It's always on either a Monday or Tuesday, more often after a long weekend. A new patient comes in and wants to "check for everything".
"OK, Doc. I know I've been bad. But now I am ready to turn the new leaf. I need to know how much damage I've done to my body. Can you check for everything, cancer, AIDS, arthritis, ... EVRYTHING you can think of ... but make sure I don't have cancer".
This sort of requests put us doctors in a rather troubled spot.
The obvious problem is cost. We cannot order "everything". Mainly because we don't really know that many... . The menu is huge! Medicare will knock on our doors even before the delivery truck arrived. Do you know how much it costs to have your liver function checked?
But then, we are always intrigued by the repentant patients. It is an opportunity to scare the living day light out of the hung over and sorry being bfore us. If we refuse to order some of the tests, he or she may disappear from our "preventive medicine radar".
Another issue is that a normal test result does not mean you are well. Our body is a constantly changing organism. I guess inside my body right now there are a few thousand cells wanting to go cancerous. Some may aleady have become cancerous. They may not show up in the test result pages.
[By the way, don't worry. If you keep your general health in good shape, your immune system and its allied armies will track down these insurgent cancer cells and knock them off.]
Also, does a normal result some how reinforce the patient's delusion that his or her recent self-destructive behaviour is OK? "Great mate. All that drinking and smoking and eating did not affect my PSA level! What's on this weekend?".
The "Whole body scan to exclude all cancers" is ridiculously misleading and is a total waste of time and money! I can tell you that you have less cancer cells in you before you inflict upon yourself with this crazy gimmick! What if it finds a cancer in a peculiar spot that we cannot get to to know what it is? What if this cancer turns out to be a very slow one and can only kill you in 200 years time?
What we should test for are the proven worthy tests: fats, sugar, blood in poo. The PSA (prostate specific antigen) is a rather hairy issue - which I will not discuss here.
Tests are not your warranty. Let your doctor monitor your weight, girth, blood pressure, and every now and then stick a few small instruments into your body. Then we will order some tests.
Thursday, October 28, 2010
Tuesday, October 26, 2010
Dr Google
Just type "sneeze cancer" in Google. Now press "Search". Whoa!
Over 400,000 hits! Yes, there are evidence of "sneeze" and "cancer" can be associated, at least as two words appearing on the same web page. By this research, I can conclude your one-off sneeze this morning could be caused by a malignant neoplastic process.
Oh! My! Goodness! ... How many times have I seen a worried person coming in with a briefcase full of printed pages of Google results on his or her symptoms.
"Are you sure doctor? That my sneeze is only a cold, and not this hideous post nasal cancer? - And just you look at that picture there. How horrible! Are you sure I am not ending up with that thing in my mouth???"
Half of the time (mainly in the morning) I will try to reassure you. But when I am tired (say 6PM), I'd let Dr Google ruin your day.
The thing about the web is that the web authors must try to attract viewers by making the information interesting. In order from most to least interesting causes for sneezing, post nasal cancer beats hay fever and common cold; and sniffing pepper comes last. So there are more web pages associating sneezing with cancer than with sniffing pepper. The real-life incidence is in reverse order. I have the feeling the pepper aetiology is a lot more common than the neoplastic one.
Examples:
A guy who coughed up a piece of foul-smelling old food, that was tucked behind his tonsils in the last god knows how long, was convinced it was a "broncholith" - and Dr Google diagnosed it as lung cancer.
A man presented with an itch in the perineum (the area between the scrotum and the anus) was convinced it was due to prostate cancer. The malignancy was cured by changing his underpants more frequently.
The crying mother brought in her pubertal son with a tender swollen nipple. She had consulted Dr Google earlier that morning and was told even famous men like Tom Cruise could have breast cancer. The boy was petrified. I had a hard time telling him some milk may come out later and that he was lucky to have it in only one breast. I also revealed to him a secret : both of mine were more sore and even bigger during my early teen years!
Google is good in helping you find out more about your problem once it has been diagnosed. I use Google myself to find information about drugs, diseases etc, often with the patient present so we learn together. It is a great tool.
