Sometimes You Just Have To Listen To Your Gut

You wake up & have this bad feeling in your stomach (& you know it’s not the curry you ate last night). Things just go downhill from there. The car has a flat. Or the traffic is horrendous. You’re late for work. The F-O-N patient you usually try to avoid turns up & ends up in your consultation room. The waiter gets your dinner order messed up.

You also read about people with close calls who didn’t get on a plane because of a “bad feeling” & the plane ends up crashing with everyone on board losing their lives.

This sixth sense (no, not the I-see-dead-people variety) that you get sometimes is inexplicable, and unexplainable. I don’t know if it’s a gender-biased characteristic (the so-called “women’s intuition”); maybe the guys have a different name for it.

Whatever you may want to call it, this gut feel that you get can sometimes be a life-saver for your patients. I remember a few cases I encountered…

Patient A was a Malay gentleman in his early 40’s, who presented to me with mild gastric pain. Medical history & physical examination were unremarkable & he had only had the symptoms for a few weeks. Usually, I would prescribe an antacid and/or a H2 blocker with some lifestyle advice & review the patient again after a week or two, depending on the severity of symptoms.
However, in this case, something made me feel the need to refer him to a tertiary center for further investigations. 2 months later, I received a reply letter from the specialist who saw him at the specialist clinic giving me an update on his condition. Turns out that endoscopic examination revealed a gastric ulcer with very early malignant change. Fortunately, it was early enough that the patient did not need a total gastrectomy & just needed the affected area to be resected. I can’t begin to describe the feeling of relief (& some incredulity) I felt that we had caught this in time, thanks to my gut feel.

Patient B was a Chinese gentleman in his early 30’s who complained of a persistent cough of 2-3 weeks’ duration. He was not a smoker, & had no significant family or medical history of note. He had previously been prescribed cough mixture & lozenges by another doctor in the practice, without any relief. When I saw him, there were no physical signs to suggest any infection or malignancy. But again, gut feel made me order a chest x-ray…and to my horror, I saw a suspicious looking mass in the right lung. The radiologist report had daunting words like “suggestive of malignant change” & “infiltration”.

I referred him to a tertiary center. He returned to see me two months later to let me know that after undergoing a bronchoscopy & biopsy, the mass was not malignant, neither was it tuberculous (tested negative for acid-fast bacilli); even the specialists were puzzled by the diagnosis & thought that is was some unusual mycobacteria strain that had caused the infection. They ended up treating him empirically with what I believe to be a combo of Rifampicin & Streptomycin (patient was unclear as to the name of the drugs used). Happy ending – the treatment worked, & the patient was eternally grateful that number 1, the illness had been picked up, & number 2, it was NOT cancer.

Patient C was a Chinese lady in her early 20’s whom I saw as a health screening patient. During history taking, she revealed that she had a history of colonic cancer (!!!)& had a partial colectomy done. Apparently, she had seen her personal GP for (get this) epigastric pain (!!!), & the GP became suspicious & immediately referred her to a specialist for further investigations. Colonoscopy revealed early Ca Colon. I suspect that this GP had a gut feel too, that something was not quite right in this patient.

So the moral of the story is: don’t ignore that niggling voice that comes from that gray area between your conscious & subconscious, which sometimes makes you do things which you otherwise would not do. That strange feeling in your gut may not be indigestion, but your intuition telling you that things may not be what they seem to be.

Brrrrrrr

I think the older one gets, the lower one's tolerance level is towards the cold.

Cases in point:

We spent the 2004 Christmas holiday visiting my MIL in New York City. The night we arrived, the city received its first snowfall of the season. Needless to say, the kids were ecstatic - they were jumping for joy, sticking their tongues out trying to catch the snowflakes. As for me, I was chilled to the bone...the windchill factor was something like -20 Farenheit...at least it felt like it to me. As I desparately clutched the neck & hood of my parka close to my body to prevent the cold from creeping in, I thought: I don't think I will want to retire in any place that is not tropical or at least, sub-tropical!

Today I went swimming in our pool with my 2 boys. Now, we live in the tropics right on the equator (alright, maybe we are one degree north of the equator, not that it makes much of a difference) & the ambient temp today was something like 33 degrees C, humidity felt like it was in the high 90's if not 100. And yet, when one of my feet went into the pool, the water felt D**N cold (to me, anyway)....cold enough to curl your toes & make other unmentionable parts of the body shrink/pucker/retract.

But my boys? They went right in, initially went "Ooo it's cold" and within seconds (literally) were doing laps & somersaults in the water.

