Angry Doctor

Tuesday, November 22, 2005

angry doc asks - 1

Business, or personal?

I’ve actually run out of things to say this week, so I thought I would listen while you guys talk (or rather read what you guys write) instead for a change, if you will be so obliging.

In my reply to TTG’s comment in an
earlier post I quoted this passage from The Godfather (novel not movie):

"Tom, don't let anyone kid you. It's all personal, every bit of business. Every piece of shit every man has to eat every day of his life is personal. They call it business. OK. But it's personal as hell. You know where I learned that from? The Don. My old man. The Godfather. If a bolt of lightning hit a friend of his - the old man would take it personal. He took my going into the Marines personal. That's what makes him great. The Great Don. He takes everything personal. Like God."

Of course, in the movie what Michael said was:

“It's not personal, Sonny. It's strictly business.”

I have no idea why Francis Ford Coppola decided to change the line, but I think you will agree that it gives a totally different spin to the whole story.

I’m not sure which version I prefer.

As doctors we deal with people. People whose ailments are very real and very personal to them. Every pain, every discomfort, every disability, every loss.

We sometimes take the bad outcomes that patients encounter as the 'natural history of the disease', or 'known complication of the procedure'. We keep a clinical distance from the emotions. We accept them as part of our job and we move on. We call it 'professional'. But it can be personal as hell.

I once watched a colleague cry after the death of a patient, a death which he thought he ought to have been able to prevent. There, in the presence of other doctors, both junior and senior, he wept. The guilt and grief were real and palpable. At that moment there was no worry of legal implications, no thought about setting up review committees. Just raw human emotions. I didn't think him any less of a doctor then, or now.

Do you?

I end with another quote, this time from
House, speaking to Foreman about him and his former mentor:

"You took a chance, you did something great. You were wrong, but it was still great. You should feel great that it was great. You should feel like crap that it was wrong. That's the difference between him and me. He thinks you do your job, and what will be, will be. I think that what I do and what you do matters. He sleeps better at night. He shouldn't."

Thank you.


  • Qn:
    Do u start your mornings with such 'cheem' thots??

    By Anonymous Anonymous, At November 22, 2005 9:03 am  

  • Ans: No, I end my days with such thoughts, and blog about them in the morning. I don't think they are cheem though.

    By Blogger angry doc, At November 22, 2005 10:35 am  

  • I think patients would prefer that their doctors are personal. Can you imagine someone saying my doctor is very impersonal?

    But I also think they want their doctor to be professional too.

    The problem is that whether a doctor comes across as personal or professional is very subjective. To some patients, action A is personal and professional, but to another it isn't.

    One thing many people do not like however, is the thought that doctors make money. In many people's eyes, doctors should not make money. They should earn what grass cutters, and rubbish collectors make.

    By Anonymous Anonymous, At November 22, 2005 10:44 am  

  • The question is: as a doctor, do you take it personally, or do you think of failures as a course of your work?

    By Blogger angry doc, At November 22, 2005 10:53 am  

  • You know, its funny. The people that struck me the hardest were those who accepted whatever negative prognosis that went their way, instead of the usual run-of-the-mill complainers and whiners. The quiet people always got me thinking about what it means to be human. After all, a loud complaint slides of my back like water off a duck but the quiet ones...they keep me awake at night.

    By Blogger andrew, At November 22, 2005 11:04 am  

  • I read "The Road Less Travelled" on the recommendation of a relative some years back.

    Dr Peck basically wrote that "to live is to suffer". We should not be expecting life to be a bed of roses with no problems. Those who think so are mistaken. Life is about problems, about suffering, about trials.

    Those who complain and do nothing to improve their situation or overcome their problems are deluded.

    It helped me to realise that our lives are what we make of them. Yes you can complain, but do something about it.

    "If you keep doing what you always do, you'll just keep getting the results you always get. To expect it to be different while doing the same, that's the definition of insanity." - Dr Oz Bloke

    By Anonymous Anonymous, At November 22, 2005 11:30 am  

  • Speaking for myself, I do take it more personally if it is a patient I have known for some time.

    Although emotional boundaries are necessary to ensure professionalism, lack of empathy with a suffering patient is a sign of either 'burnout' or sociopathy in my opinion !

