Wednesday, January 27, 2016


    I have been sometimes asked if I would be interested in doing telemedicine . I feel that I am doing the telemedicine at times for long time and even today , though without getting paid for it . When patients call me or my office and have some complaints , I look at their charts and based on the information provided on telephone and the information that I have from the past , make a decision. It may be as simple as giving an antibiotics or as complicated to ask him to go to ER. But the modern day telemedicine is to advice patients or 'consumer'  on possible diagnosis , it's work up and may be treatment. And these are not my 'known ' patients , but brand new patients that I have never seen or examined . I do not feel comfortable with the idea , though I do that too with friend and friend'd friends all the time . I don't think this is good medicine . But I thought about this when I came across the patient who was treated as if it was telemedicine . I often say that if it was possible to do the diagnosis and the treatment this way, computers would take over. But sometimes I feel that doctors are behaving like computers.

    I saw this 70 years old patient , who was referred to me for chronic cough and abnormal chest x-ray. He was having cough for about 2-3 months and was treated with antibiotics and cough medicines . The cough persisted and so he had a chest X-ray done and it was abnormal so then the CT scan was done and when it showed multiple nodules , he was referred to me . He had no fever and though his appetite was reduced , he had not lost any weight . The cough was dry and he was minimally short of breath. He was non smoker . We had no old CT scan. So I decided to do Bronchoscopy . My initial impression was the possibility of atypical infection called MAC or Mycobaterium Avium Complex . It is in the same family as Regular TB . But it is not contagious and treatment is different. His bronchoscopy and the biopsy and the TB culture came back negative . He had multiple nodules , so if they were spread of a cancer --metastatic cancer , he was not surgically resectable stage. But I decided to send him to a surgeon and at the same time have radiologist do a needle biopsy . In between ,I am not still clear why, he was sent to a cancer doctor. I am still not sure as to who sent him to cancer doctor. But he did go to cancer doctor and she sent him to a surgeon from her own group . He sent him to radiologist for a biopsy. IDID NOT GET CONTACTED OR GET ANY NOTES. All these doctors belong to same group. He had the biopsy . None of these doctors saw him in office , but he was told that he did not have a cancer.

    So at the end of 3 months he came to me . I had not gotten any reports and I was not aware that he had gone to different group of doctors and had work up done . When my office had called him in between , he had told my office staff that he was seeing a surgeon and is having a biopsy. So I gathered the information from all the doctors . When  I got the biopsy it stated "No malignant cells seen " .It did not state as to what did THEY SEE. So I faxed request to see if they could tell me as to WHT THWY SAW , not what they did not see. I never got the answer. I also could not figure out if they had done any TB culture . So this is the computer generated medicine . It had no thought process as to the possibility of MAC . So no cultures were done . No one bothered to tell patient as to what was diagnosis and what he should do next.
   I decided to do repeat bronchoscopy and called the surgeon and told him that if my bronchoscopy was unable to get a diagnosis , then he should do OPEN biopsy , not needle biopsy. With patient's luck , my second bronchoscopy confirmed the diagnosis of MAC .I started him on treatment and he did fine .

   But the reason to write this blog is to make a point that one has to see patient and make a calculated diagnosis. Otherwise the tests don't mean much , and we might as well have computer generated diagnosis and may be treatment too ! 

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