Kencing Manis

Having been here long enough, it's easy to forget what we call Diabetes Mellitus aka 'Sugar Diabetes' back in Malaysia. "Kencing Manis" in Malay, or the same literal translation for Chinese even. 

Sweet Urine.

After all, I remember granddad saying how if you see ants being attracted to your pee, it means you have diabetes.

And so, when I saw one of my older Chinese speaking patients the other day, it's a rarity that I get to use my very rusty Cantonese. Unfortunately this time, his disease was getting a bit more out of hand. I tried to explain to him the significance of the hemoglobin A1c, or the glucometer readings of 400 mg/dL or higher.

To which he coolly replied that he wasn't worried, that things weren't bad and that he wasn't having any symptoms. 

I asked him what symptoms he might be looking out for. And was totally unprepared for his answer. I still cringe thinking about it.

"I tasted my urine everytime the meter reading was high, and never once did it taste sweet!"

>_<

Malaysian night

Kris and I are host parents to 4 Malaysian students at the local university. Apparently there are hundreds of Malaysian kids (yea, makes me sound old) running around. Anyway, we attended the Malaysian night this weekend, an evening of performances and Malaysian cuisine. They did a good job with soto and mamak mee I think.  Though the wife found it spicy

Anyway, one of their performances was about a Malaysian boy who left for the USA for 3 years of his studies. And I have to say, for some stupid reason, that brought back a surge of memories and emotions. After all, I remember that August night, when my buddies came over for a farewell party in my honor, of how I told them "Take care of yourselves. Don't have too much fun without me. See you in 3 years."  That was before residency turned into a 3 year additional fellowship. And then meeting my soulmate and deciding to settle down here. Gosh, that was 12 years ago. And though I feel blessed to have so much, there will always be a part of me that ponders the 'what ifs'.  What if I had never stayed? What if I was there with my family, to be able to be a better son to my parents? A better friend to my buddies? What if, what if?

Often, I get emails from Malaysians who are thinking of emigration. And I try to tell them that as much as you think Malaysia is dysfunctional, there will always be ties within your heart, ties that will always make you yearn, and miss what you have grown up to call home. It's a home that your children, bred in a land foreign still to you, will never know. And so, despite how I've been away since 1998, there is much I miss. But it was at least fun to have had the chance lays night to have a taste of Malaysian food, and to hear so many people speak in the accent with which I am so familiar. 

An Interesting Case of Hypocalcemia

I saw this patient for the first time last month. Young guy, who was found on routine exam to have marked hypercalcemia of 12.1. His parathyroid hormone was high as well.
Pretty slam-dunk case of hyperparathyroidism, and given his young age, extent of hypercalcemia, surgery is clearly indicated, so I sent him for parathyroid localization via sestamibi scanning, followed by a surgical consult.
The surgeon agreed, and he proceeded to have minimally-invasive parathyroidectomy. His intra-op PTH did drop by 70%, thus with biochemical cure, the surgeon closed him up. His postop Ca was normal so he was discharged home.
A week later, his PCP calls me; he presented with tingling, numbness and cramps- was then found to have hypocalcemia this time. His Ca was 7.1, with normal albumin levels.
Uh-oh. At this point, the index of suspicion should be high for hypoparathyroidism, which is not uncommon after neck surgery, often transient, even if the remaining parathyroids were left alone.Treatment in these cases should include Calcium supplementation, along with activated Vitamin D.
One should order a parathyroid hormone level to see if this is inappropriately low, which would confirm the diagnosis. Also, a Magnesium should be checked in case he had hypomagnesemia, which induces a state of PTH resistance.
His PTH came back 80 (normal 15-65). To my surprise.
Diagnosis?
"Hungry Bone" Syndrome. 
Haven't seen one of these since fellowship. Since osteoclastic and osteoblastic activity are coupled, after removal of the parathyroid adenoma, the osteoclasts suddenly slow down, leaving the still-busy osteoblasts to take up too much of the serum calcium to lay down new bone, causing the hypocalcemia. Treatment: high dose Calcium and Vitamin D. Should be self limited.

Another Dump

KNNCCB.

Yup, that's snow.

Today.

Yup, it's supposed to be spring.It was a balmy 28 degrees Celsius Saturday. And WHAM, Sunday night we get hit with snow and the temperature drops back down to 1 C.

Gahh. Spring will come. Someday.

Spot the cars

I took this picture today when I noticed an able bodied woman walk out of her illegally parked car and walked into this building. While there were at least five empty spots though at the far end of the carpark. And I counted at least two other illegally parked cars.

Could it be then, a reason why this generation will see the highest ever recorded obesity rates?

That, for a lack of a better term, we have become so much more lazy?

Patient Satisfaction: A Good or Bad Thing?

I read this article on Medscape recently, which I thought was thought-provoking. After all, I have been on the receiving end of something like this before. It's a bit long, but worth the read:

Editor's Note: 

This article first appeared in the Fall 2013 issue of Keystone Physician, a publication of the Pennsylvania Academy of Family Physicians.

