Friday, September 27, 2013


    I have been practicing medicine for a long time . Many patients and doctors are not aware of the fact that many tests that we order today or the treatments that we expect on day to day basis , were not there short time ago , like 30 years ago, There was no CT scans or MRI or PET scans , the stents that we expect for coronary artery blockage were not there .The simple Ultrasound examination came for common use in mid seventies , Ct scan in eighty and so on . So I often wonder how we functioned as 'good doctors ' in those (?good old days .)days . Were we smarter, or did we miss lot of stuff . Did we develop keen diagnostic sense , in absence of these super helpful tests .( like blind patients have other senses develop better than ordinary person ).So I am going to tell a story , where this is illustrated in the best way .
    This was a 72 years old male patient , who was admitted to the hospital with irregular heart beats , called atrial fibrillation . He was seen by the emergency MD , then the hospitalist and then by a cardiologist . Pt was worked up and the put on blood thinner and the heart medicines to control the heart rate and then discharged . He had 'routine ' blood tests , the chest X-ray and all was well . He had some arthritis of the hip and some back pain . He came back to the hospital with intractable hiccup . So again was seen by the ER doctor , hospital doctor , and was worked up and had a neurologist evaluate him too . The CT scan of the abdomen was done and a tumor was seen in the liver . The biopsy was ordered and I was called to see patient . The CT scan of the chest  was done  and  it showed a mass in the lung as well . Mind you this 'mass ' was not seen on regular X-ray . So the liver biopsy was done and I did the biopsy of the lung mass . Both showed the cancer and also indicated that it started in the lung . I was quite concerned about the extent of the cancer and so I ordered a bone scan and then MRI of the brain . To my surprise the bone scan was positive and even the MRI also showed 'multiple nodules consistent with metastasis '. I did the MRI of hip and spine and all showed the cancer . This is a guy who was in hospital 2 weeks ago , and was seeing his family doctor on regular basis and was getting regular physical examination and blood test every so often . But none of them were able to detect such a wide spread cancer . WE did not know and we would have NEVER KNOWN  the extent of the spread without these modern day tests . Our clinical sense was useless , until we did the first test of CT scan of the liver .
    So should we be doing these tests in every patient all the time ? I don't think so , but I don't have a perfect answer . There are number of studies looking at low dose CT scan done on regular basis in 'high risk patients '. But what about other cancers and what about the expense and the radiation exposure ? I truly don't know    

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