However, Googling is not so good in working out the diagnosis by yourself.
So first get a diagnosis from your doctor, THEN Google. And try to filter out the silly webpages. I don't know how they do it, but the silly hoax sites full of inappropriate advertisements always seem to get to the top of the search list.
Over 400,000 hits! Yes, there are evidence of "sneeze" and "cancer" can be associated, at least as two words appearing on the same web page. By this research, I can conclude your one-off sneeze this morning could be caused by a malignant neoplastic process.
Oh! My! Goodness! ... How many times have I seen a worried person coming in with a briefcase full of printed pages of Google results on his or her symptoms.
"Are you sure doctor? That my sneeze is only a cold, and not this hideous post nasal cancer? - And just you look at that picture there. How horrible! Are you sure I am not ending up with that thing in my mouth???"
Half of the time (mainly in the morning) I will try to reassure you. But when I am tired (say 6PM), I'd let Dr Google ruin your day.
The thing about the web is that the web authors must try to attract viewers by making the information interesting. In order from most to least interesting causes for sneezing, post nasal cancer beats hay fever and common cold; and sniffing pepper comes last. So there are more web pages associating sneezing with cancer than with sniffing pepper. The real-life incidence is in reverse order. I have the feeling the pepper aetiology is a lot more common than the neoplastic one.
Examples:
A guy who coughed up a piece of foul-smelling old food, that was tucked behind his tonsils in the last god knows how long, was convinced it was a "broncholith" - and Dr Google diagnosed it as lung cancer.
A man presented with an itch in the perineum (the area between the scrotum and the anus) was convinced it was due to prostate cancer. The malignancy was cured by changing his underpants more frequently.
The crying mother brought in her pubertal son with a tender swollen nipple. She had consulted Dr Google earlier that morning and was told even famous men like Tom Cruise could have breast cancer. The boy was petrified. I had a hard time telling him some milk may come out later and that he was lucky to have it in only one breast. I also revealed to him a secret : both of mine were more sore and even bigger during my early teen years!
Google is good in helping you find out more about your problem once it has been diagnosed. I use Google myself to find information about drugs, diseases etc, often with the patient present so we learn together. It is a great tool.
However, Googling is not so good in working out the diagnosis by yourself.
So first get a diagnosis from your doctor, THEN Google. And try to filter out the silly webpages. I don't know how they do it, but the silly hoax sites full of inappropriate advertisements always seem to get to the top of the search list.
Wednesday, October 20, 2010
Pathological Paths
Osteopaths, Naturopaths vs Psychopaths, Sociopaths - and Chiropractors
Fatigue
Every now and then I get a spanking new patient coming in with a list of investigation requests. Now is a middle-aged woman. She is quite blunt in telling me straight off that she only sees me to get a few tests done for her own doctor. Why? Because her doctor cannot refer her herself. Medicare would not pay her back the rebate for the tests.
Fair enough. Sometimes struck off doctors still have a lot to offer to their loyal patients.
It is when I see what the requests are that it really kills me. The most irritating is the serum level of some inert metal that I cannot find on my periodic table of known elements. Should I be rude enough to ask if the patient had been away from earth and somehow inhaled this toxic unknown element from the moon?
Seeing my grimace, the patient then reveals her secret. It's her naturopathic doctor who has heard of this metal and attended a course in Congo on the effect this 205th element on the poor client's "recurrent fatigue". And there are at least 2 websites on this subject. One from Romania, the other from Iceland. How could I be so ignorant!???
Don't get me wrong. I do believe in naturopathy. Lots of my patients are on herbs and other natural therapeutic products. For example, I do believe in Vitamin C, Zinc and Garlic as supplementary medicines for cold and flu.
But I get really weary of the invention of odd and baseless causes for common problems.
Most people are tired. Everyone is tired at one time or another. Tiredness is not likely to be caused by the overloading or lacking of some weird element. I think the most common causes are deficiency in Vitamin R (rest) and in Vitamin S (sleep). Vitamin M (money) sometimes helps.
