One Day Blog Silence

Top 10 Books

5 out of 10...ain't so bad.

The Malaysia top 10 favourite books (fiction) list was revealed today in The Sunday Star. I am slightly dismayed to learn that I have only read 5 of these shortlisted books, and I consider myself an avid reader.




Actually, I was an avid reader. Call me a geek/nerd/bookworm, but as a child - when the Internet was a concept you heard about in shows like Beyond 2000 - my idea of fun was being left alone with a good book. A book a day, I lapped it all up with glee. I even started my own library - my books were catalogued using serial numbers and all had a "date due slip" pasted onto the last page - except that there was no patron. I enjoyed the trips I took with dad to various book fairs/exhibition/warehouse sales around KL, when we'd take a bus down from our hometown of Klang instead of drive. Those express bus trips (aka direct trip), windows down and wind beating on my face, with me struggling to keep my eyes open, will forever live on in my mind as one of those classic father-daughter moments. We'd return home after a tiring and fruitful day, pleased as Punch, with our individual loot. Mum would roll her eyes (all done with affection) in a way that said, like father like daughter. And of course, I once fantasised that I would meet the guy of my dreams in a bookstore!

Over the years I read less and less fiction. My reading list consisted of medical text and journals, guidelines and papers, all very boring stuff, I must say. The occasional fiction I read, I read during air travels, books I purchased at the airport bookstore and never quite got around to finishing when I got home. My last book? Amy Tan's The Opposite of Fate (which doesn't really count as fiction). Status? Unfinished.

I didn't take part in the poll, but my top choice echoes that of the Malaysian public. The Lord of The Rings rules them all!



Mr JRR Tolkien

The Right To Know

It upsets me to learn that some fellow doctors do not bother revealing the origin of low molecular weight heparin (LMWH) to their patients. It upsets me even more that they think that those who do, shouldn't!

On what grounds? Look, I know most of us have the genuine intention to treat our patients to the best of our abilities. Therefore, my opponents think that withholding a minor detail such as that above is done in the patient's best interest - a so-called therapeutic advantage. They argue that most Muslim patients who were told of LMWH's porcine origin ended up declining its use. They are after all offering the best treatment there is (in the case of acute coronary syndrome - ACS).

But still I ask, on what grounds? If you're a Muslim, don't you want to know if your treatment is halal? If there is no better alternative, the origin or religious legitimacy of a particular therapy does not preclude its use. I usually make it a point to counsel a Muslim patient before I administer LMWH. Yes, it's porcine in origin. Yes, it's the best treatment available (for ACS). Yes, there is an alternative, albeit an inferior one. Yes, in my professional opinion, you should receive this form of heparin. And yes, the final decision is yours.

In the end, if you are mentally competent, able to comprehend and retain this information, the final decision is yours. It's your right, the right to self-determination. In my limited experience, most of my Muslim patients have no objection to using LMWH, since it is undoubtedly the one thing that can save their lives when they present with ACS.



We'd like to think that doctors know best (and want the best for their patients), but let's not also forget that ultimately it is the patient's right to decide what they really want. Autonomy still rules.

My Cup Of Tea

An old love affair has been rekindled.

Ah, the joys of drinking tea...rediscovered.



Growing up in a household virtually devoid of caffeine (bar the occasional root beer, cola or Sarsi during festivities), I didn't begin to drink tea regularly till I was much older. Tea quickly became my new favourite beverage. I love both its taste and after taste; I like it thick and black, slightly bitter, and hot. Of course, I also like what it does to my spirits - one cup and I'm living up to my potential. I could do a million things, I write better, I articulate better. That, as we very well know, is caffeine-driven!

I have tried a variety of tea brands, and so far Tazo has been a sentimental favourite. I remember my first days in Sarawak General Hospital, when my husband and I were housed temporarily in one of the empty rooms in the specialist clinic complex while waiting for the actual quarters to be vacated. Those were such cold days in every sense of the word. The air-conditioning was on 24-7, and I would be reduced to a cyanosed, shivering mess trying to get an express shower at midnight after returning from my "tagging" duty. My only material comfort was my Tazo tea. For that I think I have Wyeth to thank. To promote their antibiotic Tazocin, they gave away Tazo tea bags with their drug papers. What a clever marketing gimmick! My darling hubby had collected an impressive 6-8 sachets from his colleagues because he knew I loved tea. I was wary and slightly confused at first ("you sure this tea doesn't contain any Tazobactam?"), but Tazo had me at first sip.


Over the years I had come into contact with some mediocre tea; you know, those shamelessly watered down, diluted imposters. And the lure of coffee was strong. Even if coffee proved too strong for me initially - giving me palpitations, headaches, and insomnias - I soon crossed over to the dark side. Pretty soon I was downing something like 3 cups a day (which is to be considered massive given my small frame), and I realised I was more dehydrated, edgy, and thoroughly exhausted at the end of the day. One of my resolutions for the year had been to cut down on my coffee intake. First quarter review : partially successful. Will work harder on that.

