Thursday, October 30, 2014


    When I used to drive on interstate in this town , I used to see a billboard, making an announcement that "we do miracles".I could never understand as to why a hospital would like to claim to do miracles as many of the religious leaders can't claim the same.Then I was reading a book by a surgeon named Atul Gawande.He has written 4 books and written several articles related to the medicine and related topics. In one of his book he states that the medical knowledge is vast and incomplete.I could not agree more .In one of the books where he talks about medical malpractice,he described a case of melanoma , a deadly skin cancer.The case describes a patient who had melanoma and it was taken out and there was a difference of opinion between two pathologists and the doctor claimed that he asked patient to consider 'wider and more resection'. But patient refused and then developed wide spread metastasis. So the doctor got sewed.This reminded me of one of my patients.We doctors claim to know everything and the hospitals claim to do miracles. So it is not of surprise that patients expect that we will 'know everything ' and can' predict 'every outcome.
      I was called by this doctor about a patient that he wanted to me to see. The patient was having a cough and so the doctor treated her . She was a nonsmoker and had no other medical history.When she did not respond, he did chest X-ray. Then he did a CT scan .The scan showed a small mass in the center of the chest.He wanted me to see patient ASAP. I checked with my office and they gave her an appointment within 5 days of the call. I was thinking that she probably has a benign thing called THYMOMA. This gland called Thymus is present in early infancy.And then it disappears in adulthood. Some people continue to have it or in some patients it enlarges or even becomes cancerous.In a patient who had not smoked this was the most likely possibility. So when she came to my office ,I came to know that several years ago she had uterine cancer. She was followed by the oncologist.When I saw the CT scan , I also saw a small mass on the center of left hill um.I was concerned about it .I was worried about may be a lymph node cancer called Lymphoma.I decided to do the PET scan that picks up cancer in almost 90 %. She was also scheduled for bronchoscopy.The PET scan was done and then before she was to have the bronchoscopy,she got very short of breath and her oxygen was very low . So she was admitted to the hospital Another CT scan of the chest was done .It showed that there was also a congestion in the left lower lung.The lung was still inflated. The other areas of the abnormality were same . When I saw the PET scan it showed increased activity in the center of the chest , left middle part and also on right side and also in the lymph node in the neck.I did the bronchoscopy and I saw the tumour in the left main bronchial, completely blocking it. This was not expected.I could not do biopsy as I felt it was too risky.The appearance was was that of a tumor called carcinoid. These tumor bleed on doing the biopsy. So then a surgeon saw her and did the biopsy under anesthesia . I also had radiologist do biopsy of the lymph node in the neck. So we got multiple biopsies and enough tissue to analyse as to the type pf the cancer. We continued to have diagnosis of "adenocarcinoma",a type of a cancer which can arise in several different organs. The best that they can tell us is that it could be uterine in origin or lung as the origin of the cancer. So we still did not know . (FORGET about doing a miracle,we can't even tell where did the cancer start.)
      That is why the medical knowledge is vast and incomplete.  

