After I retired from my academic position at the University of Miami, I started working as an intermittent ob & gyn in various cultural settings in the US and abroad. In 2006 I practiced in a hospital in New Zealand.
I saw many interesting cases during my six months at Whangarei Hospital. One stands out in particular. This was a middle aged native Mauri woman who had been seeing her family doctor for several years because she was gaining too much weight, her abdomen was getting bigger, and she was constipated. Each time the family doctor saw her, he did not examine her but patted her on the back and encouraged her to eat less, eat more fruit and vegetables and be more active so that she would lose weight. When much later he finally examined her, he noticed a large tumor in her abdomen and referred her to the hospital.
To make a long story short, we operated on her and removed a large ovarian cyst weighing more than 18 kilograms (about 40 pounds). This cyst fortunately turned out to be benign and the woman did well. The operation itself was something else as we needed an extra assistant to hold the tumor in her arms while we removed it without breaking it.
Even though this large tumor was certainly not a record, we ended up publishing the case in a New Zealaned medical journal for family practice (see reference below), not so much for the nature of the tumor itself as for pointing out to family doctors (all doctors, in fact) that examining patients before giving them advice is most important.
Alison Gale, Tommy Cobb, Robert Norelli, William LeMaire. Increasing Abdominal Girth. The Importance of Clinical Examination. New Zealand Family Physician. 2006; 33 (4): 250-252
Describes how genes that make light and heavy chains can be randomly assorted to produce a unique type of antibody and so wil bind to a specific antigen~
Facebook : http://www.facebook.com/ArmandoHasudungan
Like may of you who work for a hospital, HMO or other organized medical care, I have often been frustrated by the rigidity and dullness of administrators. Many of them go by the rules and seem to be unbending.
Once in awhile one comes across some one who does not fit into that category. A personal example will illustrate this.
After I had retired from my academic position at the University of Miami I was doing intermittent "locums" work. I had just finished a six month assignment in Okinawa, Japan and was in my traveling mode. I needed to find my next "job" and had applied to an add from Mount Edgecumbe Hospital in Sitka, Alaska. That Indian Health Service Hospital was looking for an obstetrician and gynecologist. I was interested, applied and was invited for an interview.
I liked the job and they must have liked me as I was offered a two year contact. However as a new hire they offered me only two weeks of vacation and one week of Continuing Medical Education leave. For someone with my seniority, I thought that that was insufficient and said so. I left Sitka in a sad mood as I really would have liked that job, but was not ready to accept their offer of only two weeks of vacation time. I was told that that was the Company's policy, and that they were not ready to start a precedent.
Some days later, I received a phone call from the medical director of the hospital. She started off by apologizing again that she could not offer me more vacation, as that was the Company's policy for new hires. Right away I felt discouraged, but then she added: "We really would like to have you work for us and what I can do is give you two addition weeks of unpaid leave and raise your salary by two weeks (which, by company rules she was free to do). I was elated and accepted the offer for two years. We liked it there so much that we ended up staying seven years.
I thought that this hospital administrator was using her authority to make a very creative and imaginative decision. We all benefitted.
There should be more administrators like that.
Those interested in reading more about my experiences can download an e book for free from Smashword at: http://www.smashwords.com/books/view/161522 or just Google: "Crosscultural Doctoring. On and Off the Beaten Path".
Amended from Wikipedia and other sources
Stage means spread
Grade means histology
Prostate cancer staging – spread of the cancer
There are two schemes commonly used to stage prostate cancer. TMN and Whitmore Jewett
Stage I disease is cancer that is found incidentally in a small part of the sample when prostate tissue was removed for other reasons, such as benign prostatic hypertrophy, and the cells closely resemble normal cells and the gland feels normal to the examining finger
Stage II more of the prostate is involved and a lump can be felt within the gland.
Stage III, the tumour has spread through the prostatic capsule and the lump can be felt on the surface of the gland.
In Stage IV disease, the tumour has invaded nearby structures, or has spread to lymph nodes or other organs.
Grading - Gleason Grading System is based on cellular content and tissue architecture from biopsies, which provides an estimate of the destructive potential and ultimate prognosis of the disease.
TX: cannot evaluate the primary tumor
T0: no evidence of tumor
T1: tumor present, but not detectable clinically or with imaging
• T1a: tumor was incidentally found in less than 5% of prostate tissue resected (for other reasons)
• T1b: tumor was incidentally found in greater than 5% of prostate tissue resected
• T1c: tumor was found in a needle biopsy performed due to an elevated serum PSA
T2: the tumor can be felt (palpated) on examination, but has not spread outside the prostate
• T2a: the tumor is in half or less than half of one of the prostate gland's two lobes
• T2b: the tumor is in more than half of one lobe, but not both
• T2c: the tumor is in both lobes but within the prostatic capsule
• T3: the tumor has spread through the prostatic capsule (if it is only part-way through, it is still T2)
• T3a: the tumor has spread through the capsule on one or both sides
• T3b: the tumor has invaded one or both seminal vesicles
• T4: the tumor has invaded other nearby structures
It should be stressed that the designation "T2c" implies a tumor which is palpable in both lobes of the prostate. Tumors which are found to be bilateral on biopsy only but which are not palpable bilaterally should not be staged as T2c.
