparoscopy. She then sued, saying that she no longer could eat big meals and enjoy steaks. She neglected to reveal that between the time of my laparoscopy and the suit, she had a gastric bypass and stomach stapling."
In addition, some lawsuits occured not because that doctor made a mistake- but merely because he/she was involved in a patient's hospitalization. Having seen the patient as a consult or something of that nature, but enough to have their name associated with the patient file. Pan-suing every doctor associated to a patient, to maximize money, seems to be a strategy some take.
Some lawsuits were also directly the patient's fault- failure to show up for follow-up and then being lost through the cracks. I see this as a problem with my practice too; if you no-show your follow up with me, I'm not going to call you and ask you to come back to see me to see how you are doing. But the lawyers say this isn't a good approach, it seems.
Almost a quarter stated that being sued was the most horrible experience of their life, many spending over 40 hours preparing and being in the trial, with some legal proceedings lasting over 5 years. After the lawsuit, almost a third of physicians stated that they no longer saw patients the same, that they no longer trusted them and began to see them as adversaries. That is a shame, because as much as a patient-doctor relationship is a formal one, many of us enjoy visiting with our patients, many of whom we may see as almost friends.
And some advice the respondents gave: "It is perfectly legitimate to order every test that you feel is acceptable to prevent another suit." and "Don't assume ANYTHING!! If it hurts, CAT scan it. If it hurts between the nose and the toes, consider it a heart attack and stress-test everyone from 9 to 90!". And people wonder why the cost of healthcare is so high.
It's sad to read that report. And it's scary to think it's only going to be a matter of time before it's my turn, whether or not it was medically justified. After all, I've been asked by several patients to help be their 'expert witness' in suing someone else- even those very frivilous ones. Like that guy with a BMI of 55 who eats at McDonalds every day who wants me to claim that his diabetes is related to a pill his GP prescribed, which he took only for a week- I gently refused and suggested it was related to his weight- and he never came back to see me. Every night, I see TV ads talking about lawsuits and trying to recruit plaintiffs. Every day, the ads play on the radio as well.
Medicine is getting too complicated these days. Perhaps the legal system here should adopt what a friend told me they do in his home country: if a lawsuit is thrown out or judged to be in the accused's favor, then the plaintiff has to pay for his legal fees as well. Right now, it seems that one has nothing to lose suing another, and only money to gain. This system has to change.

Saturday, July 20, 2013


One of my favorite Malaysian dishes is satay. The other is lor-mai-kai. Amongst the zillion other dishes that make a Malaysian expatriate homesick, this is my number one.
Lor-mai-kai I was able to learn to make a few years ago, enough to satisfy my cravings till my next trip back.
But satay has always eluded me. Perhaps I was intimidated by the recipes I've read. Perhaps I was disappointed by the satay marinade mixes I've bought. Perhaps I thought making the satay sauce was just too much damn work. Or that the few times I've tried to make it, it tasted like meat cooked in someone's armpits (too much cumin that time, I guess).
Every trip back I stuff myself with these marinated skewers of meat. And everytime I visit a Malaysian restaurant in the US, satay is always something I'd order.
Today, I felt adventurous. The recipe I found here didn't seem that intimidating (maybe it had something to do with the pretty chef too!). And the ingredients I had or was able to find quite easily.
Anyway, after tinkering around in the kitchen for a few hours, I present:
I'd be lying if I said this tasted like Kajang Satay. But omifarkinggawd this was the best satay I've tasted in the last 2 years (our last trip). Between the 3 of us (Kristin, Allison and I) we devoured the 4 chicken thighs I used to make the meal. Ok, I ate most of it obviously- but it did turn out pretty good.
And strangely enough, I'm more proud of this achievement than my academic accomplishments!

