Musical chair

Recently the clinical director stepped down, another consultant has taken over the role. In my hospital there is this tradition where the clinical director will occupy this big room next to the clinical oncology seminar room. Thus each time someone steps down, the old director will move out, and the new will move in. However there are not many rooms available so people have to move around. At the same time, one of the consultants is retiring (the pervious director is moving into it), and another has unfortunately passed away prematurely.

I was thinking perhaps I should upgrade to a better room now, since my room is pretty hot, without proper ventilation nor conditioning esp in the winter. The air can be very stale and stuffy.

So I asked the new clinical director. I have been eyeing his previous room, which is just across where my current room is.

Unfortunately another consultant (more junior than me) has made the first move, so it was his. His existing room is quite far away in a separate building and he would rather be near the majority.

Doop!

Well, the only room left is the room vacated by the consultant who died prematurely.

The only other chineses consultant in the hospital told me: don’t move into that room; bad fung shui (bad omen, since the previous occupant died prematurely). I couldn’t help but laugh that a consultant colleague can be so superstitious!

Giving A level tuition

For half a year now I have been giving free A level chemistry tuition to church friend’s son. They have very modest earning income; so I was happy to obliged. I thought surely a level chemistry can’t be too hard, since I got an A without any sweat those many  years ago.

But then it was more than 20 years ago! My goodness, how have I underestimated the challenge. So many things that used to click instantly seem so difficult to work out. My knowledge of chemistry have narrowed over the years into medical molecular biochemistry that simple organic and inorganic chemistry seem to be french to me.

I am also too busy with work and my kids to have proper time reading it up properly. But I don’t want to let this kid down. So I try my best, helping him through his past year papers, frantically reading his chemistry text books and revision notes as I do. It was a humbling experience: I learnt that I may be able to do a lot of things, but I am not necessarily as intelligent as I think! There are many times I just have to say I don’t know, looking things up from the books and the internet (which I don’t have easy assess to in his house).

Surprisingly, I got lots of feedback through the parents how happy he was with the tuition I give. Well, it wasn’t just because it was free. He got better grades during his class assessment, his teacher was surprised, and he was so much more confident. However he didn’t get as good a grade as he wished in the real A level exam, though he got an average of B in Chemistry. 

Has has more assessment coming up: I’ve got much more work to do…

Emotional shock

What do you get when you mix indignation and disapproval with sympathy, sorrow and regret? I don’t know how to describe it: the mixture of feelings roused up more emotion: resulted in a deep feeling of lost, perhaps mixed with some shame.

I had this colleague in my hospital who has been on “gardening leave” for more than a year. He was under investigation for professional misconduct, which included various things from treating patients beyond his area of expertise to changing patient records and fraud. During all this time I had a deep sense of resentment because taxpayers were still paying him a full consultant salary, whilst he is on gardening leave (used to be a joke: consultant physician with subspecialty interest in gardening).

I thought: what a waste of resources, large amounts of money that could have been used for patient care, patient service improvement, new treatment development. Instead, we are paying someone to stay at home. Worse than that; whilst he was awaiting disciplinary hearing from GMC, he was allegedly still heavily engaged in private practice in his spare time. How unethical, I thought. He was being paid a full salary for not doing any NHS work; in the free time he earned lots of pounds privately. I was fuming. Come on: get on with the GMC hearing; either reinstate him if he is guiltless; otherwise suspend him and sack him!

Something just happened. I heard that whilst he was attending his GMC hearing, he collapsed suddenly. CT scan has confirmed massive haemorrhage from a large aneurysm. He died very quickly.

Suddenly everyone in my hospital, including myself, felt so sorry for him and his family. He left behind a wife and a few young kids. There is this collective guilt: did the hearing trigger a hypertensive episode that led to the bleed? Wonder how the family feel when they received a collective condolence letter from the hospital.

Well, guilt is illogical. He could have died even if events were different and he wasn’t in a discipliniary hearing. Or you could say he brought this on himself by his unprofessional behavior. Legally it was out of our hands anyway. We didn’t initiate the investigations; it all started due to whistle blowing from a distressed private secretary, who didn’t work for our hospital.

Nevertheless it was such a horrible event. The sorrow and guilt wil no doubt linger for a long time..

Aiyah more respect lah please

Compared to many Caucasians my age I look young. Many Orientals do look much younger than their Caucasians counterpart for the same age. Well, untill around 50, then there is that sudden plunge. Then the appearance of aging seems to accelerate to an diabolical speed…

Well, many of my patients find it hard to believe I am a consultant when they first see me. When I first started as a consultant, I noticed it straightaway. I asked my wife if I should shave less often; that might make me look a bit older. She just laughed.