    On the other hand, personal involvement impacts deleteriously on the quality of medical care. You either over- or under- treat if, to exemplify, you try to treat a family member.

    I think the key is acknowledging we are human and accepting that as such some patients will affect us deeply, but to allow one's emotions to impact at all on the care provided is highly inappropriate, and unprofessional.

    By Anonymous Anonymous, At November 22, 2005 11:41 am  

  • 'Cheem' thots.. I meant it's emotionally draining enough having to face all the drama for 1 working day.. not necessary to carry it over to start the new day, ya? :)

    From a patient perspective:
    Don't expect the Dr to be the best pal with every single patient... but at least make the effort to educate the patient so that patient has better understanding of his/her health condition and learn to self-manage and take better care of himself/herself.

    By Anonymous Anonymous, At November 22, 2005 12:00 pm  

  • balance is probably the most important.

    Should the doc who made a mistake cry?

    Personally, I think it is not not important if he expresses guilt or just taking it as a matter of fact that these mistakes happen. What is more important is how this experience shape his practice. Some will learn from the lesson while others may not live past this lesson. I think this is a big responsibility to shoulder and good doctors have to be able move on.

    By Anonymous Anonymous, At November 22, 2005 12:03 pm  

  • Some input from your friendly neighbourhood patient:

    In the West, doctors from interns to specialists see probably no more than maybe 15 patients a day and that is already pushing the envelope. When you consult them, it is not just a perfunctorily effort to find out what it is that is ailing you but a nice friendly chat followed by a pretty thorough body examination. You can also tell from the doc's countenance that he is thinking hard and arriving at some sort of well thought out diagnosis and maybe a prognosis.
    If he still cannot understand your problem, he will probably even think about it at home and try, try his very best to help you. Of course like everywhere else there are the rogue doctors but they are a minority. I don't suck up to the west, but they(medical health personnel) epitomise the ethos set out in the hippocratic oath. Health care costs is high but what you pay is what you get.

    Contrast this with the Singaporean neighbourhood "money milking shop". An average GP with a decent clientele sees probably about 60 to 70 patients a day. You go into his room and the first thing he asks you is, "Yes?" in English. For the dialect speaking, "Seem me dai chee". There is no attempt at civil niceties. It is always cutting to the chase. The eye is always on the bottom line. What's today' takings? The consultation and the diagnosis thereof is a textbook set piece. The medication is the cheapest available on the market commensurate with what they will be charging the patient. Most cannot charge what is recommended by the SMA because to do so would drive away their clientele.They are constrained more by market forces rather than any altruistic motives. When you leave their room, that's it adieu till the next time you come in again. Even if he suspects that you may have an insidious life threatening illness, he will not contact you ever if you do not keep your next appointment. Let someone handle the unpleasant aftermath.

    The scene in our polyclinics and government hospital outpatient specialists clinics is no better. A polyclinic newbie sees about 100 patients a day sometimes. Is that possible? A specialists about 30 to 40 a day, perhaps? I am just wondering what kind of special medical expertise he can bring to the poor patient when his brain is almost cooking in the pressure cooker. And...compounded by knowledgeable patients who questions his prescription or diagnosis, it is really the last straw for many. Who are they to question, me, a specialist, they'll be mumbling to themselves the whole day.

    I don't mind doctors making money. I do mind the methodology about getting that money. For all the years of mugging, internship and training, it is right that they earn more, much more than grass cutters or rubbish collectors.

    Therefore, to hear anguish coming from our doctors is to say the least unbelievable. Having said this, there are highly motivated men of medicine but they are the exception rather than the rule. In Singapore, you can probably count all these fine men with your ten fingers.

    I have a good family doctor. It took me fifteen years to elicit a friendly smile from him now when I see him. A consultation with him is always supplemented with "homework" from me to find out the what I am afflicted with, what medication should I take, and what I can do to alleviate my problem. For $25 a visit plus medication, you know it will not go a long way without you yourself doing something proactive to HELP HIM TO HELP YOURSELF!

    To all members of the honourable profession on this "comment" segment, I do apologise for any unintended offence. I just want to give a prespective from a patient's point of view.