As for me, I stayed seated on the side of the pool with just my legs dipped into the water (up to the knees), to 'allow' my body to gradually accept the sudden change in temperature. Took me at least 10 minutes before I was able to totally submerge myself in the "icy" waters.

42

Today.

Me.

Winken Blinken and Nod

Insomnia hits me occasionally. Often, it is due to unresolved issues, running through my brain although the body is exhausted, preventing Sleep from taking over.

Tonight, there is no reason why I should not be fast asleep in bed right now. I can't think of anything that is bothering me, which may be keeping me up. My eyes are falling shut even as I type this. And yet, when my head touches the pillow, sleep eludes me. The harder I try, the further Mr Sandman seems to run from me...

Maybe I should try counting sheep...

Hugs & Kisses

As I read an article written by Linda Baker for the New York Times titled "When a mother must muzzle the nuzzle", about her attempts at weaning off the physical bonding she has with her children, it struck a chord with my own childrearing experiences.

I have always been a touchy-feely type of parent to my two boys. Hugs & kisses have always come freely from me to them & vice versa. Maybe it's a rebound phenomenon of my own childhood in which, as is typical of Asian upbringing, physical expression of love was not exactly a norm.

They still give me hugs & goodnight kisses. But I miss those "cling-to-your-neck-&-nuzzle-their-face-against-my-shoulder-&-neck" type of hugs which they used to give me. Something happens between the ages of 10 & 12. They develop a reserve that prevents them from giving you that all-out expression of affection. I guess it is a first step towards growing up. Perhaps this gradual weaning off process is a natural way to prepare for the day when they eventually leave the nest to make their own way in the world. I don't think it would make it any less painful, though.

Ahchoo!

Been sneezing up a storm. My allergic rhinitis has been acting up the last few weeks. Must be something in the air - mould, or the haze from Indonesia. Let me tell you, sneezing is very strenuous activity. It really drains your energy. I wonder how many extra calories I burnt up because of my allergy attack.

Those who suffer from VMR can empathise with me. Before the days of steroidal nasal sprays, one would wake up every morning with runny noses, sneezing fits, & oftentimes, clogged up sinuses. I think I spent most of the first half of my life breathing through just one nostril. Those of you who are not cursed with this affliction, don't take for granted this luxury of being able to use both nostrils at the same time.


Signed up for an ENT CME symposium this weekend. One of the topics being discussed: Allergic Rhinitis - A new Look at Immunotherapy.

Whoopee. Very timely indeed.

Blown Away

Wow.

What a concert it was last night. Mr A-Z (Jason Mraz), performing with percussion & vocal support from Toca Rivera gave a mesmerizing performance showcasing his vocal & guitar-playing talents.

I was amazed by the versatility of sounds & melodies displayed by a simple acoustic guitar with the accompanying percussion instruments (a small standing cymbal and a drum - not sure of the exact type, but it had a very Caribbean sound!). Even my boys, who are usually fans of heavy metal music a la AC/DC/Deep Purple/GunsNRoses, were suitably impressed (& hopefully inspired to add Mom's type of music to their repertoire of songs!)

I was blown away by how effortless he made it seem, with his improvisations, and his vocal acrobatics. The casual bantering with the audience was the icing on the cake.

This is what I call Talent.

Arty-Farty

Circles of Life- Angst

The Person

In the latest episode of Grey's Anatomy, Dr Christina Yang reveals to Dr Meredith Grey that the clinic she has gone to to "take care" of her unplanned pregnancy needed an emergency contact in case of unforeseen circumstances. And Christina has appointed Meredith as "The Person".

Scene

Meredith puts her arm around Christina's shoulders & leans her head against her in a show of support of what she is about to go through.

Christina (in her usual acrid tones): "You do know that this constitutes a hug?"

Meredith:" That's OK...I'm your Person."

This poignant & wonderfully written scene, which was brilliantly acted out by the two actress (Sandra Oh & Ellen Pompeo respectively)showed the friendship, trust & loyalty between the two friends.

I am lucky that I have a Person in my life. Someone who may not neccessarily be from within your family, or even your spouse, but whose relationship with you is such that he/she accepts, respects & supports you & your decisions at face value, no questions asked.

I hope everyone has their own Person too.

So Many Places, So Little Time...