Back pain
Likewise, most people have back pain. Unless you are some kind of robot, you must have had some back pain once in your life. It is simply because man has not evolved well. His head is too heavy for his tiny neck and his hips cannot sustain his weight well. He decided to walk on two legs long before his spine had evolved to accommodate such change. So he wobbles a lot, then sometimes he waddles (during pregnant periods in women and during beer drinking years in men).
Not only we are designed poorly; we also do crazy things to our body.
We fashioned our hooves ala Prada-style. And thanks to the computer mouse we no longer use our shoulders and arms. We only use our right index finger and our right wrist. A farmer's back pain does not last long because he knows he must use the correct muscles. In contrast, an accountant is a totally different animal; designed to climb trees but instead he sits dead still for 10 hours, cranks his neck and stares at the monitor, and only moves the mouse in right hand back and forth repeatedly every 10 seconds. At home he slouches uncomfortably on the sofa, stares at the TV while his thumb frantically harrasses the remote control.
I believe human will evolve into a cyclop with one finger attached to a large remote.
So instead of moving about like you are supposed to (ie, be the homo-sapien that you are) and retraining your muscles to regain your painless posture, you hobble a long way to get a quick fix from some "back guy". This guy has such healing power your best friend (or neighbour) cannot even describe.
Again, I have nothing against genuine chiropractors and osteopaths. It's the psychopaths disguised as healers that really get me. They have most odd methods of practice.
What with the pencil lines being ruler-ed onto the spine Xray films!??
Yes, thanks to the pencil markings, I can see you have a half a degree tilt to the left. So what! If that's how you already are for the last 40 years, why fix it now? Your back pain started last week, but your spine has been like that for half a century! God (or mother nature to atheists) did not create us with a ruler! So don't use rulers and protractors to measure our spine!
And Xrays are not that helpful in managing simple back pain, and sometimes dangerous when not interpreted correctly. A doctor friend of mine was silly enough to have ordered a spine series for his grand-mother. The old Chinese lady had some minor backache but still was quite well and was able to walk to the shops everyday. When she asked him about the mild compression fracture seen in one of her vertebrae, he foolishly described her osteoporosis as "rotten bone" in Chinese. The lady was so frightened she decided to lie in bed all the time. She fixated to the false idea that standing and walking would in further damage her back. My friend tried really hard to get his grandma off the bed but all his effort proved useless. Soon immobility took hold, she shrivelled away and died.
It's a different story if you are a pre-teen with scoliosis; I would immediately refer you to the spine specialist.
Fatigue
Every now and then I get a spanking new patient coming in with a list of investigation requests. Now is a middle-aged woman. She is quite blunt in telling me straight off that she only sees me to get a few tests done for her own doctor. Why? Because her doctor cannot refer her herself. Medicare would not pay her back the rebate for the tests.
Fair enough. Sometimes struck off doctors still have a lot to offer to their loyal patients.
It is when I see what the requests are that it really kills me. The most irritating is the serum level of some inert metal that I cannot find on my periodic table of known elements. Should I be rude enough to ask if the patient had been away from earth and somehow inhaled this toxic unknown element from the moon?
Seeing my grimace, the patient then reveals her secret. It's her naturopathic doctor who has heard of this metal and attended a course in Congo on the effect this 205th element on the poor client's "recurrent fatigue". And there are at least 2 websites on this subject. One from Romania, the other from Iceland. How could I be so ignorant!???
Don't get me wrong. I do believe in naturopathy. Lots of my patients are on herbs and other natural therapeutic products. For example, I do believe in Vitamin C, Zinc and Garlic as supplementary medicines for cold and flu.
But I get really weary of the invention of odd and baseless causes for common problems.
Most people are tired. Everyone is tired at one time or another. Tiredness is not likely to be caused by the overloading or lacking of some weird element. I think the most common causes are deficiency in Vitamin R (rest) and in Vitamin S (sleep). Vitamin M (money) sometimes helps.
Back pain
Likewise, most people have back pain. Unless you are some kind of robot, you must have had some back pain once in your life. It is simply because man has not evolved well. His head is too heavy for his tiny neck and his hips cannot sustain his weight well. He decided to walk on two legs long before his spine had evolved to accommodate such change. So he wobbles a lot, then sometimes he waddles (during pregnant periods in women and during beer drinking years in men).