Sunday, October 19, 2014


    It is that time of the year, when we get to 'choose; the health insurance .I can change my health insurance in November (private insurance ) and the new medicare enrollment will also start now.I was talking to some patients and some doctors and some nurses.I was surprised to realize how little many of us 'know' about the Medicare.So I thought that I will write as to how many insurance companies work.
    So let me start by saying that the medicare expense as part of Federal budget was 14% in 2013
The money comes from general revenue ,(41%),pay role taxes(38%),and the beneficiary contribution(13%).The government collects the money and then pays out as the 'claims' are submitted by the 'providers',such as hospitals,doctors labs and outpatient clinic and radiology centers.There is off course management cost , and that comes out of the expense.Now since the medicare is supported by the federal government, there is no limit to the expense.So each year the medicare expense continues to go up.This is where the HMO come in picture. The companies like Humana, Welcare, or Freedom and many more like to have the piece of the pie.So they go to the federal government and tell them that they will 'manage ' the health cost of the recipients. So Let us take number, though not accurate, it is for understanding purpose only. The federal government is spending $1100 per month per medicare patient. So these companies will accept payment of $1000 per month,per patient.Now the federal government is off the hook for the expense. If the expense is less than $1000  then Humanas or wellcare etc will make profit. If the expense is more than $1000, then they loose the money.But wait a minute, .The HMO have expenses too. They need to pay agents who sign up patients and the expense for advertisement, and the claim managements and the office and the other expenses. They also need to have some profit so they can stay in business.So they have to 'manage' all this in the amount less than the medicare was spending when it was done by the government.So how do they do it?
       They go to different providers and offer them contracts that are less than what they would have gotten if it came directly from the government. So they go to primary care physician and 'offer' him 'fix' amount of money per patient per month. Say $25 per month and then they assign say 100 patients . So the primary care physician gets $2500 1st of every month, irrespective of how many patients and how often he sees.So if a patient sees him 3 times a year , he gets same money as if he sees the patient 10 times a year. But then there a catch . The year end 'bonus; will depends upon how much is actual expense on 'his assigned  patients if the total expense is more than what insurance company wants , then the bonus less or gone .So this is" the carrot and stick approach."So now you can see that the primary care physician has motive to spend less money,which means less tests, less consultants ,less costly medicines and less hospitalizations.In a way this is good as it eliminates unnecessary tests and referrals. But it is not good as the referrals or expensive tests  are not ordered.Every provider gets pay cuts, may it be Labs or Radiology clinics or consultants.This very easy to understand . If the insurance company is going to get less money than what the federal government would have spent, and they have spend money too get patients to sign with them and they have to 'manage' providers and on top of this they have to show profit to their stock holders. So The actual money spent on 'health care; is anywhere from 70% to 85%.(under new law this has changed.)At one time one HMO was spending only 67 cents out of a dollar that they collected.THEY CALL IT MEDICAL LOSS RATIO!!.Most of the primary care physicians do this kind of contracts.But there  an another way of doing these contracts and that can be more daring and more lucrative.
       Some doctors feel that they can manage better than the HMO insurance company.So they now approach the HMO and get money from them and now HMO are off the hook if the expense is more than what they collect. Now the doctors manage it and so you can imagine. The money that was spent by government is more than the HMO spending and this 'risk contracts' doctors spend even less . So now everybody gets deeper cuts and less  tests and referrals are done.This is a reality. The patients don't understand as to why the consultants won't see patients without getting referral or would do a tests as if they do , they won't get paid.
     So if any one signs with the HMO ,does not matter which one ,the money spent on health is less.This does not mean that one will get inferior care . It definitely means that there would be more restrictions on your care. Which consultant you go, which radiology clinic you go , which lab does your blood tests, who gives oxygen or other equipments  etc are all predetermined .I am sure there are more questions than answers after reading, but get the answers before you sign. 

Friday, October 17, 2014


    The medical field is changing. I know that the doctors are not same and the patients are not the same . Patients go to a particular doctor not because they want to go and like him , but their insurance tells them to go to a doctors who are on their insurance plans. There are exception to the rule.I have many patients who would 'change' the plan if they can not come to me . But even today's doctors are different. When I talk to some new doctors, they would prefer to work 8 to 5 type of job.It is difficult to say the least. The medical life is different .When someone in non medical life spends too much time in his or her business, then we criticise him. We say that he is too much after money or he does not care about own family.But when a physician does this to take care of a patient, we say that he is 'caring'. We praise his behaviour and say that" he is so good that he does not care about his own family when it comes to his family."This is the medical paradox that I was telling. But this is not limited to the doctors only . Even the nurses and other medical support staff does this all the time . Today I am going to mention two such short stories.
      I was invited for a 'surprise '50th birthday of a nurse that I knew .I was told to come to the house and park the car 2 blocks away. She was working 12 hours shift ,7 to pm . So she was not likely to come home before 7-pm.So I decided to go around after 7-30 pm.I went in the house and there were about 20 other people . The nurse did not show up.So we contacted one of the nurses who  was also working with the nurse.She was to call us when this nurse would leave the hospital. We waited till 9 pm before we got the call and then the birthday girl arrived . There was a sick patient , who needed to be transferred to the ICU and she worked on him till he got the transferred.
      The second story is that of a respiratory therapist.I was seeing a patient who had respiratory failure. The patient was doing well and appeared to be ready for extubation, to take patient off the respirator.So I was sitting at the desk and told the respiratory therapist to do the test to see if he was ready . (they do blood oxygen ,carbon dioxide and check 'mechaniques'--to check the strength of the respiratory muscles.)The therapist went to do it I could see him from where I was sitting . He went in the room . I saw him stumbling and falling down . I ran to to the room .The other nurse came in too. We got him out of the room and put him in a chair. He was sweating and was cold and clammy. The nurse was putting a blood pressure cuff. I told her to grab 50%glucose . I got IV line and pushed the glucose while the nurse checked the blood glucose.I was not surprised when she told me that the glucose was 53 very low. The therapist woke up .I gave him couple of orange juices. I did not know he was diabetic and was taking insulin.He was so busy that he did not have time to eat the lunch.So his sugar dropped and he almost lost the consciousness. Like the other nurse who had birthday , he also did not care for his own health.

