Saturday, June 28, 2014


   When I see patients, who are either smokers, or alcoholic or are obese, I try to tell them the health hazards of all of these. Everyone knows that smoking is bad for the lungs. But not many people are aware of the facts that  the chance of  cancer of every organ is higher in smokers than in nonsmokers. Be it a cancer of lung , throat, breast , prostate or esophagus or stomach and many others.The smoking also increases the chance of stroke , heart attach , and many circulation issues and need for amputation due to gangrene.But in spite of all the information that I give , people still smoke . This is due to number of reasons . Smoking is highly addictive and also many patients 'enjoy' it. Many patients do try to quit and are successful. But at times it is too late. The story that I am going to tell you is one such , but not what you may be thinking of.
     I saw this patient who was 55 years old and was seen by me for shortness of the breath. He was a smoker and also used to drink significant amount of the alcohol. He was also obese. He had history suggestive of sleep apnea. So I did the breathing. I did show that he had some damage to the lung related to smoking and so I put him on medicines for the CO PD. I also told him to quit smoking.The chest X-ray was OK . I also told him to reduce or quit drinking too much alcohol. We also ordered a sleep study It showed that he had severe sleep apnea and so he was put on a CPAP, pressurize mask to help sleep apnea and improve oxygenation.He was also told him to do exercise and loose weight.
      I saw him on follow up. He continued to smoke , continued to drink and had not lost any weight.He had tried to use the CPAP but did not like it.So was not using it . I gave him my 'serman'. Told him to quit smoking, and drinking.and told him the advantages of using the CPAP.I saw him several times and the story did not change . Then one of these days he missed his appointment and then rescheduled it . So when I saw him , it was almost 6 months , since my last visit. I was pleasantly surprised.He looked better. He had lost 40 lbs. quit smoking and drinking and was 'reborn'christen .I was very happy . I asked him as to what had happened that he turned his life around.He told me that he had started going to church and had met a lady and now planning to get married to her . He had retired and was planning to move to cost.
   I saw him one more time after that. He was moving out of town and wanted to get records ,so he can take them to new doctors . He had further lost some weight , about 25 lbs and was feeling better . I told him that he may need new sleep study if he continues to loose weight.
   I met his wife , I had seen her with his previous follow up. But now they were married.I gave him copies of some of his tests and told him that if he needed something else he or his new doctor can call our office and we will fax them to him .
    I got a call from a physician that I had not known or heard before . He was working in a hospital 50 miles from my office and he had some questions about this patient. He was hospitalized there in Intensive Care Unit.As I asked some questions ,I came to know more. He owned a boat , a small one that he took for fishing.When he went out once , he lost his balance and fell down , and broke his neck and dot paralysed neck bellow . So he was admitted to ICU and was on respirator . Had not much chance of recovering from the paralysis and get off the respirator.I told him as much as could , but I was left with very bad taste in mouth . Here was Guy , who had after several years of abusing his body with smoking , drinking and eating,(yes eating too much is as bad as any other wicc) , had improved and was following my advice ,and now was at the end of life or at least good life.So unfortunately as it turned out it was too little or too late.

Saturday, June 21, 2014


    I had written about the price of the drugs in past under similar title . I thought of writing again about the same topic as i have seen no change in cost of drugs with all the new things that are suppose to occur with new or change in law related to health care.
   I tend to clear my messages in my office about 2 to 3 times a day.First time is around 1030 AM , then when I come to office at 12 noon or little latter, and again at 4-30 PM when patients are done.Invariably 2-3 messages are asking for the 'samples'.Either it is because of the sample that I gave has worked and now they are ordering 3 months supply and need a sample and before it comes, need a sample or their insurance co-pay is too high and they are going to order from Canada,or they can't afford it and 'want' the samples.I am fully aware of the cost of many drugs that I prescribe and so I can understand it.I never think that the samples that I get or the 'pens' that they give my office staff is a 'gift' and they can buy me with it . The associations of physicians feel that we should not accept these gifts as they are 'bribes'. I don't agree with it . I believe that if it was not for the drug reps. many of the physicians would not know about new advances and will not be in position to try expensive medicines or for that matter usual drugs.Take for example simple , known , old drugs like Advair or Symbicort, used as a standard treatment of bronchial asthma or COPD.If I decide to prescribe it ,it costs over $200 for every inhaler. So if patient buys it and can't tolerate it then $200 is down the drain.So I am not sure how any one can afford the medicines that we physicians prescribe.
     The cost of medicines has gone up and not down. The other day I was given some 10 tablet of a medicine. When I prescribe this drug, it is sent to patient directly by specialty pharmacy.I know it is expensive. But when I was told that I should keep them in a 'safe' place as the cost was more than $3000, I almost fainted. I knew the yearly cost , but it had not 'sunk' in my mind how much one pill costs.
     I am revisiting this issue as I often see most of the physicians' journals singing praising the new law about the health care and no one points out that it has not reduced the cost , nor it has made it any easier to practice medicine.Second reason was a visit by some drug reps.There is a new drug on the market to treat a disease called Sarcoidosis.As usual when I see a new drug I ask for the cost of the drug. Even though I know that drugs cost and cost too much , when I heard the price of this new drug, my mouth was wide open and I passed out. The 5ml vial costs $30,000.(NO I DID NOT ADD A ZERO BY MISTAKE )!!!!!!  


