Tuesday, September 22, 2015


       In medicine there is a term used called 'standerd of care' . One who is not in medicine , might wonder as to what is standard of care and how can standers of care can change . The easiest way to understand is to understand the circumstances under which medicine is practiced . So presume that there a doctor who is practicing medicine in a remote town . He will do much more on his own -not refereeing the patient to far out center for treatment or care. If the CT scan or MRI is not easily available , he may not order it as often as done by some one in city where several CT scanners or MRI centers are easily available.So the standard of care that one has to follow is different for different areas of the country , and also the education of treating physician. So who decides the 'standard of care'. There is no one person or a medical society decides it . But there are guidelines for almost every disease. Everybody knows that the HBA1C should be monitored in patients with diabetes. But the point that I am going to make is not about the usual standards that are set by various societies or communities. What bothers me  is that now a days the standards are set by the INSURANCE COMPANIES OR HMO, and nor necessarily by these medical societies . This brings me to today's story or may be I thought about this due to a patient that I saw . 
       I saw this 70 years old male for shortness of the breath . He was a smoker for many years and has been diagnosed to have COPD. He was little obese and had reduced the physical activity. He was started on medicines and was doing OK . He had quit smoking only one or two years ago. He had all the blood tests done , not only once but several times. But when I asked about chest X-ray , it was not done for several years . In fact he could not remember as to when one was done . He never had breathing test done. As a routine I ordered the chest X-ray and breathing test and oxygen check . As expected he had severe compromise in the pulmonary reserve.The oxygen was low and it would drop with walking , so he needed to be put on oxygen with walking. The chest X-ray showed 2 nodules. So I had to do the CT scan . The CT scan showed the 2 nodules and it was suspicious for Cancer. So I did the PET scan and it showed there was increased uptake in the nodules . So it was very likely that the nodules were cancerous. My bronchoscopy was poorly tolerated and so I did the needle biopsy. It confirmed the diagnosis of cancer. He was not a candidate for resection due to very poor lung condition. So only option of treatment was radiation treatment. 
    This is the story which made me think . He would have not been candidate for surgery even in the past . He had 2 nodules and he had quite advanced disease  which did not come in suddenly . So diagnosis of the cancer did not alter the out come . But what surprises me is that every one of these patients get check on their blood tests . But there was no requirement for doing the X-ray or the breathing test , so most of the patients don't get chest X-ray done . Now a days there is a change and even a ROUTINE CT scan for high risk patients is recommended and approved . But that will increase cost . So up till now this is not a standard of care according to HMO and so it is not done routinely. So the standard of care is set by the Insurance company in this instance . 

Friday, September 18, 2015


   One of the main difference between the Hindu religion and the other religions -at least perceived by the followers of other religions, is that the Hindu religion believes in reincarnation. The concept of the reincarnation exists in Christianity too , but conventional teaching is made simple and uncomplicated so as to get more people to follow the religion. The Hindu religion is quite complicated and some what difficult to understand. It is simple to understand that if one does 'Good things' the GOD will be pleased and then one is allowed to go to Heaven .On the other hand if one does "more BAD than GOOD", then he will go to Hell. So all that one has to do is 'get passing grade' may be 51% to get entry in to heaven . There is nothing about 'Law of Karma'  or the 'attachment to body' or 'desirer' and bondage due to them and rebirth. So it becomes difficult to talk about it as we have too many questions and not satisfactory answers. I have known this for long time and have myself several questions that no one has been able to give satisfactory answers. To just give an example , Why do some animals sleep in owner's bed and other end up in pound. What about the thousands of animals that are bred for food and have 'no life' .What do you think about the fertilised and frozen human embryos, do they have 'soul' . And many other . But this came to surface when one my patient asked me something related to this subject.
    I have known this patient for many years. She a young lady and had gall bladder surgery. After the surgery she was on the respirator and could not wean off it. So I was consulted . She had no past history and was not taking any medicines. She definitely had no previous lung problem. Her lungs sounded clear and her chest X- ray was normal. I tried to wean down and she would be OK up to certain reduction on the respirator , but then it would become difficult . I suspect muscular weakness , called myopathy. So I consulted neurologist , who cold not imagine myopathy in this mid forties patient without any previous history. He did not feel that was the problem . So I called the surgeon and deed the muscle biopsy. The surgeon was reluctant to do biopsy , but then agreed and it was done . The biopsy showed myopathy. So she has been on respirator for last 25 years . In the early part of her diagnosis she was on respirator for 12 to 14 hours . It gradually increased and now she need to be on the respirator for 24/7. She was little depressed. So with her last visit we talked about the present life , reincarnation , and many other things . I told her to read a book . The name of the book is 'Many lives -many Masters'. She not only read it , she took notes and gave me a letter. Without going in to the details of the content of the letter, I will tell you what she asked me . What did I do wrong that I have myopathy and I am on respirator for rest of my life.
    I don't have the answer ,( though I can give some general answer.)
    I had thought about this and wished we had a book like the Human Laws , where we know what is the punishment for Say for example stealing or killing or assault. But we don't know what will happen if I take a pen from the work place or some more serious bad action. But one thing for sure, we are attached to THIS life and attached to people around it and the desires that arise due to our MIND, INTELLECT, AND THE SENSE ORGANS AND THE ACTIONS that we do . I will tell a story .
      There was this swami or saint , who had discarded everything and was not attached to anything mortal. He had meditated and had achieved highest levels of SAMADHI . So he knew that when he dies he will not be reborn. He was on his death bed and he told his disciples that when he leaves his mortal body , and reaches NIRVANA , there will be a loud sound of bells ringing. So he died and there was no sound . All the disciples were perplexed . So one of the senior disciple had an idea. There was tree of berries out side his bedroom window  The saint could see it from his bed . The disciple went out and plucked few berries and opened them . In one of them there was an fruit insect. He killed it . AND THERE WERE RINGING OF THE BELLS. So the explanation was that when the saint dies , his attention was diverted to the berry and he had transient DESIRE to eat it , exactly at the time of death . So he had to come back to FULL FILL the desire.
     The story was that of old lady . She had cataracts and doctors had advised her to get it operated. But she had lost her husband and then she lost her son . So she told her friends that 'she wished that she was not alive to SEE all this .and what was the use of having the eyesight?'So one of the saint told her that these kind of thoughts could lead to BLINDNESS in the NEXT LIFE . So to know  the co relation between the desires and attachment to the next life , is very difficult but not impossible . 