Not only we are designed poorly; we also do crazy things to our body.
We fashioned our hooves ala Prada-style. And thanks to the computer mouse we no longer use our shoulders and arms. We only use our right index finger and our right wrist. A farmer's back pain does not last long because he knows he must use the correct muscles. In contrast, an accountant is a totally different animal; designed to climb trees but instead he sits dead still for 10 hours, cranks his neck and stares at the monitor, and only moves the mouse in right hand back and forth repeatedly every 10 seconds. At home he slouches uncomfortably on the sofa, stares at the TV while his thumb frantically harrasses the remote control.
I believe human will evolve into a cyclop with one finger attached to a large remote.
So instead of moving about like you are supposed to (ie, be the homo-sapien that you are) and retraining your muscles to regain your painless posture, you hobble a long way to get a quick fix from some "back guy". This guy has such healing power your best friend (or neighbour) cannot even describe.
Again, I have nothing against genuine chiropractors and osteopaths. It's the psychopaths disguised as healers that really get me. They have most odd methods of practice.
What with the pencil lines being ruler-ed onto the spine Xray films!??
Yes, thanks to the pencil markings, I can see you have a half a degree tilt to the left. So what! If that's how you already are for the last 40 years, why fix it now? Your back pain started last week, but your spine has been like that for half a century! God (or mother nature to atheists) did not create us with a ruler! So don't use rulers and protractors to measure our spine!
And Xrays are not that helpful in managing simple back pain, and sometimes dangerous when not interpreted correctly. A doctor friend of mine was silly enough to have ordered a spine series for his grand-mother. The old Chinese lady had some minor backache but still was quite well and was able to walk to the shops everyday. When she asked him about the mild compression fracture seen in one of her vertebrae, he foolishly described her osteoporosis as "rotten bone" in Chinese. The lady was so frightened she decided to lie in bed all the time. She fixated to the false idea that standing and walking would in further damage her back. My friend tried really hard to get his grandma off the bed but all his effort proved useless. Soon immobility took hold, she shrivelled away and died.
It's a different story if you are a pre-teen with scoliosis; I would immediately refer you to the spine specialist.
Thursday, October 7, 2010
Corporate Medicine
I read on smh.com.au the sorry story of a GP who signed up with one of the corporate medical mammoths and later got chewed up by the same monster. It sent a tingle up my spine to think I nearly went the same way 10 years ago.
In 2001, 2-3 weeks after I opened the door of my GP practice in Avoca Street Randwick, a highly ranked representative of a medical corporate appeared. He sat in my waiting room for about 30 mins, counting my clients like sheep - well, I saw only 10-15 patients per day at that time. Then he came in to see me and told me to either sign up with his business or get out of town. He told me I would not survive here.
"We buy you out, or you join us. We don't want this practice to be here."
He offerred to pay off my debts, all of them (Yay!).
The condition was I would have to work for his boss for 5 years (Boo!).
He would look after all my income issues (Yay!).
I just had to work HARD - including odd shifts in odd places (Boo!).
After 5 years, I would be able to leave (Yay!).
However, I ought not to open a practice within 5km radius from any of his centers (Boo!).
The temptations were there. The only problem was I hated the way the guy spoke to me. He and I are both doctors. There usually exists a fraternity mutual respect between decent doctors. This guy got nothing. He was one big fat business bully!
I politely showed Dr Bully the door and promised when my business collapsed, I would consider calling for his help. He looked at my empty waiting room, threw a wry smile and said he'd get my call in one month.
Ten years on, I am still struggling to make ends meet. I don't like the car I drive, an old Honda - no Mercesdes, not even a BMW. I don't like the butterfly in my stomach every time I read the loan statements.
But I like the way I work - as my own boss.
I can spend 1 minute to give a script or 1 hour to calm down a distressed newly widowed man. No receptionists can knock on my door to hurry me up. I do home visits. I joke and laugh with my colleagues and staff. I walk out to a quick lunch even when there are people waiting for me - I can't help them if I am too hungry to think.
