Thursday, March 20, 2014

I got an unexpected message in the office today.
Karen, the daughter of one of my patients, called to let me know she passed away.
Mrs. G was a delightful 89 year old woman with hyperthyroidism from toxic multinodular goiter. My first rule of thumb when dealing with the elderly is, they've gotten so far on their own: don't screw them up!
So, I tend to be more conservative and try the simplest route; be it my diabetes patients or other issues. In her case, we went against the norm and instead treated her with antithyroid medication.
She responded wonderfully, so over the years, I've come to see her just annually. I saw her just 2 months ago at which she demanded I show her pictures of our visit to Malaysia. Which I did.
Her daughter called to say that she passed away from respiratory failure from pneumonia. But wanted to let me know they really enjoyed their visits here, and that Mrs. G really liked me. She also wanted to let us know she won't be coming next January.
It was a bittersweet type of call. On one hand it's nice to know that some patients do appreciate what you do. And having seen some of my patients for years, I do enjoy the social aspects of the visits, too. On the other hand I was saddened to hear of her passing, though her daughter and I agreed that she had led a long and very productive life, and it was just her time.
Goodbye Mrs. G. It was a pleasure knowing you...

Saturday, March 08, 2014


Look what came in the mail yesterday!
Thanks to the goodness of Suanie's heart, she was crazy enough to mail a package of precious, precious Penang White Curry Noodles to a sad, deprived and hungry man in the Midwest USA, in the final grips of the longest winter in memory.
For now at least, this will be more precious than my daughters. I shall have to take my time to savor then. I have to say I was surprised this went through customs.
Thanks, Suanie!!

Wednesday, March 05, 2014

Vitamin T

You could call me the hesitant endocrinologist.
After all, I might be a hormone specialist (and I use the term specialist very loosely. Maybe only my wife and mother think I'm special), but I really don't like to prescribe these things unless the needs exceed the risks.
In this case, I'm a sceptic, I'm old-fashioned, I'm cheap.
I ask for the evidence behind the treatment. Good old EBM.
And so, it is a challenge when in the recent years, I see so many men asking for testosterone treatment.
The mild: older men with mildly low free and total testosterone. Studies suggest mild hypogonadism do not need treatment. Most feel no improvement.
The wild: young men in their 20s, who despite having normal testosterone labs, believe their levels should be "higher". Because they work out. Or believe they should be more virile. Or because their personal trainer told them so (I kid you not).
Where do we draw the line? Our lab's normal range is 350-1000. I've had guys say their 450 isn't normal. They should be at 800. I saw a chap whose T was 1200 last week (on replacement), refusing to budge his doses down because he feels good.
The winner in my short career thus far, is probably the very muscular, athletic man I saw 3 years ago- with a total T of 8000. Refused to believe me when I advised him for safety reasons to reduce. Never came back to see this quack endocrinologist, because I obviously don't know what I'm talking about.
And just weeks ago I saw a man who is a professional athlete (apparently is involved even in the Olympics), who had normal levels but feels he should be higher. And when I told him I couldn't in good conscience suggest treatment, his last words to be as he left the exam room were: "Well, if you won't prescribe it, I can easily get it from the gym...".
Why is there a need to justify medically how we feel? Low energy, fatigue, low sex drive, ED, lack of stamina, inability to lift XX lbs of weights?
If I looked at the list of hypogonadism symptoms so artfully advertised by pharma, I personally have 6 of them (don't ask me which).
And so, why do we need a medical diagnosis for what could be life? More importantly, why are we so keen on taking hormonal treatment for a mild low, or even a normal? I imagine a large part has to be the misconception that all fatigue must be low T. And all low T must be treated. If you get treated, you'll feel like a new man. A devious, ingenious scheme of pharmaceutical advertising.
While the risks have been known all this while, the more recent cardiovascular studies remind us this is not to be toyed with. Not just amongst the elderly or those with a history of CAD, but even the younger male population.
And so, while I usually cringe when I see lawsuit ads on TV by greedy lawyers, when the testosterone lawsuit ads started appearing 2 weeks ago, a part of me was somewhat pleased.
Perhaps this will give some caution to pharma to back off on their aggressive direct-to-consumer advertising.

Sunday, March 02, 2014

Jeff Dunham!

As a rare treat to ourselves, Kris and I got a sitter and went for the Jeff Dunham show- Disorderly Conduct. If you don't know, he's the ventriloquist famous for characters like a dead terrorist, redneck, and grumpy old man. Basically, not the kind of performance you'd come to expect from a ventriloquist.
I heard about him way back during my fellowship years, as one of my attendings was in love with Achmed. But only in the last 3 years, when we happened to stumble upon him on the Comedy Channel, did we actually learn to appreciate his humor.
And so months ago, when we found out he was coming to our city, we jumped. Booked the tickets without any hesitation; this would have been my first ever 'concert', by the way.

The show was about 2 hours. Had most of his usual characters, with a new guy. But obviously, the favorite and his opening was Achmed, the dead terrorist.
It was a 2-hour session of gut-wrenching humor, which he somewhat personalized for the Midwest. At times though, it did feel like a sales promotion, with how he was hawking his products, but it was a great show nonetheless. And he seemed pretty down to earth- I didn't feel like our ticket money was going to some spoilt young brat who's doing drugs and egging his neighbors' homes. And though the hall was huge and he was tiny from where we were sitting, it was also projected to the large screen- so it was still nice to be able to see him perform "in the flesh".
Whatever flesh his puppets are made of.
P.S: He's headed to Malaysia and Singapore next month! So catch him if you can!