Evaluation of the regional lymph nodes ('N')
NX: cannot evaluate the regional lymph nodes
• N0: there has been no spread to the regional lymph nodes
• N1: there has been spread to the regional lymph nodes
Evaluation of distant metastasis ('M')
• MX: cannot evaluate distant metastasis
• M0: there is no distant metastasis
• M1: there is distant metastasis
• M1a: the cancer has spread to lymph nodes beyond the regional ones
• M1b: the cancer has spread to bone
• M1c: the cancer has spread to other sites (regardless of bone involvement)
Evaluation of the histologic grade ('G')
Usually, the grade of the cancer (how different the tissue is from normal tissue) is evaluated separately from the stage; however, for prostate cancer, grade information is used in conjunction with TNM status to group cases into four overall stages.
• GX: cannot assess grade
• G1: the tumor closely resembles normal tissue (Gleason 2–4)
• G2: the tumor somewhat resembles normal tissue (Gleason 5–6)
• G3–4: the tumor resembles normal tissue barely or not at all (Gleason 7–10)
Of note, this system of describing tumors as "well-", "moderately-", and "poorly-" differentiated based on Gleason score of 2-4, 5-6, and 7-10, respectively, persists in SEER and other databases but is generally outdated. In recent years pathologists rarely assign a tumor a grade less than 3, particularly in biopsy tissue. A more contemporary consideration of Gleason grade is:
• Gleason 3+3: tumor is low grade (favorable prognosis)
• Gleason 3+4 / 3+5: tumor is mostly low grade with some high grade
• Gleason 4+3 / 5+3: tumor is mostly high grade with some low grade
• Gleason 4+4 / 4+5 / 5+4 / 5+5: tumor is all high grade
Note that under current guidelines, if any Pattern 5 is present it is included in final score, regardless of the percentage of the tissue having this pattern, as the presence of any pattern 5 is considered to be a poor prognostic marker.
The tumor, lymph node, metastasis, and grade status can be combined into four stages of worsening severity.
Stage Tumor Nodes Metastasis Grade
Stage I T1a N0 M0 G1
Stage II T1a N0 M0 G2–4
T1b N0 M0 Any G
T1c N0 M0 Any G
T1 N0 M0 Any G
T2 N0 M0 Any G
Stage III T3 N0 M0 Any G
Stage IV T4 N0 M0 Any G
Any T N1 M0 Any G
Any T Any N M1 Any G
T (Primary tumour)
• TX Primary tumour cannot be assessed
• T0 No evidence of primary tumour
• Ta Non-invasive papillary carcinoma
• Tis Carcinoma in situ (‘flat tumour’)
• T1 Tumour invades subepithelial connective tissue
• T2a Tumour invades superficial muscle (inner half)
• T2b Tumour invades deep muscle (outer half)
• T3 Tumour invades perivesical tissue:
• T3a Microscopically
• T3b Macroscopically (extravesical mass)
• T4a Tumour invades prostate, uterus or vagina
• T4b Tumour invades pelvic wall or abdominal wall
N (Lymph nodes)
• NX Regional lymph nodes cannot be assessed
• N0 No regional lymph node metastasis
• N1 Metastasis in a single lymph node 2 cm or less in greatest dimension
• N2 Metastasis in a single lymph node more than 2 cm but not more than 5 cm in greatest dimension,or multiple lymph nodes, none more than 5 cm in greatest dimension
• N3 Metastasis in a lymph node more than 5 cm in greatest dimension
M (Distant metastasis)
• MX Distant metastasis cannot be assessed
• M0 No distant metastasis
• M1 Distant metastasis.
Urothelial papilloma – non cancerous (benign) tumour
•Papillary urothelial neoplasm of low malignant potential (PUNLMP) – very slow growing and unlikely to spread
•Low grade papillary urothelial carcinoma – slow growing and unlikely to spread
•High grade papillary urothelial carcinoma – more quickly growing and more likely to spread
The book of the week this week has been Chris Patten’s “Not quite the diplomat” – part autobiography, half recent history and a third political philosophy text. It is a fascinating insight into the international community of the last 3 decades. The book has really challenged some of my political beliefs – which I thought were pretty unshakeable – and one above all others, the EU. I read this book to help me decide who I should vote for in the upcoming MEP elections.
I have to make a confession, my political views are on the right of the centre and I have always been quite a strong “Eurosceptic”. Although recently, I have found myself drifting further and further into the camp of “we must pull out of Europe at all costs” but Mr Patten’s arguments and insights have definitely made me question this stance.
With the European Parliamentary elections coming up, I thought it might be an interesting time to put some ideas out there for discussion.
From a young age, I have always been of the opinion that Great Britain is a world leading country, a still great power, one of the best countries in the world - democratic, tolerant, fair, sensible - and that we don’t need anyone else’s “help” or interference in how our country is run. I believe that British voters should have a democratic input on the rules that govern them.
To borrow an American phrase “No taxation without representation!”
