YOUR AND MY MONEY AT WORK

       In US we have health care crisis  and  the cost is way out of hands . We are spending money that we don't have . We have patients that DEMAND work up and we have physicians that order too many tests as they are afraid of malpractice  and want to make more money . We have hospital which has cost which is out of this world. and the medicines  are so costly that even well to do patients  can't afford. Lawyers are advertising on TV to sue anybody for any reason  and are looking for any bad out come  and or bad side effects . No wonder the cost of health care is out of hand . And to make it worst NO ONE CARES  and no party or politician has any clue how to fix it . Some believe that competition will reduce cost , others believe that government taking over will fix the problem and neither is ready for listening to others  or TALK to people like me - not any physician's associations -none of them have  any understanding how we practicing physicians work and face problems .
     This brings me to today's patient story . I have known this patient for last few years . She has mild  asthma  and recently I was thinking that her problem was due to heart problem and the the work up did confirm that she has leaky valve  and irregular heart beats  called atrial fibrillation that was contributing to her shortness of breath. She was followed by cardiologist and she is doing better. So the other day I had a call from the hospital that she was admitted . I went to see her . She had some upper respiratory symptoms  and she saw her primary care physician  and he gave her some antibiotics  and then ordered chest X- ray . The X- ray was OK and the fever was gone . But she was still 'congested '  and so she  and her daughter decided that she should come to ER. They did not call primary care any other doctor. As it is USUAL now a day ER did the CT SCAN of the chest . She had no fever  and had normal oxygen saturation and normal white cell counts. The CT scan was OK.
I saw her . She was started on 2 antibiotics by hospital doctor. Her lungs were clear and she had no fever and the CT scan did not show  any pneumonia . She was comfortable  when I saw her and did not need oxygen . But as a 'routine she had CT scan and as a routine she was started on IV antibiotics. I was consulted  and so was cardiologist and kidney specialist . She had mildly abnormal renal function and she was followed by them as out patient . The nasal smear came back positive for a virus --COMMON COLD VIRUS !!!

   So she had cold and she was admitted for 2 days . She was hospitalized for 'observation . This means hospital makes more money rather than regular hospitalization . The hospital doctor makes money  and so does the cardiologist and kidney doctor  and I . So we have spent lots of money for treating COMMON COLD !!!

FINAL PATHWAY ??

   Recently i came across some cases in my friends  and colleagues where I can not explain how  and why . Let me tell you on these patients . We recently lost a physician who was very young and had never smoked . He ad lung cancer and that did spread to brain and he died  in spite of all the treatments that he could get at various centers. Then there is elderly friend our our family who also never smoked and had lung cancer diagnosed. She is lucky and it was detected early and so she had surgery and it is in early stages  and there is good chance (Why good chance  and not 100 % chance ?) that she will be cured . And there was another case of a  cancer in a another physician who was completely unselfish , devoted her life to God  and community and again never smoked or had alcohol . She also dies of cancer. We all see this  and experience this in our life  and fail to understand why this happens.Some people ask me as to why some one gets cancer . And certainly there are definite causes and risk factors like smoking and also chemicals  and pesticides. In absence of obvious causes how do you explain the cancer and suffering that it brings in . And then why a stage 1 cancer is cured in some  and not in others . We have technology that can tell us -sometimes- as to who may recur  and who may not , buy not always So what is the answer to all these questions ?
      I DO NOT HAVE PERFECT ANSWER OR EVEN AN ANSWER .!
      But I may have some possible explanation based on my faith and Law of Karma  and reincarnation. I am sure this will not be acceptable to all  and also those who may accept the Reincarnation also may have difficulty to explain why would someone get CANCER and suffering .
The Law of Karma states that EVERY Karma has a fruit  and one will ave to accept it sometimes -in this life or next or next. We are reborn for several reasons .
 1 We must pay the debt that we have accumulated with other individuals .
2 We have to have to accept the fruits of our actions
3 We must fulfill our unfulfilled desires  and we not do that without PHYSICAL BODY .
4 We need PHYSICAL body if we want to UPLIFT  our self . (when we help someone which is Good Karma - most or all of then are related to helping physical body , e.g. food shelter, sickness,or any comfort .
    So we must have physical body and to have NEW physical body after death of old physical body there has to be Rebirth. But then the question arises as to who wants to suffer  and who will have Desire to suffer ?
    To answer this one must understand that the Karma is done every second with MIND and BODY . When the two come together then the Karma is complete . The intention behind the MENTAL or Physical Karma will determine the Effect or the fruit . If I have transient bad thought about some one  and O do not ACT on then it may not or will not have ant fruit . But if I continue to have a thought ALL the time -say lust or some other it will create enough impression that I will have to fulfill it in pr there will be fruit to the thought. If I have a physical action which happened but there was no Thought behind it -I kick some one by accident and I had no intention of the kicking - I will not have much fruit , but if I have intention of kicking someone and I act on it , then I will have Fruit to it .
    One more thing to remember is that our PRESENT life is sum of effects of many Karmas  and not one Karma . So there are many forces and effects that determine the final effects  and so the FINAL EFFECT  may not be such that we can RECOGNIZE THE ORIGINAL KARMA - as it is sum of many karmas .
     This may explain the things that happen to us that we can not explain easily based on our ACTIONS in this life or even if we believe in Reincarnation , can not TRACE to one isolated Karma , that could have caused it .
   

