UroStream

Dude Fest!

2009-04-27T20:24:00.001-07:00

I'm attending a complete dude fest, also known as the annual American Urological Association (AUA) meeting. It's held in the illustrious city of Chicago this year, and it's been quite fun and informative so far. Though it has "american" as part of its acronym, the AUA is actually quite an international event with tons of international urologists in attendance. I'm constantly hearing Spanish, Portuguese, Arabic, French, Korean, Japanese, German and many other languages in the meeting halls. It's quite impressive and makes for a nice multi-cultural event.

However, I'm never more amazed at the paucity of women in urology than when I attend a meeting like this. There are literally thousands of urologists buzzing around at the convention center, most in a conservative (and dare I say unfashionable) grey or navy suit, with the occasional woman thrown in for good measure. The ratio is quite impressive, and I do somewhat feel like a single daffodil in a bed of roses. (or something like that...I can't think of another analogy right now). And more often that not, when I see another woman, she really ends up being a pharmaceutical representative....

The one HUGE advantage for me are the mostly vacant women's restrooms. There is never a line and most of the time, I have the multi-stall bathrooms all to myself! When does that ever happen anywhere else?

And with such a concentration of urologists in one meeting, the conversation is bound the be fascinating!!! Urine, prostate, ED... what more could you ask for?

Show and tell

2009-04-15T18:39:00.001-07:00

Doctors love it (NOT) when patients come into the office carrying jars or other homemade specimen containers holding all manners of bodily fluids.
I am sure that the average PCP or ENT doc has seen their share of "funny-looking" or -insert favorite color- sputum that the patient carefully brought with them to the office, after they had been saving the used Kleenex for a day or so....or perhaps the occasional stool specimen.

You can see where this is going, since I am a urologist....

I actually encourage patients to bring me the kidney stones they have passed. We can get those analyzed, and the information is quite useful in terms of preventing new stones. I've also had patients bring me samples for semen analysis, and it never fails, but these patients always seem to bring the specimen in a baby food jar...?!
However, I have also been presented more bizarre specimen, including incontinence pads where "the urine just looked a funny color", but nothing can quite top the patient who comes in with hematospermia.

For the non-medically inclined, hematospermia means "blood in the semen", which is most often a benign condition, though it may be somewhat alarming to the patient who experiences it for the first time. I've actually had patients bring me their used condoms as demonstration aids. However, the recent octagenarian who saw me for hematospermia had the good graces to bring me two used kleenex full of ejaculatory material in a ziplock bag... and they didn't exactly look like recent specimens... After donning gloves and gingerly placing the ziplock in the trash, my first thought was actually congratulatory: 80+ years old and sexually active? Way to go!!!

New favorite website of the day

2009-04-06T21:36:00.000-07:00

This is why you're fat.
It's like watching a car accident in slo-mo – I just can't take my eyes off of it. It makes my stomach churn, but I can't figure out whether it's in a good or a bad way.

Picture perfect

2009-04-02T11:04:00.001-07:00

Imagine this scenario:
Two hard-of-hearing patients both in a crowded clinic waiting room.... (sounds like the start of a good joke, doesn't it?) The nurse opens the door and calls out a name: "Mr. Will Shakespeare!!!" An elderly patient stands up and walks into the exam room. The nurse proceeds to take vital signs and obtains a urine sample and other pertinent information before informing the doctor that the patient is ready to be seen.
The doctor walks into the room and says: "Hi Mr. Shakespeare, how are you doing today?" to which the patient promptly replies: "Huh??? My name's not Shakespeare, it's Andre Gide!"

Yes, indeed, the wrong patient got up from the waiting room after mishearing the name (though the two names did NOT sound alike in the very least), and no-one figured this out until I walked into the room. The real Will Shakespeare had not even heard his name being called in the waiting room. Yikes...
Not only that, but the same thing happened TWICE that day, though the second time, the nurse caught the mistake early in the encounter.!!! But what are the chances????

I have subsequently become a total convert on the merits of patient pictures pasted clearly on the front of the chart. Many practices, especially those with EMR have this in place already, and I simply cannot wait until we get ours. The practice of medicine is confusing already without identity snafus. And please wear your hearing aid at the doctor's office.

Happy National Doctor's Day!

2009-03-30T19:26:00.000-07:00

I know this was the main thought of your day today, with March 30th being national doctor's day. And there was great celebration and rejoicing!!! ...huh, not really. Despite the fact that this has been an annual event for the past several years, I'm only really aware of it when I start getting letters from my hospitals telling me how much they appreciate me.

So I did a little internet research regarding this so-called holiday. Apparently this got started on March 30, 1933, a date which marks the anniversary of the first use of general anesthesia in surgery. However, the first national doctor's day was not officially celebrated until 1991.

Anyway, the perks for me include cafeteria coupons from two hospitals for $2.50 and $5.00, and another hospital actually offering a free lunch today (!), which I was unable to attend because of a crazy schedule. I just wonder whether the hospital who gave me the $5.00 coupon cares more about me than the hospital that only offered me a $2.50 coupon....

Redemption

2009-03-27T17:19:00.000-07:00

Despite the nature of my job, and despite what some of my readers may think, I don't actually enjoy causing pain and suffering. In fact, I'm barely able to watch a gory horror movie though I know intellectually that special effects and acting (some of it bad) are creating the images.

I'm acutely aware that some surgeries/procedures hurt more than others, whether the pain be purely physical, or with a significant psychological aspect. I think orchiectomies (removal of testes) definitely fall into this category.

Even though an orchiectomy is technically a very simple procedure, most patients (especially the male patients) tend to cringe more at the very thought of it, as opposed to something like a nephrectomy (removal of a kidney), even though the latter is a much bigger and complex operation. I know men who have undergone significant guilt and trauma at the thought of neutering their male dogs.

Unfortunately, when a patient is diagnosed with a solid testicular tumor, we need to remove that testis since the chances of it being testicular cancer is extremely high (>90%). Thankfully, testicular cancer is a relatively rare disease with approximately 8000 new cases diagnosed each year in the US. It affects mostly younger patients (kids to men in their thirties) and it's an extremely curable type of cancer, with Lance Armstrong being the poster child. In fact, I tell newly diagnosed patients that though it sucks to have cancer, if you had to get cancer, this would be the one to get. Even with metastatic disease, the survival rate is about 96%!

Normally, I tend to see one new testicular cancer patient every couple of years, but this past month exceeded my expectations. I saw two new patients within a week of each other, and ended up doing their orchiectomies back to back on the same day.

"Ball buster" and "emasculator" were some of the more polite nicknames being passed around in the OR that day, and truth be told, I wasn't too comfortable with these monikers. For some reason, removing a pesky kidney or prostate just seems so much less personal to me. One of my older partner's tried to console me by telling me his record of NINE bilateral orchiectomies in a single day. (Those were the olden days before the advent of Lupron, when patients with prostate cancer needed to be surgically castrated to keep their cancer in check. Lupron is an injectable drug that lowers testosterone that we use nowadays as opposed to surgery.)

And then just yesterday, I had a patient come into the ER with testicular torsion. He was one of the rare patients who presented in enough time for me to swiftly whisk him to the OR and save his testicle! (there is a window of 6 to 8 hours before the testis undergoes permanent damage for lack of blood flow and oxygen, at which point I have to do an orchiectomy). I felt some degree of redemption, and all was right in the world again....

Out of Jail!!!

2009-03-11T21:02:00.000-07:00

I would like to say that I was pitifully huddled on a pallet in a Singapore jail, awaiting my sentencing for smuggling illegal chewing gum, but the truth is much more simple: I have just been busy and preoccupied. Thanks for all the caring and concerned messages you have left on my last post. It's really nice to feel loved...I am very much alive and doing quite well.

The last time I wrote was before my trip to Southeast Asia, which now seems such a long time ago. How did we get to be in March already? AND it's the year 2009???? Yikes... Time really seems to fly by when you are busy. And please, don't think that I am complaining about being busy. Au contraire, I say a daily prayer of thanks for having a steady job that allows me to pay my bills... And more importantly, brings out the creative literary side of my character...

Being in Southeast Asia was quite an amazing experience. I especially enjoyed Hanoi in Vietnam because I felt so removed from the Western world. There is still very little western influences in Vietnam compared to the rest of Asia, and it made for a truly enjoyable and memorable authentic experience.

Another immediate noticeable difference in Asia was the average body mass index. This trip really highlighted a recent urology consult request by the hospitalist. It was one of my least favorite type of consult: difficult foley catheter insertion.

Now there are many things that can cause problems with placing a foley catheter including urethral strictures, BPH (enlarged prostate), tight sphincters (really!), previous prostate-related surgeries etc... But this was the first time I was asked to help in actually locating the patient's penis! He weighed in at a whopping 550 lbs, had been bed-bound for the last year or so, and his thighs and belly were so big that no-one could actually find his penis.

I was a little apprehensive after getting the call. I mean, this was not a typical difficult foley consult. I wasn't really sure they needed a urologist per se as opposed to an archeologist with a team of excavators... I can finagle a catheter through the tightest urethral stricture, but trying to find the opening of the urethra (meatus) when the penis is "lost"amidst a sea of flesh? A daunting task indeed...

I went to the ward armed with my physician assistant and four nurses. Two nurses held apart the patient's legs while two others were pulling up his pannus (the big hanging belly fold) away from his groin area. Where the genitalia should normally be was just a big dimple and my hopes for a miraculous emergence were dashed. Using both my hands, I pushed down onto the area where I thought the penis should be, and with a lot of pressure, something that looked like the meatus slowly unfolded. With even more steady pressure, the rest of the shaft slowly materialized and my PA was finally able to slip in a catheter.

I felt victorious for a self-congratulatory second, but these feelings quickly faded as I interacted with the patient. He was actually a very nice man, but completely trapped into a unmanageable body that was rapidly failing him. How does anyone get so big? Why does this seem to happen mostly in the States?

Happy Holidays!

2008-12-20T14:27:00.001-08:00

I will be taking a short break over the holiday season. We are traveling to Southeast Asia for the very first time, and I am really looking forward to all the new culture, colors and culinary delights awaiting us. Moreover, we will be traveling with my parents, which should make it an even more interesting trip.

I will be back the first week of January to give a mini trip report. Hope everyone has a safe and happy Christmas/Hanukkah/New Year!!!

Radiation scare

2008-12-11T09:40:00.000-08:00

Recently, I have begun to see more and more patients who are sent to my office from the ER with presumed renal/ureteral stones without a CT scan.

They present with typical symptoms such as blood in the urine, sudden flank pain and mild nausea, and if they've had a stone in the past, some ER physicians will not order a CT scan for fear of radiation exposure, and subsequently will send these patients to see me as an outpatient.

With mounting evidence on the risks of radiation, especially after multiple studies, I can understand the reluctance. However, what am I supposed to do with the patient? How can I offer them any medical advice, including the likelihood of spontaneous passage, if I don't know where the stone is located, what the size of the stone is and assess the presence of hydronephrosis? I'm good, but I'm not Superurologygirl with X-ray vision.

So what do I end up doing? Yup, I order a CT scan after talking to the patient about the risks of additional radiation, especially if the patient has been suffering for a few days already without resolution. Most patients are willing to do this since they also want to figure out what is going on and determine the best course of treatment. The last such patient actually had a 5 mm stone with severe hydronephrosis, and I took her to the operating room exactly 17 hours after I ordered the CT.

So I understand the desire to cut back on unecessary and potentially harmful tests. If the patient already had a CT that revealed stones, and he returned to the ER a couple of days later with the same pain, I probably would not order another one. But there are also times when these tests are crucial.

PS: I'm forever grateful to my husband who tirelessly constructs new looks for my blog. I really like the new simplified motif, though I'm glad he still left some pink, being that it's one of my favorite colors. Thanks honey!

Pantomime

2008-12-02T09:51:00.000-08:00

Though one of my nice older patient does not speak a word of English, this has never been a problem since he is always accompanied by a bevy of daughters who provide excellent translational services. However, communication issues arose after his admission to the hospital, when his relatives were not always present as I made rounds.

Though I speak four languages pretty fluently (including English!) and know a smattering of words in a dozen other languages, Vietnamese is not one of them... In order to ask a few basic questions, I resorted to pantomiming at his bedside.

As I was trying to ascertain whether he had ambulated that day, I did my version of the moonwalk. Then I asked him whether he had lunch by putting an imaginary spoon to my mouth and masticating imaginary yummy hospital food. Then wanting to know if his pain was under good control, I contorted my face into a painful grimace while holding my belly. (Now you must all envision this happening while I'm wearing nice pants with high heels and a white coat...)

I know Marcel Marceau would have been proud of my miming abilities! I want to go as far as to say that even the patient was duly impressed with my fine acting skills and I think he understood everything I was asking.

However, I had to draw the line at asking whether he passed gas or had a bowel movement....

Giving thanks

2008-11-27T14:54:00.001-08:00

I am on call this year for Thanksgiving, and it's already been mildly painful and busy (an exploratory laparotomy AND a kidney transplant last night!). The even more painful part is that this call lasts from wednesday until monday morning!!! Yikes....

But as I was rounding at the hospital today and encountering sick patients and their families, I became profoundly thankful that my loved ones are in good health. Perhaps I am getting more emotional in my dotage, but I was feeling almost teary as I was walking through the wards, as there are few places sadder and lonelier than a hospital during the holiday season.

Harley riders: beware!

2008-11-24T09:54:00.000-08:00

I have to admit that I've never liked motorcycles, especially Harleys since their riders seem to derive great enjoyment at making their machines be as loud as possible. I find it rather obnoxious. However, as this new information is coming to light, it might be possible they are trying to compensate for something????

This information is straight from the AUA (American Urological Association) Daily Scope:

"Australia's The Age (11/23, Benson) reported that a survey found that men who ride motorcycles "risk impotence and urinary problems because the engine vibration damages nerves in their penises." For the survey, researchers looked at "more than 230 motorcyclists who ride for about three hours every weekend." They "found that almost 70 percent had problems getting an erection or emptying their bladders." In addition, researchers "in Japan, who published two studies on the dangers in the International Journal of Impotence Research, said most motorcycle seats put undue pressure on the area between the anus and the scrotum, cutting blood flow to the penis." Furthermore, "vibrations from the engine also caused a decrease in two growth hormones in the bladder and prostate related to bladder relaxation."

Not looking foward to it yet....

2008-11-21T21:54:00.000-08:00

As the appointment with a follow-up patient was nearing its end, he suddenly quipped: "I gotta tell you doc, I don't know what you did to yourself but you look about 20 years younger than when I last saw you. I hardly recognized you...."

Considering that I just saw him only a month ago, that comment took me somewhat aback. I could take it as a very nice compliment, or it meant I simply looked like hell a month ago...

After trying to convince him there had been absolutely no recent plastic surgery involved, I informed him it was actually my birthday today, but that I was really not too excited about this event ever since I turned 35 years old a few years ago.

The patient then told me he reached the point where he was actually looking forward to each of his birthdays, as an acclamation of being alive for another year. He began to feel this way when his friends started to pass away, one at a time.

I'm not sure when this turning point happens. In your 60s? 70s? Never? I guess it really depends on the person. All I know is that I'm not yet looking forward to another birthday, but now it will be a whole year before I turn 40.

What do you do for a living?

2008-11-09T09:18:00.000-08:00

Simple question for most people.... However, this seemingly innocuous question used to stress me out when I first began training as a urologist. I was raised by my very conservative parents that talking or even mentioning certain areas of your anatomy was taboo, or at the very least, not an appropriate subject to bring up. Yet, the very essence of my job entails a journey into a realm which produces squirming in a polite society.

Inevitably, this question would be raised in public setting such as in a plane, at a bar or some sort of social gathering where escape was not a possibility.

I thought about lying outright and feigning to be an actuary, but I couldn't come to terms with that deceit (thanks mom!). So I usually tried to reach a compromise by trying to be vague and mentioning that I might work in the medical field. Unfortunately, with the medical field holding some kind of svengali like attraction vis-a-vis the general public (explaining the huge popularity of all these medical based shows on TV), this prompted even more questions to the point where I had to finally confess that I was a urologist (and not a neurologist)...

Which usually brings about a contemplative (or just plain shocked) silence for a few seconds, even a few minutes. Then the questions really start. What does a urologist actually do? And what kind of advice do I have for Aunt Ginny/Uncle Bob/you who was diagnosed with kidneystones/prostatecancer/incontinence/diabetes/heartdisease/psoriasis/ colonicpolyps? It never fails that all kinds of very personal medical issues (most of which have nothing to do with the field of urology) crop up during these times.

I've always found it rather bizarre when perfect strangers have no qualms about revealing delicate information about themselves to someone they have just met. (OK, this also describes my interactions with new patients, but at least I'm in clinic, and not at a bar...)

Nowadays, I'm much more direct when asked this question. I will say "I'm a urologist", and then move on to a completely different subject. Like politics...

Hope

2008-11-05T18:23:00.000-08:00

I have been criticized for talking politics on my blog (though my long-time readers will know that it's certainly not the first time). We have just voted for the new president of the most powerful nation on the earth. How could I not speak about it today unless I lived with my head buried in the ground?

