Endless hallways to learning

Day 13. National Blog Posting Month.

Conference centers are like mazes only with poorly designed signage. Seriously this place is so confusing and watching a group of doctors all thinking they know where they are going only to find find out they were supposed to turn left at the fork then right at the double doors then right again is kind of funny.

The morning sessions were pretty good. I got a refresher on the difference between episcleritis and scleritis and learned its never a good idea to prescribe steroid drops for the eye. I also learned that the adolescent brain is very vulnerable to substance use and their neurobiology doesn’t full mature until well into the mid-20s.

I had a very educational 3 hour workshop/course this afternoon. I learned some key tools that I think will go a long way in helping me with some of the more challenging patients I encounter.

Overall it was a great day aside from the ongoing gastro and bronchitis I am still plagued by.

Now to pretend to care about dinner. Honestly, this lack of appetite is getting old.

Sex and Gender.

I think I may have discovered another area of medicine that I’d like to do more of – primary care of the transgendered individual.

In the past two years I have had 3 individuals disclose to me their desire to change their gender.  It is a fascinating area of medicine, one that I know almost nothing about, but that is all about to change.

Before my maternity leave, one of these transgendered individuals told me about a comprehensive guide developed by the local trans community for primary care physicians.  He gave me the website and I downloaded the guide (about 100 pages) and planned to read it while I was off.  Sadly, it remained on my desk  unread for 6 months, until today!

Gender Identity Disorder is a recognized psychiatric illness in the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV), though labeling it as a “psychiatric” illness does little to ease the stigma for these individuals. Thus, a change in terminology is being implemented with the new edition of the manual:

In the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), people whose gender at birth is contrary to the one they identify with will be diagnosed with gender dysphoria. This diagnosis is a revision of DSM-IV’s criteria for gender identity disorder and is intended to better characterize the experiences of affected children, adolescents, and adults.

The core criteria for diagnosis of Gender Dysphoria are the following:

  • Cross-gender identification
  • Desire to live as a member of the other sex
  • Sense of inappropriateness in the gender role belonging
  • to one’s natal sex
  • Discomfort about one’s assigned sex
  • Desire to have sex characteristics of the other sex
  • Discomfort about one’s anatomic sex 
  • Wish to get rid of one’s natal sex characteristics

All of my patients who have told me they desire to be the opposite sex fit the above criteria.  In my city, there is a multidisciplinary clinic dedicated to Gender Dysphoria and I have referred them all.  Only one has been seen and he recently had chest surgery (ie. elective bilateral mastectomy).  Unfortunately, the wait list is close to 2 years and for the majority of patients seeking to start treatment, this can be an excruciating wait.

Imagine feeling like you were born into the wrong body. Imagine coming to terms with wanting to be the opposite sex. Imagine “coming out” to your family and friends. Imagine the feeling of dressing like the gender you wish to be for the first time.  Imagine telling your family doctor, then imagine having to wait 2 more years to get treatment.  Can you imagine what that must feel like?

I saw such a patient this week.  “He” is a genetic male but has never felt comfortable with his male genitalia.  “He” wants to be a female.  “He” wants all of his male organs removed permanently.  “He” wants to be a “She”. She has picked out her new name and really, really, really wants to start hormone therapy.  She looked at me with desperation in her eyes.  “Can you please help me?”

This patient has been referred to the multidisciplinary clinic and is on a very long waiting list.  The initial referral was made over a year ago and we were told the wait was minimum 16 months.  In the meantime, the patient has gone to trans support groups, has come out to all of her friends and family and is now ready to start making the transition physically.  She eventually wants sex reassignment surgery but realistically, this won’t happen for a few years. In the mean time, she is ready to start looking more female.