LIMITATIONS

    In  past I have always stated that there is a limitation in medicine. I was taught to do physical examination before ordering tests . But even before one could put his hand on patient to examine , we were suppose to take history.Now a days then things have changed  and most of the physicians that I see and meet  do reverse way . They sit at the computer and see the X- ray and the labs  and the 'other notes' and then go to see the patients. Some times there is not much of history or even physical examination . They depend upon  nurse practitioners or ER physicians who in tern depend upon their nurse practitioners .I am still old timer and do my OWN history and physical Examination. But I have realized that the history and physical examinations also has limitations  ans sometimes we get diagnosis with TESTS rather than history or examination .This brings me to today's patient

    I was asked to see this new patient in the hospital . She was 72 years old patient who was having dry cough and so she saw her PCP . he gave her some medicines  and then did chest X- ray and then told her that she has allergies  and she should take some over the counter medicines for allergies . She continued to feel poorly and did see PCP and there was no change in treatment . Then she saw cardiologist as she was  also having some swelling of the feet and shortness of the breath. He gave her some medicines  and was going to do some more tests . But then when she was checking out at front desk , she was noticed to have significant shortness of breath . So she was admitted and I was called in . She had some lung scan done to rule out clots  and that was OK. But she has some fluid around the right lung. So the CT scan was ordered.
   When I saw her she was having dry cough . This was going on for last 2 months . She was getting short of breath for 3-4 weeks . She had worsening edema in legs . She had never smoked  and she had lost some weight , When I asked her about that she told me that she feels 'full'  and so could not eat more . On examination she had reduced air entry on lower part of right lung and she had edema . When I examined her belly , it was obese  and I felt it was 'tight' or firm . I could not feel much  and I did note that in my note . The CT scan showed 2 spots on lungs one on each side  and fair amount of fluid on right side. I told her the possibility of cancer and decided to do the procedure where upon I take out fluid . I took out more than 1000ml of fluid  and I ordered PET scan . The PET SCAN picks up cancer in body . It is about 88 to may be 90 % . The PET scan is done where glucose is injected  and the glucose pick up by cells is recorder . The cancers have higher metabolic rate  and so the cancer cells pick up glucose at much higher rate than the background . Since it is metabolic or biological scan we do not see the structure or the anatomy . So it is accompanied by CT scan . The lung Marses were positive suggestive of cancer. But to my surprise there was big tumour in pelvis  and it was 14 cm  and it was positive . She also had some fluid in belly. She had told me that she had hysterectomy and her ovaries were taken out partially . So it was a shock to me that she had cancer in pelvis . The fluid came back positive for ovarian cancer,

      So in spite of taking adequate history and examination, I did not anticipate the diagnosis . So sometimes one needs to get diagnosis which was not suspected . 