I know we cannot agree on everything politically. This very choice is what makes this country so great!!! We have the freedom to research and make informed decisions based on it. It is the basis of a democratic nation...

I love this country, as I am sure all of you do as well, and I want the best for it. Whether you are blue or red, I think we can all agree on that premise. I just happen to feel that Bush was not the best choice for our country. No matter what the spin is, a lot of us will agree (as evidenced by last night's outcome) that he has not been one of our better presidents.

Call me foolish and idealistic, but I care about people and the society in which we live. I really do! And we all have to make certain choices in order to make this country what it is.

I choose peace over war. I choose green over pollution. I choose freedom (of religion, politics etc..) over infringements of rights. I choose responsible taxing and spending over a trillion dollar deficit. I choose tolerance over prejudice. I choose hope over fear.

Is this what makes me a radical left liberal? Then so be it.

A new day has arrived...

2008-11-04T20:58:00.000-08:00

With tears in my eyes and a soaring heart, I extend a huge welcome to President Barack Obama!

I feel that I have just been part of a historical and unforgettable moment in the history of the United States of America. He ran an amazing, almost flawless campaign, but the victory truly belongs to the man himself. He is smart, thoughtful, eloquent and inspirational, basically the anti-thesis of Bush. He is a breath of fresh air after eight years of a truly horrendous and corrupt administration.

I even liked John McCain tonight during this concession speech, though I cannot feel the same generosity towards Sarah Palin. What an odious woman...

Finally our beautiful glorious country can begin to unite and heal.

Hallelujah!!!

2008-10-28T10:58:00.001-07:00

O Most glorious of days!!! Most anticipated time since AD 1991!!! Sweet bright light at the end of the tunnel!!! Most welcoming of happenings!!!

I just officially paid the last cent off my medical student loans today!!! And I thought this day would never come...

I started med school in 1991, right after graduating from college, and I didn't want to burden my parents for additional funds after they had generously paid my college tuition in full. I distinctly remember the first loan check I got for my medical tuition, and feeling scared... very scared... (but not as scared as some of my medical colleagues who went to private med school and racked up >$125,000+ in loans). With each additional year of schooling, I saw my debt mounting into a mini version of Mount Everest (at least in my mind), and despaired ever seeing the day that this particular monkey would get off my back.

Over the long years of residency, when pay was inadequte yet hours were long, I paid off just the minimum amount to keep from defaulting, wherewhich the interest compounded and grew.

And now, it was all been paid off!!! Hallelujah!!!
So now I just have to wait 27 years for my mortgage....

Risk management

2008-10-27T10:51:00.000-07:00

I recently attended a risk management workshop with presentations from various medical professionals and attorneys (both plaintiff and defense) regarding ways to avoid being sued. It's an absolutely lovely way to start your saturday morning (7:30AM!!!)

This is especially apropos after reading Shadowfax from Movin' Meat receiving his first lawsuit notice. I really feel for him, since this is one of the most dreaded event in the career of a physician.

The workshop consisted of impromptu video interviews from people off the street who were invited to talk about their doctors, and what they considered good and bad medical care.
One major theme began to emerge from these interviews about being a good doctor: spending enough time with the patients without feeling rushed, good communication using everyday language and transparency.

The perception of a "bad" doctor was lack of availability, lack of quality time spent with the patient, lack of listening skills, and a perceived lack of caring.

And the key word here is PERCEPTION. You may not actually spend a tremendous amount of time in the examining room, but if the patient feels that you are truly listening and spending quality time, then that is what matters. If you begin the visit by sitting down instead of standing and having your hand on the door knob, it goes a long way in making the patient feel comfortable and less rushed.

The point is that patients certainly appreciate a smart doctor who may be very skilled, but they appreciate even more a physician who takes time have a real conversation and shows some degree of caring. In short, they want a nice person as their doctor. Sounds easy, right?

As an aside, I want to say that this is pretty much the opposite of what someone wants in a plaintiff's attorney, where being an aggressive and rude are the qualities of choice (just my biased view...) There was a video interview of a plaintiff attorney, and it was an excellent decision on his part NOT to have been physically present at the worskshop. At the end of the interview, I was ready to lead the lynch mob comprised of normally mild-mannered physicians with a pitchfork. The guy was so condescending and unpleasant. There was a synchronous groan in the conference room when he made this one comment: "you don't have be that smart to be a doctor; you just have to be compulsive." I wanted to reply: "you don't have to be smart to be a malpractice lawyer; you just have to be vicious."

Shot interrupted

2008-10-20T14:41:00.000-07:00

It's flu shot season again, and I know I've covered my morbid fear of injections in prior posts ad-nauseam, but here we are once more. Doesn't it seem to come sooner every year???

Yes, call me a hypocrite, a poltroon, a coward, but whereas I have no trouble wielding a scalpel or a hypodermic syringe on my patients, the thought of getting an injection on my tender deltoid puts me into a hyperventilating diaphoretic mess. Mind you, it's not the pain, because truth be told, the stupid injection does not hurt a bit. I've had more painful sessions with a pedicure... But it's just the thought of a needle... going into my flesh... argh...

My nurse just announced today that we got our flu shots delivery for the office, and wanting to change my usual pattern of endless rumination and worry leading to procrastination, I volunteered to have it done today.... only to recant and cry out like a baby as soon as I rolled up my sleeve. This was even before the alcohol wipe touched my skin.

Finally, at the end of the day, I got up the courage to ask my nurse to give me the damn shot. I rolled up my sleeve one more time, gritted my teeth.... and tried to escape like the yellow-bellied dastard that I truly am... Foreseeing this turn of event, my nurse firmly caught my arm, and before words of protest could even escape my lips, plunged the virus-laden vaccine into me. Thank god for my no-nonsense nurse who will take shit from nobody, not even me...

So until next year...

No need for thanks

2008-10-15T21:04:00.000-07:00

I was finishing up a clinic visit with a new patient, when, as I was heading towards the door, she uttered these parting words:
"Thank you for seeing me and taking my insurance."

Since I don't personally check ahead of time what insurance my patients have, I was intrigued by her comment and asked her who provided her healthcare coverage. She answered Tricare, which is the healthcare insurance provided to the United States Armed Forces and their families.

The reason for her gratitude was because she was finding it progressively more difficult to find physicians who would accept Tricare. Though it pays marginally better than Medicaid (not Medicare), it is one of the worst insurances around, with notoriously finicky pre-authorization requests and terrible reimbursements for doctors (usually less than half of commercial insurances). Truth be told, I think we actually lose money by seeing Tricare patients if you take into account the increased work done by our billing staff, which why an overwhelming numbers of doctors have stopped accepting it.

I've already written in a previous post how utterly deplorable it is for members of our active military and their families to be offered this type of insurance. It speaks volumes about the priorities of our government...

I proudly count two veterans of the USAF amongst my partners, and there is no way we would NOT accept Tricare. I am lucky that I belong to a physician group large enough to absorb the costs of "less-than-ideal" insurers, but I could understand how a solo practitioner or a smaller group would not want to deal with Tricare.

However, especially in light of current affairs, I really think it's the right thing to do. No matter your views about the war in Iraq, it does not change the fact that thousands of Americans are risking their lives. I actually just wanted to say to that patient:
"No, on the contrary. Thank you."

Please don't make me cry...

2008-10-07T15:03:00.000-07:00

Though no death is ever easy to deal with, I find it particularly emotional when it's one of my older patient who has recently lost their spouse. It's absolutely devastating to see the sorrow etched on their face, the dazed and lost look they have in their eyes and the palpable grief emanating from their body.

One of my patient had recently lost her husband of 59 years. Thankfully he passed away gently in his sleep, but it had obviously taken a toll on my patient. A normally brave, independent and spry woman in her 80s, she looked incredibly vulnerable and tiny that day. She could not help the tears that slowly rolled down her face as she told me their story.

And I have to tell you, this is a surefire way to make me lose my composure in the exam room.

Alternative treatments

2008-09-12T08:03:00.000-07:00

Few things frustrate me more than patients diagnosed with cancer that could be cured via conventional medical therapy, who end up resorting to alternative "treatment" options.

I could learn to accept these decisions if these were real legitimate treatments they were exploring, as opposed to the utter quackery offered by exploitative and unscrupulous individuals.

I'm already distraught enough when I have to reveal the diagnosis of cancer to a patient, and I usually spend a good amount of time in clinic discussing the problem, prognosis and various legitimate treatment options. But then my distress turns to perplexity and disbelief when the patient wants to try the new "cancer-fighting" minerals found only in the jungle of Ecuador, or the all juice antioxidant diet or the mind-over-matter cancer protocol. After my initial shock, I stress the simple important fact that this particular cancer can be cured with early treatment. I gently argue and point out the flaws of these so-called treatments, and I state unequivocably that I do not believe these "cures" work. But my words fall on deaf ears, and to my dismay, the patient will shun traditional therapies.

Proponents of these holistic remedies will argue: well, what about a little faith? What about the power of positive thinking? What about good nutrition? And my answer is that I wholeheartedly approve of that.

I'm not saying that I don't believe in the value of good nutrition, with herbal supplements etc.., but I think these work in conjunction with traditional medicine as opposed to in lieu of them. I sincerely do wish these "natural" chemical-free surgery-free remedies would work for cancer. But while I read the testimonials from all these websites touting their success, I remain profoundly skeptical.

The proponents of natural remedies don't mention in their website how many patients they fail to cure. That's because I'm the one that sees my patients return a few months or years later, with the inevitable progression of the disease which has rendered their condition now incurable. I've had patients with bladder cancer, kidney cancer and prostate cancer try these remedies, and I've seen these same patients die when the cancer ate away at their bodies. And the frustration I feel is indescribable.

Shivers

2008-09-05T12:01:00.000-07:00

There are few things as horrific as seeing a patient with advanced penile cancer. Thankfully, it's not a common disease, and over the last 6 years, I've only seen a handful of cases, which is to say a handful more than I want to see...

The horror comes not only in the diagnosis of cancer in such an unusual area (most people are probably shocked to learn that there even exists such a condition), but also in the treatment for this diagnosis which, even in the best possible scenario, can only be called mutilating.

Unfortunately, the best cure lays in surgical extirpation of the cancer. In lay terms, that means we have to cut it out... If the cancer only involves the foreskin, then a simple circumcision can be enough, but unfortunately, a lot of these cancers affect the glans or shaft of the penis, at which point we are talking about doing either a partial or complete penectomy.

Emotionally, this is an extremely difficult operation, both for the patient and the surgeon, and my being a woman does not lessen in any way the impact of the surgery. I feel terrible when I have to make the diagnosis, and when I have to operate. Though I have received many criticisms for my blog and some of my detractors have portrayed me as a "castrating lesbian prison guard"(they know me too well...), I get unpleasant mental shivers when I am performing these types of surgeries.

And for all those people who are rabid anti-circumcision advocates, let me tell you that this disease ONLY happens in uncircumcised men. Yes, it's rare, and indeed good hygiene can probably prevent this, but it only takes seeing one penectomy before I find myself in the pro-circumcision camp....

Atonement

2008-08-14T20:33:00.000-07:00

Med list for my new patient:

-Omega 3 fish oil
-Gingko biloba
-Green tea extract
-Centrum multivitamin
-Saw Palmetto

He's actually quite healthy without any serious medical issues. Yet despite all these nutritional supplements that would seemingly identify him as a health-conscious individual, I also noticed that he smokes a pack a day for the last 40 years....

I'm always a little amused yet perplexed when I see something like this. Do the supplements somehow "atone" for all those cigarettes? Do the antioxidants negate the carcinogenic effects of tobacco? If only it were that easy...

Perhaps this line of thinking is akin to ordering a double burger with fries and a diet coke. Drinking a regular coke with that meal would put it over the edge!!!! Or taking cholesterol lowering medication without changing any part of your high fat diet.

My idea of atonement for eating cookies at lunch was running on the treadmill for 25 mins. Not as easy as taking a pill for my transgression, but certainly more effective.

Summer fare

2008-08-08T22:01:00.000-07:00

I'm just writing a little warning note for my readers. Don't expect any insightful posts (have I ever written one?), or even any posts at all over the next 17 days. Didn't you hear? The summer Olympics just started tonight!!!!

I absolutely ADORE the Olympics, especially the summer games. There is something almost surreal about thousands of athletes from hundreds of different countries coming together for a little over two weeks to compete. I love the individual stories of people who, against all odds, are able to make it to the games. There are people who know they are never going to win a medal, yet still compete just for the sake of participating in this global event.

Despite the fact that this year's Olympics is fraught with political undercurrents, I love the fact that during the competition itself, politics takes a back seat and only personal achievements matter. There is unbearable drama, extreme elation, heart-wrenching upsets and nail-biting thrills which all contribute to a an overwhelming emotional roller-coaster. Call me a huge softie, but I have shed tears for strangers coming from countries I have never even heard of.

I was sorely disappointed to find out that NBC was delaying the live opening ceremony by 12 hours to fit it into their "primetime" viewing hours. Money before anything else... And could there have been any more commercials? I hated the fact that part of the ceremony and the parade of the nations was cut off to accomodate ads. argh....

The opening ceremony was awe-inspiring this year, and definitively proved to the world that China is a force with which to be reckoned. I don't think I'm exaggerating when I say that China may be the most powerful country in the world right now. I'm saddened to see how the US has lost almost all its manufacturing industry to China and how we owe an unimaginable amount of money to that country from our huge deficit. Well, that's another topic...let me not spoil the enjoyment of the 2008 summer games by bringing reality to my world right now...

Tardiness

2008-08-03T11:40:00.000-07:00

One of my biggest pet peeves is tardiness. As a rule, I am a fairly punctual person, and I like to be even a little early for my appointments. Call it my obsessive-compulsive nature, or a lifelong fear of displeasing others, but few things stress me out more than being late. I think my upbringing also plays a crucial role, since my parents are known to show up at the airport a minimum of two hours before their flights. They both have type A personalities that will not allow them to be tardy for anything.

There are lots of surgeons who are known in the OR for showing up chronically late to their cases, which drives me crazy since by a cascading series of events, they end up delaying everyone who follows them. I am proud to say that I have a reputation for being on time.

But enough about me and my issues with punctuality, the question is, in this society that is becoming increasingly lackadaisical and casual about everything, including time, what is an appropriate length of time to wait for a patient who is late for his/her medical appointment? 5 mins? 15 mins?

Different clinics have different set of policies, but I will not see someone who is more than 15-20 mins late, unless they have a really good excuse. It may seem harsh, and invariably I will have someone comment that the patients themselves always seem to wait an innordinate amount of time to see the physician. However, accomodating tardy patients will ensue in making me late in seeing other patients, and will guarantee to throw off my whole schedule for the rest of the day. In any case, I really do try to run my clinic efficiently with a minimal wait time for my patients. It puts a lot of angst in me when I am running behind (OCD, OCD!!!) so I do my best to avoid being constantly stressed out.

Of course, being tardy is still better than not showing up at all, which is the pinnacle of rudeness. My partners and I usually have an appointment waiting time of 2 to 4 weeks (unless there is an emergency), and the appointment for which the patient did not show up could have easily gone to someone else. And I do have a "three strikes and you're out" policy where if you don't show up without calling three times, you will not be able to make another appointment with me. And I think that's pretty generous...

E-mail funnies

2008-07-20T10:02:00.000-07:00

Two e-mails put a smile on my face today:

The first came from my AUA Daily Scope (daily news bites and articles of interest from the American Urological Associations) with a bold title that announced:

"Global warming may increase kidney stone rate!"

Mind you, not that global warming is funny at all, but the headline just sounded so unnecessarily alarmist, and so unlike the usual "less sensational" articles the AUA presents. And as a side note, I do believe that global warming will make us urologists busier.

The second came from one of my bestest of friends, whose mother actually reads my blog! Mom came to visit her, and said:

"I don't like it when she (meaning me) writes about penises."

Yikes, that puts a severe restriction on the variety of my posts.....

Not so insignificant

2008-07-13T13:12:00.000-07:00

Even though I'm just a dumb surgeon-type, and not a clever endocrinologist or nephrologist, I still need to know all my patients' medical history in detail. (I've always thought the specialities mentioned above attracted the super intellectual types...Urologists are more akin to the humble plumbers whereas the nephrologists are considered the engineers...) Yes, I like to be in the operating room and I like to use a scalpel to help people, but that doesn't mean I don't do some thinking of my own.

I am always astounded at the details that patients omit on their medical history form. I'm clued in when I look at their medication list and see 3 different antihypertensive medications, yet they don't list hypertension as one of their medical condition. Usually the explanation is something like: "but with the meds, I don't have high blood pressure anymore...." I can usually guess the medical conditions by corresponding it to the appropriate medications, but that is not so easy when the patients forget a medication, or are not taking a medication at all for a significant condition.