So how did I rediscover tea? I was at a conference recently and expecting to be fed the usual inferior quality brown beverages passing off as tea/coffee during the multiple tea breaks. But this particular hotel of the many many 5-star hotels I know had this charming little booth where tea bags were displayed and we could have our own pick. Fine tea all, measured in bag per cup, not in parts tea per million. My cup of tea, precisely. So there I was, one tea break after another, trying a different flavour each time, quietly but rapturously sipping my tea in the corner. Ah, the simple pleasures.

For now, I'm sticking with tea. The perfect cuppa? Tazo Awake, an English Breakfast blend, of course.

*Tazo says it best : Before the advent of Tazo Awake, most of humanity lived in a kind of dazed, dreamlike state where nothing much got accomplished on a regular basis. This made organising things like the Internet pretty much unthinkable.
Tazo is available at Starbucks.

Steve Versus Bill

Poser of the century : PPC or Palm? Canon or Nikon? Mac or PC?

While I have sworn allegiance to Canon, and would switch to a Mac in my next upgrade, I still don't own a PDA because I cannot decide which to get.

Anyway, here's a hilarious Steve VS Bill cartoon I found in You Tube. (Note : Bill has the green lightsaber, but why is he the good guy?)

Drug Wars

It's war between the drug cartels (small fry need not apply). Drug pushers are sent out to the streets to ply their trade, and we're caught in the cross-fire. No, I've not migrated to some drug-lord infested South American nation. I simply work in a hospital.

The hospital, or for the matter any health institution is fertile ground for drug-pushing. I don't mean that in a bad way. Pharmaceuticals is a multi-million dollar industry, and understandably it's break-neck competitive. The prescribing policy of a hospital could mean a windfall for a particular company and bust for another. New drugs and old ones given new indications are pushed into our faces all the time. So how does one choose?

Life just keeps getting more and more complicated. Choices, choices, choices! From skin care to hair care to brand of cereal or fresh milk, I am swamped with choices. Consumer products are petty matters. With drugs, my choices can have a huge impact on patients' lives and health economics. So how do I choose?

All drugs being more or less equal in terms of efficacy, tolerability and cost, do I choose based on

• the strength of evidence of drug trials
  
• my consultant's prescribing preference
• the likeability of the pharma rep
• the agreeable appearance of the pharma rep
  
• the support from pharma company (i.e. sponsorship for CMEs, conferences, department, research grants)?

All of the above for me, to a certain extent, with the exception of the physical attributes of the salesperson (there are more comely young lasses than lads in the pharma industry anyway, so not very interested). Our prescribing practice usually mirrors that of our specialists and consultants in the early years, with some fine tuning along the way as we mature into experienced practitioners. Ultimately, most of us prescribe within the confines of consensus guidelines where they exist, and where cost is not prohibitive.

In the meantime, we enjoy the attention. Sales blitz is the latest marketing ploy, where reps sometimes dress and give out lunch packs or snacks according to theme. My favourite so far? Sushi packs, as sushi=fish and fish="mascot" for one 3rd generation cephalosporin. The most desperate? Secret Recipe cakes for energy to last you 24 hours, to remind us of a certain ARB's "24-hour protection".

We are not complaining.

*CME : continuous medical education; ARB : angiotensin receptor blocker

Disclaimer : Opinions expressed are entirely the author's and may not reflect the truth of the situation, and certainly do not represent the views of the doctors practising medicine in Malaysia.

Roma Fan

This is old news, I know. That Manchester United trashed Roma 7-1 like ages ago. Yawn.

Anyway, just thought I'd share this because I find it amusing.

Spotted in my ward the day after the breathtaking match :


The caption should read : Roma fan keeps flag (towel) flying. Poor thing. I bet she didn't even know her team had lost!

I Know Who You Are

The realm of cyberspace isn't that vast after all.

Ever since I started blogging, I have spotted some bloggers with profiles matching people I know. Being the sleuth wanna-be that I am, I was spot-on each time!

All right, Jimbo sniffed me out first but I still had to figure out who he was - which I did. Small world, eh? It turned out that we work in the same hospital. And so does Two Woods.

Blooddoc was quite easy. A Malaysian hematologist working in Germany? I know one. Pictures of his adorable girl posted in his other blog Travelogue-Southern Germany confirmed his identity. A fine physician/hematologist I had the privilege to work with some years ago.

YYYap of The Tent was obviously the easy one, complete with name and all. We were products of the same medical school.