Wednesday, October 15, 2014


        I often see patients with the fluid around the lung or sometimes both lungs . When I try to explain my patients , i try to make it simple . I often tell them that there is always some fluid around the lungs , but it is so small that we can not see it on the plain chest X-ray.Now a days there are so many CT scans done that we see so many abnormality that need to be addressed. In past when we did only chest X-ray we did not appreciate these minor things . So as much as we can diagnose cancer at it's early stage, and can get cure , we also see things that means nothing on the long term,but we still have to do follow up and do more CT scans.The Ct scans do show more fluid as it is done when patient is lying supine and the fluid layers down and so looks worse.So many a times when I do not see much fluid on plain X-ray , I would elect to do follow up X-ray and 9 out of 10 times I don't have to do anything.(drain fluid ) I also tell patients that there is constantly fluid made and constantly absorbed.So when there is more production (as in case of infection , pleurisy or TB or cancer) or there is less absorption,(as in case of weak heart ,liver disease or kidney disease).But there are other causes of fluid too. But they are are so uncommon, that in usual ,cases I don;t mention them.Sometimes in case of patients who have had some kind of surgery, the possibility of 'blood' can be there.But today The case I am going to tell is one that is not uncommon.
      I saw this patient,who is almost 88 now. When I saw her she remembered me. She told me that I was the one who had 'drained'fluid after her heart surgery. When I checked old records, I realised that Indeed I had seen her almost 18 years ago. She had coronary artery disease and then had work up and then was advised to have a coronary bypass.She did  quite well and was discharged. She had a follow up chest X-ray.The chest X-ray showed fluid on the left side .In many cases of open heart, there is some fluid on the left side and it is simply due to the surgery. In most of the cases it is blood and the body tends to absorb it if given time. I have seen many patients that have had it and who were advised to have it drained and by just waiting , and doing follow up X-ray I have avoided the procedure in at least 9 out of 10 patients. I explained this to patient in general. But when i repeated the chest X-ray , it showed no improvement, but showed some worsening. So I decided to drain it.In past I had one or two patients , that needed to have surgery as there was significant blood.The fluid was not that worse , but I was concerned.
    So I did bring her in the ultrasound department and decided to do the drainage of the fluid. I did the ultrasound and marked the spot for insertion of the needle and then the catheter . When I inserted the needle , followed by the catheter, what came out shocked me . IT was a milky fluid . Normally the fluid is like clear water .In case of fluid with high protein , it is yellow .may be like concentrated urine.And then there is blood.But the milky fluid is very uncommon and indicates injury to or blockage of LYMPHATIC DUCT. In view of the recent heart surgery, the injury to the lymphatic duct was high. Most of the people don't know about the lymphatic system This system also drains fluid and drains to special glands, called lymph nodes.So sometimes in case of cancer of the lymph nodes, lymphoma, fluid can collect. But I have seen may be one case of the collection of such a fluid . So in this case it was related to the heart surgery. In most of the cases the leak stops automatically and nothing special needs to be done . In case of this patient I just did the follow up chest X-ray and the fluid was gone.I did not have to do anything more. 

