Odysseys of George

Today in the newspaper, the Director General of Health spoke on a few issues namely:
1. The exorbitant fees in private practice
2. The failure of medical curriculum
3. The loss of human touch
4. Mushrooming of medical schools
5. Quality of Housemans

Lets look at the issues which actually has been around for ages and yet the typical Malaysian attitude prevails that is to make noise and then forget about it as fast as it was brought up.

The issue of exorbitant private fees have been brought many times but what most of us fail to understand is that while the doctors charges are regulated by the MMA, the private hospital charges aren’t. Well, then again there are many aspects that this matter can be looked at. The doctors who do their job and charges according to the MMA schedule, well I guess that should not be an issue. However, there will always be the ugly ducking, where charges are made unethically, though bounding to the schedule – that is to say there are abusers of the schedule — people who will make multiple charges for a 10 minute procedure for instance. From the hospitals standpoint, medications, technology and utility charges are rising and therefore the need to increase the charges gradually but saying this some hospital managements are equal to that of hotels. I suppose that it is difficult to regulate the hospitals as many sitting on the top of these hospital managements are linked politically or another and thus are indispensable. So the best way – squeeze the doctors!

The failure of the medical curriculum and the mushrooming of medical faculties are issues that have been voiced for many years. The problem is that those who now enter universities are not mentally prepared to undertake the real university education which for the failure of our secondary education, the tertiary education has been modified. Many lectures and professors have been heard saying that students that enter universities nowadays are not mentally matured as what it was before. The students are less resilient and the need to “hold hand and guide” is so high that if the past system maintains there would be many more failures and mental breakdowns. This I believe is the failure of the primary and secondary education. Then we have the major migration of brains to overseas especially to our neighboring Singapore. Then we have so many medical schools that blooms faster than mushrooms that dilutes the brains further. This has caused many major medical faculties to fall to the support of younger inexperienced staff to teach. Many of these new medical faculties do not have enough staff to teach their medical students and are dependent on the support of government specialist to assist the teaching of their students. The remunerations in pay and the acknowledgment of the work of those who did this country proud has been forgotten and left unattended to the extent frustration would be the natural response. Now, in government service everybody is sitting on the same scale as long as you are a specialist regardless of seniority and experience which is paramount in medical fraternity. I regress. The curriculum has been modified over time to make medical education more fun and attractive at the price of the quality of education. The so called US-based system is adopted without taking into consideration the local health system. There are more assignments and projects which has overtaken the need of medical students to spend time with patients. So, one wonders why the loss of human touch? Medical students nowadays hardly spend anytime with patients unlike my time. I have seen this happening in UMMC,UITM and also USIM. I am sure it is across the board.

Then we have the new houseman. As it is with students entering universities, we now have fresh doctors who are not ready to work and fail to realize that they are in a job that deals with life. Our government has spent billions to send some “brains” to many ambiguous medical universities overseas where the curriculum is worse than that of our very own — where they hardly have exams and that these fresh doctors hardly know what the thyroid gland is or what hernia is all about. It irritates me that the DG says that the onus are on the specialist to train these fresh graduates when at the same moment protects these bunch of fresh doctors with various rules and regulations. These new doctors are so not ready for the job that in recent years, as the DG says, “There have been many instances where housemen experienced mental anguish, depression, anxiety, stress and suicidal tendencies while undergoing training and this is no laughing matter.” But the truth to the matter is not to then blame the specialist but to then go back to the crux of the issue – stop sending these students to such places. As a patient, would you be happy to be treated by somebody who know not where the thyroid gland is or know not how to ascertain your diagnosis because he has no clue what your complaint is about? Is it fair for the public to be treated by these generation of fresh doctors even though there are specialist supposedly overlooking their work? There are people you can train and teach and there are the ones you just can’t! To make things worse, the DG decides to enforce a promotion exercise where part of the assessment is from the housemen– “As such, he advocated a two-way assessment system where not only the specialist and doctors provide feedback, but the houseman would also be given an opportunity to provide feedback on their trainers. On the criteria for promotion of public service doctors, Ismail said it was based on five main aspects, namely service, training, research, one’s standing in the eyes of peers and the 360 degree perception” — ridiculous — it only encourages the system to get worse then any better as now those specialist who really care and are strict would be judged badly and those who have no regards for the future of the medical system would be promoted quickly – Bullocks!

This is just part of the matter but I have said enough for now!

I have always wanted to watch a stage show – a theater, a musical etc. Recently, I managed and I was left in awe of the show – so much so that it still seem like it was just yesterday I watched it. Maybe, I could relate to it at many levels – and thus this musical really did touch my heart and I found myself crying. This show that I speak of is non other than our very own, “Adam, the Musical” .