    By Blogger uglybaldie, At November 22, 2005 1:25 pm  

  • Dear uglybaldie,

    Your observations are spot on!

    Just to add a few points. Do patients in Singapore want to chit chat with their doctor? Some may some may not. I personally try to talk a bit more. But some patients are in a hurry.

    On the other hand my record was seeing 60 patients in 3 hours. And I was still deemed too slow for the company's HR manager.

    All in all, you are absolutely right about you get for what you pay. In the west doctors don't see 15 patients a day. That's too little lah. They see about 3-4 a day and work about 8 hours a day. So 24.

    The doctors also are more personal with their patients and do keep in touch.

    In the west people are generally more polite and have a sense of humor.

    In Singapore I once tried greeting patients "How are you" And they would scold me and say "of course no good lah ask for what?" So these days I say "good morning, how can I help you?"

    I used to say "bye bye see you again" and the patients complained to the girls outside that the doctor curse them to get sick again. So it's just bye bye now.

    I think it's a cultural problem. And perhaps I just don't like Singapore's culture. Which is why I much prefer to go to Australia to work.

    You get what you pay for. Do to your neighbour as you would have them do to you. I think in Singapore that's the problem. The majority are just not into politeness and courtesy.

    By Anonymous Anonymous, At November 22, 2005 1:41 pm  

  • "60 patients in 3 hours"

    Wow. Just wow.

    By Blogger angry doc, At November 22, 2005 1:54 pm  

  • Yeah. It wasn't practising medicine in my opinion.

    But the HR said most of the workers just wanted MC, cough cold and could be seen in 30s, very easy. They didn't realise many of them were diabetes and hypertension cases, smokers etc that needed time to see.

    But I learnt a lesson in life there. The paymaster was not the patients, but the company HR. And the HR dictated how I worked even if it meant it wasn't medicine. But my medical malpractice insurance was the same and I paid for it myself. I left that practice shortly. My parting shot to the engineers working in that company was "How long does it take to check a plan? 1 day? Why so long? If I can see a patient in 30s, you can approve the plan in 1 hour lah. I doctor can tell engineer how to work"


    By Anonymous Anonymous, At November 22, 2005 2:12 pm  

  • I think crap doesn't quite cover it.

    It merits some Hokkien.

    By Blogger angry doc, At November 22, 2005 2:46 pm  

  • Hi OZ doc,

    It takes two hands to clap and believe me, your patients would prefer that you were friendly, sympathetic and be able to empathize with their circumstances.
    As you may know, sickness is often psychosomatic and a friendly ear and a smiling face is often reassuring if not therapeutic. A dour looking doc. for me is a turn off. Do continue to be your good natured self. Your patients, most of whom may not really be pr practitioners may say certain things that may sound reproachful but trust me, deep in their hearts, they are already getting to like you and accept you as a skilful partner who will lead them to the path of recovery.

    Singapore patients are now much more informed and the days when doctors were treated with absolute unconditional respect, nay reverence even, is over.

    No real medical breakthroughs has been discovered in the last twenty years. Cancer is still a death knell for most. Aids is still incurable. The most frequent and profound medical refrain I've been hearing these days is............"We don't know why.....but we do know....
    Wu Sim mee yong?

    We are now on the fringe of a pandemic that is estimated by WHO with the potential to cost at least 150 million lives worldwide. Yet, a vaccine is still not available. The big boys of the pharmaceutical world is still working out their profit and cost analysis to find out breakeven points before they commit funds to intense research. What a really sick world!

    By Blogger uglybaldie, At November 22, 2005 3:27 pm  

  • Dear uglybaldie,

    You are again right!

    I call the industry I am working in the "sick care industry". What do we do mostly? Help people who are already sick become not sick. Not very ideal honestly.

    People generally like other people who are friendly, smile, polite and patient. I try to always be that to all my patients. I greet them nicely, I talk to them nicely and ask them politely. Some patients usually will smile back. But Singapore does have a service sector problem and it isn't just to do with the service providers. It's the customers too. Otherwise why would PM LHL mention it in a NDR?