Monday, June 16, 2014


     Many a times I am asked if patients care to know if patients care as to which physician they see. Now a days we have many HMO and patients enroll in to them based on the 'benefits',rather than which doctors participate in to it or if they can go to their previous doctors. I can not not say that every patient that I see or for that matter any other doctor sees , does care for their own doctors , but I can certainly state that majority of my patients would like to come to me rather than going to someone else , simply because of the new insurance plan .I think I am lucky to have these patients ,that care for me as much as I care for them . The story that I am going to tell is one such story , that touched my heart. Unfortunately the end was not sweet.
     I was seeing this 63 years old female who had smoked for many years . She had developed very advanced COPD and within short time after I started seeing her ,she was put on oxygen.She was short of breath walking 50 feet . She had significant cough and got recurrent respiratory infection . She also needed to be put on steroids on and off.I

    I continued to do the follow up and in next 2 years she was in the hospital few times . She continued to get worse , but had strong will power and did walk at times , but then ended up in a wheel chair. She knew that her disease was bad.She was on respirator twice and each time it was difficult to wean her off respirator. The second time she was on the respirator for 14 days and came very close to having tracheostomy. After that incidence , when she was about to be discharged , we talked about the DNR .She told me and the husband that she did not want to be ever put on respirator again. She would rather die , than go on respirator for test of her life --and I did feel that it was possible that next time she may not be in position to be weaned off.So we agreed that we would do everything medically possible but no artificial means .
     She was admitted to hospital once and did OK . The husband was a builder and the economy was not doing well , and the construction was down . So he could not survive , so he sold his house and moved to a place 80 to 90 miles from my office . It was much smaller place and he had gotten a job near by . He still continued to come to me and I continued to follow her.
    I had admitted her in our hospital , when the husband would call me, telling me that she was bad .It was one Saturday morning.I got a call from the husband that she was not doing well and needed to be admitted . I told him to take extra dose of steroid and get her to local hospital , if she was bad . She did not want to go to local hospital.She lived 80 to 90 miles from our hospital . So I expected her to take at lest 2 hrs. So I told the husband that I will make arrangement  for her to be admitted and I will see her when she is admitted . It was about 10 am . So I thought that by the time I am ready to leave the hospital , she should be arriving. I called the admitting office . As she was admitted to the hospital before , they had all the information about her . I also left the preliminary orders like blood count x-ray , steroids, and other orders , in case I had left the hospital before she came in.
        She was not in the hospital by 12-30 pm , I was going to wait for short time and call the husband on his cell phone and ask him on their where about.Then I got a call from some unknown telephone number. I called the number and it was sheriff, highway patrol.He asked me if I knew the patient . I said yes . He told me that while the husband was bringing her to our hospital , she died on her way to the hospital . He wanted to know if I would be willing to sign the death certificate.I said off course. I spoke to the husband , there was not much to add . He had asked her if she wanted to go to other emergency room or hospital , and she had told him 'no '. She did not want to be treated by anybody other than me.