Saturday, October 11, 2014


     I believe in reincarnation and I also believe in Law of Karma.I do not have any direct proof for it , though I often come across the situation that leads me to believe that both of them are real. The question that is always asked is ,is it nature or nurtured?The things that we see in different family members occurring , is it due to the simple 'chance' or is it because the environment under which the family members are brought up is same or is it due to some kind of relationships that we develop that continues beyond single life ?(which means is it due to the our karma and it's effects , which causes reincarnation).I often see patients whose spouse also start seeing me if they have lung problems. So I often wonder when I see sick patients , whose spouse also has significant pulmonary or other medical issues.
      The story that I am going to tell is one that is related to the patient in my last blog . The patient that I described had 3 lung cancers at 3 different times and sarcoidosis and then developed breast cancer and died of it.One of these days this patient told me that I was going to see her husband . I had known him for some years as he used to come with her.Now he wanted to see me . He was a 70 years old white male who had significant cough, mainly dry and some shortness of breath. He was getting tired.He had mild cough and had some crackers on physical examination. I did the chest X-ray and then the CT scan . It confirmed that he had pulmonary fibrosis.I had also sent blood for rheumatoid arthritis and some other conditions that can cause the fibrosis. The rheumatoid factor was positive .So he had rheumatoid arthritis and it had caused the fibrosis in the lungs.The breathing test that I did,,showed that the diffusion capacity-how the oxygen is transferred across the lungs in to the blood,was reduced . This was consistent withe the diagnosis of the fibrosis. I sent him to a arthritis specialist and he was started on treatment for the RA.He came to see me in 3 months and was OK but did not look very happy .He had lost some weight and still felt tired. But he had no fever . His appetite was good ,but he was not gaining any weight. I decided to do the Bronchoscopy. Sometimes these patients with the fibrosis and the one that are taking immuno- suppressants ,get atypical infections, like atypical TB.It came back negative. So I decided to do the follow up .He came to see him Had lost more weight and was feeling more fatigued and short of breath.I did the new diffusion capacity .It was not any worse . I had done the Echo cardiogram , to rule out cardiac cause and it was OK. I walked him in our office for 6 minutes,and he did OK. So I was not sure as to the cause of his weight loss. I had asked gastroenterologist to do endoscopy ,colonoscopy to rule out occult cancer and it was negative.So I did not know and he WAS WASTING away. And it struck me .I was surprised that I had not noticed it before. HE was loosing not only weight, but was also loosing the muscle mass. I sent him to neurologist and this time my hunch was correct .He had myopathy, a muscle disease in which his muscles were wasting and as he was loosing the muscle mass he was loosing weight.There was no treatment for his condition.
     In the past he was the one who would help his wife ,when she was short of breath. He was strong and big and had no problems. Now he was himself short of breath and was weak. He could not be of much help.In next less than a year he died .
     So the question that I had was was by any chance that these two were married and both saw me and I had diagnosed  the different conditions , that would lead to death finally.

Thursday, October 9, 2014


   I watch evening news and many a times there are stories,which include police power abuse and also about medical negligence or missed diagnosis. Recent case in point is in case of Ebola in Texas.I do not no much more about Ebola or about the case in Texas.But the families always believe that the police are not careful in cases of criminal cases and doctors are not careful in cases of medical cases ,especially when the out come is bad.Even though I am sure that there are cases where the doctors are at fault.But I also believe that as in case of police ,the work of doctor is not easy . To get a line from Dr.Atul Gawande, the medical knowledge is wast and incomplete, it becomes difficult to be correct 100% of the time . I am going to tell a story of a patient that had so many complicating issues ,that it was impossible to have something definite diagnostic test than doing a intellectual educated guise work.
      I had seen this patient for many years. She was a smoker , who had quit .She had mild lung problem related to smoking in the past. But she was not bad . But when she saw me she had abnormal chest X-ray.She had some lung congestion or infiltrates and her lymph nodes in the chest were enlarged. The possibility of a condition called Sarcoidosis was entertained by me . In this disease patients do get the enlarged lymph nodes and they do get problem in the lungs Some patients ,<1%will get worsening and will get short of breath.She was quite concerned.I did the lung biopsy, and it did confirmed the diagnosis of the sarcoidosis..She was worried about cancer . So I sent her to a chest surgeon and he did a lymph node biopsy.It was positive for the diagnosis of sarcoidosis.She was happy and we decided to do the follow up.
     Over period of next couple of years , I did the several CT scans . They continue to show the enlarged node and the the lung congestion . The one of these days she had a nodule. I was not sure if this had anything to do with the sarcoidosis or it was a cancer. The further work up was neede . So we did the biopsy and then finally I sent her to a chest surgeon.He did the open biopsy and took out the part of the lung that had the tumor. The good part was that not only it was a cancer that was contained, and the nodes were negative for any spread of the cancer.She was happy . I just wanted to just point out that if in case of lung cancer, if the nodes are involved , patient becomes inoperable and incurable.But in the case of this patient, there was no way to know if the enlarged nodes were due to cancer or due to sarcoid. Even though in latter part our follow up we had PET scan.In PET scan ,tagged Glucose is given IV and images are taken. The glucose is picked up by metabolically active cells and by normal cells. The metabolically active cells pick up glucose more actively and so we can pick up cancer. The problem is that the infection or sarcoid will also pick up glucose more avidly and so it does not differentiate between cancer and sarcoid or infection.So you see the difficult?
    In near future she developed another nodule .I was not sure what to do other than do the usual work up . I did send her to a surgeon and it was taken out .And it did not stop there. She did well with this surgery.But then again developed a small nodule. Please realism that I followed her for may be 10 years or more.This time , the third time when she had new nodule and the nodes were same , I sent her to a surgeon. I am not sure why , but the he decided to do the biopsy of the lymph node and not the nodule . I was thinking that the nodule was cancer and the nodes were sarcoid .She also had develop breast cancer. To my surprise the nodes came back positive for cancer.and she HAD BREAST CANCER in the lymph nodes and the . So I was not sure why he did that but it was more helpful than the PET scan .
    So the difficulty that we have is no test is perfect and your intuition is not perfect and every time one can not do major surgery or do biopsy . So this is not a perfect science and like any other time we go by what is more common.She had 3 lung cancers and a breast cancer and Sarcoidosi , each one can cause the enlarged nodes and positive PET scan.
     The lady was given chemotherapy , continued to have problems and got metastatic breast cancer and died about year and half after the breast cancer diagnosis.