    Cancer is indeed one of the great "deceptions" of the medical world. If you look up any respectable textbook, it will tell you that 5 year survival rates for cancer have improved. But overall mortality from cancer has kept the same or is rising. In other words, while we can prolong people's lives after they get cancer, we cannot cure them of the cancer. This is western medicine.

    There are many other schools of medicines eg Chinese, Aryuveda, etc etc. When western medicine says there is no hope does that mean the patient should stop searching for an answer?

    I think not. And as a doctor I am frank with my patients about this. And yes I do go back, think about it, dream about it and read up about it and share what I learned with them. They are always appreciative. But such patients are few and far between in Singapore. Most would just say "You young doctor dunno anything lah"

    By Anonymous Anonymous, At November 22, 2005 3:37 pm  

  • OK, Oz Bloke, uglybaldie, here's the expose:

    Everybody dies!

    Like I posted before, it's either going to be cancer (now the COMMONEST way to die in Singapore) or a heart attack or stroke. Next down the list are pneumonia and trauma.

    Nobody dies of "old age"! It's one thing or another, so we'd better teach people to stop worrying about staying alive, and start living.

    By Blogger angry doc, At November 22, 2005 3:47 pm  

  • Agreed!

    And hence as family physicians we are the best people to share with our patients what is healthy living. What is healthy eating etc. Preventive advice is best given by FPs. Hospital specialists are poor at preventive health. Why? They usually only see REALLY sick people who need tertiary care.

    Strangely we get these specialists to teach FPs how to prevent stroke. And the talk goes into prescribing drugs to lower cholesterol, treat diabetes, treat hypertension, treat AF etc.

    So to a specialist, to prevent disease and be healthy, you take drugs.

    By Anonymous Anonymous, At November 22, 2005 3:55 pm  

  • I think the pharma are pushing their luck too far now with their current 'EBM' about how you can never have too low a blood pressure or lipid level, and the new combi-pill that promises good health and longevity.

    ACE-I and ARBs are supposed to give good outcomes beyond their ability to reduce BP, through some magical processes which are incomprehensible to me... How many patients will live longer and by how much when translated to real life?

    I once had a patient who tried everything to control his lipids, forgoing all meats but fish, and then only steamed. No smoke, no drink, lots of exercise. I asked him:

    "Are you enjoying life?"

    He didn't know how to answer.

    By Blogger angry doc, At November 22, 2005 4:04 pm  

  • Interestingly, I can share with you a lot of have learned about cholesterol and humans.

    One thing is, we NEED cholesterol!

    A lot of patients who are on statins and have ridiculously low LDL levels of <70mg/dL are usually very fatigued and malaised. Many male patients also have erectile dysfunction and low libido.

    Yeah you're right, what's life without quality of life right? I'm sure the stroke patients will attest to that!

    By Anonymous Anonymous, At November 22, 2005 4:08 pm  

  • Everything is a balance lah.

    When patients say this and that heaty no good. I ask them. So are ALL heaty things bad? Or are ALL cooling stuff bad?

    You just need a balance. Most of the foods we eat are either cooling or heaty by definition. We just need to balance them. So if you need to eat heaty medicine, then drink more cooling water. It's that simple. Similarly with cholesterol. Remember T.Chol/HDL ratios?

    Balance is the key to all things in life.

    By Anonymous Anonymous, At November 22, 2005 4:11 pm  

  • Hi OZ Doc,

    Yo bro., I am really confused on what is preventive medicine.

    EVERYONE knows:

    It is harmful to smoke.
    It is harmful to eat too much char kway teow, ba kut teh, chai tau kway, etc. etc.
    It is harmful not to exercise.
    It is harmful to drink till you are intoxicated.
    It is harmful to lust after women.
    It is harmful to have a diet low in fibre.
    It is harmful to eat too much salt.
    It is harmful to be angry. (angry doc. why are you angry by the way?

    YET: why do people still die? some who do not do any of the above e.g. monks still die before their time?

    IN TRUTH: There is really nothing to prevent. Step 1, get primary health care. (That's you, OZ doc.) Step 2, get secondary health care if necessary. (that's you, Angry Doc.) Step 3 Prepare for the picnic with your maker.