I found one such omission when I ordered some pre-op labs for a patient who was scheduled for surgery. I found his Calcium level to be somewhat elevated, and repeated it only for it to come up with the same abnormal results. Since hypercalcemia is actually something that urologists are familiar with (it can lead to kidney stones), I called the patient to set in motion a full workup for hypercalcemia before his scheduled surgery, only to be told that he had been seeing an endocrinologist for quite some time for hyperparathyroidism (a condition that can cause an elevated Ca level).

I must admit that I was mildly annoyed. If only they had told me this from the beginning, I could have saved him an extra lab test and a headache (mine)....

Apprehension

2008-06-28T08:46:00.000-07:00

You know my previous post about the rule of three? Well, I just took care of two penile fractures in a 24 hour period of time.

OK, technically the human penis does not have a bone (though other animals like dogs do), hence a "fracture" is somewhat of a misnomer. However, this is the correct medical term for a rupture or tear in the tunica albuginea, which is the tough yet elastic sheath that surrounds the erectile tissues in the penis called the corpora cavernosum. (I admit that there is a tremendous amount of incomprehensive medical mumbo jumbo, but don't blame me for the nomenclature since I wasn't the one who thought up of all these names. Blame it on some dead white guys. If it were up to me, I would have chosen much better and cuter gwords...)

There are certain sexual positions associated with a penile fracture, most commonly when the female partner is on top. (I'm really not making these things up!!!) In any case, a fracture occurs when the penis is forcefully bent while erect, causing a tear in the sheath. Some patients report hearing a pop sound, immediately followed by penile detumescence and an impressive amount of bruising. Though it all depends on the elapsed timeframe before the patient seeks help, the recommended way to treat this is surgical intervention where you find the tear and repair it by placing some sutures. And lest everyone reading this is inclined to be less adventurous in the bedroom, I have to reassure you that that it is not a common condition. Over the last 10 years, I have personally encountered only 6 cases or so.

But knowing full well the truth behind the rule of three. I am anxiously waiting for the next call in the middle of the night.....

Retained stent

2008-06-16T11:07:00.000-07:00

Seaspray's unfortunate close encounters with ureteral stents reminded me of the nightmare that is a retained stent. (not that you have that Seaspray, and I really hope you feel better soon!!!) If anything is guaranteed to shave years off the life of a urologist, it would be a retained stent.

Ureteral stents, unlike vascular stents, are not meant to stay inside permanently. They need to be removed, or at least changed every few months (depending on the patient and the type of stent), otherwise the stent becomes calcified and it becomes virtually impossible to remove the stent. Anytime there is a foreign object in the urinary tract system, crystals form which lead to stone formation. Imagine having concrete poured directly within the ureter and letting it set inside, and you can understand what it is like to deal with retained stents. Obviously, the longer a stent has been in place, the more calcified it becomes, and the harder it is to remove.

As soon as I even hear the words "retained stent", multiple cell layers of my stomach start to slough away because I know this will most likely require multiple procedures in order to remove the offending stent while protecting the kidney and ureter. The surgeries are often complex and time consuming and though I love challenges, I don't generally like them in the OR.

Patients who come in with retained stents have a variety of reasons for not coming in sooner. Most of them are just lost to follow up, not realizing that stents are not supposed to be permanent. Others were not aware that they even had stents in the first place. (!!!) Others just "forgot" they had stents.

The oldest retained stent I've taken care of is one that had been left in place for 3 years! And did that one give me a few grey hairs.... But I have to admit there is something EXTREMELY gratifying about finally removing something like this, and as the OR staff cheers and rejoices when the stent is finally extracted, I feel like a champion!!!!

The rule of three

2008-06-07T10:17:00.000-07:00

There must be some cosmic rule that urological conditions come in groups of three. I have mentioned this on a previous post, but I have noticed that when I see a patient with a somewhat unusual medical condition, I am guaranteed to see two more patients within a short period of time with the same problem. I'm not talking about UTIs, stones or incontinence, but more like ureteral tumors, penile cancer and peri-urethral cysts. Nothing that is outrageously unusual, but not conditions we see daily.

Recently, within a span of one single week, I have see three patients with acute urinary retention (over 3L) being admitted for elevated Cr (over 10) whose renal function improved markedly with catheter drainage but needed to stay inhouse for a few days because of post-obstructive diuresis (over 6L/day).*

This condition itself is not extremely unusual, but three patients within a week at one single hospital is not that common. The funny thing is that each of these patients were admitted to different services: I had one admitted to me , one to internal medicine, and one to the renal service. It is one of those rare medical condition where you can appropriately justify an admission to these three very different specialties. In fact, I can't think of any other condition where one could do the same...
I wonder if the ER felt we should all get our fair share....

*For the non-medically inclined: having over 2L in the bladder is markedly abnormal. Most of us want to empty our bladders when we reach about 250cc or so. With that much pressure and urine in the bladder, the kidneys start to shut down. The creatinine (Cr) is a blood test to look at kidney function. A normal value is around 1, and the higher the number, the worst your kidney function. Post-obstructive diuresis happens after you relieve the source of obstruction and the recovering kidneys start producing massive amounts of dilute urine, which can cause severe dehydration and electrolyte imbalance. Depending on how much we drink, we normally produce around 1 to 2L per day.

In a slump

2008-06-05T23:01:00.001-07:00

Sorry about the long break. It seems that within just a few days of returning from vacation, I felt like I never went away at all. Isn't that always so?

In any case, I have been trying to keep afloat of my very hectic schedule. Besides my clinical duties, I've also had an unusual amount of administrative type meetings that are always scheduled at the convenient time of 7AM. Things have been so crazy busy at work that I have even cancelled one of the few treasured activities that I strive to attend bi-weekly: my Pilates class. Not only is it badly needed exercise, it is also a huge stress reliever and one of my therapeutic indulgences.

I love Pilates. I discovered it a few years ago, when I was tired of hauling my protesting body (and mind) to the gym, to work on a treadmill or an elliptical machine that I hated. I have never enjoyed exercising that way, feeling more akin to a rat running aimlessly on his wheel inside a cage than anything else. I was looking for a form of exercise that I would find more enjoyable and less of a chore.

After my first Pilates class on a fateful saturday morning, I was totally hooked, and I have been attending classes twice a week. It's a time just for me, and it really helps not only my body, but also my state of mind. It's something that I consider essential for my sanity and I view the time for these classes to be almost sacrosanct. Nothing short of a true emergency will make me cancel a session, and I rarely have any time conflict since my classes are scheduled during "off" hours.

Well, today was one of those emergency days, and I had to cancel my class. There was a patient needing surgery, and because of my hectic schedule, I could not find any other time to do it.

I know my complaint seems so petty in the larger scheme of things, but there have been so many times (perhaps one too many) over the last 15 years when I have felt this job severely encroaching upon and overwhelming my personal life. It's just a teensy straw adding just the right amount of excess weight on my back. I can't help but pout a little tonight and feel a tiny bit sorry about myself.

But dear readers, fray not! I will heave myself out of this one person pity party and I promise to be back with a better frame of mind saturday morning - right after my Pilates class.

How to tell you are married...

2008-05-01T10:16:00.000-07:00

Our nightly bedtime ritual involves my husband lovingly putting a Breathe-right strip on my nose. (allegedly, I snore, though I'm not convinced) .

Before my LASIK surgery, I used to fall asleep next to my husband with my glasses on. Really sexy...

When I reach over to cuddle with my husband, I also try to sneak in his monthly testicular exam.

Hubby now feels perfectly comfortable to inform me that I look like a "car accident victim with a head injury" when I wake up in the morning. Granted I'm not a morning person and my AM conversation usually involves unintelligible monosyllabic grunts (hence the head injury part), and I guess I don't look so hot either.

I sleep with all 9 (yes, that's nine) of my stuffies (stuffed animals) at night and hubby doesn't complain. In fact he encourages this behavior by periodically adding to the collection. Thank goodness for our king size bed.

So all I want to say today is: Happy Anniversary honey, and thank you so much for the awesome new wallpaper!!!

PS: to celebrate our wedding anniversary, we are going on vacation and I will be out for the next two weeks. I will try to post if I have access to a computer, but I can't promise anything.

Gratis

2008-04-24T13:28:00.000-07:00

I encountered a somewhat difficult patient the other day to whom I recommended a standard of care cystocopy as part of a hematuria (blood in the urine) workup. He proceeded to question everything I was doing and my decisions for doing so. I usually encourage these questions, but I had the sense that this patient was extremely anxious and was just talking himself into an even higher state of anxiety.

Finally, after all the relevant medical questions were exhausted, he asked me how much the procedure was going to cost, and I told him that "it depended but I could give him a ballpark figure". He then flew off the handle and ranted about how medicine is the only business where the key players don't know how much things are going to cost and how could such a business survive etc...

I gently corrected him by saying I knew very well how much my practice charges for the procedure, but how much he was actually going to pay out of pocket (and conversely what I would get paid) for the procedure depended entirely on his individual insurance plan, his co-pay and our contract with said insurance company. I can charge whatever I think is appropriate, but that does NOT mean I'm getting paid that amount due to the third party payer system we have here. The only people immune to this are plastic surgeons or other doctors who have a strict fee-for-service business and don't have to deal with insurance at all. They can post their fees openly because they will get what they ask, just like other regular businesses.

As his final trump card, he exclaimed: "well, what do you do for people who don't have insurance?", to which my immediate response was: "if it is medically necessary, then I would do it for free, and have done so many times.". My response seemed to subdue him, as if he had never thought of that possibility.

Indeed he was correct about one thing: there is no business like medicine. Who else would spend countless hours working (oft in the middle of the night) with patients euphemistically referred as "self-pay" knowing full well that they will not get paid at all? Your lawyer? Your plumber? Your favorite movie actor? I dare say nay. I honestly cannot think of many examples, yet almost all of the physicians I know do pro bono work frequently; it's just another part of being a physician in the 21st century...

Six word memoir meme

2008-04-19T15:42:00.000-07:00

I'm very late in the game as this meme came out a few weeks ago, but I got tagged by Seaspray, and since I've let her down so many times before, I thought I would give this one a try.

The Rules are:
1. Write your own six word memoir.
2. Post it on your blog and include a visual illustration if you want.
3. Link to the person that tagged you in your post and to the original post if possible so we can track it as it travels across the blogosphere.
4. Tag at least five more blogs with links.
5. Leave a comment on the tagged blogs with an invitation to play.

I've been very busy these past few weeks, to the extent that I've even had to do an elective surgery this saturday (my off day since I'm not even on call!) because my regular weekday schedule has been triple booked....

So I was tempted to write something pithy like:

Sacrificing saturday for nephrolithiasis is worthwhile

But after some thought, I came up with:

Personal and professional life? Never dull.

Vocabulary lesson

2008-04-09T20:49:00.000-07:00

Presenting some new medical verbiage in the field of urology, as introduced to me by numerous patients:

Prostrate:
Male gland that likes to worship face down on the ground. Frankly it makes me feel uncomfortable when I encounter it because my god complex is not that highly developed.

Sphinxter:
Enigmatic yet strong lion-like little muscle in control of certain nether functions. May have egyptian etymology.

Urether:
In-betwixt a urethra and a ureter! It transports urine directly from the kidney straight out into the toilet!

Blatter:
Can be used to store and hold urine, as well as carry food on special occasions.

Penes:
A multi-purpose instrument. Urination, reproduction, calligraphy...

Information overload

2008-04-03T20:12:00.000-07:00

We are required by law to give an informed consent on any medical procedure/surgery we perform. This involves explaining in detail what the procedure is, what the risks and benefits are, and what other alternatives are available for treating the ailment. It's something we are taught to do very early on in our career, not only because it's a requirement, but it's also the correct course of action in order for the patient to make an informed decision about his/her medical care. Should you fail to do so, not only would you be deemed a bad doctor, but there are many unpleasant legal ramifications that can await you...

I take care to go into great detail about each surgery I am about the perform. I really want the patient to understand exactly what is going to happen, what the expectations are after surgery, and all the potential risks attributable to the surgery.

The questions is: when is it too much information?

My answer is NEVER, but there are many times when I feel like I am really putting the patient off by describing too many "gory" details. For example, when I describe a ureteroscopy with a stent placement to a male patient with a stone, I have to tell him that I am going to place a long thin scope up into his penis, find his ureteral orifice, go up the ureter to find the stone and laser it, then end the procedure by leaving a long plastic tube inside that will span his entire ureter from the kidney to the bladder. Albeit all under general anesthesia, but I can usually see the patient physically wince and cross his legs... and this is even before I go into all the potential risks and complications from the procedure...

But what else can I do? The patients needs to know, and I want them to know. That's part of practicing medicine in the 21st century. Gone are the paternal days of medicine when the doctor decided what was best for the patient without any questions asked.

I've changed my middle name

2008-03-26T21:30:00.000-07:00

I've come to realize that I have become increasingly obsessive-compulsive in my old age. I don't know exactly when this change occured, but I can assure you that I wasn't born this way. Procrastination was my middle name. Growing up, I always did my homework at the last minute, waited until the very end to send in college applications and always pulled all-nighters to finish up papers and other assignments due to poor time management. Medical school wasn't much of an improvement, and the lack of sleep and constant fatigue during residency ensured that I rarely did anything ahead of time. Utility bills were often paid late and I once had my water shut off because I wasn't home enough or even cared enough to dig through the mail. I could hardly call myself a very organized person.

However, I've had an almost 180 degree change in character since starting my practice. Some might even call me "anal" these days and I would not dispute that description. Certain facts indubitably point to this metamorphosis:

- I've already submitted my tax return for 2007.... one month ago.
- I check labs and vital signs on my inpatients from home every night even though one of my partner is on call.
- I pack for trips on the eve of my departure. (trust me, huge improvement!)
- I try on outfits and pack for longer trips at least 3 days before departure day.
- I brush my dogs teeth almost every day.
- I brush my own teeth BID. OK, I've always done that, but some might consider that "anal".
- The cat gets a manicure/pedicure (by me) once every two weeks. Actually, so do the dogs.
- I frequently wake up before the alarm clock goes off.
- I set my alarm clocks on weekends... even when I'm not on call.
- I arrive to appointments on time, often even a few minutes early.
- I get really annoyed when other people are late.
- Online bill pay has ensured that I pay 100% of my bills 100% on time. But I still check.
- I know when my next haircut will be (May 24th if you were curious)

Is this enough proof? The scary thing is that I could go on...Why have I turned into a Blackberry?

Perhaps it's because I have lost the "student mentality" and feel more like a responsible member of society. Perhaps it's that electric jolt I got at work from a defective toaster a few years ago. Perhaps it's the core strength finally going to my head after years of Pilates. I don't really have an answer, but in any case, I want to believe this change is for the better.

PS: I'll write again in exactly 5 days 9 hours and 35 minutes. See you then...

Please don't press that button

2008-03-24T10:07:00.000-07:00

PCA (Patient Controlled Analgesia) is a godsend for most patients and nurses. It's a pump attached to your IV that contains your narcotic of choice (usually morphine or dilaudid), and by pressing a button whenever you need it, you are able to get a preset amount of pain med into your system.

You can order the settings in a variety of ways, from the dose of each pain med, to how often it can be administered, to a four hour maximum dose limit. This way, no matter how many times a patient pushes on the button, you only get a certain set amount, and very rarely do you see overdoses. And if you don't need any pain meds, you just don't push on the button. Simple as that.

I almost always use a PCA pump for my post-operative patients. This way, they don't have to call the nurse and wait for them to come around with pain meds. My standard setting is 1mg morphine every 8 mins, with the ability to increase to 2mg q8 mins if necessary, with 20mg to 30 mg maximum 4 hour dosage. I don't like continuous delivery settings because frankly, I don't think it's safe. Naturally I adjust accordingly to the size of the patient and other medical factors.

The system usually works beautifully. The patients are in charge of one aspect of their care, which is so important in a hospital environment where they usually feels as though they have relinquished all control of their lives. In addition, the immediate relief of the surgical pain can really help in the post-operative course. The whole concept of a PCA works when the patient is the one pushing the button whenever there is a need.

The system goes awry when well-intentioned family members want the patient to feel as comfortable as possible, and will push the PCA button for him/her, even when the patient is asleep or not in any obvious pain. The family will keep a vigil over the patient's every single facial expression, and if there is a suspicion of an involuntary grimace, or a little moan that escapes during the nap, they will press the button. Certainly well-meaning, but probably not the wisest course of action especially when the patient goes into respiratory depression and Narcan has to be administered rapidly.

Just call me Bozo

2008-03-16T19:59:00.000-07:00

For those of you who don't give a hoot about women's hair issues, you can stop reading now. This post is for the 51% of the population who can commiserate with me. I had a somewhat eventful trip to my hair stylist yesterday whom I love and who usually does a top-notch job. She just returned from an 8 month hiatus and had been sorely missed. Since I was overjoyed at seeing her again, I decided to entrust fully in her artistic flair and became putty in her capable hands. She cut my hair to perfection, but when I mentioned I wanted "vibrant highlights" in my hair, she interpreted this to mean "fiery orange-red".