I believe that democracy is not perfect but that it is the best system of government that humans have been able to develop. For all of its faults, voters normally swing back to the centre ground eventually and any silly policies can be undone. This system has inherently more checks and balances than any meritocracy, oligarchy or bureaucracy (taking it literally to mean being ruled by unelected officials).
This is one of my major objections to how the European Union currently works. For all intents and purposes, it is not democratic. Institutions of the EU include the European Commission, the Council of the European Union, the European Council, the Court of Justice of the European Union, the European Central Bank, the Court of Auditors, and the European Parliament. Only one of these institutions is elected by the European demos (the parliament) and that institution doesn’t really make any changes to any policies – “the rubber stamp brigade”. The European Council is made up of the President of the European Council (Unelected), President of the European commission (Unelected) and the heads of the member states (elected) and is where quite a lot of the "major" policies come from but not all of the read tape (the European Commission and Parliament).
I am happy to be proved wrong but it just seems that the EU, as a whole, is made up of unelected officials who increasing try to make rules that apply to all 28 member states without any consent from the voters in those states – it looks like the rule of “b-euro-crats” (bureaucrats – this version has far too many vowels for a dyslexic person to use).
A beurocratic rule which many of us do not agree with but seemingly have to succumb to, a good example for medics is the European Working Time Directive (EWTD) which means that junior doctors only get paid for working 48h a week when they may spend many, many more hours in work. The EWTD has also made training a lot more difficult for many junior doctors and has many implications for how the health service is now run. Is it right that this law was imposed on us without our consent? If we imposed a treatment on a patient without their consent then we would be in very big trouble indeed!
I cannot deny that the EU has done some good in the world and I cannot deny that Britain has benefited from being a member. I just wish that we could pay to have access to the markets, while retaining control over the laws in our lands. I want us to be in Europe, as a partner but not as a vassal. In short, I would like us to stay within the EU but with major reforms.
I know that any reforms I suggest will not be read by anyone in power and I know they are probably unrealistic but I thought I would put it out there just to see what people think.
I would like to see a NICE’er European Union.
The National Institute for Clinical Excellence is a Non Departmental Public Body (NDPB), part of the UK Department of Health but a separate organisation (http://www.nice.org.uk/aboutnice/whoweare/who_we_are.jsp). NICE’s role is to advise the UK health service and social services. It does this by assessing the available evidence for treatments/ therapies/ policies etc and then by producing guidelines outlining the evidence and the suggested best course of action.
None of these guidelines are enforced by law, for example, as a doctor you do not have to follow the NICE recommendations but if you ignore them and your patient suffers as a consequence then you are likely to be in big trouble with the General Medical Council.
So, here would be my recommendations for EU reform:
First, we all pay pretty much the same as we do now for access to the European market. We continue with free movement and we keep the European Council but elect the President. This way all the member states can meet up and decide if they want to share any major policies. We all benefit from free movement and we all benefit from a larger free trade area.
Second, we get rid of most of the rest of the EU institutions and replace them with an institute a bit like NICE. The European Institute for Policy Excellence (EIPE) would be (hopefully) quite a small department that looks at the best available evidence and then produces guidance on the policy.
A shorter executive summary would hopefully also be available for everyday people to read and understand what the policy is about - just like how patients can read NICE executive summaries to understand their condition better.
Then any member state could choose to adopt the policy if their parliaments think it worthwhile. This voluntary opt-in system would mean that states retain control of their laws, would probably adopt the policies voluntarily (eventually) and that the European citizens might actually grow to like the EU laws if they can be shown to be evidence based, in the public’s best interests, in the control of the public and not just a law/red tape imposed from above.
The European Union should be a place where our elected officials go to debate and agree policies in the best interests of their electorates. There should therefore be an opt-out of any policy for any member state that does not think it will benefit from a policy.
This looser union that I would like to see will probably not happen and I do worry that one day we will wake up in the undemocratic united federal states of Europe but this worry should not force us to make an irrational choice now. We should not be voting to "leave the EU at all costs" but we should be voting for reform and a better more co-operative international community.
I would not dare suggest who any of you should vote for but I hope you use your vote for change and reform and not more of the same.
The Foundation for the Advancement of Medical Education and Research (FAIMER) is a US-based non-profit organisation committed to improving health professions education to improve global health.
FAIMER traditionally offers a two year fellowship programme; 2 residential and 3 distance learning sessions and an education innovation project in the fellow’s home institution. The focus is on education methods, leadership/management, scholarship and the development of an international community of health professions educators.
During the past 5 years, FAIMER has expanded the programme and established regional institutes in India, Brazil and Southern Africa (SAFRI). We implemented the programme in Africa in 2008, introducing 5 innovations to the generic programme. SAFRI was created as an independent voluntary association to reflect the multinational intent of the programme.
Aim of project
To understand the impact of the innovations in the structure and implementation of the programme on its quality and the experience of the participants in it.
Faculty development programmes can significantly enhance their impact:
Be sensitive to the local political climate
Demonstrate wide ownership
Focus on developing a community of practice
Work within the professional time constraints of Fellows and faculty
Maximise learning opportunities by linking to other scholarly activities