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 . 

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