Not so long ago, I was doing a clinic, looking rather clean shaven. One of the elderly patients I saw for followup gave a gentle pinch on my face, telling her husband how lovely I was, just before she left the room. I was stunted. Yes by all means appreciate me, but please I am not a baby! I wasn’t so much upset as embarassed.

Not too long after, in the very same clinic, another elderly patient rubbed her hand on my recently cut hair, again mentioning to the clinic nurse and her relatives she thought I wa a lovely doctor, before she walked out. Embarassed again.

I do try to be nice to patients, but I seriously do not try to be cute. Esp not as an oncologist. I don’t mind the appreciation, but somehow those “adoring” gestures seem a bit lacking in respect. Despite the age gap, afterall, I am still your consultant….

Hmm.. maybe I should stop shaving for several weeks…

Mother and child

Unfortunate family. Mother and son are both my patients. Mother in her 50’s has stage 3 lung cancer, son in his earlly 30’s has Stage 3 head and neck cancer.

Son responded real well to treatment, almost a year since completing chemotherapy and radiotherapy, MRI showed no disease.

Mother had little disease response from chemotherapy and radiotherapy, although it was given with a curative intent. Been keeping an eye on her clinically every couple of months. Just this week, the most recent CT scan showed metastatic disease. It was devastating. More for her than for me, of course, but I was so affected.

I usually pride myself in being able to detach myself emotionally when it is needed so that I can be objective and be the best oncologist I can be for my patients. Most of the time I could do that. But in this case I have built such a strong relationship with the patient, her husband and her son over the years, it feels like I am so much a part of their life. Having to honestly tell her now that all is lost, disease is now incurable, and her life expectancy short felt like being kicked in the groin.

In the clinic I got to tell myself: pull yourself together! Think logically: what are you going to do for her? There are a few good phase 2 clinical trials going on at the moment so I recommended those. If she fails screening, then I could offer her standard 2nd line treatment.

Couldn’t help thinking how strange it would be as I continue to see the son when eventually the mother will die from her recurrent metastatic disease. How will that impact on our relationship as doctor patient: how it will affect his faith in me.

A lesson in humility

It wasn’t the nicest of experiences. Being dragged into an inquest in a coroner’s court. It seemed so unfair: I wasn’t given the post mortem report prior to the inquest. The pathologist (general pathologist, with no subspecialty interest in oncology nor have seen many such cases) thought that the patient died from acute lung injury due to the treatment I have given, and I had to give my defence without any prior preparation. In the end the verdict was aginst me.

I was furious. I brought the case back and discussed it in an oncology centre, in a meeting with 2 medical oncology consultants, 4 different clinical oncology consultants, an oncological cardiothoracic surgeon and 2 radiologists with subspecialty interest in oncology. After reviewing the case, everyone felt that the verdict was wrong and the patholgist was mistaken to attribute the acute lung injury to my treatment. The timescale were all wrong, he had treatment too long ago prior to the acute respiratory eposide. Lucky for me, the patient has a CT of his thorax about a week before his death which showed no lung parenchymal abnormalities. This confirmed that the ARDS  had developed between the date of that scan and his unfortunate demise. That CT scan was done about 6 months since I had given him radiotherapy for a critical 67% malignant tracheal stenosis. More likely than not he would have developed his ARDS from undetected viral infection, or aspiration, or allergic reaction to antibiotic treatment in his disctrict hospital for presummed lung infection etc etc.

I felt a bit vindicated. One of my colleagues in the meeting suggested that I should write to the pathologist.

It was a really traumatic experience. Thank God my fury over the sense of injustice settled quite quickly as I reflected: what does God want me to learn through this experience. Surprisingly I started to feel very calm when I learn to be humble under God’s hand through this bitter humiliating unfair experience. Sometimes in life, the important thing is not to get vindicated so that the wound to my pride can heal. Perhaps it is more important that the wound doesn’t heal, so that pride can be replaced by humility. Yes, even when I am right.

Generate savings

I have just been issued with an e-mail from the clinical director asking all consultants to write down how each of us has made savings for the Trust. Then within a week, some manager came to the consultant meeting and repeated the request, suggesting that the exercise will allow the trust to know how we have been making savings for the Trust, so that the money can be reinvested into the appropriate department for development.

Can’t help but feel skeptical. There have been numerous occasions where donations (from my patients) earmarked for my department, or sponsorship from drug company have disappeared into a black-hole somewhere in the Trust never to be seen again. Do I really think they will reinvest the money into the department?

Furthermore I find it really ridiculous that clinicians (who are supposed to be concerned about patient care) have been asked to do jobs (providing evidence for financial savings) which managers are meant to be doing. After we have done it for them, they simply take it up, write it in their CV and end of year performance report as an evidence for a bonus. Yes, and they have the guts to ask busy clinicians to do it for them!!

I could think of a few things I did which may have created increased efficiency and savings over the last year, but not sure if I would bother to write them a report!

