Time with kids

I’ve got 3 kids. Currently 7, 4 and 2 years old. Sometimes as a dad, I can get so catch up with the essentials of keeping them alive (cooking, cleaning, bathing, dressing, rescuing them from one life threatening emergency to another), I find it hard to spend time with kids.

When I do spend time with them, I get so engrossed about educating them, I loose sight of the whole glorious purpose of spending time with kids. Not that I don’t have fun with my kids; there is always laughter in my home every day. But there are times when I get obsessed about educational goals and aims that I subconsciously and consciously set for my kids.

Example one: “Arrgg you are playing the piano notes wrong. ..Stop! I told you the timing is wrong… come on hurry up .. you need more expression here … come on practice! PRACTICE!!”

Example two: “Just keep pedalling the bicyle, that way you will keep going and won’t fall … I said keep pedalling. HOI! KEEP PEDALLING!!!”

Example three: “Come on, you have written this chinese word many times before. Don’t tell me you can’t remember!.. Do it again!! No, that looks disgusting. Write it again! “

It is often when I sit back and relax, after all the kids have gone to bed: what is the point of me getting stressed when I am spending time with kids. I look back and cherish those moments when I just hold my oldest child as a baby in my arms, doing absolutely nothing but adoring this lovely creature God has given me. Why don’t I have moments like that anymore.

Time with kids: It is not just the education; it is the bonding, the relationship, the love, the laughter. That is what my kids will remember when they are adults, not how I flog them to finish their chinese homework. But as a professional middle class parent, it is so easy to loose sight of it all.

I’ll fight

Sometimes patients are keen to have whatever you can throw at them. Even if it may not do them any good and may in fact harm them.

Got a very old man at the moment. Diagnosed with a locally advanced cancer, whom my usually agressive surgeons felt was inoperable. He had a MI before but otherwise smart chap. Wanted me to do everything for him.

Unfortunately in his case, given his age, comorbidity and performance status, I thought the best thing for him would be palliative supportive care only, managing his symptoms only. He was starting to have bleeding from his tumour I offered him palliative radiotherapy. I didn’t feel that he could benefit from chemotherapy. In particular, the chemotherapy for his type of cancr is cardiotoxic; and he had a MI before.

However he was keen. he bargained and reasoned with me, tried his best to twist my arm into giving him chemotherapy. He has latched on to a newspaper article on how a breast cancer patient who was given months to live, was still alive 2 years later because she had chemotherapy and this new drug on the block.

It was with great difficulty that I explained that that drug doesn’t work in his type of cancer; and that giving him chemotherapy may in fact harm him, and shorten his life. He was adamant; saying that it is his life anyway; and he’d rather die fighting. It was at that time that I found out he had a bad experience with a close relative who unfortunately died from cancer, and that relative was treated with best supportive care only (again was not suitable for chemo). He didn’t want to go down the same way, and would rather die fighting.

A conflict. On one hand: The patient’s right to receive a dangerous inappropriate treatment. On the other: A physician’s right to live by the Hypocratic Oath; to first do no harm. Not easy to resolve as both sides came to a standstill. I reasoned (very honestly) that even if he was my father, I would still have made the same decision. The patient ain’t convinved.

I ended the consultation by saying we can discuss the chemotherapy at another date; meantime I will organise some palliative radiotherapy. I expect another battle of wills again the next time I see him in clinic. I suppose I can always offer him a second opinion from my colleagues. Maybe after seeing a few oncologists with the same conclusion, he may back down. Or the disease may get him first?

Touchy

It is great having advanced practitioners helping you out in clinical work. Some are very senior nurses, some are senior radiographers. Some perform quite mundane duties like pre-clerking patients in for surgeries; others are involved with assessment of new patients and making decisions on rather complex medical management (from palliative, care, to oncology treatments, to COPD treatment and RA treatment, etc etc). Some perform complex duties including interpreting plain XRs, doing barium enemas. Cause they have been in their role for so many years, often they are better clinically than your average registrar that is new to the team.

 

Having advanced practitioners is good for the hospital: as it saves cost (cheaper than doctors), reduce waiting time, it is good for them as it gives them more advanced roles with their seniority and experience. There have been studies that shows patients are more happy with nurse clinicians than doctors, as they tend to be more approachable and give a more thorough assessment. However, one need to take into account the fact that some advanced practitioners only see 2-5 patients in the clinic, whereas a junior doctor may see 8-15.