HONESTY IS IT THE BEST POLICY

          There is saying that the Honesty Is the Best Policy , but is  it really true?In life we have incidences where the honest answer may be crude or cruel or not pleasing . In Ganapati ATHARWASHIRSH, it is state the 'I will say Pleasing and Truth'. In personal relationships between the husband and wife and children and friend, this is true.But even in many other aspects of our life we don't have ti lie but we can still say truth without hurting the other person or the relationship.Sometimes we can not tell our boss what we 'feel ' about him or his decisions. We still can say the fact or the truth. In medicine this holds very well. I have come across this on number of occasions. This more often happens when we have a patient who has cancer . This brings me to the today's story.
      I had seen this 75 years old lady who was smoker and had some lung issues . Over course of my follow up she developed a mass in the lung . In all probability it was cancer and so we did do the work up and then i sent her to surgeon  and it was taken out. She did well- had some problem post op. But overall did OK. She needed oxygen after surgery , that was arranged at home . She was doing better and then may be 18 months or so after the surgery , when we did the follow up CT scan she had a mass . We had her see radiation  and oncologist . She had needle biopsy and then the recurrence of the cancer was diagnosed. She had localized mass and so she received radiation. She then saw oncologist , who decided to start her on some chemo . In spite of the chemo she developed new nodules and so the chemo was changed . Now she had multiple nodules in both lungs  and radiation was not option and so she had continued the chemo. She has been old  and has some dementia . She has COPD  and does need some oxygen .She was admitted to hospital with multiple issues , including anemia related to chemotherapy and also had low salt and worsening kidney function and also had swelling of the legs . Further work up showed that she had clot in the legs  and  for some unknown reason (at least to me ) someone ordered a CT SCAN of the belly and that showed a mass in colon.
She was in no shape to do any invasive procedures for diagnosing colon cancer , but more than that , diagnosing colon cancer would alter any treatments . Due to fear of bleeding from colon mass if she was started on blood thinner and with her low blood counts , we decided to do insert a filer in one of the blood vessel so that clot from legs would not travel to lung- embolism..
   When the radiologist went to insert the filter he realized that the entire blood vessel was filled with clot. So he could not do the procedure. But more of  a problem was that the clot occurred in the blood vessel as it was compressed by external tumor. So the narrowed blood vessel developed the clot and that was blocking the drainage  and so she had swelling of the legs . So then we had a catheter inserted in that blood vessel and clot busters were started . Now she will have to be on blood thinners too.
      So we have 80 years old patient  who has spread of a lung cancer , who also has anemia  and kidney failure and oxygen need for COPD , and has possible colon cancer and the a tumour that is pressing on one of the major veins that has clot. You get the picture. No matter how successful we are in treating the clot , her long and may be even short term prognosis is not very good . I did try to talk to her family as she has some dementia about this . But the cancer doctors and their nurse practitioners have not said a word about bad prognosis and so we are doing the bandage approach without being able to treat the underlying cause of the problem . The need to be honest but not blunt  and compassionate but still telling truth.

NO TWO OPINIONS

     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 !!!!

