Sunday, January 26, 2014


    I get some of the emails , that tells me the medical news and also new inventions , drugs , some studies and some opinion polls . I recently got one ,that was I think was from New York Times. Knowing well that the New York Times is a very 'liberal ' news (?) paper , I knew that the article will have liberal slant and will not address the real issue. I was partly right . It told a story of a history professor, who was seen by a 'physician extender' and was suspected to be a cancer and was further worked up and then the cost of the entire work up was $25000. The article stated the opinion that the consulting physicians make 'too much money'. The article never address the real problem with the health care cost . So I thought of writing about my opinion .
    One of the problems in medicine today is the physician extenders . I really have no problem with the physician extenders, namely the nurse practitioners or physician' assistants . They do a great job or may be even better job than originally they were suppose to do . But when I see them being used as physicians and not as physician's extenders , I feel that that is a  misuse. I often see that they are the only health care providers who are seeing patients in the hospitals ,  most of the time replacing the consulting physicians .This is not the best way to utilize the talent of these group of health care providers.
      The second problem is the way in which health care system works . In past the consulting physicians got more fees for " consulting ", as they had more training in a specialized field . For last few years , may 4 or so , the amount that is approved for a new medical graduate or a cardiologist or a brain surgeon is same , even though the training that a brain surgeon gets is several years more than new medical graduate . So in essence it is like saying that a high school graduate and a person with masters degree or doctorate should get same salary. But in medical field this how it is . So many doctors are trying to find a way to see more patients, to compensate for this lowering of the fees . There is a limit to how many patients can one physician see in a span of 8 hours or so . So then they stared having physician assistants see the patients . This may lead to more referral to other physicians. In turn it will cost more money .
      The issue that has cropped up is disparity between the reimbursement that physicians get and what hospitals make , sometimes for the same procedures . For example , the endoscopy , physicians may make $150 , while the hospital charges may be as high as $2500. Now a days many of these procedures are done with sedation , that is administered by anesthesiologist .This adds to he cost and since they are employed  by the hospitals, the money goes to the hospital. Doing a ultrasound test for heart for example will cost double if not more , if done in the hospital than done in doctor's office . If physician is employed by the hospital , the fee that he gets is much higher than if he was on his own . So when the hospitals ' employ '  physicians , the hospital makes more money and the physician makes more money and the cost of the health care goes up .
    There are many more reasons for the increasing cost of the health care , like new drugs , say for pulmonary hypertension , cost $50000 per year, new tests and treatments , ICD a defibrillator, price tag of $27000, just for the device and the hospital charges  probably same .
    One additional factor is the big gap between the 'charges' and the actual reimbursement The latter has gone down over period of time for certain procedures and if one looks only at charges , then it does not give real cost of health care . For example in past the colonoscopy was paid as much as $600 or even more with private insurance. Now a days it pays  less than half of that , but the charges have not been reduced . So the charge may be $1000, and physician will get $250..
    What I felt is that instead of trying to find a real cause for the increase cost the New York Times took a view as to criticize the consulting physicians .
     If they are interested in reducing the cost or helping the primary care M.D they should contact people like me not those who live in Ivory Towers .   

Saturday, January 18, 2014


   I was driving on the highway and I saw a billboard. It was an advertisement for one of the hospital . It stated " we do miracles !". It made me think . Do we really do any miracle at any time or any place ? or we just 'think' that we are in 'charge or control".I am in practice for long time and I do not want to take any credit for 'saving ' anyone nor do I want to get any blame for the bad outcome . When someone states that they do miracles , they simply do not understand the reality of medicine . It remind me of old story that I had read about a gastric surgery , that was done quite commonly many years ago , not done much now . In a meeting of the surgeons , the speaker was talking about all the complications associated with the particular procedure . One of the surgeons from the audience stood up and stated that he has done many of the same surgeries and never had any complications . So the speaker answered , " Sir , either you have recognized the complications or you have not done enough surgeries to get them . Because if you would do enough surgeries , then you will get complications . ". I feel the same about the medical tests or the treatments and the outcomes. The story that I am going to tell is one such case .
    I had seen this 68 years old white female for long time . She came to me for abnormal chest X-ray and further work up showed that she had a lung cancer and I sent her to a chest surgeon and she was operated and did well . There was no evidence of spread and she did not need an additional treatment . The only unusual thing was that when the lymph nodes were resected out to 'stage ' the lung cancer , they were negative for cancer , but they showed findings of a disease called sarcoidosis . The sarcoidosis causes lymph node enlargement and lung nodules or scar tissues .It may cause shortness of breath .So we followed her up . She continued to have the abnormal X -ray and it was attributed to be due to sarcoidosis . The PET scan came to market and her oncologist would do the PE scan and then then when it came back abnormal , would send to me . and the I had to look at the old scans , CT scans and decide if any further work up was needed .This is because the sarcoidosis also can cause abnormality on PET scan .So it becomes difficult to know if cancer is coming back or is it sarcoidosis . To our surprise she developed second lung cancer and we took it out .We continued to do the follow up She developed a lung nodule and it grew . I could not do any test to find out if it was cancer or sarcoidosis . So after discussion we decided to do a open biopsy , to resect it out .The surgeon decided to do lymph biopsy . The lymph nodes were not enlarged or changed from the old CT scans . So with the diagnosis of sarcoid I did not feel that lymph node biopsy was needed . But to my surprise he did the biopsy and IT SHOWED CANCER and so she was not resectable .So the PET scan and the CT scans were not helpful and the biopsy that I thought was not indicated,( based on the findings of CT scans and PET scans ).gave us the diagnosis .
      The story did not end there . She was treated with radiation and chemotherapy .She was more and more short of breath and needed oxygen . And then one day the oncologist told me that she developed Breast cancer .
     SO in my mind we do not do any miracles nor are we capable of doing any miracles . With all the new tests we still feel like we are wandering in dark and are lucky if we are successful(!) in treating patients .

