Saturday, July 6, 2013


    In recent past the technology has added to our understanding of the diseases process . We also can diagnoses the diseases better and treat better . The ultrasound came for the general use in most of the hospitals in mid seventies . Then came the CT scan and then the PET scans. We now can virtually see arteries going to heart --the coronary arteries without doing the cardiac  catheterization.. We can  biopsy of  almost any organ without cutting .And we almost don't need any autopsy to see any organ . New endoscopy techniques have added to our ability to get to the bottom of the diseases.. But I often feel are we really any better ? Are we not doing too many things ,and they do not  really help patients .This came to my mind when I saw couple of patients on follow up in my office .
    I had seen this patient in office for may be 2 or 3 years . He had large nodules in both lungs . He  was seeing other lung specialist . In fact he had seen 2 different lung specialists in last 5 years and they had done endoscopies .No cancer was detected . The CT scans had remained stable with no major change in the nodules . I had followed him for the asthma that he also had . He was doing OK and I had done the follow up on his CT scans. H e had missed his last 2 appointments and the he came to see me after a gap of about 8 or 9 months . He told me that he was fairly stable and his medications were renewed by his family doctors .But then he told me that he was hospitalized . and had many tests . I had not known this and he was admitted to the hospital ,that I don't go . I reviewed the hospital records . I saw his CT scans , not one but 3 and then he had 3 bronchoscopies . He also had CT scan of the Abdomen and number of other tests . The CT scans had not changed , when compared to older scans from 3 years ago . But the first  bronchoscopy and biopsy was non conclusive . So he had  a second one . That showed some abnormality . and so he had a third one with special type of biopsy . Through the scope and ultrasound is done and then a biopsy of lymph node is done . They also used another ultrasound technique to do the biopsy of the mass . Both these techniques are new , may be developed in last 3 years and still not done by 75 % of the endoscopists . One of the biopsies showed that he had a benign disease called sarcoidosis .This was not diagnosed by any of the special techniques, but by simple deep biopsy. The sarcoidosis is a disease , etiology of this is not known . It can affect any organs , but commonly we see the lungs involved . In some patients we see significant scars in the lungs and patients have chronic cough and may be short of breath . Not even one % patients die . I have seen may 2 patients who had progressive disease .
     So now I am wondering as to what did we achieve with 2 CT scans of chest , one of belly , 3 bronchoscopic , one of which was under anesthesia , and cost of thousands dollars .We did not have the diagnosis in the past , but now that we have diagnosis, did it change anything . Did he need any treatment that he was not getting ? If we would have continued to do follow up on his CT scans or even simple X-ray, would it not have sufficed ? We do have new technologies and they do help us in diagnosis . But we need to not loose the sight of risk -benefit ratio. This patient had masses on both sides of lung . They had not changed in at least 5 or 6 years . So the 'chance ' of cancer was very -very low or nonexistent . If indeed he had cancer, he would not have been  a surgically resectable stage . So did we spend all this money for nothing ? You have decide .

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