To my dismay, as I stepped out of the salon, my hair actually glowed in the sunlight. I admit that the effect was rather striking, and would have been perfect had I worked in a creative field such as advertising, designing, or even at the circus. Alas, the medical world is rather conservative, and I didn't know how my colleagues and more importantly how my patients would react to such a innovative hair color. Perhaps things would have been a tad easier had I been a pediatrician, since kids tend to like clowns....

I decided to see if my hair would magically tone itself down during the wondrous process of sleep restoration, but when I woke up this morning, the combination of orange-red with bed hair did little to calm my disquietude. Again, perfect if I were working at an art gallery expounding on the juxtaposition of the artist's angst and loneliness demonstrated by his use of color and stippling effects throughout the canvas. However, not ideal if I'm trying to instill confidence in Mrs Jones so I can operate on her kidney stones.

Thankfully husband extraordinaire saved the day. He did a lot of research online about "hair coloring gone wrong" (I can attest that there is a TON of information on this subject!) and "consulted" with "le couleur expert" Christophe from L'Oreal's website (a great interactive tool where you can plug in your questions, and Christophe will magically devise a solution). We went to our local drugstore and purchased the recommended subduing color. Husband applied the stuff while I prayed outloud and 30 minutes later, the results far surpassed my expectations! I had great color with perfect highlights!!!

Smug and proud of it.

2008-02-25T11:33:00.000-08:00

At the risk of sounding extremely smug and self-satisfied, I have to tell you that I had a very productive Saturday morning this past weekend. Alas, I happened to be on-call, and there were several patients at different hospitals that needed to be seen, in addition to new consults and procedures to be done.

Nevertheless, before 11:00 AM, I was able to:

-Wake up at 6:45 AM. (Come on! Remember that this was a SATURDAY... this should be considered a major achievement already!!!!)

-See a trauma consult for a bladder rupture and meatal stenosis (tightness at the opening of the urethra, making insertion of a foley catheter impossible). I reviewed the CT scan, evaluated the patient, dilated his urethra (some might say 'tortured with barbaric instruments") and placed a foley. Thankfully the ICU nurse was kind enough to give the patient ample amounts of morphine and versed.

-Round on the patients at that hospital and write semi-legible notes and orders.

-"Speak" to a Russian-only speaking inpatient. Through a combination of slow english, bad russian (from my residency days), miming, facial and body contortions, I was able to make myself understood. I discharged her from the hospital and arranged for follow-up with my partner. (at last, those acting classes taken during high school extracurricular activities are finally paying off!!!!)

-Crush and stamp out a painful kidney stone via a ureteroscopy with holmium laser lithotripsy in the OR.

-Eat a banana and drink a latte in under 2 minutes flat while driving over to a second hospital.

-See a fresh post-op patient in the ICU of above mentioned hospital.

-Rush over to a third hospital whilst avoiding any speeding tickets to see a couple more patients. Wrote illegible chicken scratch notes. Spoke to many nurses. Resisted the temptation to nibble at the most enticing chocolate-frosted donut in the staff lounge. (Probably the proudest achievement of my day)

-Stop by my favorite frozen yogurt place for THE most amazing honey frozen yogurt. Tart, just slightly sweet with a hint of honey, and fat-free!!! This is a weekly saturday pit stop, whether I'm on call or not.

-Returned home to kiss my dogs, cat and hubby. (in that order!)

Lunar Eclipse

2008-02-21T10:34:00.000-08:00

Was anyone else able to catch a view of the lunar eclipse last night? It was quite amazing! I was worried that clouds would obscure our view, but it was an unusually clear night, and the event was wonderous.

We have a telescope that I bought as one of my better christmas present for hubby several moons ago, that is now mainly used as a decorative accent to our living space. I always feel like Jimmy Stewart from "Rear Window" when I look through it, but this was the perfect opportunity to use it as it was originally intended. The shadow of the earth eclipsing the moon is a sight to behold!

Girl's best friends

2008-02-20T11:42:00.000-08:00

No, not diamonds, but high heels!!!

I just read this little article on high heels from BBC online which suggests that "high heels may improve sex life".

An Italian urologist and self-professed lover of the sexy shoe set out to prove that high heels are not as bad for women's health as some suggest. Although high heels can cause a host of problems, Dr Maria Cerruto asserts in her letter to European Urology (an academic journal) that they improve pelvic muscles (Kegels anyone?), which can assist in sexual performance and satisfaction, and provide support to the pelvic organs, including the bladder.

I'm inferring from the article that if high heels tighten pelvic muscles, they can help with urinary incontinence. Who'd have thought that those Manolo Blahnik heels would actually become a useful urological device? I could write prescriptions for Jimmy Choos! I could finally combine my unnatural love of shoes (or so my husband says... I don't think it's so strange) with my work!

My dreams would come true if I could submit my Nordstrom shoes receipts as a bona fide tax-deductible medical expense!!! Never mind the footaches, the constant risks of ankle injuries and the slight deformity on my little right toe (who needs little baby toes anyway?), I am a fan of high heels. Being burdened with the genetics of average height, and having a hubby over 6ft tall, I like to boost my standing with the magic of heels. I love all shoes, but hold a special fondness for heels. I usually wear comfortable low-heeled clogs in the OR, but I have been known to do some of my shorter cases in heels...

And you can guess what I wore to work today...

"Street" diagnosis

2008-02-16T18:54:00.000-08:00

I was walking around my little part of town this Saturday with Hubby, doing a little shopping--embracing the clinical benefits of retail therapy, not to mention fulfilling my patriotic duty to help out ailing retailers in these dog-days of looming recession.

I was feeling just a tad sorry for myself since the last three pairs of jeans I tried on were far from flattering, emphasizing the less desirable aspects of my physique. Try as I might to shift the blame on the jeans themselves, still, I could not help being just a little sulky. Hubby attempted to convince me that my thighs were not hideously obese and lard laden, but I could not be persuaded...

We then simultaneously noticed another pedestrian walking towards us, with the biggest bulge EVER in the crotch area of his jeans. Incredulously, hubby looked at me and mouthed the question: "is that a boner?", to which I immediately replied: "no silly, that's just a huge hydrocele!"

For those in the dark, a hydrocele is a fluid collection around the testes that accumulates in the scrotum. They can range in size, from minimal and asymptomatic to gigantic. They are benign, but as you can well imagine, they get uncomfortable once they grow past a certain size, and can cause difficulties with routine activities such as fitting into your pants. They can only be repaired with a simple outpatient surgery called -suprisingly- a hydrocelectomy.

Well this guy's hydrocele was gargantuan!!! Probably the size of a medium honeydew melon. Though I may be occasionally prone to hyperbole, this is NOT one of those times. He could hardly walk, and that big bulge in his pants could only be politely described as "obscene".

As a physician, I make "street diagnosis" all the time. They are mostly dermatological in nature since that is what is most readily apparent: acne vulgaris, vitiligo, rosacea, rheumatoid arthritis, hemangioma, acute ETOH intoxication etc... but this must be the first time that I've made the "street diagnosis" of a hydrocele!

Project Runway

2008-02-14T19:01:00.000-08:00

Why hasn't anyone told me about this show before??????

I just discovered it last night because hubby was working late, and I was listessly flipping through channels, looking for anything of interest. I suddenly happened upon Heidi Klum looking annoyingly perky and blonde amidst a group of anguished would-be designers, and the remote control locked itself in place.

There is so much drama, cruelty, back-stabbing and tears!!! I was immediatly hooked.

I admit that I don't usually watch the "popular" TV shows. I've never seen "Grey's Anatomy", don't know that the big deal is about "Lost" and couldn't tell you what "Desperate Housewives" is about (though I have a pretty good idea from the title...) The resolved writer's strike really did not affect my viewing options at all.

But I have to admit that I will most likely continue to follow this reality show. It's addictive and absolutely fabulous!!!

Mr. Grumpy

2008-02-05T19:17:00.000-08:00

I've known Mr Grumpy for a little while now, and he didn't come by this nickname because I love Snow White. (well, I actually do love classic Disney animated movies, but that's beside the point). Mr Grumpy always comes to my office full of piss and vinegar, generally annoyed at the whole world. The 30 minutes office visits consist of a litany of grumbles about everything, even when I try to direct the conversation to pleasant topics like kittens and pink cotton candy. Perhaps he is allergic to cats, but then again, he would have to be allergic to the whole world to excuse his mindset.

Mr. Grumpy has cancer, and I have to operate on him. The thought fills me with some trepidation because I can predict with great certainty that his mood will not improve with the presence of a large surgical incision.

I meet Mr. Grumpy's family. I'm pleasantly surprised when I find them all rather nice. Naturally they are all concerned about the cancer and the visit is very serious, but I find them all to be naturally optimistic people. (how did this happen?) They all shake their heads good-naturedly when they listen to Mr. Grumpy's constant gripes. They understand that the post-operative course will not be easy for anyone, and my thoughts are mostly with Mrs. Grumpy (who is not grumpy herself) since she will have the bear the brunt of the recovery process.

So I perform the surgery, and everything goes quite well. However, as anticipated, Mr. Grumpy does not suddenly develop a sunny disposition on the ward. He goes through several different nurses throughout the day and my daily rounds consist mostly of listening to his *long* list of complaints. Certainly I can appreciate that some of them have merits, such as the "quality" of the hospital food, but when he starts ranting about the nurses, some of whom are amongst the best surgical nurses I've met, my patience wears thin.

I'm hoping for him to crack a smile, or at least stop complaining for one short minute when I tell him that the pathology has returned and the cancer is completely gone. He is cured! He grants me a few seconds of reprieve before he tells me how bad the coffee tastes. I, like his family, can only shake my head.
As the leopard cannot changes its spots, Mr. Grumpy cannot change his demeanor.

Abbreviations

2008-01-30T08:21:00.000-08:00

Abbrevations are incredibly common in the medical world. They are practically a way of life in medicine, and I use them on a daily basis in my notes, dictations and orders. It was a mark of great pride when I managed to write the following clinic note as a 3rd year medical student:

67 yo H M c/HTN & DM, dx c/PCa (init PSA 5, Gleason 3+3) s/p RRP 3 yrs ago. PSA:0, DRE: neg. No c/o. No LUTS, mild ED. RTC 6mo with PSA.*

This two-liner managed to convey all the critical pertinent information while being terse enough as a surgical note, and even my senior resident at the time was thoroughly impressed by this feat.

However, recent JCAHO rules has prohibited some of the more common abbreviations for fear of causing medical mishaps, and hospitals have really rallied behind these changes.

This "no abbreviations" rule came to a fever pitch when one of my partner, whose name is John K. Smith (you might have guessed, but only his middle initial is real), read his most recent operative report that named him as John Potassium Smith**. Ha!

*67 year old Hispanic Male with hypertension and diabetes, diagnosed with prostate cancer (initial Prostatic Specific Antigen of 5, Pathologic Gleason grade 3+3), status post a radical retropubic prostatectomy 3 years ago. PSA today is zero, digital rectal exam is negative (for new nodules or mass). No complaints. No lower urinary tract symptoms, mild erectile dysfunction. Return to clinic in 6 months with a follow up PSA. (see how long this takes in longhand????)

**K is the shorthand for Potassium (Kalium in latin). K is the recognized abbreviation for Potassium on the periodic table, and is very commonly used in the medical world, even in our speech. I frequently ask "what's the patient's K today?" And my partner's middle name is definitely NOT potassium.

Heavy stones

2008-01-29T09:53:00.000-08:00

Again, I must apologize for my lack of blogging of late. My insidiuous cough has persisted, keeping me up at nights, and it's been rather trying. Moreover, being the ever dutiful wife, I have given this lovely virus to my husband who is seriously attempting to cough out one of his lungs.

Needless to say, neither one of us has gotten much sleep recently, and I'm feeling tired and perhaps the tiniest bit guilty. I have been concocting some homemade naturopathic remedies from the "old country" consisting of lemons, pears, ginger, dates and honey (slice and dice, mix it all up and pour hot water to make a wonderful aromatic and restorative tea). I'm truly convinced of its miraculous medicinal properties, but after three nights of little or no sleep, my husband has become rather skeptical, and has asked for some codeine laced cough syrup. I'm now arguing with him that he needs to drink at least 4 to 5 mugs a day (and night) for the cure, but he is showing some resistance...

In any case, a couple of readers from my previous posts asked me to expound on the relationship between kidney stones and obesity. There has been a host of articles over the last few years that show an irrefutable link between the two. Kidney stones usually come in several varieties, but the most common ones are calcium oxalate in nature, with uric acid stones coming in a distant second. And it seems that obesity has a close link to both types. There has been many speculations as to the etiology, and I believe the reason to be multifactorial.

Patients with higher BMI (Body Mass Index) have shown to excrete more urinary oxalates, uric acid and sodium, all of which are stone "promoters". Diet plays a pivotal role in this, where low fluid intake, a high sodium rich animal protein intake (ie: not enough water, too much meat, too much fast food) will additionally cause a low urine pH (acidic urine), which also contributes to stone formation.

The bottom line is that for stone prevention, I always recommend a lower animal protein, lower salt (less than 2400mg Sodium/day), lower oxalate diet with a minium of 2 liters of water intake per day. There are also substances known as "stone inhibiters" such as citrate, which is readily found in lemon juice and certain nutritional supplements which can really help for those "frequent stone formers".

Diplomacy needed

2008-01-17T10:54:00.000-08:00

Sorry about the recent lack of blogging. The recent combination of the start of the new year, the return from a week off and a heavy on-call schedule has conspired to keep away from writing.

On top of it all, I am now harboring an odious virus whose intent is to have me cough out a bronchus or two. I'm at the tail end of this infection, and I no longer have chills and muscle aches, but the persistant coughing is keeping me up at night. I really do not understand how smokers can tolerate this slight perpetual shortness of breath and imminent phlegm. Yuck...

Though I don't think I'm still in the infectious stage, I'm also in the process of losing my voice in between fits of coughing, so simple conversations with my patients have become rather strenuous.

I have always had a difficult time talking to patients about weight issues. I don't have any problems telling ( lecturing) the patients about smoking cessation, to the point where some of my regular patients will immediately confess as soon as I enter the exam room that they are still smoking, and they know it's bad, and that I don't need to say anything else to them. Of course, that doesn't dissuade me from speaking my mind (again!) and denouncing the evils of tobacco.

However, I never feel comfortable bringing up the subject of obesity. Yet beside the obvious increased risks of cardiovascular disease and diabetes, obesity can play a very large role in many urological disorders, including kidney stones and incontinence, and there have even been links to renal and prostate cancer.

I feel like patients who are overweight are clearly aware of the fact, and don't really need another person to state the obvious and make them feel bad. However, over the years, I've really made an effort to bring this up when I think it really affects the patient's health. Perhaps these patients did not realize the connection of their weight to their recurrent kidney stones or persistant urinary incontinence, and I feel it's my job as a urologist to explain it to them.

But I don't like doing it. I feel like a bad person when I bring up the subject. I felt like the biggest cad on earth when a patient burst out in tears in my office when I gently mentioned that losing weight might really help in her treatment, since being over 300 lbs was putting a lot of pressure in her pelvis, and undoubtedly contributing to some of her severe incontinence.

The last thing I want to do is rub salt on your wounds, but I also think it would be remiss not to mention all the contributing factors to your medical condition.

Some culinary delights, courtesy of Mexico City

2008-01-01T08:05:00.000-08:00

We just came back from a fantastic trip to Mexico City. The colors, culture and cuisine were just some of the highlights. Six days were hardly enough but to get a small sampling. As you have all probably realized by now, food plays a huge role in all of our trips, and here are some pictures to prove it:

This was the popular Tostaderia Coyoacan in an enclosed market with an infinite number of toppings available for a delicious tostada.

Yummy yummy tostada de ceviche

Limon con coco: a sweet mexican delicacy from the famed Dulceria Celaya. Candied lime stuffed with coconut. My new favorite sweet snack!

Quesadilla de flor (squash blossom). Que sabrosa!

Churros y chocolate

Carne al pastor

Taco de carne al pastor

Aguachile de callo (scallops in "chili water")

Coctele de ceviche

Feliz Nuevo Ano!

Who? Moi?

2007-12-23T17:02:00.000-08:00

STDs (Sexually Transmitted Diseases) commonly seem to affect the patient who hasn't had sex in 5 years, or the person who professes to be completely monogamous, or the guy who swears he uses a condom every time.

I'm getting cynical these days, but anytime I see a patient with the slightest suspicion of an STD, I will do a urethral or a vaginal swab for GC/Chlamydia. I've seen too many positive ones to do otherwise. And I always hate the ensuing conversation when I have to tell the patient about the results. There is always some amount of disbelief and denial, recriminations (with the partner but often with oneself), and a very large dose of anxiety.

Recently, a patient came in with a new labial lesion that looked suspicious for HSV (Herpes Simplex Virus), and when I sent her for blood work, her HSV-2 (the genital type as opposed to the oral one) titer came back very high. She was flabbergasted when I told her the news, and even asked me how she could have gotten it. I wanted to give her the same answer if asked "how did I get pregnant?", but refrained.

Home Ed

2007-12-17T21:30:00.000-08:00

You can easily tell the guys who have a "strong" wife at home. They're the ones who clean up the exam room before they leave.