Wednesday, January 15, 2014


    I often tell patients that do not ask for the direction to the place that you don't want to go . So what do I mean by this . I often see patients that have definite problems , but getting diagnosis without an invasive tests is not always possible . I can probably give you many examples . I have  a patient that has weak heart and has a defibrillator , has bad COPD and still smokes , is on oxygen . He has a nodule , in the lung . I have watched it with follow up CT scans and it was stable for a while , may be a year . But then it grew and the PET scan done showed that the nodule was metabolically active , suggestive of it being cancer . Due to his other problem , he and his family wanted him to be on Hospice . But they agreed for the opinion for radiation . My feeling was that with the given data it was highly likely to be cancer and radiation treatment will give good response and may even cure it . But rest of the people in tumor  board wanted additional biopsy . It would have taken general anesthesia , and in my mind diagnosis may not be established . So if it was cancer confirmed on this special test , the treatment would be radiation and if no diagnosis was established , then the treatment , if we decided to do it would be still the radiation . So why go through the procedure with some risk , definite expense , and no guarantee of the diagnosis ?
     When I see patient with lung cancer, who does not want chemotherapy , I tell them my story . Once I went to a stake house with some friends . I do not eat meat . So when the waiter came to take orders , I asked him if he had anything which is vegetarian . He looked at me , as if I was from mental institution . So I tell the patients , do not go to the oncologist and say tat you want something other than chemotherapy . That is the way they they know how to treat cancer , and that is the only way they know .
      But the story that I started to tell is little different . I saw this older patient , about 87 years , who had history of kidney cancer . Her kidney was taken out and she was doing fine . Her CT scan done by previous doctor had shown stable findings . So when she started seeing me ,I did follow up CT scan , The first one was OK . But the next one in4 or 5 months showed increase in the mass next to trachea . We talked about it , and discussed the work up . After some time we did do the bronchoscopy . It was unable to get the diagnosis . I talked to the patient and her daughter. After the talk they decided to do needle biopsy by the radiologist . The patient did not want chemo , nor did the daughter. Patent's husband had cancer and had chemo and had bad experience . I told them that radiation is option . They were not sure if they would consider it . So we did the biopsy . (we are trying to get the diagnosis , but we don't want treatment , We are asking for the direction to the place that we don't want to go .) The biopsy was limited due to many factors. It was highly suggestive of metastasis from the kidney cancer . But the tissue was small . Again I had discussion and told them that if no treatment is to be done we should do no further tests . There was an option of surgeon doing biopsy was there . So they decided to see the chest surgeon and he told them the same thing . But after 3 weeks the patient decided to do the surgical biopsy . With her age and other medical problems , what could have been one day surgery , she was in the hospital for 10 days , She needed cardiologist , a kidney specialist and many other things , She was also seen by oncologist and a radiation doctor . She also had a blood clot i the lungs and neede to be put on blood thinner . The patient and the daughter decided  that  they did not want any treatment . So my question is why did we ask for the direction to the place that we did not want to go ? 