 

Given their more complex roles, some are campaigning for the same pay as junior doctors. I support that they should be paid according to their expertise and role; but provided they also bear the same level of responsibility. As it stands, if anything goes wrong with the treatment or the patients, the final responsibility falls on the consultant, not the advanced practitioners. There are so many safety measures in place to protect advanced practitioners, so that it is almost impossible for them to be made responsible for an adverse event eg death or injury. Even junior doctors are made to be held accountable for their errors and they can get struck off if the medical error is large enough. This is so rare with advanced practitioners; so I do feel that they need to consider taking more responsibility if they want the same level of pay as junior doctors.

 

One interesting thing about advanced practitioners (that I seldom see in junior doctors): they are very touchy about being recognised and acknowledged. Today, one of my consultant colleagues is on leave. I reassured the surgeon that the registrar is covering the clinic. I got a very unhappy phone call later; when the nurse clinician said I didn’t mention she was also covering the clinic. She felt that I have not given the appropriate honour to her role by not mentioning her and the registrar on the same breath; since she does take referrals from the surgeons and assess new patients for treatment. She did acknowledge at the same time that I have never personally treated her “like a nurse” but like an equal colleague; just that she also want that done publicly.

I suppose many of them still feel rather insecure in their roles.

Practice variation with different local expertise

Quite intersting to see how different surgeons approach things. When I started my job with this new MDT, different surgeons from 2 different big hospitals merge together for the weekly case discussion. One group was used to working with a H&N oncologist, and has seen the good results with non surgical approaches. The other group used to work with an oncologist who did not have subspecialty interest in H&N, and who subspecialise in major big surgeries and reconstructions.

The first group is quite happy to send all oropharyngeal cancers to me, whether early or advanced stage, cause they know radiotherapy (with or without chemotherapy) has very high success rate without the morbidity of surgery.

The second group however is still keen to cut, then send over to me for postoperative radiotherapy. It is quite obvious from the way they discuss options with patients that they sell surgery as a good option. Unfortunately none of the oropharyngeal cancers they have operated on, even very early cancers, have gotten away with surgery alone. All of them required postoperative radiotherapy, either because margins are inadequate, or cancers more extensive than initially expected. Others were already advanced (eg with lymph nodes spread and needed postop RT anyway).

This is being questioned now at the MDT. Why put patients through the morbidity of both treatments, when they have the same likelihood of cure without surgery? In most major cancer centres in USA, they have already abandoned primary surgery for most oropharyngeal cancers because of excellent results from radiotherapy +/- chemo; most reserve it for post chemoradiation failures. However, it is hard for surgeons to give up cutting.

A doctor’s paranoia

Most of us got good training how on to recognise melanoma. The ABCDs. Yeah, can still remember it from medical school days, though it was 16 years ago.

Then when I start practising oncology, a bit devastated by how many patients presented with metastatic melanoma, and their initial mole was diagnosed as a benign naevus by GPs. Even met a really young consultant obstetrician who died from brain mets from melanoma. Surely a consultant would be able to recognise it? Apparently not. But there are times when melanoma can look like a mole.

So every now and then when my wife or I look at our moles; we ask “Opps, have I seen this before?”, “Err has it changed, or not?”, ” Should I get it excised and examined?”. Once, I had a GP remove a “suspected melanoma” on the sole of my foot. Results: benign. Well, diagnosis? Medical hypocondriasis.

Teaching for med school finals

I have been giving OSCE tutorials to a final year med student from my church. Poor girl; just months before her finals, her main tutor, who was meant to be giving her group tutorials in preparation for exams told the group he would rather concentrate on his private work he couldn’t do it. The medical school didn’t get any replacement; and her group was not in a habit of doing group study/practice examination. Since she is a friend, I offered her private tutorials. She was so grateful she even offered to pay me! Of course I declined.

I took a few sessions, and she was making improvement. Then, really close to the exams, I found out that I will be one of her examiners. She was concerned that it is “illegal” for me to continue teaching her, since I will be assessing her.

Thankfully medical school has encountered this many times; given that there are so many medical students in this city, one medical school and a finite number of clinical tutors; there is always going to be cases where an examiner examines a med student that they have been teaching. So med school issued a statement that iis unavoidable, but encouraged all examiners to be objective, and mark the candidates based on their performance on the exam day rather than the examiner’s pre-conceived opinion of the candidate based on previous experience.