After I'm done with the examination and discussion, I usually get up and head towards the door, expecting the patient to follow me and make their next appointment. However, these are the patients who immediately wipe the water splashes on the counter with a paper towel, put away all the magazines back to the rack and roll out a new exam table paper sheet before they leave.

For lack of a better expression, they are "well-trained" by someone who obviously rules the household with a firm hand. I know this for sure because many a times have I tried to stop a patient from cleaning up, and they will just sheepishly tell me -while continuing to straighten up the room- that this has become an ingrained habit after years of living with a neat-freak wife. I'm surprised they kept their shoes on before entering the exam room!

Mind you I'm certainly not complaining, but I am just a little taken aback when the patient performs maid service. This definitely goes WAY beyond the usual call of duty. And truthfully, I'm also thinking "Bravo to those wives!".

(No) dress code part II

2007-12-14T10:52:00.000-08:00

My previous post about the bathrobe-clad gentleman in my office reminded me of this other occasion when I was leaving the hospital and walking towards my car. Right across the street from the hospital is a convenience store that sells the usual sundries at inflated prices in addition to some alcoholic beverages.

Imagine my surprise when I saw a hospital patient inside the store, wearing his hospital gown (yes, the kind that exposes the whole back), but also thoughtfully wearing pyjama pants and hospital slippers. He was encumbered by his IV pole, but that did not stop him from standing in line with a six-pack of beer in his hand.

I wonder where he kept his wallet...

Euphemisms

2007-12-09T09:57:00.000-08:00

I have discovered that the "art" of medical dictation is actually a carefully nurtured skill. You want to give as much information as possible in a concise manner, yet you don't want to spend an inordinate amount of time doing so. I try to do my dictations in between patients during "down-times", but that is not always possible on a busy day, and when I see the mountain of charts piling up on my desk, a sense of overwhelming fatigue and languish takes over. I must admit that dictating is one of my very least favorite chores as a physician. (It ranks very closely to washing the dishes...)

Over the years, I have fine-tuned my dictation skills, and I have become much more proficient, but I remember the first few dictations I've had to do, and they were not pretty. I think my very first operative report took my about 15 minutes to dictate, something I can now do in less than three. Yes, I've certainly come a long way.

I've also learned to use certain euphemisms when I encounter particularly difficult or unpleasant patients at the clinic. I don't want to sound unprofessional and write in my clinic note that this patient was a complete a%$-hole or a total bit#^. After all, this is part of the patient's permanent medical record, which will eventually be sent to his/her primary care physician. So I have developed my own way, dare I say a more civilized manner, to ascribe these attributes.

I try to use relatively inoffensive adjectives and let my readers deduce the rest. Some of my favorite euphemisms include:

very pleasant = normal nice people which make up the majority of my pratice. Actually this isn't really a euphemism, it's just the plain truth.
challenging = incredibly difficult and unpleasant
loquacious = could not get a word in edgewise and office visit took up an hour more than scheduled
confused = demented
unkempt = unhygenic. Needs to be best friend with soap & water.
unfocused = crazy as a loon
grandiose = delusional
erratic behavior = I'm this close to calling security
obese = obese
pain issues = drug seeker
inconsistencies = lies

The use of the adverb "extremely" in conjunction with my euphemisms would indicate an unusually severe issue. I tend to use that adverb very judiciously, but watch out when I do!

(No) Dress code

2007-11-29T21:59:00.001-08:00

A urology clinic would be a difficult place to work in if you have prudish sensibilities. There are frank discussions about sex, STDs, urinary and bowel functions and other delicate topics. Because we address the genitourinary health of patients, we are singularly interested in the "nether regions", hence our particular focus in the area "below the belt" during our physical exams. ("What made you go into urology?" is an oft asked question, both from patients and family members, and perhaps a topic for a future post).

At one point or another, I have seen most of my patients naked from the waist down, just like an opthalmologist would have looked into the eyes of all his/her patients. It just part of being a urologist. During my very early days in medical school and internship, there was a mild sense of awkwardness during these exams, but I've matured and I now have a very straight-forward professional demeanor that seems to put patient at ease.

However, I like to keep nudity within the confines of my examining room, though there are many patients who seem quite comfortable walking around my clinic with a minimum of clothing. I've seen a few of them going to the restroom with just a paper sheet wrapped around their waist, and one of my patients was caught trying to leave his room stark naked. Luckily he only made it a few steps before my nurse intervened.

The most recent incident occurred when one of my patients showed up to my clinic – that would be my extremely busy clinic with a packed waiting room – just wearing an old beat-up and obviously well-loved terry cloth bathrobe, and nothing else. He was even missing the tie around the bathrobe. OK, I exaggerate... he was also wearing sneakers. As he was ushered into the exam room, his bathrobe kept slipping open, much to the horror (and delight) of my staff and other patients. I carried on a perfectly normal conversation with him, studiously ignoring his state of undress, and he left my clinic in a completely un-selfconscious fashion. I did feel bad for him though since it happened to be a rather brisk morning with temperature in the low 40's.

Disposable Dell

2007-11-25T17:15:00.000-08:00

My barely three year old Dell laptop died last week. It was quite sudden and completely unexpected. There were certainly no symptoms at all until my husband came home one afternoon, and found it down in our study. There were no lingering agonizing last moments, no prolonged suffering (except coming from yours truly) and no obvious reasons. He tried a couple of heroic maneuvers, and finally brought her emergently to the computer hospital (his IT department at work), but alas, even the IT professional could not revive it. Apparently the hard drive and motherboard (who knew computers had moms?) were both completely fried, and I lost everything. My photos, itunes, powerpoint presentations on fun topics like hematuria, incontinence and interstitial cystitis.... argh...

The IT guy told us that the lifespan of a PC laptop was in the 3 to 4 year range, so apparently this should not have been unexpected...

This means that I am presently without a computer at home. I am using my husband's Mac, but it's just not the same as having your own machine (he gets a little territorial), and this may result in less frequent posts until I get a new computer.

I'm even thinking of going over to the dark side and have been looking at the Macbooks...or does it just mean that I am finally seeing the light?

What's up?

2007-11-15T19:18:00.001-08:00

Being generally averse to using public restrooms, I try to avoid using those at the hospital that are situated in high traffic areas. I'm talking about the restroom next to the main elevators, cafeteria or in the main lobby. I usually like the ones that are located in restricted areas or remote corners of the hospital. I consider that one of the few perks of being a physician.

Today, I just wanted to wash my hands and entered for the very first time the women's restroom located right next to the emergency room, which I conjecture to be quite busy.

Imagine my surprise when I saw a condom dispenser next to the sink!!! What an unlikely and perhaps even inappropriate place for one. Would this be in the event of extra long waits at the ER? Before a visit with your convalescent loved one (and hoping for a private room)? A quick romp in the doctors' lounge? Hospital parking lot adventures? Special Physical Therapy?

Close to home

2007-11-12T20:49:00.000-08:00

Many members of my family as well as close (and not so close) friends started to ask me for medical advice very early on in my medical career. Dare I say the first day of medical school? There were all sorts of questions ranging from laryngitis to irregular menses, and I always tried my best to answer them, with the ever present caveat that I wasn't a real doctor yet, and didn't know all that much.

Since specializing in urology, I have a similar caveat, that I still don't know much beyond the genito-urinary system, but that certainly doesn't stop the phone calls and e-mails. I'm happy to answer all queries and give medical advice (which usually goes something like: "It sounds like you have sprained your ankle. Ice it down, take some ibuprofen and try not to bear any weight on it, but if it doesn't get better in a few days, you'd better see your PCP." Or "I think you are having an allergic reaction to the poison oak. You should take some benadryl and put on some calamine lotion but if it doesn't get better, you should really call your PCP.")

Sometimes I actually feel useful when it's a urology related question like a simple UTI or enuresis (bedwetting), or even something in the vicinity of urology, like an inguinal hernia.

Well I hit jackpot yesterday. My poor brother-in-law woke me up Sunday morning when he called complaining of severe flank pain radiating down to his lower abdomen accompanied by nausea and vomiting and I promptly diagnosed him with a kidney stone. My sister drove him to their local ER, and the CT scan confirmed my suspicions. At last, I could truly be useful and I was able to give him all kinds of advice without my boilerplate caveat! Thankfully he passed the stone on his own, but he will soon be receiving a stone prevention handout with lots of handwritten advice by his caring sister-in-law!

A tale of two patients

2007-11-10T11:25:00.000-08:00

Both patients are elderly women in their eighties, who live in a skilled care facility.
Both have advanced dementia and are no longer able to make decisions for themselves.
Both have close relatives who have power of attorney over their medical care.
Both are admitted to the hospital on the very same day for failure to thrive.
Both need a urology consult.

And that's where the similarities end.

One patient was found to have advanced invasive high grade cancer of the renal pelvis extending into the ureter and the bladder and I had to fulfill my very least favorite task as a physician: telling patients and their loved ones that they have cancer. This diagnosis came as a complete surprise for the family. Fortunately for the patient, she was really beyond understanding what was happening to her. I then discussed all the treatment options with the family which would include an extremely major surgery involving removal of the kidney, ureter and bladder (the only true chance for cure), versus chemotherapy/radiation therapy. All the options would inevitably lead to a lot of stress and suffering for the patient. The daughter was quite clear from the onset. A few years ago before the devastating effects of dementia took hold of her, the patient had clearly expressed her wishes should such an occasion arise. She did not want to participate in any major surgeries or invasive procedures. And the patient's daughter did not choose to go against her wishes. The patient eventually returned to her nursing home, to be placed in hospice should she take a turn for the worse.

The other patient did not have such a dire diagnosis, but was truly failing to thrive at her nursing home. Like a great number of little old ladies in nursing homes, she was admitted to the hospital with a rip-roaring bladder infection, severe chronic constipation and had stopped eating on her own. She was also much more somnolent and had stopped interacting with everyone. The family member with the power of attorney stated that he wanted everything done for her, which in this case, meant she had a full GI workup including a colonoscopy and an upper endoscopy, swallowing studies and had a PEG tube placed for tube feeds (a tube placed directly into her stomach to give liquid food). Multiple CTs and MRIs later and after several weeks of hospital stay, the patient returned to her nursing home, not much improved in her mental status, but now kept alive with tube feeds.

I understand that it is an extremely stressful and difficult job to decide the medical care and deicsions for other people, especially loved ones, and nobody wants to be accused to "killing off" grandma or grandpa. However the greater question is would grandma really have wanted to live her last months with a tube in her stomach, persistanly staring at the wall? I certainly would not, and my loved ones are sure to know this.

Office flora

2007-11-05T10:34:00.000-08:00

Erma Bombeck once quipped:" Never go to a doctor whose office plants have died".

If you were to heed this sage advice, I would have to warn patients about coming to my office. After we remodeled our clinic a few years ago, I wanted to make my office space a little cozier by adding some plants. Make that many plants... I have to admit that we've actually had a succession of plants that have ended up shriveled and a wee bit on the dead side despite my attempts at excellent botanical care. I've tried Miracle Gro, special potting soils, frequent watering, infrequent watering, sun, shade, daily sweet talks, directing my positive 'chi' towards them etc... Sadly, I've discovered that leaving the plants alone, and letting my co-workers take care of them is their single most important survival advantage.

There was this one plant that turned black and literally just died overnight. I am not exaggerating here. The leaves all shriveled up and all that was left were a couple of dessicated stems. Thankfully my physician assistant performed some sort of plant CPR, and with some TLC, the plant began to sprout a couple of new leaves (and no, the new shoots are not weeds!) I have been asked (politely) to leave the plant alone during this fragile recovery period. This also proves to me that plants can be a little bit dead, unlike animals where it seems to be all or nothing....

Needless to say, all the plants at my home are artificial...

Confession of an addict

2007-10-29T18:58:00.000-07:00

I've finally admitted it to myself after my husband confronted me the other night, but I have a seriously debilitating addiction. It's been consuming me for the past month, and though I have truly been busy at work, this is probably the reason why I neglected my blog recently.

I've also neglected TV, conversations with my husband and reading books because of this addiction. I obsess over it once I get home, during dinner and until the wee hours of the morning. I can't stop and it's driving everyone crazy, myself included.

SUDOKU!

How can a simple numbers game take over my life? This goes way beyond solving the daily sudoku printed in the newspaper. I bought an actual sudoku book with over 150 puzzles before we left for Orlando. This was supposed to keep me busy during the long flight, and it certainly did that, and more. Since returning from Orlando almost a month ago, I've been in a complete frenzy, doing as many puzzles as humanly possible.

I am an avid reader, and usually have a couple of books I'm working on. On average, I read about a book a week, but I have read zero books this past month. Zero, zip, nil.... My husband complains that I never talk to him anymore, and the dogs have joined in on the general lamentations.

Well, dear readers, I'm proud to say that it's all over. I am re-joining civilization and will be a proud contributing member again. Truth be told, it's not through any great force of willpower, but just the fact that I finished the 150th puzzle last night, averaging about 5 puzzles per day (these were all in the "difficult" category).

Needless to say, I will not buy any more Sudoku books. I will fight the constant craving to solve but will limit myself to the one printed in my daily paper. I don't have to go cold turkey do I?

Blonde moment

2007-10-27T12:08:00.000-07:00

I was seeing an elderly patient for the first time, and I was in the midst of obtaining a full medical history. She was accompanied by her daughter, who was helping out with some of my questions.

I came upon the subject of past surgical history, and asked the patient when she had her hysterectomy. Both women paused for a while to think about the answer, and the daughter finally turned to her mother and asked:

"Mom, did you have your hysterectomy before I was born?"

As soon as the words tumbled out of her, all three of us looked at each other and burst out laughing. The daughter turned to me and good-naturedly remarked: "another blonde moment for me!".

In the blink of an eye

2007-10-25T18:42:00.000-07:00

It's just amazing how life in general can really get in the way of keeping up a blog. I went on vacation for a week, then returned to an extremely busy schedule at work (to make up for the fact that I was gone for that week), and next thing I know, it's been five weeks since I last wrote!!!! It feels like I blinked and time just flew by....

So never fear, I'm still here. I'm just reeling from the fact that it's now the end of October and my vacation was a month ago!!! Yikes....

Orlando was as much fun as anticipated. Husband and I just love DisneyWorld, though truth be told, we would probably have enjoyed the parks more if there weren't so many kids running around. (I jest...but not really...). I also had ample time for a few of my patented keen observations:

Crocs: I'm talking about the rubber clogs that is all the rage right now. They should be strictly limited in public for the 10 and under age group. If you are an adult, please wear real shoes, unless you are a gardner, chef or health care professional. They are incredibly ugly and clownish. They may be comfortable, but so are my bedroom fuzzy slippers and I don't wear those outside.

Sandals: I love them, and they are a must in warmer weather, but if you are wearing them, a minimal amount of footcare is necessary. I'm not talking about a professional pedicure here. I'm just asking for a toenail clip within the last 6 months or so.

Body image: I'm certainly no waif (ha!), but this vacation was one of the few times when I actually felt good about my body. After a week of being amongst my fellow americans, I can believe the statistic of 60% being overweight, and 30% being obese. How did America get so fat?

Hair woes: Florida weather and any semblance of a hairstyle are not compatible. My hair drooped like a limp rag the minute I stepped outside my hotel room. How do people who live in FL do it?

Truants: why were there so many kids out of school? We figured that going to DisneyWorld at the end of Sept, right after school started would have been a safe bet for a quieter park. Alas, parents did not seem to share the same views as us.

Hemorrhage: I'm talking money here. There was no way to stop the flow. The Disney people have truly mastered the art of maximal wallet extraction. Even as a medical professional, I could not stop the bleeding...

Kid' menu: chicken fingers, hot dogs, burgers, fries, pizza. I guess this answers why Americans are so obese. But I was flabbergasted at what people find acceptable to feed their children. Why can't they eat real food? Why can't they enjoy nutritious food? As a child, I remember eating what my parents ate, and there was no special allowances made for children. We ordered off the regular menu and we liked it!!!

Thriving on stress

2007-09-20T22:06:00.000-07:00

I've discovered that in order to be a successful physician, especially a surgeon, you have to like being on edge. In fact, I'm not sure it's such a big secret. Why else would we have chosen a profession where responsibilities and major decisions are daily events? Not only do we like stress, we also thrive in it.

It's not always as obvious as I make it sound. Certainly if you were to ask any practicing physician, I don't think any of them would willingly admit to liking stress. None of us in the right frame of mind would knowingly put ourselves in a stressful situation, yet we do it all the time when we go into the operating room or take call for an emergency room.

Right before a major surgery, or before facing an unknown situation in the ER, I get a mild sense of trepidation combined with an almost pleasant sense of anticipation, which work together to give me the focus I need. It's also true that there are some extremely stressful situations which only serve to age me prematurely and which I would dearly love to avoid altogether, but for the most part, I find a little stress and a little adrenaline to be helpful as long as you learn to process it in a healthy way.