Monday, September 7, 2015


      I was reading a magazine called SWAROOPYOGA . This is published in India and covers Hindu religion . Most of the articles are written by the Founder of the magazine , Madhawanand.But one of the articles had mentioned the conversion of Hindus. In past and even today this is a practice that is followed by Christians and Muslims . The conversion is carried out under pressure and by force by Muslims and in other ways by Christians.The Hindus do not 'convert' anybody as we believe that each one of us has choice and each one of us can 'follow' our own path at the 'level' that we are at. But I am not writing this to talk about the conversion. I am writing this one to point out the similarity between the Christianity and the Hindu concept . This is MY VIEW and not necessarily mentioned by teachers of the Christianity.
     So in HINDU religion we have AUM - TAT- SAT. This is often repeated by Hindus . In Christianity there is a mention of the The Father -The Son -and The Holly Ghost. These two are essentially the same . In Hindu concept the GOD is INFINITE and has no qualities.At the 'begining' of the universe HE splits in to the SPIRIT and the NATURE. The spirit pervades all the and everything in the universe. In Hindu concept the first Sound is AUM. So the SAT IN HINDU concept corresponds to the THE FATHER , from whom every thing originated and is Unchangeable and has no specific qualities. The TAT in Hindu concept corresponds to THE SON , which is Universal consciousness or the SPIRIT without which nothing exists . And the AUM is the HOLLY GHOST in Christianity and is the MOTHER NATURE or PRAKRUTI of Hinduism . This is also the first Sound and is said by various names in different religions. AUM is HUM in Tibetans ,AMIN of the MUSLIMS and the AMEN of the Egyptians, Greeks, Romans,Jews and the Christians.
     The Hindu religion happans to be the oldest of all the religion. In ancient times the as our knowledge increased we added months and the month of MARCH was the first month corrosponding to the Indian first month Chatrya. But more about this in the future blog. 