I recently was at the Scientific Assembly of the American Academy of Family Physicians (AAFP) in San Diego, giving a lecture to a large audience of Academy members on respiratory syncytial virus (RSV) bronchiolitis. I mentioned why I thought identifying the RSV virus was important. I stated that if you tell the family the infant has RSV and that there is the expectation that cough will last 1-2 months, this may forestall them going to the ER or urgent care center. In those assembly lines of healthcare, they will be told that their child has "bronchitis" and will receive the inevitable azithromycin script. This will make the parents happy, free the healthcare provider of the need for further explanations, and result in a satisfying visit for the administrators of that facility. The trouble, of course, is that an antibiotic has again been used to treat a self-limited viral infection.

A physician came up to me afterwards and agreed with me but said that he had no choice. He works in one of those venues and is subject to surveys to measure "quality." For him, quality is measured in 2 ways: The first is by getting the patient door-to-door in 45 minutes, and the second is by a Press Ganey survey to see if the patient was happy. Because of these measures, he is forced to abandon his role as a responsible steward of antibiotic use to keep his job and get a bonus.

Another physician in the audience told the crowd that he was able to increase his satisfaction score by 7% simply by prescribing an antibiotic to all patients who call with a complaint of cough, sore throat, or sinus headache. One doctor reported to the media that he had to give Dilaudid® for minor pain because his Press Ganey score was low the previous month.

I believe that this little-known company, Press Ganey, from South Bend, Indiana, has become a bigger threat to the practice of good medicine than trial lawyers. They are the leading provider of patient satisfaction surveys for hospitals and physicians. For the past decade, the government and healthcare administrators have embraced the "patient is always right" model and will punish providers that fail to rate well in these surveys. Press Ganey's CEO, Patrick Ryan, said, "Nobody wants to be evaluated; it's a tough thing to see a bad score, but when I meet with physician groups I tell them the train has left the station. Measurement is going to occur."^[1] Obamacare has budgeted $850 million in reduced Medicare reimbursement for hospitals with lower scores.

The mandate is simple: Never deny a request for an antibiotic, an opioid pain medication, a scan, or an admission. One emergency room with poor survey scores started offering hydrocodone "goody bags" to discharged patients in order to improve their ratings. And doctors face the reality that uncomfortable discussions on behavioral topics -- say, smoking or obesity -- come with the risk of a pay cut. If you tell a patient that their knee pain is related to weight, that their smoking is worsening their child's asthma, or that they can't lose weight because of French fries and not a glandular problem, your ratings and pay will take a hit.

Overtreatment is a silent killer. We can overtreat and overprescribe. The patients will be happy, give us good ratings, yet be worse off. We must have the ability to deny treatment for a patient's own good. Patients aren't the best judge of what is best for them. Several years ago, an elderly female patient wanted me to write a prescription for tamsulosin because she got a coupon in the mail. It did not matter that she lacked a prostate.Satisfied patients are not healthy patients. In a paper published in 2012, researchers at the University of California, Davis, using data from nearly 52,000 adults, found that the most satisfied patients spent the most on healthcare and prescription drugs.^[2]They were 12% more likely to be admitted to the hospital and accounted for 9% more in total healthcare costs. Strikingly, they were also the ones more likely to die.

We should try to be kind to our patients and take time to understand them, but we must resist these misguided pressures and do the right thing. Sometimes patients have to be told "no," and the leadership in healthcare must understand this. Take heart in the words of Mark Twain: "Always do what is right. It will gratify half of mankind and astound the other."

While I am all for consumer satisfaction, and this includes healthcare, I do think the are numerous caveats and problems with this system. I hear it all the time, from my ER and hospitalist colleagues. From the negative reviews from patients I personally have gotten, for "not prescribing Testosterone treatment because I didn't feel good" (despite having normal levels to begin with). Or because "Dr. Vagus practices based on science only, and didn't want to give me pills to help me lose weight and feel better".  While satisfaction is important, it is also subjective. And in situations of disease prevention, the patient might not necessarily see the end result of our intervention (by not having a heart attack), instead looking at parameters which might not be concordant to our medical goals. In my case as an endocrinologist, it's usually something related to weight, or libido, or hair, or sexual performance, or something like that. And so, if the system evolves into one that rewards physicians based on satisfaction surveys, it's not surprising to have things backfire.

Sure, I could do what that other group of "hormone experts" in town are doing; non-fellowship trained practitioners (some not even doctors) prescribing all sorts of supplements to make one have enhanced libido or sexual prowess, or to make an 80-year old man ripped like good ole Arnie (or that octogenarian you see in the airline magazines). But is that why we are here? Is that what our Oath was about? To satisfy the patient? And not to save lives, or enhance health?

I shudder to think about what kind of healthcare we will end up delivering.