Residency was a great way to learn this. Though I pride myself on having a strong constitution and an iron-clad stomach, I developed all the signs of a peptic ulcer during a particular strenous period in residency. I learned to deal with this (the ulcer and the stress), and my stomach hasn't really acted up since those days, unless I happen to eat something particularly noxious (the last incident was a particularly tasty black chicken covered with scotch bonnet peppers in Hong Kong. For those who are not in the know, scotch bonnets have similar scoville units as habaneros, and are positively painful... My stomach took about three months to recover from this particular dish. )

However, thriving on stress does take its toll, and I'm more than ready to take a few days off from work. It's a good thing then that we are going to Orlando in a couple of days. This proves again that hubby and I are just big kids at heart, and we are going to spend a few glorious days in fantasyland (and frontierland, and adventureland and tomorrowland...). See you guys in a week!

Why does it always come as a surprise?

2007-09-12T10:33:00.000-07:00

The cycle of life and death is an inexorable constant of Nature, death being one of the inescapable absolutes of life.

As a physician, one would think you would get used to death since we tend to encounter it more often than most people. You confront the whole concept of mortality the very first day of medical school when you come face to face with a cadaver in gross anatomy, continuing on in pathophysiology and pathology when you learn about all the different processes that can eventually end your life.

But the truth is that you NEVER get used to death. Rationally I understand that people don't live indefinitely, but it's hard to come to terms with that, perhaps even more so as a physician. We are trained from the very beginning as wide-eyed malleable naive creatures in med school that death and disease are things that MUST be stopped and stamped out at all cost, which is why the death of any of my patients always comes as a surprise.

I have many septuagenarians, octogenarians and even nonagenerians in my practice. I have seen some of these patients for years due to a variety of chronic conditions, and their office visit is part medical and part social in nature. Together, we have laughed at the latest antic from their great-grandchild, commiserated on the current political state of affairs and cried when their spouse of 50+ years have passed on. I have grown attached to these patients and I suppose that I somewhat expect to see them forever.

That is why I am just so shocked when I hear that some of the patients have passed on. Our office usually finds this out when we call the patient as a reminder of their appointment, and we are told by family or friends that they are no longer with us. I think our entire office staff gets a jolt as well. When I hear the sad news, I always think back to their last visit with me, usually chatting away, completely oblivious to what the future holds.

Telephone woes

2007-09-07T19:48:00.000-07:00

This is just a small annoyance, but when the pharmacist from MegaSuper Pharmacy pages you about a prescription that you or your partner has written, I wish they would give me a direct number so I could bypass the whole automated beginning. They make me go through their entire menu before I am able to talk to a real live pharmacist, and I find the whole process thoroughly distasteful and annoying.

I detest those automated voice prompts. More and more pharmacies AND medical offices are using them, though I'm proud to say that our clinic hasn't fallen prey to those things. It's one thing when my credit card company makes me "talk" to the voice prompts for 10 minutes, but it's another when it's the PCP's office.

They are probably more "efficient" than a real human being, but I feel that medicine is already getting so de-personalized and the last thing we need is an automaton answering the phone.

Lonely on call

2007-09-02T17:42:00.000-07:00

I'm on call this entire Labor Day weekend, and I have to tell you that there is no place lonelier than a hospital on a holiday weekend. The usual hustle and bustle of a hospital is normally muted during weekends, but it seems especially more pronounced on holiday weekends. As I wander down subdued hallways, look at films in a deserted radiology area, and search for special catheters in the eerily quiet OR, I feel strangely isolated.

So far, I've been proud of the fact that on saturday, I was able to finish two OR cases and round at 4 different hospitals all before 11:30AM. Of course, I won't tell you what time I started my day... I've also been able to save a patient's testicle from torsion, placed a couple of "difficult" foley catheters in patients with retention, and removed a few pesky kidney stones. I've checked numerous labs, looked at a few CT scans, discharged several patients while admitting a couple more.

All in all, lonely as it may be, it's been a good productive weekend where I've been able to do some good.

Happier hunting...

2007-08-27T09:30:00.000-07:00

I can barely bring myself to write about this now, but we had to put down our 16 yo terrier mix a few weeks ago. She was affectionately referred to as "Crusty McTerrier" by my husband, mostly because she had that typical terrier coat that gave her a slightly disheveled (yet adorable) look, but also because of her curmudgeonly demeanor.

I adopted Crusty when she was 3 months old, about one month before I started medical school. I was walking through the heart-wrenching kennels at the local Humane Society when I spotted a rambunctious and scruffy looking puppy that was just begging me to take her home. And the rest is history. We went through medical school together (her favorite subject was pathophysiology as evidenced by several bites taken out of Robbins' textbook), then she spent some quality time with my parents during the craziness of internship and residency, after which she came back home to me. I was barely 21 years old when I adopted her! An entire lifetime ago...

She had a passion for food (didn't care if it wasn't gourmet) and usually found EVERYTHING (and I mean everything) edible. We called her a goat for her incredible ability to digest the unlikeliest items (eg: cigarette butts off the street), never suffering from any gastrointestinal distress. Even I was getting jealous of her iron constitution.

She was quite healthy and active until the last few weeks of her life when she slipped downhill very quickly. When she began to reject her beloved doggie food, I knew this was a major turning point.

My husband took her to the vet that very last time, and he shed tears. I cried at work when he called me. My sister cried when I called her, and my parents cried when I told them. Yes, she was just a crusty little dog, all of 25 lbs, but she was loved, and will be missed.

Going bare...

2007-08-23T20:55:00.000-07:00

...which, in the medical world, refers to the practice of not carrying malpractice insurance.

There are many states where it is mandatory for every physician to carry medical liability insurance in order to practice medicine and be on staff at a hospital. However, there are a few states where having malpractice insurance is optional. Notably Florida is one of them, and there is a growing number of doctors who are "going bare".

It is certainly not surprising, especially when you consider the fact that some of the "high-risk" specialties such as OB-GYNs need to shell out between $150,000 to $300,000 a year to have coverage. I am sure that even the harshest critic will agree that is an INSANE amount of money! In fact, I'm not sure that as an OB, you can make enough money to pay for your premiums and be able to provide for you and your family.

I recently talked to someone who has "gone bare", and they have posted a sign in their clinic saying that this medical group does NOT carry malpractice insurance. If patients have a problem with that, they will most likely go somewhere else. I'm guessing that this will help weed out patients who may have litiginous intents, but I am also guessing that this would discourage a lot of malpractice lawyers from pursuing a case if they realize the lack of a huge "jackpot" at the end of the rainbow. That particular medical practice hasn't encountered any issues so far, but it makes for an extremely precarious situation, not a place in which I would feel comfortable.

The idea of "going bare" is certainly appealing. Intellectually, it has its merits and idealistically, it would be the perfect course of action. Mostly, it would bring me great joy to really screw with the legal system and its ambulance chasing lawyers. Alas, the harsh reality is that we do not live in Utopia, and I suspect the main person getting in trouble would be me.

Quote of the day

2007-08-14T12:47:00.000-07:00

From today:

As I was talking to the patient's husband in the surgery waiting room, he remarked:
"Even though you are a surgeon, you are knowledgeable about medicine..."
I think he meant this as a compliment, so I just smiled and nodded.

From yesterday:

I scheduled a pre-op patient for a test that was absolutely necessary in order to proceed with a planned operation. I learned yesterday that he didn't show up for the test, and when we called him about it, he replied:
"Well, I talked it over with my family, and we decided it really wasn't the right thing to do. But we are still going ahead with surgery right?"

The answer would be NO. How about talking it over with me, your doctor?

We're all in this together...

2007-08-07T22:11:00.000-07:00

Our clinic once employed a physician assistant who left shortly after she was hired. During her exit interview, she stated that she felt she was given work that was "beneath her".

I actually never got to work with her personally, since we were mostly at different locations, but I was shocked when I heard this. What work could we have given her that was so distasteful?

After going through a surgical internship and residency, where you really are in the trenches, I would NEVER assign something unpleasant that I wouldn't be willing to do myself, and haven't already done so on multiple occasions. As a surgical resident, we are trained to be very "hands-on", and as an intern, we are actually asked to do all the scut work ourselves (removing drains and skin staples, changing the packing in an open wound, irrigating foleys etc...) . In fact, our hospital's OR policy was for the resident to shave, scrub and prep the patient her/himself instead of the circulating nurse.

So what haven't I done throughout my career?

-Manual fecal disimpaction? Done it.
-Cleaning up -vomit, feces, blood, sputum, urine, pus, insert favorite bodily fluid here- after a patient? Done that.
-Mopping the OR floor to facilitate turnovers? I'm an old hand.
-Wheeling the patient to X-ray, OR, ICU etc? Just call me the Mario Andretti of the medical hallways.
-Filling out endless paperwork for insurance companies/work release/disability/government/pre-authorization nightmare forms etc...? I do it in my sleep.
-Phlebotomy? whenever I can.
-Assisting patients to the bathroom while pushing their IV pole? Yup, been there.
-Talking, comforting and crying with patients and grieving family members? Part of the job. (but may I add that this is one of the most difficult and challenging aspect of medicine)
-Cleaning examining rooms? just yesterday.
-Changing the diaper of a patient's baby while mom is temporarily unavailable? actually, I did reach my limit there....

The bottom line is that whether we are in clinic, the ward or in the OR, we are a team. We need to work together and do whatever needs to be done for efficiency sake and for the good of the patient. There is not a job in clinic that I consider "beneath me". I'll answer the phones (albeit pretending not to be me, but the receptionist), room the patient myself if the nurses are busy, draw blood, dip the urine and do other "non-doctor" like work, because no matter what the hierarchy, we are all in this together.

And just to prove that I'm a total geek:

2007-08-06T20:00:00.000-07:00

The sorting hat says that I belong in Gryffindor!

Said Gryffindor, "We'll teach all those with brave deeds to their name."

Students of Gryffindor are typically brave, daring, and chivalrous.
Famous members include Harry, Ron, Hermione, Albus Dumbledore (head of Hogwarts), and Minerva McGonagall (head of Gryffindor).

Take the most scientific Harry Potter Quiz ever created.

Get Sorted Now!

Self-explanatory

2007-08-03T14:42:00.001-07:00

Before I entered the patient's room, his caretaker took me aside and whispered:
"He's from West Virginia".

He said it in a tone that suggested I should immediately understand all the implications of that statement. After seeing my rather blank look, he elaborated:

"Well, that's why he can't read or write, and why he may be prejudiced against seeing a lady doctor".

So I thought about just dictating on my Assessment and Plan:

1. From West Virginia. Period.

Politeness versus common sense

2007-07-26T15:09:00.000-07:00

I am certain that there is no polite way to tell a patient that a large part of her medical issues stems from poor hygiene and that my treatment plan would largely include showering at least twice a week. I venture as far as to say that even a shower once a week would fall under good patient compliance.

The patient was seen for recurrent bladder infections, and upon spending just a few minutes with her, it was eminently clear why she was prone to them. She desperately needed a few private moments with soap and water.

The icing on the cake came towards the end of the clinic visit when the patient wanted me to culture her belly button, upon which she proceeded to insert her index finger into her umbilicus, dug around for a few seconds, then placed it up to her nose for a deep extended inhale before presenting it to my nostrils for my "medical opinion" of the bad odor emanating from there.

My very first instinct was to recoil instantly from the proffered digit, complete with a fingernail embedded with months of dirt and bellybutton "grime". However, since she continuously held up her finger as an invitation for a sniff test, my ingrained politeness (thanks mom!) overcame my initial revulsion, and I carefully advanced my face towards her finger. About a foot away from the offending index finger, I took a few tentative and discreet sniffs before exclaiming that I really couldn't smell anything at all.

Pray tell dear readers, what would you have done?

Unfortunate allergies

2007-07-19T21:21:00.000-07:00

Compilation of drugs with corresponding "allergic reactions" as described to me by patients over the years. (I kid you not)

Compazine: nausea
Benadryl: rash
Prednisone: anaphylaxis (I encountered this one today which prompted this post)
Epinephrine: heart racing
Valium: dizziness
Percocet: constipation
morphine: hallucination
Coumadin: bleeding (OK, I made this one up)

And my all time favorite:
"general anesthesia": completely puts me out

You know you're a surgeon when...

2007-07-14T07:44:00.000-07:00

You change your own flat tire at the hospital parking lot (and you're a woman!).

You don't own a stethoscope anymore after you lost the last five during medical school and residency.

You freak out when you discover your dog has eaten your favorite Dansko clogs on the morning of a busy OR day.

You have extra clogs stashed at all the hospitals in which you operate.

Your H&P has never been longer than one page.

Your discharge summary has never been longer than half a page.

You like to butter your toast with a surgical instrument.

You use unused OR sutures and a needle driver to mend your clothing and darn your socks. (I prefer 2-0 silks for my black socks)

You rise earlier than anyone else you know.

You fall asleep as soon as you hit horizontal.

You have the bladder of an elephant (they have big bladders, don't they?).

You actually like the smell of Hibiclens.

You've considered using Betadine to give yourself an artificial tan.

You live in scrubs and you love them.

You wear a stiffly starched white coat buttoned up at all times. (perhaps to hide the fact that you wear scrubs all the time).

You fondly recall your residency years as "fun times".

You always refer to the left or right as the "correct" side and not the "right" side.

You can be kept entertained for hours by flipping through a surgical instrument catalogue.

You secretly wish you had a surgical instrument named after you. (Could you hand me the Keagirl clamp please?)

OR barbershop

2007-07-10T21:55:00.000-07:00

Over the years, I feel I have developed a special talent for haircuts.... below the navel. It's common practice for surgeons to clip the area of the surgical incision in order to minimize wound infections and for ease of the surgery itself (don't want to be fighting with hair), and naturally, my area of expertise just happens to be in the nether regions.

I have removed hair on innumerous occasions. That's just part of my job, and I have tried many different approaches. I have recently switched from razors to clippers, mostly because the surgical literature suggests that clipping is better than shaving in terms of reducing wound infections. I started out shaving/clipping just in the vicinity of the surgical incision, but many times, that would result in a very uneven pattern. The asymmetry really worked against my sense of esthetics, especially when the subsequent result would be outright odd looking. So odd in fact that some of my patients would comment on this during their first post-op visit.

More recently, I have resorted to clipping the entire pubic area. It's just easier for me and the patient. I don't have to try to be "artistic" with the clipper, and I've never gotten any negative comments from my patients. I do try to comply with any specific requests before surgery (today's request was for "no landing strip please", which I was more than happy to follow). I guess the downside is that by clipping everything, there is more cause for itching when the hair grows back...

By the way, I MUST give credit to my wonderfully artistic and talented husband who created my new portrait. I love it!!! He is the genius behind all the artwork on this blog, including the plumbing for my title and I cannot thank him enough.

Glamorous life

2007-07-04T16:10:00.000-07:00

Being a general urologist, I don't restrict my practice to any particular urological condition (and despite rumors to the contrary, I will see patients with dermatological issues on their genitalia), but there are some conditions that I see more frequently in my practice. Kidney stones are very common and because of my gender, I see a lot of female patients with incontinence and recurrent UTIs year round.

After days of dealing with very similar chief complaints, I will begin to reflect that it's been a while since I've seen a new patient with kidney cancer, or helped out with a kidney transplant. No sooner do these thoughts cross my mind that I will suddenly encounter four new patients with a kidney mass, and get involved in a marathon weekend of transplants. Call it fate, irony or the Gods of probability and possibility, but it never fails to happen. And the old adage "it never rains but it pours" holds true for me.

This particular week was "pus week". To be perfectly honest, I hadn't really been thinking about pus all that much. In fact, already being the pariah of many social gatherings where I've been a tad bit too explicit about certain aspects of medicine, I generally avoid thinking or talking about pus. However, as anyone in a surgical practice will tell you, pus is never far away.

It all started last week when I admitted a patient with an obstructing kidney stone that was infected. Pus + obstructing stone = pus under pressure= very ill patient. As soon as I placed a stent to relieve the obstruction, an ungodly amount of pus was seen draining from the ureter. A few days later, I took a patient to the OR emergently, this time to incise and drain a scrotal abscess. The pus this time was not only copious, but foul smelling. And to top the week off, the last patient I saw had a gigantic perinephric abscess. (approximately 3 liters).

At least I don't have to deal with peri-rectal abscesses (fondly referred as "butt pus"), which remains the exclusive domain of the general surgeon.

So, to summarize the life of a urologist:
Glamorous? no
Boring? never

Major gaffe

2007-06-27T22:08:00.000-07:00

One of the cardinal rules in medicine is NEVER MAKE ASSUMPTIONS. .. about anything... This may explain why I'm such an insane micro-managing control freak.

However, I was meeting a patient in the pre-op area today, and there was a nice older man accompanying her. I said hello, chatted a little bit, then turned to her companion and asked:

-"So are you Dad?"
-"No, I'm actually her husband"

I normally do not make this kind of assumption (my usual question is: "are you family or friend?"), and my only sorry excuse was that my defenses were down after an unusually long day at work. I was absolutely mortified and apologized profusely. Yikes... This is on par with asking a woman: "When is your due date?" when she is not pregnant.

Adults only...