Monday, October 6, 2014


   As a child I learned the story of the crying wolf .I have thought about it on many occasions in life . We may be talking about the politics (it is always a crisis of some kind for some politicians), or your own son or daughter, or it may be in medicine, this phrase and the story is illustrative of our response.I have myself experienced this in my own decision making , even though I try to sort out my 'feeling' and the findings. Some ties it may have to do with the circumstances , but one must be careful.
      I had seen this elder,y patient , over 90 years of age,who was admitted to the hospital with the diagnosis of pneumonia. She had no fever nor did she have any elevated white cell count,( which is elevated in case of any infection)I saw her old chest X-ray done about 4 weeks ago.It was similar to the one done now. So I was not sure if she had indeed the pneumonia the diagnosis that she was admitted with.I wanted to do some investigations, but she was older , more than 90 years of age , and I was not too sure what did she want. I spoke to her and her son . She was not very keen on many "tests".But after discussions she was agreeable for the CT scan and an endoscopy. (Bronchoscopy.) Even though she was 90 plus she was quite clear in her thinking. She was allergic to many drugs and it was difficult to treat her. I did the CT scan and it did not add much . She had congestion , findings similar to the one seen on plain chest X-ray.The bronchoscopy also did not help. It showed no cancer , which was helpful .But the cultures were OK .The infectious disease consultant wanted to give 3 antibiotics.He did not want to stop any even though all the cultures were negative. I had no other choice as I did not know anything more.
      My plan was to do follow up X-ray in 3-4 weeks and then decide. But every day that I saw her, she had some complaint. One day the IV got out and they had hard time starting another one.Then she was constipated and the medicines thy gave her was not good and caused her to have abdominal pain. Then she had diarrhea.She did not want the breathing treatment and then felt that steroids were causing problem . Her physical findings were not any different. Her oxygen was OK and there was no fever and she sounded clear.The one day she got the laxative that she wanted and then felt like throwing up. She had 4 or 5 loose stools and may have been mildly dehydrated.Her blood pressure dropped and she almost passed out . I saw her in less than 10 minutes. She was fine and her oxygen saturation was OK and blood pressure was OK . I ordered some blood tests and new X-ray and gave her some fluids. The X-ray was better and labs were OK except one which was borderline for heart attack.Her ultrasound of the heart was normal and there was nothing to suggest heart attack on cardiogram.She continued to do OK , but every day had new complaint from stomach upset to constipation to diarrhea to problem with IV site and so on .
       One night the nurse called me stating that she had 'worked herself' up and was short of breath , The oxygen was OK, she sounded OK and blood pressure was normal She wanted an inhaler ,that she had stopped on her own before. I had respiratory therapist give her a nebuliser treatment and gave the inhaler . I also ordered new Chest X-ray. It was 1 am As soon as I hung up the phone I realised that I was brushing aside the complaints as she had complained too often . I called the nurse again .I ordered new cardiogram, blood test for heart attack and blood test for congestive heart failure. I also ordered IV Lasix, a diuretic.
       She did have the congestive heart failure and the X-ray and the blood test showed the congestive heart failure. So the diuretic helped . She was better.Next day I spoke to her and her son . She was doing much better and in next day or so was discharge to rehab unit.So I was about to be caught with the "crying wolf" and not doing the right thing . But I did OK.and so did the patient.