She wants to start hormones. My initial thought was, “I can’t do that. I don’t know what to start!” Then I remembered the guidelines handbook my other patient gave me, which I never got around to reading.  While the patient was in the examination room, I went to my office and got it off the pile of other reading on my desk.  I quickly flipped to the section  “Hormone therapy for the male-to-female transgendered individual”.  Together with the patient, I read the guidelines and at the end of the 30+ minute appointment, the patient was given a prescription for an anti-androgen; the first side effects of which would be lessening of coarse facial hair and cessation of spontaneous erections.  The latter side effect made the patient smile with relief.

I sent the patient home with a requisition for baseline blood work, a prescription for the anti-androgen, and a follow-up appointment in a month.

I have to say, it was a such an amazingly satisfying encounter.  I could see the relief on the patient’s face when she realized I would support and assist her in starting hormonal treatment.  I felt like I really made an impact.

As I mentioned at the outset, it’s a growing field of medicine that I feel privileged and honored to be a part of.  These individuals need more physicians to advocate for them.  I hope to become one such physician.



Cancer Blows.

Prior to my maternity leave, one of my patients had been diagnosed with pancreatic cancer.  She was set up with specialists, I reassured both her and her husband that they were in excellent hands with my locum and promised to be in touch with them as soon as I could.  My locum has been keeping me up to date on this particular patient as well as a few others.  This patient had major surgery a few weeks ago to remove the tumor and reportedly has been doing well.  I read the operative report today.  She had a procedure known as the Whipple.

The Whipple is a complicated procedure.  I saw one performed once as a medical student and all I remember is holding a retractor for a very, very long time.  Generally speaking, pancreatic cancer is not a good cancer to be diagnosed with – I mean, no cancer is, but this one in particular can kill a patient very quickly if it’s not caught early.  Thankfully, I believe my patient’s tumor was found early and according to the operative report, the Whipple procedure was considered curative.  Curative!! If I believed in God and Angels, I would say she definitely has an Angel looking after her.

Cancer is one of those illnesses that, I believe, touches all of us in one way or another.  My mother had breast cancer, diagnosed 12 years ago while I was still in medical school.  My mom was one of those women who always did self-breast examinations because she was prone to developing cysts.  I remember when I was a lot younger, she went in for day surgery to have a lump removed.  It was benign, but ever since then I always remember her feeling her breasts, always checking for something.  Well, on one of those checks, she felt something different.  Her family doctor couldn’t feel it; the radiologist couldn’t feel it; the breast surgeon couldn’t feel it.  But my mom did and the mammogram proved it. She had a lumpectomy about a month later and it was proven to be contained within the breast with no evidence of spread to the lymph nodes.  She had 5 weeks of radiation therapy, took Tamoxifen for five years and is considered cured.  Her having breast cancer does not necessarily increase my risk as she was post-menopausal at the time of diagnosis, but I still plan on being vigilant and likely will get my first mammogram next year when I turn 40.

Husband’s father was diagnosed with bladder cancer at the age of 62. Like most individuals diagnosed with bladder cancer, he presented to his doctor with gross hematuria (frank blood in the urine).  His tumor was small, localized and initially treated with an immune-stimulating drug called BCG (made of the bacteria that causes Tuberculosis).  It seemed to work at first but several months, maybe a year later, he developed acute renal failure and it was discovered that the tumor had spread outside the bladder wall and was blocking one of the ureters that drains the kidney.  I believe he underwent chemotherapy at that time, as surgery was no longer an option due to local spread.  Sadly, he died about a year and a half after the initial diagnosis. His risk factors were his age (>40) and his sex (male).  He never smoked, but he did work in the pharmaceutical industry as a pharmacist for many years back in Scotland, so it’s possible he was exposed to some chemicals back then.  We’ll never know.   As husband has just turned 40, I remind him periodically that he needs to go for his check up.

I remember a particularly difficult case I worked on during my family medicine training.  I spent two months on the Palliative Care unit. Palliative care is end of life care. More than that, it is medical care and treatment during the process of death and dying, not only for the patient, but for the family as well.  Difficult under any circumstances, but brutally awful in this particular case,which was a 44-year-old mother of two children, dying of colon cancer.