2007-06-23T15:48:00.001-07:00

Thanks to Seaspray and Gruntdoc, I found this fun site that rates your blog as if it were a movie rating. This was the result:

This rating was determined based on the presence of the following words:

penis (16x) pain (10x) semen (4x) poop (3x) orifice (1x)

Who would have guessed I was an X-rated sort of girl? And who knew "orifice" was a key word for an NC-17 rating?

This brings home the fact that my husband lamented on the content of my previous post. Because of the key words "penis" and "ejaculate" and "semen", I'm sure my blog is popping up at the top of every google search with those particular words, which means lots of "unusual" traffic for my site. And there, I did it again!

Are you sure you wanted the urologist?

2007-06-14T18:48:00.001-07:00

There are many times when patients or doctors call me, and I ask myself if they really needed or wanted the services of a urologist.

One of the most appalling abuses of our on-call service happened to me recently. Seeing a doctor from our group means that there is always someone available 24 hours a day, seven days a week. It is understood that when you contact the physician on call after hours, it is usually for an emergent reason. Even more so when it's in the wee hours of the morning, when sleep is all you should be thinking about.

I got a call at 1AM, and when I tried to call the number back, the line was disconnected. The patient had given us a wrong number. I could do nothing else but try to go back to sleep. He actually called 45 mins later, with another wrong number until our answering service got the bright idea of using caller ID, and obtaining his correct number that way. By the time I reached the patient, it was 2:30AM, and he had already called the service 3 times.

So by this time, I was thinking that this must be a really emergent situation. The conversation went something like this:

Me: Hi, this is Dr. Keagirl. How can I help you?
Patient: I'm calling because I'm having really severe itching. I have a bedbug problem in my apartment, and the landlord was scheduled to fumigate soon, but I'm really having a hard time going to sleep.
Me (flabbergasted): Err, are you having any itching in the scrotal area? (I was trying to give him an chance to see if there was ANYTHING remotely urological about his late night call.)
Patient: Actually, it's my lower legs and the back of neck that's itching like crazy. I was talking to my family about this, and they thought I should call the doctor since it's an urgent situation for me.
Me: So why does this require you calling a urologist at 2:30 in the morning?
Patient: I thought you might be able to help me.

I will not go into the rest of the conversation, which was rather terse and somewhat scolding from my end. The patient was shameless, clueless and remorseless.

Do patients think that on-call physicians stay up all night long by the phone in clinic, eagerly awaiting the next page? (and for free for that matter since we don't bill for any of our telephone calls). Do they not realize that when calling late at night, you are waking someone who has a full work schedule the next day, and that it has better be an emergent, or at least urgent situation.

White Cloud

2007-06-11T09:01:00.000-07:00

I was somewhat dreading call this weekend, because one of my partner who had been on the call the previous two weekends, including Memorial Day weekend, had been slammed. He performed an insane number of surgeries (about 10 cases over 3 days), and saw a lot of hospital consults.

My dreaded weekend was actually quite calm! I've always had a black cloud on call during residency, but this state of affairs seems to have turned around now that I'm in private practice. On the other hand, this one particular partner ALWAYS has weird events happen to him while on call. He IS the black cloud of the group, though truth be told, he loves being busy and operating during his call days, so I guess he wouldn't really consider himself unlucky.

My lone triumphant moment this weekend was when I was called for a difficult foley placement in the ER. They told me they had tried all kinds of techniques and different catheters to no avail. I showed up, and slipped in a catheter in under 10 secs without any problems. It was hard NOT to gloat, but being just a lowly human being with weaknesses and foibles, I was secretly smirking inside.

Equal opportunity

2007-06-06T21:47:00.000-07:00

For those of you who think I only direct my frustration and anger at my husband, family, friends and patients, let this post tell the truth! I am an equal opportunity venter! (this may explain why I have no friends...) I was quite disappointed in some of my fellow urologist the other day.

I was in the esteemed company of about 30 of my colleagues during the Vegas workshop, and we sat through an hour-long lecture before moving on to the cadaver lab. Much to my dismay, there were ringing cellphones galore!!! The added insult was that all these urologists who received calls actually answered them in the middle of the lecture, while the speaker was going over his powerpoint slides!!!!

"Hello? How are you doing? Blah blah blah...(for what seemed like an eternity...) Listen, I can't talk right now, but I'll call you back soon..."

I kid you not. At least 5 of these calls were heard during the talk. How rude is that? How hard is it to turn off your phone for an hour, or at least put it on vibrate mode?

This made me think about Tokyo, which is probably the cellphone capital of the world, where EVERYONE who can carry on a conversation (ie: over the age of 2) has a phone, yet I never heard one ring in public. They were all in the silent or vibrate mode because the japanese seem to understand that it's really rude to subject others to noise pollution and loud conversations.

OK, end of rant.

Vegas

2007-06-03T19:26:00.001-07:00

I was in Las Vegas over the weekend for a workshop. When the plane landed, it was 95 F at 9PM, and I really don't like Vegas at that temperature. Truth be told, I don't like Vegas at any temperature, period.

Vegas is gross. That's the only adjective that comes to mind when I think of that city. It's just not my style. The throng of people hypnotically gambling away, drinking and smoking just puts me off. And I hate that ad that says "What happens in Vegas stays in Vegas". It insinuates that it's perfectly fine and even encouraged to do sleazy, anonymous things in this crazy city and then return to your normal life without any consequences. I'm far from being a puritan, but I'm just not a big fan.

But Vegas was where this workshop was being held, and I really wanted to learn how to do this new procedure, a "male sling", which would help with male incontinence. This included a cadaver lab so we could practice and perfect the technique.

As I flew into Vegas, I was thinking that I was probably the only person who was coming to Vegas to work with dead people.... Then again, this is Vegas, so who knows????

I mentioned this in a previous post, but I have to tell you that I cringe at the thought of donating my body to science after my death. Take all my organs for transplant, but let the rest of my body be peacefully cremated.

It sounds so hypocritical since I started my medical career with the help of cadavers in gross anatomy, and they have continued to educate me in my career with these hands-on labs, but I can't get over the whole distaste of being "worked on" after my demise.

Let's not use our brain

2007-05-31T09:38:00.000-07:00

I know that JCAHO is coming down hard on hospitals, and we've all been told to be on our best behavior. This is especially prominent in the OR, where the paperwork nazis have been working extra hard to obfuscate matters by adding a few more forms to fill out before we are allowed to take our patients to surgery. In the guise of patient care, this has made it more difficult for us to do what we really want to do, namely practicing medicine.

In one particular hospital where bureaucracy reigns, the nursing staff has been recruited to become paper pushers, to the point of ridiculousness.

Case in point from a page I received a few days ago, after I just finished a case and sent the patient to the Recovery Room (RR).

RR Nurse: Dr Keagirl, you just finished with patient X, and I noticed that your brief OP Note was not completely filled out. And you know that's required by JCAHO.

(Note: An Operative Note is something you fill out right after a procedure detailing the pre and post-op diagnosis, procedure, name of surgeon, type of anesthesia, complications, blood loss and findings. You still have to dictate a full op report, but this is the abbreviated version)

Me: If you check the paperwork again, you will find that I did fill out the OP Note.

RR Nurse: Actually, you filled out most of it, but you left the part about name of Assistant blank.

Me: Err, that's because I didn't have a surgical assistant. I alone was performing the surgery.

RR Nurse: Then you have to fill out "NO Assistant".

Me: That's ridiculous! If I fill out everything else and leave that part blank, it should be assumed that there was no-one else helping me.

RR Nurse: Our protocol dictates that no such assumption be made. And you will be written up if you don't fill out that part.

The conversation continued fruitlessly, leaving me somewhat frustrated. I mean, when you watch the credits at the end of a movie, do you ever see:
Assistant Director: none
Supporting Actor: none

When did bureaucracy supercede common sense?

No time for frivolities

2007-05-25T22:17:00.000-07:00

It's probably the fact that I've been away for two weeks, but clinic has been extremely busy this past week. I've barely had time to catch my breath.

Friday (today) was the culmination of this grinding schedule. I was double booked the entire morning, and had two prostate cancer discussions back to back. Cancer discussion is never an easy task. First you have to break the news to the patient that he has cancer, which is difficult in itself, then you have to go into all the treatment options and risks and benefits of each said treatment. Sometimes the choices are easy because you only have one viable option (eg: nephrectomy for a large kidney cancer). Options for prostate cancer treatments are numerous and quite varied, which means that it takes a minimum of 30 mins for one of these discussions. Add to the mix a patient who requires an interpreter, and you are talking about running REALLY late on your clinic appointments.

It's a pet peeve of mine, but I absolutely despise running late. However there are many times when a patient is more complicated than usual, or when you end up doing an unexpected procedure, or when you have to see unscheduled patients on an emergent basis.

In any case, I finished with my last morning patient at 12:50PM (I even drew his blood myself! OK, it doesn't sound like much, but when was the last time you saw a urologist draw blood from a antecubital vein??? Just saying...) This gave me a full 10 mins for lunch where I gobbled up a quick bowl of microwaved soup, and I was ready for my first afternoon patient at 1:00PM.

Many things today were absolute lifesavers:

-The Tide pen. You've seen it on TV. It is a tremendous aid when you are a big klutz like myself, and you are forever spilling things on yourself and your white coat. I wore a nice white linen blouse today (first mistake of the day!) and some of that soup splashed on it. I panicked, then remembered I always keep a Tide pen in my desk drawer, and presto...problem (and embarrassment) solved. This pen is one of the few things that is as good as advertised, and has even removed blueberry pie filling from my white coat.

-The expresso machine in our break room. My partner bought it a couple of years ago, and initially I thought of it as a completely unecessary indulgence. I admit I was a FOOL! Caffeine is NEVER overrated. Period.

-Secret stash of expensive dark bittersweet chocolate in my drawer (scharffenberger or valrhona) for emergency purposes only. Today was such an emergency...

-My nurses. Thank you! I couldn't have gotten through this day without you (and yes, I shared the chocoloate)

-My bladder. I realized that after my first morning void (around 7:30AM), I did not go to the bathroom again until about 5:30 PM. I must have forgotten to drink any water today. I don't think my two double expressos really count, though my minestrone soup must have had some water in it... Anyway, who has time for such frivolity as bathroom breaks?

Overheard at The Great Wall

2007-05-20T16:25:00.000-07:00

Amazing place, incredible views, brutally tough climb...

I have to admit that scaling the Great Wall really kicked my ass. Husband and I had to take frequent breaks to catch our breath.

It was a little disheartening to see little eight to ten year old girls whizz by us and realizing how out of shape we were.

My weekly pilates sessions just didn't prepare me for the Great Climb. But it was all worth it for the view and most of all, the immense sense of history and achievement...

It's also very telling when you return from a two week vacation much fitter then when you left. Though we did consume an obscene amount of food, we must have walked the equivalent of 10 to 20 miles a day (no joke!).

Naturally, no matter what corner of the world we were in, there were always Americans announcing their presence everywhere within hearing distance because truth be told, we are a LOUD bunch. This is especially more noticeable amidst cultures that encourage serenity, discretion and quietness, wherein I could recognize the closest American by hearing him first, then seeing him.

So during the Great Climb, I distinctly overheard a college-age American man say: "I like engineering but I'm looking into med school because I like patient interactions..."

That random comment stopped me in my tracks. Lots of thoughts and emotions flashed through my mind and I almost turned to exclaim: "you don't really know what you are getting into!!! Think hard before you jump into this field."

I relived this whole episode when I read Panda Bear's letter to a medical school applicant. Informative, realistic and somewhat cynical. I think Dinosaur sums up my thoughts in his post.

I agree that most medical students, especially the starry-eyed one straight from college, don't know ANYTHING about the realities of practicing medicine in the 21st century. I was certainly one of the more naive in the lot, wanting to be a doctor since I was 5 years old. (see Previous post on this subject). I honestly did not think about money and reimbursement issues when I applied to medical school. You just can't think that way, nor do you know enough about the business of medicine to even ask those questions. I just felt like it was a calling and could not think of anything else I would rather do.

I have been lucky to have fallen into a specialty that I love, and which pays reasonably well. Retrospectively, had I known what surgical residency was like, I'm not so sure I would have had the courage to pursue it, but that's like a lot of things in life. So yes, surgical residency was awful at the time, I'm still a long way away from paying all my med school loans, paperwork and insurance is a bitch and patient care can be challenging, but in all honesty, I love being a urologist!

Why pediatrics was never an option

2007-05-18T12:51:00.000-07:00

I must admit that I'm not a huge fan of little kids. I don't know how to talk to them (in residency, I tended to refer to 3-4 yo old toddlers as "Mr. or Ms. Smith"), I don't interact with them all that well, and I generally don't do well with anxious parents. It's just not in my nature, and I've accepted that and stayed as far away from Peds as possible.

However, there is the whole subspecialty of pediatric urology, which doesn't come into play until the pediatric urologist from our group goes on vacation and off pager. I absolutely DREAD those moments because it means I have to deal with the parent calls at night.

"The surgical bandage fell off. What shall I do?" (Nothing)

"There is poop all over the surgical bandage. What shall I do?" (Just take the dressing off.)

"There is poop all over the surgical wound. What shall I do?" (Gently rinse off aforementioned poop with water and a washcloth)

(Notice the inordinate amount of poop-related questions with pediatrics...)

"There is blood EVERYWHERE!!!! (Please calm down). Uh, OK... what I really meant to say is that I'm seeing a dime size spot of blood on the dressing, but no active bleeding. " (Quite normal after surgery to see some oozing)

"My child is crying all the time. What shall I do?" (Console him, give him some pain medications and do what you normally do when your child is crying)

"I was told to keep my child quiet, but he is now bouncing off the walls and jumping all over the furniture. Uh, yes, that's his normal behavior. (Parenting skills are not part of my medical advice)

Writer's block

2007-05-15T20:27:00.000-07:00

I've been back to the States since Saturday night, and I have to admit that it has been an unwelcome jolt to be whisked back to my "real life" after two amazing weeks in Asia. I cannot even begin to describe the sights, sounds and cuisine we experienced! (but I will try...)

For some reason, though I went back to clinic on monday morning, I'm not feeling all that tired or jet-lagged. I had a really hard time adjusting after our trip to Hong Kong in December, but I'm physically feeling quite well at this time.

Mentally, it's a different story. I'm finding it somewhat arduous to return to the drudgery of dictation, paperwork, charts, labs and e-mails (Mt. Everest of medical charts and postal mail was awaiting my desk monday morning...). Thankfully, either through sheer luck or the foresight of my front desk, I've had a preponderance of mostly "nice" patients, all of whom I'm only happy to see. And to my relief, there were no medical disasters in my absence, which, despite my personal beliefs, proves that I am expendable.

In any case, I've been suffering from Blogger's block since I've returned. My mind is paralyzed from the trauma of returning to work, and I can only think about the glorious memories of my vacation.

Perhaps my dear readers would understand more if I posted some pictures:

This is the GLORIOUS Peking duck we had for dinner one night. Or I guess the correct terminology would be Beijing duck... I've had duck before, but this was by far the BEST duck I've ever eaten. It was finished off in a wood burning oven for about 45 mins to render the skin brown and deliciously crispy. The duck was brought to our table as soon as it came out of the oven, and the chef expertly carved it in front of our eyes. The duck tasted light and delicious, and the skin just melted in my mouth.

And yes, husband and I ate the whole thing between the both of us. Obscene, but we didn't travel 10,000 miles for nothing!!!!!

So I ask you, how can I concentrate on foley catheters, genital warts and urinary incontinence when you see these pictures?

Ode to The Imp

2007-04-27T09:41:00.000-07:00

Hello dear readers, I'm The Imp. I'm guest blogging for my mommy Keagirl because she is going on vacation (again!) on a trip she calls "Asia Extravaganza". She will be traveling to Seoul, Beijing and Tokyo for the next two weeks . Keagirl (we're actually on a first name basis) wasn't sure how much internet access and time she would have during her travels, since she and the Tall-Guy-Who-Feeds-Me will be exposed to so many new sights, cultures, customs, languages and food. Hence she asked me to fill in for her today.

She has written so much already about the three canines with whom I share this abode (rather insipid and inane creatures in my humble opinion), and I was feeling a tad bit neglected. But Keagirl knows I am smart and literate despite my purring habits, and she was confident that I would be able to write a great post.

As you can see from the picture, I am incredibly beautiful. I admit that modesty is not one of my (many) virtues, but I'm just stating the obvious. I have used my feminine feline wiles to steal the heart of everyone who meets me. I look and act like a miniature black jaguar, and though I only weigh 7 lbs, I make them count. When we all gather around the kitchen for a tidbit (I love roast chicken), the canine creatures respect me because I will fight for my fair share. I would never deign to go through some of the antics they pull to get food. I just sit there looking pretty, and I will instantly get what I want.