My latest revelation? Cytusm! Every alphabet of his moniker stands for something; when the realization hit me his name made perfect sense. If I were to follow suit, I'd be called something like cylusm. Doesn't sound very nice. Anyway, it's great to reconnect with another senior from university in the blogsphere.

So if you think I sound like someone you know from school, college or work, please establish connection. I am looking forward to hearing from you!

Toilets That Kill

This is nothing like the high funda toilet that fellow blogger Jimbo raved about in his blog. This is a third-rate, third-world toilet - or what's left of it - in the third-class ward that I work in. The cistern came crashing down one fine day. My patient somehow had the foresight to pull the flush handle only after she had stepped out of the cubicle, hence she escaped what could have turned out to be a horrific freak accident. No where is safe anymore, is there?

A Less-Than-Regal Dinner

I had been invited to attend a dinner cum talk (in conjunction with the recent National Heart Association meeting) on a fine Saturday evening. The speaker was a professor of cardiology from France and the venue was the rather exclusive Carcosa Seri Negara.

I simply couldn't pass up this opportunity.

Me, I like fine things. Carcosa promises just that - grand colonial mansions, lush sweeping lawns, dainty tea cups, gleaming silverware and exquisite china. Not my typical weekend. You could tell I was psyched. (Incidentally E&O Hotel is one of my favourite hotels, Smokehouse in Jalan Mayang KL is my favourite fine restaurant - I love structures with a distinct colonial influence.)

We arrived to find the place in a less than pristine state. Well, maybe the lighting wasn't flattering, but was it not peeling paint here and a water stain on the wall there? I didn't get a chance to explore the place, as we were quickly whisked-off to the function room where the talk promptly began. No matter. I was too embarassed to take out my bulky DSLR camera - stuffed somewhat pathetically in my bag - to begin snapping away anyway. Like, hello! Have never been to Carcosa ah? Actually, no!

Dinner took place in Gulai House, supposedly well-known for its local specialties. I'm no food critic, but after years of eating out I'm inclined to think that I have developed discerning taste receptors. The food, to say the least, was disappointing! After a decent starter of satay skewered in lemongrass stalks and a somewhat salty prawn and spinach soup, things went downhill. Of notable mention were the prawns - they were close to decomposition! My boisterous company made no attempt to disguise their disgust. And again, I was too embarassed to whip out my monster of a camera to take some shots of the so-called food (which would have made good blog material). Like, hello! Have never eaten fancy food ah? Suffice to say, we did not stay back for dessert!

The Gulai House

I admit some of us behaved like ungrateful guests. Well, I appreciate being invited. I most certainly won't come here to dine on my own. At least I can now blog about my Carcosa experience! Then again, surely the food can be better? Especially since it's so pricey!

Top 5 M.C. Movies

5 "comfort" movies for them M.C. days (in no particular order):

Spirited Away
A classic by Hayao Miyazaki. A movie for "10-year-olds and those who used to be 10-year-olds". The kid in me always loves a fairy tale. Perfect distraction from any physical discomfort.


Love Actually
The movie tells us that "love is actually everywhere". Makes you feel all warm and fuzzy inside. Kinda like chicken soup, good for a sick soul (and body).


Shrek
Not the greatest fairy tale never told...I'd say one of the greatest EVER told.


Austin Powers 1,2,3
Oh, groovy baby! Cliched as it may sound, laughter is sometimes better than medicine.


LOTR


No reason needed!


I have watched one of these movies everytime I was on MC. Therapeutic value - proven!

*M.C. = medical certificate

Foodis horribilis!

This may be a problem peculiar to my hospital, but I'm inclined to think that most hospitals are afflicted.

The affliction? Bad food. Or in the case of my hospital, bad AND expensive food!

We demand better food. It's a pretty basic human right after all - the right to decent food. Especially if you are paying for it. I am not a picky eater. I'm an omnivore, I don't practise food taboos and I have no reservations paying more for palatable meals. But walk into the establishment thinly disguised as the "hospital cafeteria" and you will empathise with me. I suffer from anorexia of sudden onset everytime I walk into this joint. It's the usual "cafe fare" - measley portions of meat, boiled veggies drained of colour (and whatever vitamins they contain) and overfried fish that cost a fortune. A simple meal consisting of a chicken drumstick and 2 pieces of tofu (and half a portion rice) can set you back something like RM4.58. The odd 58 cents? Government tax. Like I said, I'll willingly pay for real food but this, I'll do so grudgingly.

Of course, there's always the option of eating out. Except when you have rounds that go on till 1 pm and clinics that start at 2pm sharp, eating out remains a luxury. Besides, once you vacate your parking bay at lunch time, do not expect to find an empty slot when you come back that is not at least 3 slopes, 2 blocks and 1 mortuary away from the main building (coming soon in my blog : car park woes in my hospital)!