She was nervous on that day but performed well, along with most of the other med students. She recently found out that she passed.

Received a big bad of thank you goodies (biscuits, chocolates etc) from her.  Glad to be of help.

Moving office

I was asked if I would like to move my office by the clinical director. My current room can be quite stuffy, esp in the summer. The ventilation is noisy, and doesn’t keep the room cool; the window is to a corridor, not to outside fresh air. It is like a cave, a dungeon; and a hot stale and stuffy one.

 

A senior consultant has retired and rooms are being moved about. So I was meant to move up the ladder to a better office with air conditioning. My room will then be occupied by a consultant who has just been appointed. There aren’t much land nor room to expand in my hospital; so this happen quite often when there is a retirement or a new appointtee. We move up the ladder to better offices, depending on seniority. So the more junior ones get the more lousy rooms.

 

Not sure why we have always accepted it that way. I know statisticians and research nurses who get into much better offices (though they have to share with a few different staff); I know hospitals who build new office blocks when there is consultant number expansion.

 

The new person who was meant to take my room is someone I know quite well.  In fact she started training same time as me, but took much longer to finish cause of maternity leave and returning to training part time. I find it hard to leave a crappy room to her. I thought Christ would have been content, and be happy to give better things to other people.

 

In the end I wrote to the clinical director that I would give up my place for the better office to my new colleague; and I will stay in the lousy room. Unfortunately I doubt other people will often do something like that for me.

So hard to teach old dogs new tricks

Trying to learn Chinese, amongst other things. Regret didn’t learn it properly when I was young. I wouldn’t have any interst to learn it now if not for my kids. Now Chinese has become a big thing; everyone saying how important it is for the future. SO trying to push kids to study the language, which is REALLY difficult given we are in a foreign country that barely speaks any other language. Also a bit of a hypocrite if I push them to learn it and I don’t learn it myself!!

 

So much hard work. I guess I am so busy with so many other things. Learning an oriental language when one is much older is so much harder work. Not impossible, as I have Caucasian friends who can speak and read Chinese much better than I do. But the amount of effort they put in is phenomenal. I couldn’t get the time nor discipline to put so much time into it.

 

So in the meantime, you can hear me practising broken Chinese with my kids.

ZZZZZZ

A friend of mine is a professional English Chinese medical interpreter. She was with a chinese chap one day undergoing doppler ultrasound for his carotids and his leg arteries. She did her usual translations about the procedure, and the patient laid down for the examination.

 

Not long after, whilst the ultrasound was still happening, a very loud noise filled the room. It was a very loud snore. It was the patient, who has fallen asleep. The snore is so loud it was difficult to politely imagine it wasn’t there. My friend was starting to feel extremely embarassed, although she is only acting as a professional interpreter, and is in no way related to the patient.

 

The radiologist, noticing her face turning maroon red, calmed my friend down, and said don’t worry it does happen every now and then. But I suppose not that many people snore that loudly.

 

Hmm, does that reflect on the radiologist: that he is poor cause he takes so long, and is so boring; or that he puts patient so at ease that they are completely relaxed.

 

 

Fire alert

I hate it when a false fire alarm go off in the hospital. Waste a lot of my time when I am already busy or behind schedule in doing my clinical work. Not once had any of the alarms been genuine fires; the most common cause by far is stupid people burning their toasts.

Many years ago, when my wife was on call, the fire alram went off. The ward was still full of patients, but no ward staff is to be seen anywhere. “Surely dedicated nurses have not abandoned their patients’ lives for their own safety” she thought, “After all it is very likely to be another false alarm”. My wife needed to go to the loo quickly before she join the mass of people outside the hospital main entrance.

When she went into the toilet, it was packed full of nurses, she hardly had a place to stand. All of them were putting on make up and lipstick, and doing their hair etc. Then it dawned on her.

You see, there is an obsession in a lot of Western females for firemen; cause firemen are meant to be macho, handsome, interesting, altrustic, attractive etc etc. Many young Western girls fantasise about romantic encoounters with firemen.

But who would have expected a whole throng of young nurses putting on makeup in the toilet during a fire alarm, in anticipation for the arrival of young dashing firemen?