Thursday, July 18, 2013

Thyroid nodules

This week seems to be thyroid nodule week.
I did yet another ultrasound-guided fine-needle aspiration of the nodule today, assisted by my resident. And so we got into a relevant discussion about how to approach these.
The truth is, nodules are common; indeed in certain groups, thyroid nodules are found in the majority of people whether or not they know it.
The first question diagnostically to ask is if this might be a hyperfunctioning nodule- if the TSH is suppressed, this certainly opens up that possibility and in that case, radioiodine uptake and scan should be performed. And so the TSH should be one of the earlier diagnostic tests.
If however the TSH is normal and the nodule has large enough solid components, then FNA is probably indicated. Thyroid uptake/scan might not be too helpful as many thyroid cancers may not appear 'cold' while many 'cold' nodules might not be cancerous- so the decision to biopsy should depend more on sonographic features.
If one is dealing with multiple nodules, the conventional route was to biopsy the largest. These days though we'd often choose the sonographically most suspicious nodule, not necessarily the largest. Some suspicious features may include:
  • Hypoechoic nodules
  • Hypervascular on Doppler
  • Presence of microcalcifications- may increase likelihood of papillary carcinoma
  • Irregular or ill-defined borders
Typically, I do 4 passess with a 25G needle with an aspirator. Sometimes if it looks like a dry tap, I might pick a larger needle, but never a core needle. While some centers still do core biopsies, in my opinion this should not be done anymore; I'm obviously biased as I've seen some large hematomas with these, and I published a comparison study comparing core biopsies to FNAs. It's always best working with an experienced thyroid cytopathology group- fortunately we work with a good group of pathologists here.
Thankfully, all the biopsies this week came back benign. In these cases it's reasonable to repeat the US in 6-12 months to document stability; in the absence of growth I tend to back off on the surveillance intervals.
It was a good, relevant teaching topic for my fresh resident (only 2nd week into her 2nd year) as thyroid nodules are very common and so familiarity with this is necessary for a primary care physician.

Tuesday, July 16, 2013

So I made some noodles for dinner the other day. And to get an idea of how to prep it for my mee goreng, I read the instructions:
I almost died laughing.
And yes, I'm aware this expired in 2012. But as someone once told me, when it's a dry product, expiration dates are merely suggestions. 

Friday, July 05, 2013

My daughter says the darnest things!

  • Daddy, don't drive so fast! (But I was going 62 mph in a 65 zone!)
  • Daddy, I ate my booger (said loudly, while we were in an airplane)
  • Poopy, please come out (while sitting on the toilet, apparently constipated)
  • Bye, poopy (2 minutes later as she flushes the toilet)
  • Mommy doesn't need to go to the gym. What about daddy? Daddy go- daddy fat!
  • My butt chow-chow (I had to teach her some Hokkien, right?)
  • Daddy, can I have some salty juice? (that's what she calls soda. And no, we don't usually let her drink that)
  • Daddy, I need some PRIVACY (while she's sitting on the toilet. I guess it's ALREADY begun)
It's unreal how fast they grow, and how quickly they pick words up. And then you realize you have to be a lot more careful with YOUR words in front of them.

Tuesday, July 02, 2013

The Men & Women in Uniform

This one goes out to all the men in blue out there. The members of the police force, people whom we often take for granted. Or about whom we complain when we get a parking or speeding ticket. It's easy to under-appreciate them.
However I'd like to take a moment to recognize the service they provide to the community. I was reminded of this the other day when I had to call the police department for help.
I got a call from Mrs. V in the morning, a pleasant 78 year old woman on insulin who lived in a town an hour away. She got her numbers mixed up and inadvertently overdosed herself with insulin, more than 5 times her supposed breakfast dose.
I suggested she checks her glucose every 15 minutes, and provided some instructions on snacking and how to keep the numbers up. Also urged her to call back if she had issues.
She did 30 mins later; her sugars were starting to drop though not dangerously so. She promised to keep testing herself.
30 mins later I called to check up on her, but her phone was busy. Between patients later, I tried again but her phone remained busy. So I had my nurse try again several times, but over a 40 min period she was unreachable.
And so, lacking other options but worried about her, I Googled the number of the local police department and called them up. I spoke to a receptionist and asked if someone could do a welfare check on her. She suspiciously asked why, but after I explained story the quickly transferred me to the despatcher who made a call out.
20 mins later I got a call from the police, informing me she was OK. I thanked them for the update, and shortly after my patient called. She was appreciative for the concern; she wasn't unconscious or in a hypoglycemic seizure;  she sheepishly said she left the phone off the hook by accident. She was OK. My nurses and I breathed a lot easier the rest of the morning.
But it was one of those moments when I realized that our men and women in uniform do so much more than realize.