The show started on the 12th May 2010 and will be the first ever to run for over a month and ending on the 20th June. The show written by Mark Beau De Silva and directed by Joe Hasham, is based on issues pertaining to HIV/AIDS. The crew was excellent and delivered the musical so very well. The music was good and I especially liked the song,” Here, Here’s a Lollipop” and “I dont need a wheelchair anymore”. The actors and actresses was all very very good with the likes of Dato Faridah Merican, Malik Taufiq, Tabitha Kong and also who could forget the role played by Tria Aziz.

This musical brought many thoughts to my mind. As a doctor, I have come across many HIV/AIDS patients and have taken time to listen and care for them.I have also seen how the community and also the medical institution treated these group of patients. Many would say, “They deserve what they get for the way they behaved!” I never agreed with these remarks as I feel nobody deserves to be sick of any disease what ever your character or conduct is like. Furthermore, who am I to judge them, as I myself have my own shortcomings. Then again how would that remark above fit for those born of mothers of HIV/AIDS or those who got it from blood transfusion. It made me remember of this one particular patient I took care of in my early years of service. A young Chinese man diagnosed with AIDS and then at that time AIDS was new to the world. His family deserted him. He had no visitors. He understood why but was feeling very alone without anyone to confide in. He had many things to say but to no one. Nobody was interested enough to listen. He did not want advice, he did not want empathy but just a ear to hear him. I was that ear ………. and he as my patient has somehow become my unofficial teacher and thought me that my duties as a doctor had a wider definition. For that, I owe him for being who I am today. I watched him deteriorate every day and breathing his final breathe, brought tears welling in my eyes then… I still remember his face.

The other part of this musical that touched me was the emotional dynamics that was going on between the couple and their respective family. The musical depicts the lady, Sylvia and her sister and the gentleman, Adam and his Auntie, who took care of him as her own after the death of Adam’s mother. It also touches a little on the fact that both are of differing religion. It also the addresses the emotional and realistic issue of loving a person who has AIDS/HIV from birth. What or how would you react if your spouse or loved one was found to have HIV/AIDS? I had recently had a friend who was diagnosed to have HIV and he expressed to me his fear of telling his girlfriend of his condition. We had the same discussion over tea a few times and despite my medical advice which I have given him, I understand the fear and worry he harbors.

Watch it before it finishes, I assure you, you would not be disappointed.

Taken from article written by Martica Heaner, M.A., M.Ed., for MSN Health & Fitness

Burning Fat

When your body moves (or any cell in your body does any type of ”work”) it needs energy. The amount of energy needed is measured as a unit of heat—or a calorie. The fuel to produce this energy comes from several sources, mostly fat and carbs (glucose), and occasionally amino acids (protein). How and when fat is ‘”burned” (or metabolized to provide energy for the body) and how that affects body fat levels and weight is a very complex area of physiology research. There have been hundreds, maybe thousands, of studies exploring the utilization of fat for energy under a variety of different conditions. There is still much to be understood, but this is how we know it works so far:

Whether you are watching TV or running around a track, the fuel your body uses to give you the calories your cells need for energy comes from burning mostly fat and carbs. Your body nearly always burns a mix of both fat calories and carb calories. So normally, for every calorie burned, the fuels are around a 50/50 split of both fat and carbs.

How hard you are moving during exercise is one major determinant of which fuel your body will use. Carbs provide a faster energy source. So whenever you need to do something fast or produce force, carbs are the better fuel. Fats are favored during long, low-intensity activities. It’s not that you stop using one or the other fuel, it’s that the ratio of both shifts depending on your activity. In more scientific terms, you alternate between aerobic (more fat-burning) and anaerobic (more carb-burning) metabolism.

Losing Weight by Burning Calories

When it comes to weight loss, it really doesn’t matter whether you are more or less fat burning. It doesn’t matter what your calories are made of, but it does matter how many calories you burn—and the more the better. So when you are sitting—and burning more fat–you are burning only about one calorie per minute. Clearly, even though you’re in a greater fat-burning state, no one ever lost weight by sitting! (How many calories you burn depends on many factors, including how heavy you are—the more you weigh, the more you burn.)

You do burn less fat when you work anaerobically, but it doesn’t matter because you are burning more total calories. You will always burn more calories the longer or harder you exercise, no matter what your intensity is. So doing cardio for only 15 minutes makes no sense unless you are short on time. Burning BOTH fat calories and carb calories can result in fat loss or pounds off the scale.

The Ideal Amount of Cardio

How much exercise you need to do depends on your goal. Even small amounts of exercise are great for your health. Just moving a little every day can improve metabolic functions, such as how sensitive your body is to insulin and how it reacts to excess blood sugar. Exercise can also reduce your risk of heart disease and other chronic conditions. That’s why the U.S. Centers for Disease Control and Prevention and the American College of Sports Medicine recommend that all healthy adults accumulate 30 minutes of moderate intensity activity on most, if not all, days of the week. Although all types of exercise count, generally the recommendations reflect more cardio activity than lower-calorie-burning moves like strength work or stretching.