Sunday, January 12, 2014


   We just had a new year started . The year 2014 . HAPPY NEW YEAR . When I was thinking about it , I thought about the concept of the Time . According to modern science and based on Einstein's theory , the time is not constant . It is affected by motion and by the various forces , namely the gravitational force . Just to give couple of 'known ' and 'unknown ' examples will suffice.If on travels in a today's airplane , and takes a watch , and similar watch is left on the earth , the time that the two watches will show will be different . The watch that is carried in moving plane will be slower than the one on ground.The difference is so minute that we may not be in position to realize it , but if the speed of the plane is close to the speed of light , then the difference will be obvious . So the time 'lapsed ' is not constant , but changes . This is one example of variable time . The second one is related to the gravitational force . If one could stay at "event Horizon "  of a black hole for say a year , then the time lapsed on the earth will be thousands of years . So you will be older by one year , and rest of the people will have noticed thousands of years gone . ( the event horizon is the closest one can get to the black hole , without getting sucked in by the enormous gravity , which will tear everything if you get any closer . )So this the concept of the time to the modern science .
     Now the Hindu concept . Time never stops . But the cycles which continue have been meticulously calculated . This also gives us some concept of origin of the universe and it's end and then the beginning of another cycle .In Hindu scripture , the existence of the universe is calculated i different segments . There are 4 YOOGAS, YOOG is singular . They are as follows , SATYA, TRETA , DWAPAR AND KALI . We are in the last of the 4 , Kali YUGO . Each of these yooga last for different years . the Satya , 1728000 years , the Treta , 1296000, the Dwapar for 864000, and the Kali Yooga for 432000 years . So far we have completed 5113 years of the Kali Yooga . 4 yoogas make on PARYAY. (4320000 years ) The current Paryay is 28th Paryay .It is called Shwetawarah -Paryay. 71.4285 Paryay will make one MANWANTAR. The current Manwattar is the 7th Manwantar  14 Manwantar will make ONE DAY OF THE CREATOR  CALLED BRAHMA It is also called KALPA .
  The the cycle of universe continues as long as it is the day of Brahma . The universe is 'unmanifested when the Creator is sleeping . Then when he wakes up the universe is manifested and the cycles continue .
    I am not sure if this real or not , but for sure I am fascinated by the thought process and the concept of time that these ancient Rhishis had .

Friday, January 10, 2014


     I often see patients with possible lung cancer .Unfortunately only 25 %of cases are operable . Even today 'cure' for the lung cancer is possible with surgery and not with chemotherapy or radiation treatment.There are cases when patients get cured with treatment other than surgery .But these are rare cases . So many a times when I have a patient who has inoperable  cancer ,  I do not make a comment on cure , but I talk about the control of the disease .Invariably I get a response   like 'he is strong ' or 'the God will cure ' or 'he is a fighter ' . Even though I know that the cancer is not curable and the patients and relatives know in their heart that the cancer is not curable , they all don't want to state it . But there are exceptional patients . My next patient is one such  patient
    When I saw this 68 years old patient , he was a having persistent cough .He was ex-smoker He had X -ray done and it was abnormal . So he was referred to me The X-ray was suggestive of the lung mass , or lung cancer . I did CT scan of the chest and did the bronchoscopy and biopsy .It confirmed the diagnosis of the lung cancer . Due to the CT scan findings of the spread to the central nodes , he was inoperable. So I told him about it He was quite calm , may be he expected it .He told me that he had ;trust' in Jesus and HE will take care . I told him that the surgical option was out of question and we could do radiation and or chemo . He was ready for radiation therapy and was not very keen on chemotherapy . I sent him for the radiation treatment .
    He completed the treatment and was followed by me and the radiation doctor .We did the follow up CT scans . There were abnormalities , but they were attributed to the treatment and there  was no evidence of cancer .
     I continued to follow him for his cancer which seemed to have been 'cured ' and the CO PD the smoking related lung problem . After 6 years he had new X-ray and it was reported as abnormal . Due to change of insurance it was done at different place . I did do a CT scan .It was abnormal , but there was no major change . I repeated the scan and it was worse . So I did the PET scan . It was suggestive of a new cancer . The additional biopsy showed that he had NEW cancer . The tissue type was different , so he had new cancer . This time he had a cancer that was called small cell cancer. The primary treatment is chemotherapy . So he was started on the chemo . There was no change in his attitude . He was still calm .
     I did the new scans The CT scan was worse and the PET scan showed new uptake on left side . The original scan had shown cancer in left lower lobe , now there was uptake in upper lobe on left . . So I did the bronchoscopy and the biopsy. I saw narrowing of the lower lobe and did the biopsy from that area . I then looked on the right side . There was no abnormality seen on right side on CT scan or on the PET scan . But I saw a small mass obstructing the right upper lobe . I did the biopsy from it . The biopsy did show a different cancer .
     So this was a patient who had inoperable cancer , that got cured and then got new cancer , that seemed to be getting better or gone , and now has new type of cancer .    .