Sunday, September 27, 2020


     The health care is changing for many years . We used to have family doctors and primary care doctors used to take care of the patients in offices and also in hospitals and also 'answered' to the questions  and treated minor element on phone after hours . But that all ended with HMO - the so called Health Care Maintenance organization that in my opinion decreased the quality of medical care  and also reduced income for many and most physicians  and made money for 3 piece suits - the so called management of theses HMO. Now the dust has settled on that change  and we have gotten used to the change  and have accepted the obstacles that ordinary physicians have to face due to rules and regulations -that are primarily meant for reducing cost and not helping any patients,-we are seeing another problem . This has been brought to surface more due to COVID. This is aging population. So that brings me to today's patients . 

     I was asked to see 2 different patients - happened to be in 2 rooms next to each other . One was 91 years old and other was 02 years old . Bothe of them were awake, alert and orientated . They both had a fall and that was not related to any black out spell or dizziness or anything unusual in the house. They both had rib fractures on right side. Fortunately they did not have much fluid or blood related to rib fractures  and had no puncture of the lung. They were admitted  and I saw them . They were pretty much with the program  and they were not in any respiratory distress. Their oxygen level was normal. So I spoke to the families and told them that we will watch them for a day or so and ask them to take deep breath and that will prevent collection of secretions  and then that can lead to pneumonia. The body does not do anything that causes pain and so with rib fracture of ribs, the patient automatically takes shallow breaths as deeper breaths will cause pain. But this shallow breathing and not coughing as coughing also causes pain , will lead to secretions not being cleared and then getting infected  and that causes pneumonia . So all that we as physicians do is to give pain medicines  and ask patients to take deep breaths every hour or so. So as per my plan they should be ready for discharge in 24- at the most 48 hours. 

     But as it happens the things don't work out as we like it to. The patients did well . The pain control was good  and the oxygen continued to be good breathing room air  and they did get out of bed and walked with physical therapy. So in my estimate they were ready for the discharge. But the problem was with the age. Both the families felt that they could not go to their prehospitalization level of living. They needed more physical therapy. So they had to be discharged to physical therapy unit. So now comes the COVID problem. We had to have COVID test done  and that has to ne negative . One family did not like one unit that was approved on her HMO insurance  and so we had to look for another one.So what could have been treated as out patient in younger patient, needed hospitalization. What I thought will be only 1 or 2 days became 5 days in one  and 6 days in other. 

Saturday, September 19, 2020


         I have been in medical practice for many years and I did practice medicine when the family practice physicians did go and see patients in hospitals. Then the HMO insurances under misguided thought process decided that 'employing' some physicians who do not have office practice  and do only hospital practice can 'save money' -the sole goal of Insurance company. I still remember that the family doctors complained about this  and then the insurance company decided to 'allow' these physicians to see patients while they were in hospitals , but they will mot be paid. Now you tell me who would see the patients manage  and take risk  and not get paid . So they stopped seeing their own known patients in hospitals a nd thet lead to crop of new group of physicians called hospitalist. This is suppose to help health care. In my view they have added NO BETTER CARE  and have increased EXPENSE. But I am not writing this blog for my view but want to tell about everyday problems that people like me face as consultant. So let me give stories of 2 different patients.

    I have known this patient for long time  and he had sleep apneas and I used to see him every 6 months . When he came to me last time, I was talking to him and realized that he had diverticular abscess - collection of pus due to infection in colon . He had no lung issues  and I admitted him and did work up and got him started on treatment and drained abscess and he was seen by people that could manage this condition- surgeon, infection specialist. He was discharged  and I did not want to see him as his problem was not related to my specialty .By the way he had seen gastroenterologist before I had seen him and decided to hospitalize him. 

     I had forgotten about him  and then the wife called me  and wanted to know if I was out of town as I did not see him. I called her and found out that after the discharge , he was OK  and then in 3 weeks he had seen infection specialist  and he did new CT scan of belly and that showed clot in lungs and so he was admitted . So this time he had LUNG PROBLEM  and he was admitted by hospitalist  and I did not get notified or called to see him. He was discharged  and the patient and the wife had lots of questions like why did he get it . how long the treatment  and the time gap between his CT scan of abdomen and the then the hospitalization. I had no answer as I had not seen him and I had to check the hospital computer  and with the modern day computer generated notes I had hard time getting the information . So I had spent time to get information that was very difficult to get and may not be 100% correct. The hospital doctor - THE HOSPITALIST are not seeing him and have no office  and they can not be approached by this patient, so it becomes responsibility for people like me who have to reconstruct the story based on someone else notes. In this case it was not that difficult but in my other patient I have gotten 6 phone calls on 3 different days for the questions related to hospitlazation when I was not consulted . 

Sunday, September 6, 2020


       The modern day medicine is complicated.The things were simple when we used stethoscope and did not have Ct scan, PET SCAN  and many more cardiac tests  and so on.In the past we used to diagnose cancer and there were limited therapy and we did it. Now a days we have tumor markers  and specific chemo for different types of markers  and mutation and so we need more tissue to diagnose  and then we use different treatments . I do believe that the treatments are more specific for particular type of cancer  and certainly that is much better . But how much it has changed the final outcome is to be seen. ( I know that patients are living longer for sure but not sure how much longer NOW with inoperable cancer than they did in PAST) That brings me to the story for today. 

     I had seen this male patient may be 16 months ago.He had chest pain and he was worked up  and I  saw him and  my work up showed that he had cancer of the lung. Based on the PET SCAN and other things he was thought to be not operable candidate  and I would not go in to the details of the reasons why he was not operable. But he was sent to radiation doctor and also oncologist.He was treated  and he did OK . He did not see me for almost a year . Then he showed up as he was short of breath. I asked him as to what was the status of his cancer . He told me that the doctors have told him it is gone. I had hard time believing that as he had fairly large tumor and the chance that he would be cured was small. But he and his wife were convinced that he had no cancer now. I did the work up and treatments . He had wheezing and so I started him on steroids  and also inhalers  and neb. treatments. I also asked him as to when was the last CT SCAN or Pet scan and he had last CT scan 5 or 6 months ago. So I decided to do new CT scan. He came for the follow up and he was feeling much better , still some shortness of breath, but much better . I had also tested oxygen level and he was started on oxygen and overall he was better .But the CT scan had shown that the mass  had grown . So he had mass or cancer when I saw him and then he had treatment  and the new scan had shown the mass to be smaller . Now the new scan showed it to be bigger . I told him to see the cancer doctors  and did not do any new biopsy. He went to see them  and then he had an episode of coughing up blood . It was small amount  and cleared without any treatment. The radiation doctor called me and wanted me to do bronchoscopy. I did it and he had significant abnormality but that I thought was due to radiation and may be treatment. I did do biopsy and all came back negative for the cancer . But the SCAN was  definitely showing increasing in mass.

   He came to me for follow up  and I told him that even though the biopsy was not showing cancer, I was convinced that he had recurrence of the cancer. Certainly most of the time people don/t want to believe that they have recurrence without the proof. For me the increase in  size of the mass was indicative of the cancer and in this patient who had inoperable cancer, this was easy to see.He went to his cancer doctors  and they wanted more proof . With radiation given to the area where the cancer was diagnosed, the needle biopsy may not get tissue as there will be changes related to radiation and so we may not get the diagnosis by such biopsy. The open biopsy in my mind is futile as the surgery is not curative surgery and will not add to the treatment of cancer. So I would consider treatment for the cancer which was treated  and not taken out, under presumption of recurrence .