It is sad that medicine is going down this corporate path. It is a big machine that mows down all health funds, for little results. But it makes big bucks. Simple. You go there, your GP sees you then almost immediately refers you to the Xray specialist in the next room who also belongs to the corporate. You take the report to your GP. He refers you to the physiotherapist who also belongs to the corporate. Tching! Tching! Tching! ... within less than 30 minutes, the mower chomps down 3-4 transactions from Medicare and other health funds. And you, the corporate's valued client, bounce like a beach ball between the rooms in that beautiful corporate building. Whether you get better is not the issue. Your job is just to keep bouncing.
Sure the contract says the doctors can have autonomy. They supposedly can do what they like. But if they follow the herd and refer as often as and as many as they can to pathologists, radiologists, psychologists, whateverologists of the corporate, then the corporate will let them work in more agreeable environment - longer holidays, perhaps.
I just now read the article about the late Dr Bill Marchione. I knew Bill well, he graduated in my year. That was just terrible the way he ended his life. We doctors should never be sucked into a cut-throat business like this.
In the current climate of Ms Nicola Roxon's "health care reforms", my business might collapse. But I'd rather go to CentreLink than work for CentreStink.
And to Edmund, Primum non nocere!
In 2001, 2-3 weeks after I opened the door of my GP practice in Avoca Street Randwick, a highly ranked representative of a medical corporate appeared. He sat in my waiting room for about 30 mins, counting my clients like sheep - well, I saw only 10-15 patients per day at that time. Then he came in to see me and told me to either sign up with his business or get out of town. He told me I would not survive here.
"We buy you out, or you join us. We don't want this practice to be here."
He offerred to pay off my debts, all of them (Yay!).
The condition was I would have to work for his boss for 5 years (Boo!).
He would look after all my income issues (Yay!).
I just had to work HARD - including odd shifts in odd places (Boo!).
After 5 years, I would be able to leave (Yay!).
However, I ought not to open a practice within 5km radius from any of his centers (Boo!).
The temptations were there. The only problem was I hated the way the guy spoke to me. He and I are both doctors. There usually exists a fraternity mutual respect between decent doctors. This guy got nothing. He was one big fat business bully!
I politely showed Dr Bully the door and promised when my business collapsed, I would consider calling for his help. He looked at my empty waiting room, threw a wry smile and said he'd get my call in one month.
Ten years on, I am still struggling to make ends meet. I don't like the car I drive, an old Honda - no Mercesdes, not even a BMW. I don't like the butterfly in my stomach every time I read the loan statements.
But I like the way I work - as my own boss.
I can spend 1 minute to give a script or 1 hour to calm down a distressed newly widowed man. No receptionists can knock on my door to hurry me up. I do home visits. I joke and laugh with my colleagues and staff. I walk out to a quick lunch even when there are people waiting for me - I can't help them if I am too hungry to think.
It is sad that medicine is going down this corporate path. It is a big machine that mows down all health funds, for little results. But it makes big bucks. Simple. You go there, your GP sees you then almost immediately refers you to the Xray specialist in the next room who also belongs to the corporate. You take the report to your GP. He refers you to the physiotherapist who also belongs to the corporate. Tching! Tching! Tching! ... within less than 30 minutes, the mower chomps down 3-4 transactions from Medicare and other health funds. And you, the corporate's valued client, bounce like a beach ball between the rooms in that beautiful corporate building. Whether you get better is not the issue. Your job is just to keep bouncing.
Sure the contract says the doctors can have autonomy. They supposedly can do what they like. But if they follow the herd and refer as often as and as many as they can to pathologists, radiologists, psychologists, whateverologists of the corporate, then the corporate will let them work in more agreeable environment - longer holidays, perhaps.
I just now read the article about the late Dr Bill Marchione. I knew Bill well, he graduated in my year. That was just terrible the way he ended his life. We doctors should never be sucked into a cut-throat business like this.
In the current climate of Ms Nicola Roxon's "health care reforms", my business might collapse. But I'd rather go to CentreLink than work for CentreStink.
And to Edmund, Primum non nocere!
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