No insight

Most of the newer oncologists should have been on advanced communication courses, and through practice can often relatively good at breaking bad news to patients. But this one is a hard nut for me to crack.

Has a trainee who has been having regular probelms throughout training. Wondered whether he should have been appointed at all in the first place. Medical colleagues, nurses, radiographers, etc had found him difficult to work with. Initially it was related to his communication skills. He seemed to offend people easily, and could not communicate well to colleagues without appearing abnoxious, bullying and dismissive. It took a lot of “one to one” talk to make him understand that he has a problem. Even then he seemed to have little insight. It was not until we threathened to fail his annual registrar in training assessment, sent him on a compulsory advanced communication course that he started making some improvement.

But communication was not his only problem. He seem to have difficulty going through things logically and sensibly. A previous consultant supervisor gave him a very simple audit project to do, and he can’t even present the findings logically and to the point despite repeated coaching. He also seems to lack insight into what is appropriate and what isn’t, whether it is clinical or social issues.  For instance that it isn’t appropriate for a junior registrar to approach a director to try to secure non medical jobs for his relatives.

We have mentioned the above points to him repeatedly. Little seemed to have been understood.

He happened to pass his exit exam on first attempt whilst some other deserving candidates didn’t. Now he is pursuing everyone in the department, from consultants to clinical director for projects and for a job. And he is interested in my area of subspecialty interest. Neither my colleagues nor I would trust him with any projects; and I told him honestly that his chances of getting a job locally is extremely low. Message didn’t get through; he kept persisting and spoke to other colleagues about the same issue (who in turn told him the same message: no chance).

Whilst I am a strong believer in second chances; he hasn’t made much progress overall despite him having passed his registrar exams. Over the years I have thought about all the possible ways I could help him make a better doctor, but nothing worked. As a trainer, I think about his future, but as a consultant I have to think about the future of the department too. Having him will be detrimental to the department. I will not feel safe nor comfortable about him looking after any of my patients. I am not sure I could trust him as my staff grade, let alone a consultant colleague. I could not bear the thought of involving him in my research projects. But he still keep hassling and persisting. Unfortunately persistance alone can’t make a good consultant.

Unfortunately the likely course of events is he will still get a consultant job in St Elsewhere, where they have to bear with him; until hopefully with years of experience he will somehow improve generally. I hope.

Supplements: to prevent and treat cancer!

Alternative healthcare practiontioners have been championing various different vitamins and minerals as a way to prevent or even treat cancer. They base this on the presumption that many of these supplements are anti-oxidants; and using this pseudoscience concept they beguile the unwary public into loads of supplements. As you can guess: no randomised trails to support their claims. Meanwhile the vitamin and mineral supplement industry is grinning (in US it is a $22 million industry).

A large scale randomised trial involving 14 641 participants with follow up of 10 years have just shown that Vit C and Vit E did not lower the risk of cancer, including protate cancer.  Another large scale study, the SELECT study found that Selenium and Vit E do not prevent prostate cancer. Not only that it found an INCREASE in the risk of prostate cancer in those taking Vit E alone, and increased risk of Type II diabetes in those taking Selenium. Another study, the CARET involving 18000 subjects found that beta-carotene INCREASES the risk of lung cancer.

Meanwhile the alternative medicine practitioner continues to promote antioxidant supplements; based on their case study of 3 patients who may have felt that vitamin supplements helped. Of course it was the supplements that cured the cancer, not the surgery. Yes and they forget to mention those cases may have had other treatment such as chemotherapy and radiotherapy. Surely 3 case studies can provide all the scientific information you, need; forget the trials that involve more than 100 000 patients with longer than 5 year follow up. :0 For some bizzare reasons, the general public, including those who are better educated with degrees etc would rather believe alterative medicine, rather than evidence from phase 3 randomised trials.

The only vitamin that may be promising is Vit D; even then it has to be proven in a phase 3 randomised trial. Meanwhile physicians like us have a hard battle to try to convince people who would rather be deluded.

Christmas 08

Agreed to take lots of overseas students to my home for Christmas. Thought it would be nice for these chaps who don’t have a home to go to for Christmas. unfortunately closer to the date, whole family was hit by flu last 2 weeks. Poor wife completely flattened by the virus, was in bed all week. Wondered if we would cope with all these people descending into our house, but we persisted anyway.

On that day it turned out that there were 25 people in the house. Woke up real early to start cooking (wife was up at 0600). Kids opened their presents in a rush, but still enjoyed the process. Rushed to church, then back.

It didn’t turn out to be the disaster we expected. Another family brought some food too, and the students helped clean up in the end. After that most people had fun playing games and Christmas quiz, although I felt my throat is being ripped out in the end of it, due to my sorethroat and me trying to get everyone to participate in the games. People commented that they really enjoyed the day at our house.

Thank God it turned out well.