I got to know Keagirl when she and the Tall-Guy-Who-Feeds-Me met several years ago. What a glorious moment that was since we formed an instant bond. I was a feral kitten when Tall Guy adopted me many moons ago in the early 90s, and after years of running wild in an urban jungle, I am now a very happy indoor only cat. I've already seen the wide wide world, and I like to hang out at home nowadays. Though I have several perfectly comfortable beds, I would rather sit on Keagirl's lap whenever she is on the computer or on the couch watching TV (I'm also a Lakers fan, but I've been very disappointed by this season). I've been known to snuggle underneath the throw with her for hours. Life would be better without the drooling, sniffing and uncouth morons I live with, but then again, nothing is perfect.

If you can believe it, Keagirl was actually an unabashed fan of these slobbering fools before I made her acquaintance, and she admitted to NOT being a cat lover. Ha! I changed her mind quickly. In all fairness, I must note that she is quite allergic to cats (asthma, hives, throat swelling, the whole nine yards), but for some serendipitous reason, she has not been allergic to me. I'm just special.

I suspect that Keagirl will eventually become one of those "crazy cat ladies" in her old age, but then again, there is nothing wrong with that.

To the point

2007-04-26T11:52:00.000-07:00

Picture an elderly patient, perfect make-up, two-piece skirt suit and excellent manners. Just the quintessential darling little old lady from Georgia.
With a very pronounced southern drawl she ended the clinic visit with:

"Doctor, do I have to see you every year until I die?"
"Err... yes, unfortunately you do."
"Well dear, I don't mind, I was just wondering..."

For some reason, this made me smile and brightened up my morning.

Trauma

2007-04-23T20:11:00.000-07:00

Again, kudos to all ER physicians out there... I don't know how you all manage to work in such a high stress environment, day in and day out.

I got called to our local ER, which also happens to be a level I trauma center. They were really swamped and stressed, as they had received 5 traumas all at once. One of them was a 17 yo kid taking a ride in the back of a pick-up truck with his friends after school. The truck flipped over and basically crushed him. He sustained a spinal cord injury at the T7-8 level, and was paralyzed from the waist down. I was called because they were unable to place a catheter in him.

The poor kid was beginning to realize he was seriously injured and kept asking the staff: "is my back really broken? Am I really never going to be able to walk again?"

I also saw his friend, a 16 yo boy, who had less severe injuries, but was still on a board with a C-spine collar, with multiple bruises and contusions. Despite the situation, both boys were unerringly polite and they both thanked me when I left.

It was heartbreaking.

Sad...or is it?

2007-04-22T21:16:00.000-07:00

This is something I overheard recently during a non-medical social gathering. A woman was talking about a sad situation and uttered:

"I want to cry, but I can't because I took 2 Wellbutrins this morning."

Do anti-depressants really blunt your emotions to this degree? So many people are on them. There is no doubt that some patients really need them (I honestly wouldn't wish major depression on my worst enemy), but I do believe they are somewhat over-prescribed. They certainly help with depression and anxiety, but I fear that some patients develop a flat affect on them. Personally, I want to be able feel it all, whether it be good or bad.

Groundbreaking iguana urology news

2007-04-19T21:42:00.000-07:00

The whole subspecialty of veterinary urology may be a tad less evolved than human urology. I'm pretty sure my human patients appreciate the less-than-drastic measures we take when we deal with priapism. This article make me glad I went to med school as opposed to vet school. I guess I should expect that priapism exists in any animal species that has a penis, but frankly, I was surprised...

Cowardice or self-preservation?

2007-04-16T17:44:00.000-07:00

It is certainly no secret that there are "nice" patients and "unpleasant" patients, just as there are "nice" doctors and "unpleasant" doctors. The interaction between the two makes for a large number of posts in medical blogs, because it is such a huge component of our daily lives.

There are some patients who are simply wonderful human beings, and I truly enjoy interacting with them. I consider it an honor to be given the opportunity to take care of them, and these are the patients who make practicing medicine all "worth it". All of you health care professionals out there know which patients I am referring to. I'm very lucky indeed in that I consider a large number of my patients to belong to this group (let's call it group A).

However, there is another group of patients whom I am less eager to see, where I have to take a deep breath and brace myself before I knock on the exam room door. They divide themselves into two distinct groups:

The first subgroup of patients, in actuality, are nice people as well. However, my reluctance to see them stems from the fact that I have bad news for them. I absolutely abhor being the one to tell patients they have cancer. I try to be calm and matter-of-fact without being cold and impersonal, but I have a difficult time controlling my emotions if my patients start to cry. I offer sympathy, but I also have to convey information regarding prognosis and treatment options. It's one of those things you just don't learn in medical school, and it never gets any easier with practice. Giving grim news is just heartbreaking for me. The silver lining is that these patients can easily move into group A after their initial visit

This first subgroup of patients also includes those who have a medical condition that is difficult to treat (chronic prostatitis, interstitial cystitis etc...) , especially when I run out of treatment options, and nothing seems to be helping. The condition may not be life-threatening, but it is extremely frustrating. The reluctance to see these patients is more of a reflection of my own shortcomings as a physician, and my feeling of helplessness.

The second group of patients are those that are often euphemistically referred as "challenging" or "difficult". They are either manipulating patients who want pain meds, manipulating patients who want attention, or manipulating patients who are just plain mean.

I can't believe I'm confessing to this, but I have been known to hide out in my office, or stay trapped in the break room in order to avoid seeing these patients when they drop by the clinic unexpectedly. Pathetic, but true. Again, all of you healthcare professionals KNOW which patients I'm talking about. Admittedly, they constitute an incredibly small percentage of my practice, but the very sound of their names will bring horror to the entire clinic staff, from the front desk person to the nurses and the docs. It's usually not a good sign when my eight partners (who all practice at different locations) know the name of a patient...

Yes, I do feel cowardly and incredibly lame when I hide out, but I don't have to be brave all the time, do I?

Retort of the week

2007-04-07T00:00:00.000-07:00

I was consenting a patient today for a ureteroscopy for the treatment of a kidney stone. She asked me what the post-operative period would be like, and what her limitations would be in terms of activity.

Since a ureteroscopy does not involve any surgical incisions at all (it's a purely endoscopic procedure), I predicted she would actually have few restrictions, if any at all. In fact, I told her that she could jog the next day if she felt like it.

The patient glared at me and quipped: "do I look like I go jogging?"

5'3, 210lbs, one pack a day habit... I guess the question was rhetorical and I was duly chastised....

Pervasive

2007-04-06T20:25:00.000-07:00

I am not anti-big-pharmaceutical company. In fact, I get along well with almost all of my drug reps, and they are quite welcome to bring lunch to my staff in clinic. I really don't have a problem with that, as long as they don't talk endlessly about their product. I mean, if I've been using that drug for the past few years, it would be safe to assume that I do know something about it, and there is no need to repeat the same spiel over and over.

Pharmaceutical pens are a dime a dozen. Our office is overrun with them, and I would be hard-pressed to find a medical office that didn't have at least one pen with a drug name on it. Patients love these "goodies", and a lot of mine will take a few Viagra pens home with them.

What is more disturbing is when I see a pharm pen "out of context". I just had dessert at this small local patisserie, and when I went to sign the check, lo and behold, the pen they gave me was advertising the latest anti-cholesterol agent! And this is not the first time I've seen drug pens at restaurants...

How did that pen get there? Are these pens so ubiquitous that they are easily seeping their way into the general public? I have to say that no matter what you may think of big pharm, they are not dumb, and they know how to work the system.

Grand Rounds Vol. 3, No. 28

2007-04-03T00:01:00.000-07:00

Welcome!

I have the honor of hosting Grand Rounds for the second time! I can't believe it has already been a year since the last time I put all these great medical posts together. Time does indeed fly when you are blogging away.

I thought of many different ways to "spice up" Grand Rounds. After much deliberation, I finally decided to" stick to the basics" and just present "the facts", as I did many times before as a resident during our weekly nerve-wracking, anxiety-inducing Urology Grand Rounds.

Editor's choice:

Keith from Digital Doorway writes about the nursing care crisis. It's an eloquent, well-written and wonderfully apropos post about the current nursing shortage, especially in the military healthcare system.

Sunlight Follows Me is written by a physician from the UK, and her story, Dennis Son is my sentimental favorite. I'm a sucker for sad love stories, but what I found most touching is the time taken by the author to talk to her patients.

Life at the Hospital:

Someone who needs no introduction, GruntDoc, has an insightful post about how to call the end of a code. It is empowering and diplomatic at the same time.

Kim, our fearless ER nurse from Emergiblog, with her trademark blend of humor and wistfulness, continues to regale us with moving patient stories in Just this side of elderly.

Susan Palwick, our friendly volunteer ER chaplain from Rickety Contrivances of Doing Good, presents a thought provoking post about the limits of stimulating empathy.

From Medskool , a self-described "naive" medical student, talks about competition for residencies, which takes a look at the comparative competitiveness of matching into various specialties for medical students.

Vitum Medicinus, a Canadian first-year medical student, writes about how his dream-come-true experience of shadowing helicopter paramedics never really left the ground in the thrill of flying with helicopter paramedics. I'm also hoping that his last post is just another April Fool's joke.

Shadowfax from Movin'Meat presents a surefire way to to annoy your anesthesiologist.

The Patients and Health:

Transplant Headquarters is a blog written by a young adult who is the recipient of a kidney transplant. In growing up with a transplant, he talks about the special challenges of pediatric patients who are recipients of organ transplants.

Amy Tenderich from Diabetes Mine discusses her adventures while living with an Omnipod, which, in my humble opinion, is way cooler than an iPod.

In Never That Easy, we find that empathy is sometimes hardest to find amongst your own family, which makes it that much more hurtful.

Rachel from Tales of my thirties, has a humorous job description of herself as a person living with diabetes.

Six Until Me engages in her endless battle with the insurance company , fighting for her right to her diabetic supplies.

Ami Chopine, a self-described "collection of cells that cooperate enough to write" (loved that description!), talks about her thoughts on LASIK horror stories, and how some of these "support groups" hinder rather than help.

Kids, Teens and Health:

The Colorado Health Insurance Insider discusses the debate in Colorado about the HPV vaccine and the "wisdom" of making it a mandatory coverage on health insurance policies.

On a similar thread, InsureBlog discusses whether the new HPV vaccine is a good or bad thing. There is talk that it might actually increase the risks of cervical cancer in younger girls.

Nancy L. Brown, a developmental psychologist from Teen Health 411 discusses some of the key points from a Symposium for Mothers, and introduces this new phase in development coined "adultescence," for ages 20 to 30. (I guess that means I am officially an "adult" sigh....)

Registered dietitian Andrea N. Giancoli from The Family Fork is a nutrition advocate, consultant and educator. Kids and nutrition details one study regarding the number of food ads kids see on TV and a related study connecting TV watching to eating fewer fruits and vegetables.

Jake Young is a MD/PhD student at Mount Sinai School of Medicine focusing in Neuroscience and contributes to Pure Pedantry, and presents an association between weight gain in pregnancy and later childhood obesity.

Money and Health:

California Medicine Man, an internal medicine professor in Southern California discusses nurse anesthetists making more money than primary care physicians (much to their dismay), and an explanation behind this phenomenon.

Health Business Blog's post titled when socialism is good for capitalism refers to an article in the Los Angeles Times about health insurance becoming more difficult for the self-employed and makes a case that universal coverage would encourage business formation and increase economic growth.

Highlight Health delivers us an inconvenient financial truth about healthcare costs being dangerous for US financial stability. It is sobering article that tries to put in perspective the magnitude of this problem.

Dr. Val Jones discusses P4P. No, no, it's not a new rap group... It's a simple yet comprehensive article about the pitfalls of "Pay for Performance".

Policies, Politics and Health:

Mother Jones from Nurse Ratched wants more doctors in charge in politics. What if there were more healthcare professionals on Capitol Hill? Wouldn't it make for a better world?

Healthline Connects discusses an issue that I may know something about: circumcision and HIV. The World Health Organization (WHO) has announced that based on studies in Kenya, Uganda and South Africa, male circumcision reduces the risk of heterosexually transmitted HIV infection in men by 60%.

Universal Health sees one instance when the dreaded JCAHO can be your friend when solving the all too common problem of "ER boarders".

Health observances touches upon a perennial issue: antibiotics overuse, with reports from new studies from The University of Nebraska.

Hippocrates from Trusted.MD has a tongue-in-cheek article about jumping on the Health 2.0 bandwagon. Please keep in mind that April 1st was just around the corner....

Education and Health:

Anxiety, Addiction and Depression Treatments has and excellent and comprehensive article on the politics and the pitfalls of diagnosing clients with eating disorders .

Just in time for summer, Dr Paul Auerbach from Medicine for the Outdoors gives us really sound and simple steps in drowning prevention, which may save lives.

Dr Deborah Serani highlights research regarding anxiety disorders which talks about the importance of early diagnosis and prevention of this very common disorder.

Dr Palter from Doc in the Machine (a blog aiming at transforming medicine with tomorrow’s technology) discusses "Evil Tech", about how some people believe that some technologies are inherently good or evil - especially developments in medicine and the military.

Bertalan Meskó from ScienceRoll, a medical student at the University of Debrecen in Hungary gives us an extensive listing of Medical wikis and asserts that they are here to stay and will likely play an important role in medical education.

The medical wiki topic strikes again in Clinical Cases and Images.

Dr. Joshua Schwimmer is a nephrologist practicing in New York City and is the brains behind Tech Medicine. He talks about a little known syndrome that I will henceforth name the phobia-of-automatic BP machine induced hypertension , or PABPMIH for short. Catchy, no?

Dr. Emer from Parallel Universe discusses an exciting and novel solution to the blood shortage problem, based on recent discoveries by Danish scientists to convert all blood to type O. Can this be a dream come true for all level I Trauma Centers and klutzy surgeons?

Grandma may cook some awesome cookies, but listen to The Fitness Fixer when it comes to fitness advice. Dr. Jolie Bookspan debunks a few fitness myths.

On the same vein, Kevin, M.D. has a real issues with Dr. Nancy Snyderman who is NBC's Chief Medical Editor, and her non-evidence based cancer screening guidelines.

Dr Domenico Savatta from Robotic Surgery Blog, a fellow urologist who specializes in robotic surgery (the wave of the future!) discusses a technique to deliver the median lobe of the prostate during a robotic prostatectomy. He also has an interesting link to the Cancer Blog about an internet and medicine survey.

Dr Lisa Marcucci from Inside Surgery teaches us the step by step procedure involved in a tubal ligation via a laparoscopic Silastic Band.

Category all of its own and Health:

A second year medical student from Over My Med Body! sent me his link most decidedly after the deadline, but he did made me laugh, and I thought it was a good way to end Grand Rounds. So here it is: Product(MEDRED) . (My personal favorite is the last one...)

And that's a wrap.

Please stay tuned for Grand Rounds next week hosted by the incomparable Dr. Dork, one of my favorite medical bloggers. He is funny, charming, cute (if one can trust the picture on his blog), speaks with an Australian accent (I can only assume), with his most endearing trait being that he talks about himself in the third person.

Finally, as always, I MUST thank Dr. Nick Genes from Blogborygmi for his tireless efforts at keeping this grand tradition alive!

Up the creek, without a paddle....

2007-03-29T23:00:00.000-07:00

My worst nightmare came true last monday. I came home from clinic after a crazy busy day to find myself being paged right back to the ER on the other side of town. Alas, I was on call yet again...

I had enough time to briefly walk the doggies before their bladders exploded (rather embarassing for a urologist owner...), then quickly headed back into traffic.

Much to my horror and dismay, I discovered that I had accidentally left my cell phone at home. This would normally not be such a stressful event, but I was on call, meaning that I got paged multiple times to a couple of different ERs not to mention a few patient calls during the 20 minutes it took me to drive over to the first ER. And I could not call any of these people back right away!!!

I was really distressed. I absolutely HATE to answer pages late (chalk it up to my obsessive compulsive nature), and during the drive, I was just cursing myself. What if this was a really important call? What if this was a true emergency? And how in hell did doctors manage to be on call before the advent of the cell phone????

I remember getting my very first cell phone at the start of my intern year. That was back in 1995, and how things have changed in the interim. That cell phone was HUGE! I remember thinking at the time that it was so "portable" and "convenient", though it weighed about 3 lbs and was the same size as my cordless home phone. I remember jogging with it and using it both as a phone and a hand weight.

I am not one to jaw incessantly on my cell phone, and I have definitely overheard some inane conversations on the cell phone at highly inappropriate times (such as in my exam room), but it is a true necessity as a physician taking call. I couldn't imagine life without the convenience. I honestly don't care about text-messaging (never done it), or using the camera phone feature, or listening to music. I just want to be able to make simple calls. I had several older physicians tell me that they routinely carried change with them so they could use a public telephone to answer pages. So hurray to progress, but let me never forget my cell phone again!

Grand Rounds

2007-03-27T09:00:00.000-07:00

Grand Rounds this week are up at Medviews who is an internist specializing in Allergy/Immunology.

I have the pleasure of hosting Grand Rounds next week. It is almost to the day when I hosted it for the very first time last year, and I hope it will be as much fun! Please send me your submissions to: keagirl@gmail.com. Deadline will be Monday at noon at whatever time zone you are in.