Sunday, June 8, 2014


    I do believe in luck , bad (or for that matter good ) karma.I definitely believe in reincarnation . I still do not have answers to all the situation in life and can explain the out come or the so called bad luck that we all see and sometimes experience .Granted that if we bring in the law of Karma in bad situations  then we will be considered 'cruel' or not sympathetic . But in spite of all the problems that we would face trying to explain everything, I still believe in the law of karma . The reason I thought of all this when I met a patient of mine in the hospital recently.
   I had seen this patient , who is now over 70 years or so. I had seen her for abnormal X-ray chest almost 20 years ago. The further work up showed that she had lung cancer and then it was operated,with resection of the cancer. It was completely resected and she did not need any further treatment.I continued to do the follow up as there is always chance of recurrence and also the chance of second cancer. So she continued to come to me . In the couple of years that she came to me , she lost the job and then lost the health insurance.I still continued to see her and in fact diagnosed to have new onset of high blood pressure and did treat it. I had to treat her as her primary did not see her when she lost the insurance .
    One of these days I saw her in the hospital. She was not a patient ,but was visiting someone. The patient that I was seeing had lupus and renal failure and was on dialysis. She also had circulation problem and needed amputation. She was 30 years old and was bed bound and was in a nursing home.As it turned out she was daughter of my patient.
    I was seeing a another patient in the office that I had started seeing for only last 6 or 8 months. This was a 35 years old female who had chronic cough. As it turned out she had a another connective tissue disorder (lupus is one such ),called scleroderma. She had developed scar tissues in lung due to scleroderma and also had elevated pressure in lungs called pulmonary hypertension. She was bad and I started treating her , but with the young age I referred her to lung transplant program.She refused.So I was treating her , but I knew that her prognosis was very poor.SHE ALSO TURNED OUT TO BE MY PATIENT'S DAUGHTER!.
    So my patient had lung cancer and had 2 daughters who had bad disease, bad enough that they were likely to die soon. And they were all seen by me . I did not mention one more daughter that also had connective tissue disorder which was not bad ,
    The question that I have is "is this Karma ?"Is this shear chance? or all this was interconnected with each other with the circle of karma and the debt that all of us collect with interpersonal relationships in our 'every' life !!!!!
  I don't know the answer, but may be you do.

Saturday, June 7, 2014


   I have now seen models of computerized medicine or the decision made by the computer . Our brain does work as computer, but at times we do have instincts.And they do work better than the well thought out computer program.Many years ago I was reading a book called 'MIND Control' written by Jose Silva.It stated that we have intuition as children, but as we grow older, we are told to think 'logically' and as we develop logical thinking , we loose intuition.The computers work logically .There is no intuition in the computer decision making.It is all logic. Off course the logical thinking is programmed by the human beings.
   In medicine ,when we make decisions ,many a times it is not completely based on logical thinking, but it is based on 'feeling'. The patients that I am going to tell is one such story.
   I have been seeing this 68 years old female.She was a smoker and in 2010 I diagnosed her as having a lung cancer . She also had a history of a lung cancer in 2004. In 2004 she had a surgery and had part of her left lung removed. In 2010, after the new cancer was detected ,I referred her to a surgeon.She had a new surgery and at that time the surgeon did what is called a wedge resection . This is to save lung,by limiting the amount of the lung that can be removed, as much as possible.There is a risk that the resection margins may show cancer cells under microscopic examination ,which necessitates additional treatment and recurrence rate is higher.But as patient looses less lung , the shortness of breath is less.So this lady had 2 lung surgeries . I was following her with follow up CT scan.She had continued to smoke , had shortness of breath on exertion, and had significant cough. Few months ago the CT scan showed the increase in size of a nodule by 2 mm in span of 1 year.So I did a bronchoscopy and a PET scan. The PET scan is a biological scan . In this scan we check the glucose uptake in the spot, comparing it to the normal tissue.As cancer cells and infections have higher metabolic rate,the glucose uptake is much higher than normal lung tissue.The PET scan uptake was there but at much lower level than seen normally with cancers. So I decided to do follow up on the CT scan. The CT scan was done in 4 months.The nodule had grown by 5 mm and repeat PET scan now showed the uptake to be very high, highly likely to be cancer. I did check the breathing test and it showed adequate lung reserve. She had continued to smoke and had significant cough and was short of breath. But the nodule was still small and so in short ,she was surgical candidate. I was quite skeptical as to her ability to tolerate the 3rd lung surgery. But I had no choice but to refer her to a surgeon. Patient was not very old , had adequate lung capacity and was willing to have the surgery. So I sent her to a surgeon. I also sent her to a radiation doctor for the opinion,as if the surgery can not be done, then we could treat her cancer with radiation treatment.
     The surgeon saw her and so did the radiation doctor . Both felt that the best option was to give radiation and not the surgery. So my " FEELING "was correct ,or at least all 3 of us felt same.So if this was a computer decision, then she would have had surgery and may not have done well .