Wednesday, April 22, 2015


     I am now in practice of medicine for long time . I was talking to a student yesterday , when I told him that I would like to have better doctors in the future, as when I will need them , I want to be confident about their ability to diagnose and treat any condition. I am some what disappointed in today.s medicine. This does not mean that every one is not good or does not know medicine.But it reflects MY opinion about the current state of MEDICAL PRACTICE. No one gets paid to THINK ,and so gets paid to DO tests or it is easier to order tests. This may have to do with medical malpractice fear or demand by patients or any other reason. But result is same. Now many business entities are taking over medical practices and it is going to get worse as these Businessman do not know medicine and are in to medicine to MAKE MONEY . But what I am writing today is something little different . When I have a difficult case , I would refer him or her to centers like Mayo Clinic or Shands hospital or some other local or out of state reputed center.But when they can't help the patient any more than what I can do , then what?Let me tell you couple of stories.
     I saw this patient with possible unresolved pneumonia .He was about 42 years of age and had a history of brain tumor and surgery for it done .He also needed a shunt to drain the fluid from around the brain ,as otherwise the pressure build up around the brain will be detrimental. He was worked up by me and as it turned out he had scar tissues in the lungs . He was also obese and had some pressure built up in lung circuit, call pulmonary hypertension. I started him on oxygen and then the therapy for pulmonary hypertension. Till last October -November , there was no specific treatment for the scarring in the lungs .I had tried some steroids and it did not help I tried to get him for lung transplant .But due to various reasons he was rejected He did OK for couple of years and then started getting worse. I did put him on new therapy for fibrosis . But he continued to get worse. He was seen by one center in past and they could not do anything more. So I called other center, to see if they could do any thing. They agreed to see him. But over period of 3 months he continued to get worse and his need for oxygen continued to get bigger. After extensive concussion he was sent to Hospice and he died.I knew that I could not do anything more and I also knew that Mayo could not have done anything more. But then that is my question. What do you do when there is no further road. It is easies for doctors and probably for patients , when the diagnosis is cancer, as every one KNOWS and ACCEPTS the inevitability of the death with that diagnosis.But  when we have other diagnosis , and we can 't help and on one can answer or help, then that is what I was calling the DEAD END ROAD. The only good part is that many a times the problems are not fatal like chronic cough, and the best thing thing of all is ,it boosts my confidence ,when these patients come back with no major change in their treatment.
     So it brings me to one of my favorite statements , Medical knowledge is vast and incomplete.

Sunday, April 5, 2015


      I was reading an article on the role of physicians in telling the "bad news" to the patient or their family. Whenever there is a diagnosis of cancer or whenever there is bad prognosis, we a physicians have to tell it to patient and their family members. I sometimes have to tell the patients or their family same thing again and again. I am not sure if it is due to sometimes  patients 'blocking ' it out or may be the information is not clear or may be there is a wishful thinking. I came across a patient that I really felt bad , really could not explain why 'bad things' happen to good people.
     This was a patient who was a young male. He was referred to me for persistent cough, or that is what I thought. When I entered the room he was coughing a lot . I actually could hear it even before I entered the room. I started the my interview and the usual questions about the high blood pressure, diabetes, and asthma etc .He was smoking 3 -4 cigarettes a day and was sick for may be 4 weeks. He was treated with antibiotics and cough medicines and he continued to have cough. So chest X-ray was done and it showed possible pneumonia and some fluid around the lung. So a CT scan was ordered and he was referred to me . The CT scan was done and they brought the report with them . (He was accompanied by his wife. )The chest CT scan report was bad. There was significant fluid , much worse than was seen on plain chest X-ray.And the fluid was causing pressure on the lung and significant part of the lung was collapsed.From the other findings seen on the CT scan, it  was obvious to me that we were dealing with most likely a lung cancer.He was short of breath and coughing and I felt that to work up done quickly we should admit him. He was going to need number of tests and to do them as out patient, it would have taken long time . ( in addition to the scheduling issues that would occur, we would need 'refferel' to do every test.)So I spoke to patient and his wife and decided to admit him .
    He was admitted  and his chest X-ray showed complete collapse of the lung. THERE WAS NOT MUCH AIR GOING IN THAT LUNG. So I did the procedure to take out the fluid . I too out more than 1200 ml of fluid and his chest X-ray showed no improvement.So I consulted  a chest surgeon to put in a catheter to drain the fluid and do any additional biopsies to get the diagnosis. The fluid that I had sent did show the cancer cells , most likely lung cancer.I had told the patient and his wife in my office about the suspicion of lung cancer. They had asked me if it would be operable .I had told them that once the fluid is showing the cancer cells , it can not be operated to cure the cancer. So after the fluid came back, I sat with them and told them and explained that the treatment would be chemotherapy and not surgery.  I called the oncologist and and he had the catheter put in . We talked about the results of the surgery . He had tumor in the covering of the lungs all over, So I again talked to them about the chemotherapy and the radiation treatment . The question came again as to if we could do surgery . I had hard time answering that for two reasons , one was I had told them the answer few times and he had just introduced his 12 and 16 years old "kids" to me . I had to be very careful about the words that I spoke , but I still had to tell them the reality. This is what I call as the big job. I wish that the patient would not have asked me the SAME question again , But he did and I had to answer it .