Planning our summer vacation now. We have to make the obligatory trip to visit my M-I-L in New York City; this will make it our gazillionth time in NYC (no offense to NYC but I really would like to see other places in the USA as well :)). We'll probably have to limit ourselves to road trips on the Eastern coast of the USA within reasonable driving distance from Manhattan. Anyhoo, am looking at Martha's Vineyard (seems pretty enough on the websites that I've seen but don't want to end up going to a tourist trap), Providence (am attracted by the town from what I saw in the short-lived but excellent series a few years ago), Newport (hubby trained there while in the US Navy, & says it's a pretty town). Maybe I should also look south & see what's there.

Kids & husband don't really care as long as they get to make their pilgrimage to Matt Umanov (a guitar store that has been in the Village area forever). Of course, Woodbury Commons (factory outlet stores!!) is a must. Maybe a Broadway musical (been trying to get Lion King tickets for the longest time....seems to be perpetually sold-out...I guess I should start trying to get tickets NOW).

There are soooo many places in the world that I'd love to visit - horseback riding in the Canadian Rockies; cruising down the Nile; riding a camel to the pyramids; a safari in Kenya...these are some of my dream vacations. Oh well, one of these days...

It's Not About the Money

There has been some discussion lately about the economics and business of Medicine and some of the ethical & moral issues surrounding this. Oftentimes, these issues get lost in all the rhetoric.

In my POV, I don't think the debate is over whether doctors should make a lot of money from their profession. I don't begrudge highly skilled surgeons and well-respected, knowledgeable physicians earning large amounts of money for services rendered in practising good solid Medicine. Many have & still do make a lot of money for much needed services mostly in the private sector, to cater to people who can afford it (hopefully!).

I think most of us in the medical community have no qualms about denouncing the doctors who prescribe addictive drugs like benzodiazapines or Subutex or codeine-containing cough mixtures inappropriately. This is clear-cut inethical behaviour.

However, when doctors start to perform aesthetic procedures on teenagers, prescribe weight loss medicine to non-obese patients, or order a gamut of largely unneccessary tests under the auspices of Health Screening, I start to wonder at the motives of these "healers". I don't feel comfortable with doctors pandering to the vanity of the masses, the way they do now, with the numerous ads one sees in various publications expounding the availability of aesthetic services. They have become glorified beauticians. The LASIK procedure is also being aggressively promoted (not as bad as in the US but still...), and now that the competition is heating up, I wonder about the decision making process both for the doctors (in patient selection) and for the patients (same day service - eye assessment + procedure done on the same day...does that leave time for the patient to actually go home and think through this???).

It is all these gray areas which we should question ourselves about.

The Business of Medicine

Ooo...angrydoc is really angry today...

Like it or not, Medicine is a business now.

Young At Heart

I turn 42 in a few weeks. I certainly don’t feel 42 in my head, although my body & its various parts beg to differ & remind me of that fact constantly. And I sometimes need my sons to help me read the date on my watch :).

I can still appreciate contemporary music & don’t limit my selection of listening pleasure to songs from the 70’s & 80’s. Matter of fact, the radio stations that are “memorized” in my car’s stereo system play contemporary & rock music. Michael Buble, Linkin Park, Green Day, Maroon 5, James Blunt, count among some of my favourite musicians to listen (& even sing along!) to. Admittedly, I don’t do research into these artistes bio-data & memorise their dates of birth, favourite food, names of pets etc. like I used to do as a teenybopper screaming over Donny Osmond’s purple socks.

I occasional drool over hunks like Brad Pitt, & enjoy looking at nicely toned 6-packs (& hubby is OK with it. Really.)

I can still empathize with my teenage & pre-teen sons, nephews & niece. I know all the angst (ha! One of my favorite words!) that they feel during this hormone-filled phase of their lives.

Just the other day, my husband commented amusedly, “You’re still such a kid!” when I almost jumped up & down with excitement upon seeing a documentary on ‘How Star Trek Has Affected Technology ‘ on the Discovery Channel. During one of hubby’s usual channel surfing sessions, I had caught a glimpse of William Shatner narrating while clips from the various series of Star Trek played. I forced him to stay on that channel while I watched the two back-to-back episodes that night. I am a closet Trekkie (actually just ST:TNG or Star Trek: The Next Generation for the uninitiated; & to a lesser degree, ST Voyager); in fact, only my immediate family (i.e. hubby & sons) knows that I have watched every single episode of ST:TNG thanks to syndication in the US ☺, have actually attended two Star Trek conventions while living in the US (and no, I did not dress up as a Klingon nor a Ferringhi☺) & went to the Star Trek exhibition in Suntec City when it came to Singapore a few years ago.