Friday, September 4, 2015


      I often say that the cause of down fall of most of the mankind is due to Money, Sex and ?? . One can add anything as the third thing. I add In Laws , when I am talking to the ladies and majority of them agree with me . It is amazing to see how the money is the root cause of the problem and so is Sex . But we all knowing it can't seem to avoid it . I do not mean to say that we should not try to make money or try for more or never enjoy sex . But make sure that we don't get to a point that we start doing things that are not moral . Just look around us . Many politicians and religious leaders came down due to the greed for the money or sex. The ancient Indian sage Vishwamitra. He had done great penance and was about to reach the highest level of liberation . And then appeared the Menaka, the very beautiful dancer from the Haven and the Sage was lost. He ended up getting involved and all the hard work that he had done was gone in span of one moment. Do you remember the presidential candidate Hart or the other one Edwards?Both had affairs and their political careers are gone . How about the congressman Jefferson Clinton who was found to have $200000 in freezer or the Florida congressman who had homosexual relationship?
   One might ask what does it have to do with medicine ? Now that they are publishing medicare reimbursements to each physician, we have known the income of some of the doctors. Though this is not a good indicator as it does not take in to account the expense that occurs in doing testing. The oncologist give chemo therapy. The cost of the drug may be $10000 and the medicare may give $10200. So the actual income may be $200 but the reported income is $10200. But then I also see cardiologist who make $5 millions . There was neurologist who got over $ 500000 in income from pharmaceutical company . This is greed ---or at least I think it is . So it does not surprise me when I came across a study which made me write this blog .
     The study was conducted I think by CVS-CARE MARK of their employees. They did a study in which the employees were encouraged to quit smoking . The cost of taking care of the smoker was more than $4000.So they offered incentive to quit smoking. So they were divided in different groups. One group was offered money if they quit smoking . So they got money if they had quit for 14 days , 6 months and 12 months . So if they had not smoked for one year they got $800.There was another group . (In all there were 4 groups ,but I won't go in details )In that group employees were asked to pay a deposit at the beginning of the study and they got it back with the 'reward' if they continued not to smoke . These were compared to a group of employees who were offered 'coventional' help.  So do you want to take a guise as to the final results ?
     The group enrolment in which employees did not have to put up any money had the highest enrolment. Not too many people opted for putting own money. The success was great with employees who were rewarded when they continued to not smoke .So every one knows that smoking is bad , but till some one offered money,no one quit as conventional therapy was not as successful as in the group when the money was offered.SO MONEY MAKES ALL THE DIFFERENCE., not even own health!!!

Wednesday, September 2, 2015


      In physics we have uncertainty principle. In that situation we 'don't know' the out come till the event occurs.But I think in medicine also we have the same . But why talk about the medicine , we face it in every walk of the life . We appear in an examination ,and we 'don't know' if we passed or failed till the result of the examination is declared. So there is uncertainty. If we apply for a job and have an interview, we don't know if we got the job or not till we get the letter.So the uncertainty principle goes apply in every place . But we don't realise this as the 'out come' is predicted and some of the predictions are as close to 100% as possible .So there is no uncertainty in say some one smart and studious takes the examination. we know he is going to pass. So we don't think there is any 'uncertainty' in him or her passing the examination. That brings me to the medical uncertainty.
     I saw this 73 years old male patient, who was referred to me for abnormal chest X-ray. He was a nonsmoker and had no major complaints . But he had read 'somewhere' that one should get chest X-ray. So he had chest X-ray done . It was abnormal and so the primary care physician ordered the CT scan . The CT scan was abnormal and showed a lung mass. So he was referred to me . He came with his wife . So I saw the CT scan and showed him the pictures and showed him the mass. I told him that topically this kind of mass  in all probability will turn out to be cancer.so i usually tell patient that we need to answer 3 questions. 1 Is it cancer ,2 Has it spread and lastly 3 What is the treatment opiton . So I explained them the need to do the work up To get the diagnosis I suggested the Bronchoscopy and if needed needle biopsy or Open biopsy to resect it out , if it is resectable and has not spread. So I told them that we will do the PET scan to see if it has spread. (In PET scan we inject glucose tagged with nuclear material . The glucose is picked by every cell in the body . The metabolic activity of the CANCER cell is higher than the normal cells , so they pick up glucose more avidly. So the scanner measures the activity and one can 'predict ' the chance of the mass being cancer ) .We did the PET scan  and the breathing test. His PET scan was positive , suggesting that the mass was cancerous. and the breathing test was showing 'adequate ' reserve for the resection of the mass . He did not want any biopsy . So I sent him to a surgeon for consideration of surgery . He saw 2 different surgeons and both told him and his wife that he needs to have surgery and the lung resected. He and his wife were convinced that this mass was a fungus or 'mold' and we were all wrong . The pharmaceutical companies have corrupted the system and we were brained washed and he did not believe that he had cancer as he had no symptoms. He also had number of books and articles written by 'doctots ' that had proven how they cured this as it needs anti fungal .
       I saw him and his wife several times and we continued to have discussions and new CT scans . The mass has grown little bit but not massively . But I can not convince them that he needs biopsy or resection . So after almost one year we are at the same place as we were a year ago. So this is the 'uncertainty' in medicine . I am sure that he has cancer . He and his wife is convinced that he has fungal infection. And till we do open biopsy we don't know what it is .(Unless he comes with wide spread cancer in next few months )!