The big question is whether you’ll drop weight from this amount of exercise. The answer is that some people can. If you work a little harder in that 30 minutes, you will burn more calories and that will have a bigger effect on weight loss. If you have not been active before, then doing 30 minutes of low-intensity activity would still probably help you lose weight.

The less cardio activity you do (or the fewer calories you burn per workout), the slower the weight loss, and that’s because it’s a numbers game. In 30 minutes of moving around, you might burn 150 to 300 calories. But, theoretically, it takes burning around 3,500 calories to lose one pound of fat. So, you’re going to have to do enough workouts, at say 150 calories burned per session, to add up to 3,500 calories, or 17,500 calories for five pounds of fat, and so on.

The problem is that most people give up if they don’t get concrete results fast. Also, different people have different physiological makeups. So this theoretical caloric equation may not work perfectly in every body. That’s why more realistic fitness guidelines for losing weight or maintaining weight loss have been established. The Institute of Medicine and the USDA’s Dietary Guidelines recommend that a person do 60 to 90 minutes a day of accumulated moderate-intensity physical activity at least five days per week.

Can Exercise ‘Burn Muscle’?

This claim is slightly misleading. You certainly do not burn muscle after only 15 minutes of exercise. You start using protein (perhaps from muscle, as well as other amino-acid-containing components in the body) for energy under extreme conditions such as starvation and at the tail end of long, hard endurance events where carb stores are in short supply. The average person who works out does not need to worry about this.

Will More Muscle Rev Up Your Metabolism?

In short, probably not. The average person won’t lose muscle from doing cardio and won’t burn more fat by building more muscle, mostly because one has to eat more than usual (not diet) and lift seriously heavy weights to build more muscle. And even then that person probably won’t build enough muscle to make a difference. Dr. Joseph Donnelly and other leading exercise physiologists conducted a comprehensive review of all the research on exercise and weight loss for the American College of Sports Medicine. While resistance training was recommended for its beneficial role in potentially improving muscle strength and power, the physiologists found no evidence that increasing muscle mass enhanced weight loss, especially when combined with dieting.

48 year old lady presented with bilateral breast lump. On examination, vague breast lump at upper outer quadrant of both breast. Negative risk for malignancy. Had a procedure done in a beauty parlour 25 years ago.

Any guesses?

The elderly lady above demonstrates a case I saw in my clinic recently, but my patient was way younger in her early 30s. She developed this weakness over the left side of the face which was rather sudden in onset 3 days prior. She was otherwise very well and there was no history of trauma, infection or ear symptoms. There was neither any headaches nor any weakness associated to the upper limbs and lower limbs. She was otherwise well.

She had all the findings as the picture above, actually exactly like the elderly lady above. So what was wrong?

Well, this condition occurs when the nerve which is responsible for the control of facial muscles becomes swollen or inflammed causing the muscles to paralyse or weaken. It is usually abrupt with no apparent cause. This syndrome was first described in 1821, by the Scottish anatomist and surgeon Sir Charles Bell. From then, this condition was called Bell’s palsy. It is an interesting disease but a scary phenomenon for patients.

The nerve involved is called the facial nerve. The path of the facial nerve is complex; this may be the reason the nerve is vulnerable to injury. Two portions of the facial nerve leave the brain at the cerebellopontine angle, traverse the posterior cranial fossa, dive into the internal acoustic meatus, pass through the facial canal in the temporal bone, then angle sharply backwards, where they pass behind the middle ear and exit the cranium at the stylomastoid foramen. From here, the facial nerve bisects the parotid gland, and then terminal branches extend from the parotid plexus to innervate the muscles of facial expression.

Though the cause is still yet unknown, many believe that majority of them are due to viruses. The most common being the herpes simplex virus, which also causes cold sores and genital herpes. Other viruses that have been linked to Bell’s palsy include the herpes zoster (chickenpox and shingles) and Epstein Barr (infectious mononucleosis).

Bell’s palsy occurs more often in people who:

* Are pregnant, especially during the third trimester, or who are in the first week after giving birth
* Have diabetes
* Have an upper respiratory infection, such as the flu or a cold

Like my patient, there is also a genetic predisposition where most of them have recurrent attacks of Bell’s palsy but this is rare.

For most people, Bell’s palsy symptoms improve within a few weeks, with complete recovery in three to six months. About 10 percent will experience a recurrence of Bell’s palsy, sometimes on the other side of the face. A small number of people continue to have some Bell’s palsy signs and symptoms for life.

Eye care, steroids, pain control and reassurance are the main essence in the treatment of Bell’s palsy.

Well it has been some time since I have written anything medical based. So, I was thinking and realized that for something so common this particular problem is so little discussed with public. Then again, I guess the reason being that despite knowing much about it, we still find this a difficult issue to treat.

So what is Dyspepsia? continue reading…