Yeah, I still feel like a kid sometimes. I am not going to conform to society’s perception of what a woman approaching middle age is supposed to look like or be like. My motto in life now is "Live & Let Live". That’s the great thing that comes with maturity, life experiences & growing older – self-confidence and a greater appreciation for life.

Oh, and one more thing…I don’t need reading glasses yet. Really.

Just Being Random

angst

noun a profound feeling of generalized anxiety or dread.

ORIGIN German, ‘fear’.

(Definition from askOxford.com)


Don't you think the word "angst" is so apt in describing the emotions that one goes through no matter how old you are? It is so much more versatile than "anxiety" or "fear", don't you think?

Childhood separation anxiety, teenage hormonal-induced mood swings, puppy love, first love, broken hearts, pre-marriage jitters, maternal worries, empty nest syndrome...it's all so angsty.

At the Crossroads

In today's papers, Dr Huang gives us his take on the practice of Medicine today.

He writes: "The tragedy with the mantra, 'Medicine is now just another business', is that some among us are beginning to believe that it is true."

Let's be honest here...if one were to take a poll among medical students now on why they want to become doctors, what proportion would indicate "Want to earn a good living" as a major reason? I suspect a large percentage would.

Realistically speaking, being a doctor is like "having an iron rice bowl" (鐵飯碗 - a Chinese idiom referring to an occupation which guarantees job security & a steady income) - you would probably not end up among the statistics of the unemployment rate. Quantum of income would vary, but I sincerely doubt that any established, fully trained doctor would be classed in the lower or middle income groups. Unfortunately, the "business" end of Medicine has become, in many instances, the bottomline for many doctors & the "companies" they own or have a share in.

He also writes: " Many now strut around like some centrefold media superstar in the most unlikely magazines. 'Glam' sells and these coffee-table tabloids naturally fly off the racks."

I think he probably refers to the (mostly) aesthetic physicians/surgeons who are featured quite regularly in magazines targeted at the female population, as well as the well-heeled. Let's hope that we won't end up with the local version of "Dr 90210" (an American TV series on the gossipy E channel which features real-life cases of plastic suregeons in Beverly Hills).

Dr Huang also states that "The challenge facing us is how the medical profession is going to harness the tools that modernity affords us and, by self-regulating moderately, ensure that the 'outliers' in our profession do not tarnish the good reputation that our forebears had so painstakingly built over the centuries."

A challenge indeed. I anxiously wait to see where & whether the Powers draw the line with some of the more dubious practices we see.

If Only They Knew

The recent spate of letters related to high cost of medicine, alleged wrong prescription of medicine, & expectations of how doctors should practise medicine, have me reflecting again, on the varied reasons why I decided to take a break from clinical practice more than a year ago.

I see how patients' expectations have become so unrealistic (their ignorance is not entirely their fault, I have to add; it's just that their idealistic views have not changed with the times) that many expect their doctors to be at their beck & call, at the expense of the doctors' personal lives.

I see how money plays a huge factor in how doctors practise medicine. Unfortunately, the advent of managed health care, and medical groups becoming publicly listed, or bought over by listed companies which have to answer to their shareholders, have resulted in the dollar sign becoming a top priority when running a clinic. I know that there are ways of practising medicine (NOT negligently) which can improve profits for the company, and oftentimes, these methods are encouraged so that profit margins look good for the shareholders. However, some of these methods go against the grain of one's soul as a doctor (and no, you don't have to be negligent to practise "profit-geared" medicine).

It's a vicious cycle really, since the average patient expects that a doctor is there to look after his/her health, not thinking that the person whom they have placed on a pedestal would try to squeeze extra dollars out of him/her in doing so. Extrapolate this to corporate clients with some of these expectations who sign contracts with medical groups or managed health care companies (eg. some end up with packages which include unneccessary health screening tests with huge profit margins)- you are looking at potentially hundreds of thousands of dollars ( and I am only referring to primary care, not even specialist care here). And there ARE other ways of "making more money" which I will not mention here...

So there it is. The disillusionment sets in. Maybe eventually, the mindset of the patients will change & they will start to really question whether their healthcare needs are being taken care of cost-effectively or not ( I stress - "COST EFFECTIVELY" - not CHEAPLY). Maybe eventually the patients will also realise that doctors are far from angels (we'll gladly relinquish that image to the nurses *GRIN* who really do deserve that accolade) & are not gods & actually do have personal lives too :).

One day. Maybe. But not soon I think...