Sunday, February 10, 2019


     Many years ago I was talking to a state elected congressman, who happened to a physician. He was telling the difficulties that physicians have to a good politicians and why the lawyers have no problems. Many of the politicians are lawyers. His point was that we physicians have single tract mind . If a patient comes with history of smoking and has coughed up blood and has abnormal CT scan of the chest showing a mass, we KNOW that it is highly likely to be a cancer and we KNOW only one way to do the work up.We will not tell to just watch it grow unless off course the patient is demented or has lots of co morbidity.But even though we may not do the tests or the work up due to the circumstances , we are very certain that the mass is cancer and we do not entertain any other thought. Now take an example of a lawyer. There is a divorce case and custody battle or case of tenant and land lord.Who so ever pays the money the lawyer is on his side and he will argue if needed in court that his client is right. There is no one side which right . But for medicine , high blood pressure is to be treated and there is no argument or 'other side ' , Same with high blood sugar or any other number of cases that I can tell . So the physicians are taught to have one particular way of thinking and we do not have to change our opinion due to some one paying me more money. So we can not be good politicians who can listen to both sides and can be swayed by one or other arty that gives them more money. But that brings me to the story for today .
       In medicine I am seeing more and more older patients and it is not uncommon for me to see few 80 years plus  and some 90 years plus patients.This has changed me and my decisions  and also the way in which one can approach the same issues that we had before. I saw this patient who was 90 years old . He has coronary artery disease and had high blood pressure and also was short of breath. He had some COPD ,  and needed some bronchodialater -medicines to treat his wheezing or bronchosasm.But on further investigation I realizes that he also had elevated pressure in lungs or what is called pulmonary hypertension.The medicines that I could offer for that were expensive and are special pharmacy medicines , which means they are to be ordered through the drug company and need right heart catheterizing to be done . The cost runs $30000 -year $30000 -I did not make mistake in adding a extra 0 .So the company wants to be sure that there is elevated pressure and the value is high enough to need treatment. So he needed cardiac catheterizing. The cardiologist was not in favor of doing an invasive procedure in this 90 years old patient . But the patient wanted it and so finally it was done . It did confirm the diagnosis of elevated pressure and I tried to start him on medicines .Due to the high cost of copay, I could get only one drug started and he did do little better.
So at each step of the decision I was 'OPEN' to treat or not treat this patient as the benefit of these medicines and the cost and the side effects may not be of value in this patient.
    In few months he continued to be stable  and had to be on oxygen 24 hrs a day and also was short of breath . The he developed more shortness of breath and the chest X- ray done did show worsening of the congestive heart failure . We had to pit him in the hospital and he had some fluid. In average patient I would drain it with a catheter insertion. But in his case - who was 93 years old now I was very hesitant to do such a procedure and decided to try to just 'watch' it with medicines being given .
So even though I KNOW the best way , I am WILLING to wait and watch . This s a change in my though process . BUT I WILL NEVER BE READY FOR THE POLITICAL ADVENTURE !!!!

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