Colon cancer is one of those illnesses you think happens to a man in his sixties.  At least it was for me, as a medical student and resident.  But those two months on the Palliative care ward taught me otherwise.  Almost 10 years later, I don’t remember the details of the case, but what I do remember is that cancer can strike anyone, at any age.  My job as a family physician is to be suspicious and cognizant of that fact.  Anyone with symptoms of anemia, weight loss, change in bowel habit, vague abdominal pain/cramping, night sweats, regardless of their age – these are all red flags that need to be paid attention to.  Sadly for this woman, her physician lacked a certain amount of imagination and her tumor wasn’t discovered until it was too late.

I recently visited the RateMyMD website and looked myself up.  I was pleasantly surprised to see several new comments, and yes, they were all positive. (Giving myself a pat on the back right now!)  One in particular stood out.  This patient was new to my practice, having seen her husband’s physician for many years.  This physician was retiring and she sought out a younger, female doctor.  She got me. Apparently, at her first annual physical exam with me, I asked her about colorectal cancer screening.  She had never had a colonoscopy – it was never brought up by her previous doctor.  She had the “home testing kit” done every few years.  These fecal occult blood tests (FOBT) are designed to detect microscopic blood – blood not visible to the naked eye.  The thing is, not all tumors bleed, so the test might miss one.  Colonoscopy is the gold standard test for detecting colon cancer.  Guidelines for screening state that all patients > 50 years of age should have one every ten years.  However, this usually doesn’t happen because of wait times and cost to the healthcare system. Thus, the FOBT became a test to do in between colonoscopy.  Despite the guidelines, most physician will still recommend for all of their patients to have at least one colonoscopy.  Apparently, I talked about it enough at this woman’s appointment that she agreed to have one.  Turns out, I saved her life.  She had several precancerous polyps which were removed during her colonoscopy.

It’s a no-brainer, folks.  Screening tests work, be it mammography for breast cancer or Pap smears for cervical cancer.  If anyone reading this has a family history of cancer, or is of the age that a screening test is recommended, please get your screening done.  It really might just save your life.

Family Medicine Forum – Montreal, Day 1

Day 1 of the conference is in the bag.

I’m exhausted.  Mostly because I was out last night with my friends at DNA here in Montreal. We did the tasting menu, with alcohol.  A lot of alcohol.  I’m still a little bit hungover.  Did I mention there was a lot of alcohol?

I just finished a 4 hour session on Men’s Health.  It was great, but it was very biased toward prescribing testosterone.  So much so, that one of the doctors in the group suggested to the facilitator that he disclose his conflicts of interest at the beginning next time.  Ouch.  It’s not like he was promoting one brand of testosterone over another.  There’s one or two kinds of injectibles, one kind of oral and two kinds of topicals.  There ain’t a lot to choose from!  And the main topic was symptomatic hypogonadism.  How else is one to treat it? Seemed like a no-brainer to me.   I was always afraid of testosterone replacement therapy because of hearing all about how it caused prostate cancer, or rather, increased a man’s risk of prostate cancer, when in fact, that is just a myth.  I learned today that testosterone will increase a man’s small, shriveled up prostate to the size it would have been had he had normal testosterone in the first place.  If there was a teeny nidus of cancer in that shriveled up prostate, then testosterone treatment would, in fact, unmask it, hence bringing it to attention earlier.  Good, right?

Bottom line is that I am now a little bit more comfortable in how I’ll approach the next middle-aged guy who comes into my office complaining of decreased mood, exercise tolerance, low libido, sexual dysfunction, etc.  And I will likely consider Testim, since that’s what’s in the sample cupboard, thanks to the drug rep who came by last month with lunch. 😉

And the best part was getting a preview copy of the PAACT guidelines of Men’s Health Topics for the Family Doctor.  Boo ya! I love getting free stuff at these things.