    Here's a layman's tip to having low cholestrol, High HDL and Low LDL, and a T.Chol/HDL ratio of an athelete without medication. Get your gall bladder removed(yeah, right, I'm stupid) Some good anti chol. genetic propensity helps too.

    By Blogger uglybaldie, At November 22, 2005 4:23 pm  

  • First of all, let me remind all readers about using this blog for medical info. Don't.

    Quality of life is not a big issue in EBM, but that doesn't prevent drug companies from putting pictures of happy-looking people in their ads.

    Why am I angry? Because I think the system can be better if we talked about what's bothering us, and angry doc is the persona I chose to use for this purpose. Happy doc just doesn't seem to be as catchy...

    By Blogger angry doc, At November 22, 2005 4:30 pm  

  • Dear uglybaldie,

    ah you just mentioned all the harmful stuff. All the bad stuff. But that's the thing here. If you don't do the harmful stuff does that make you healthy?

    Does no harmful stuff mean you are doing all the good stuff?

    One of the big debates in nutrition circles is whether we can get a rich micronutrient diet with our current commercially grown food supplies. Or do you need supplementation. It's a debate.

    In the same way, those who exercise a lot can also harm the body by excessive production of FOS.

    Similarly if you eat too many vitamins but don't eat food, you can also cause harm because anti-oxidants themselves are free radicals.

    Omega 3 fatty acids (that produce series 1 and 3 prostaglandins) and omega 6 fatty acids (that produce series 2 prostaglandins). Neither is "good". It's the right balance that makes them good.

    So it's a balance and everyone's balance point is different.

    It isn't easy but we should try. Using drugs is not the way to go in my opinion. It's the lazy man in the modern world quick fix approach.

    But hey I don't have the elixir of life either. But what I'm trying my best is to give a balanced view of medicine, health and life.

    By Anonymous Anonymous, At November 22, 2005 4:33 pm  

  • Hi OZ doc,

    Once, mega doses of Vitamin A nd E were touted as the preventive panacea for all kinds of medical woes. Not anymore. At first, I was skeptical. Now I am cynical about the whole thing on nutritional supplements. Like you said, everything is about balance and may I add harmony.

    In my mind, quality of life supercedes longetivity. I believe in destiny and fate. I also believe that whatever preventive measures you take or whatever abstinence you make, it is not going to make one iota of difference when your time is come. So let's drink to that, shall we?

    By Blogger uglybaldie, At November 22, 2005 4:53 pm  

  • uglybaldie,

    Well said. Harmony is another aspect. Yes the mega doses of single Vitamins has been almost proven not to work anymore. I have read up a bit about biochemistry again, and found that there is a lot of interaction between the various vitamins. Many are cofactors of many different processes.

    Well how you live your life is entirely up to you, that's what I always say. Some want to live long, some don't bother. One man's food is another's poison.

    Whatever people want. :) I'll drink to that, but I only drink non-alcoholic wine (I am allergic to alcohol)

    By Anonymous Anonymous, At November 22, 2005 5:01 pm  

  • huh? coming from Austrylia, not drinking some alcohol is really a waste. When I was staying in Perth, I drank wine because it was cheaper than coke.

    When I was there, I fished for my dinner when I was hungry. The apples and oranges fell from the trees. (In a country up north, the natives wait for the coconut to fall before they take out the curry pot!)I pluck grapes to pop into my mouth from vines overhanging my doorway. My chickens laid the biggest white eggs you ever did see and my cow's milk sustained me on my fishing trips in my cabin cruiser. What a life! Better than any nutritional supplements or don't do this, don't do that advice!

    By Blogger uglybaldie, At November 22, 2005 5:19 pm  

  • Uglybaldie,

    you're THE MAN!

    With all that, you really don't need no supplements :)

    I hope I can have that can of lifestyle some day.

    By Anonymous Anonymous, At November 22, 2005 5:24 pm  

  • Oz Doc,

    Being the good doc, you are, I have no doubt you will some day.

    Nice to exchange notes with ya. I'm off for my evening stroll in the park with Downer (my pomenarian)

    Cheers and take care._

    By Blogger uglybaldie, At November 22, 2005 5:32 pm  

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