I remember a time not too long ago in the land of the hornbill far, far away. There was a coffee shop located just outside the hospital that served decent food - red-wine mee sua (rice vermicelli), claypot tom yam noodles, fried noodles in tomato sauce, laksa Sarawak etc. We always looked forward to lunch. Now, lunch feels like a drag. I'm not expecting gourmet lunches, but is it too much to be asking for better food?

I want this for lunch!

You know, I could go on a hunger strike, but the canteen operator will have his tender renewed year in and year out anyway. I think I'll have to start packing lunches to work.

Ridiculous blog title, you say? That's because I'm hungry - I skipped lunch today!

"Where Doctors Go Wrong"

A thought-provoking article my former cardiology boss shared with some of us. It was in the March 15 issue of TIME magazine. We're all guilty of these "sins" at one time or another, aren't we?




Where Doctors Go Wrong

By Christine Gorman

The patient was an 8-year-old California girl with severe headaches. Her parents, who were both struggling to adjust to new high-pressure jobs, took her to top neurologists and pediatricians. The child's symptoms, the doctors concluded, were a response to stress at home, along with perhaps a sinus condition. But four or five months later, it became clear that she had a brain tumor and needed surgery. When her doctors looked back at early scans of her brain, they were aghast to see the shadow of a tumor they had previously overlooked.

For Harvard hematologist Jerome Groopman, who is a friend of the child's parents, the missed diagnosis was more than just a cautionary tale. It was the start of an investigative journey. "People talk about technical errors in medicine, but no one talks about thinking errors," he explains in an interview. "I realized I had no framework for understanding these kinds of problems."

For the next three years--in addition to seeing patients and doing research, plus his gig as a staff writer for the New Yorker--Groopman began to intensively examine how doctors think and how they get sidetracked from the truth. He learned that about 80% of medical mistakes are the result of predictable mental traps, or cognitive errors, that bedevil all human beings. Only 20% are due to technical mishaps--mixed-up test results or hard-to-decipher handwriting--that typically loom larger in patients' minds and on television shows.

The result of Groopman's journey is How Doctors Think (Houghton Mifflin; 307 pages), an engagingly written book that is must reading for every physician who cares for patients and every patient who wishes to get the best care. Groopman says patients can prompt broader, sharper and less prejudiced thinking by asking doctors open-ended questions and learning to identify some of their common thinking mistakes:

ERROR 1: I RECOGNIZE THE TYPE

Doctors, like most of us, are often led astray by stereotypes that are based on someone's appearance, emotional state or circumstances. Thus a homeless man's disorientation might be quickly attributed to alcoholism when the real culprit is diabetes.
Groopman describes this kind of "attribution error" in the case of a nervous young woman who kept losing weight even when prescribed a high-calorie diet. Her doctors, convinced that she was lying about her food intake, suspected anorexia or bulimia, but her problem, diagnosed after years of ill health, turned out to be celiac disease--an allergy to wheat. Had the patient been male or older or less anxious, the doctors might have got it right in the first place.

ERROR 2: I JUST SAW A CASE LIKE THIS

"We all tend to be influenced by the last experience we had or something that made a deep impression on us," Groopman says. So if it's January, your doctor has just seen 14 patients with the flu and you show up with muscle aches and a fever, he or she is more likely to say you have the flu--which is fine unless it's really meningitis or a reaction to a tetanus shot that you forgot to mention.

The best defense--besides giving as complete a history as you can--is to be alert and ready to ask questions anytime a doctor says, "There's a lot of this going around."

ERROR 3: I'VE GOT TO DO SOMETHING

Physicians typically prefer to act even when in doubt about the nature of the problem. And yet this kind of "commission bias" can lead to all sorts of new problems if the treatment turns out to be incorrect.

"Don't just do something. Stand there," one of Groopman's mentors told him years ago when he was uncertain of a diagnosis. This buys a doctor time to think--which is especially important when trying to ensure that something hasn't been overlooked.

ERROR 4: I HATE (OR LOVE) THIS PATIENT

Groopman cautions that emotions are more of an issue than most physicians like to admit. Doctors who are particularly fond of a patient have been known to miss the diagnosis of a life-threatening cancer because they just didn't want it to be true. But negative emotions can be just as blinding, sometimes stopping a doctor from going the extra mile. "If you sense that your doctor is irritated with you, that he or she doesn't like you," says Groopman, "then it's time to get a new doctor." Studies show that most patients are pretty accurate in describing their doctors' feelings toward them.

Groopman's book makes abundantly clear that despite all the electronic databases that are being used to improve health care, a lot of medicine still comes down to a doctor or two puzzling out what might be wrong with your body. Experience, common assumptions and human nature can guide them or lead them astray. By asking a few questions--especially if you think your doctor isn't asking enough of them--you can raise the odds that your physician won't get detoured from the truth.