JUMPING TO CONCLUSION

     As a child we used to read a book called ISAP NEETY , Isap was a slave and he could talk to or communicate with animals . There used to be a another book called PNACHTANTRA . In that book also there were short stories and the animals could talk . Every story in these books had some moral to be concluded and that was stated at the end of the story . In one of the story there was lady who had a mongoose. That was her pet . She also had a infant child.She had to go out of the house to get some water from the well.The child was sleeping and so she decided to go out in back yard to fetch some water. It took her some time to come back.When she came back she saw the mongoose at the door of the room with blood on it's face . She concluded that the mongoose attacked the child when she was out. She threw the water pot at the mongoose which almost killed the mongoose. She ran in the room where the child was sleeping sound and there was  a dead snake next  to the child . So when she was out , snake came in the room and the mongoose saw the snake  and attacked the snake  and killed it . So the mongoose killed the snake  and not the child . But the lady jumped to conclusion. This is not uncommon for all of us . We JUMP to conclusion without having checked all the information. That brings me to story for today .
       I saw this patient.in hospital as second opinion He was 74 years old male who was primarily followed by VA.He was a smoker and inspite of diagnosis of COPD , he had continued to smoke.He also had coronary artery disease and had 5 stents. He also had circulation problem and had shortness of breath on walking 50 feet or less. His breathing test had shown severe compromise and the flow rate was 22%only. He was in hospital  and had CT scan done . The CT scan showed a nodule. The lung specialist that was called saw the patient and wanted to do Bronchoscopy . The patient was short of breath and the nodule was too small to have adequate sampling with regular bronchoscopy. So there is a relatively new technique called navigational bronchoscopy .The computer with help of CT scan 'guides' - navigates- to get to the small nodules that are not seen with the scope. In my experience , this needs anesthesia  and is not greatly successful in getting sample or diagnosis unless one is expert in doing it . The patient refused the procedure and so I was called in to see him . HE was obese patient  and had smoked and was fairly well aware of his medical problems. His fear of the procedure was that with anesthesia, he may end up on respirator and then will have difficult time to get off it .And in my opinion he was right.In addition to that he had 3 CT scans at VA and  he knew the results  and he thought that he had nodule in the past . Not only he was aware of the CT scan findings , but he had 'access' to the reports . I told him to pull up the reports in the computer and he was right . HE DID HAVE NODULE REPORTED - SAME AS WAS IN THE CT SCAN THAT WAS REPORTED IN NEW CT SCAN! So with his advanced lung disease, the nodule being there before I suggested to do follow up on the CT scan in 3 months and then consider PET scan . He was not a candidate for open biopsy  and the newer Radiation technique for smaller nodules is only 5 sessions and it has great cure rate. So if indeed he has cancer one could confirm the likelihood of it being cancer -nor 100% and no tissue type known - by PET scan and treat it .
     Just because there was a nodule does not mean cancer especially if he had it for a while . I agree that this still could be cancer but the diagnostic test should not cause more problems . So jumping to do a test was premature  and just like that lady was hasty in concluding that the mongoose hurt her child. 

PERSPECTIVE

     We often use this term , PERSPECTIVE - Often it is stated that one should not forget perspective in life . In medicine we need to remember this more than in any other field. But I have felt that we HAVE FORGOTTEN it . I know how the things are done in past  and how they are done here . But I also know how things are done in other counties, including India  and how we are doing things here in US . I do not want anybody to think that I am  suggesting DEATH  agencies or more control on health care decision. But sometimes it is frustrating. I think the problem may be partly if not solely due to cost of health care is not being not paid by relatives - by the people who make the decision.It may be due to lack of understanding the ability or for that matter inability of the modern day medicine . But in any case we have a problem . The health care cost not the only thing to be considered in these matters , but also the suffering of the patient as well as the relatives who make the decision. I saw 2 patients recently  and that brought me to write this blog .
       I saw this patient few months ago . He is 78 years old and has the usual issues that many at that age have . He had hypertension and has had strokes and had developed dementia . He had atrial fibrillation in which the heart can throw clots and that can eat up the brain piece meal . This  leads to loss of brain tissue and that leads to dementia . So he did have dementia . But with the strokes he also had problem  the swallowing and so he had lost some weight and then the family agreed to have feeding tube for the nutritional reasons and also to give him some medicines which otherwise he could not swallow . He was tried on blood thinners to prevent clots  and he had blood loss and blood counts dropped . So he was taken off them . So on one side he had high risk of clots and so he should be on blood thinner , but on other hand he could not be on it as he had drop in his blood counts and so not being on the blood thinners the chance of getting mini strokes increased and that can make the dementia worse , On top of that he had developed severely leaky valve and that in tern caused the pressure in the lung to be increased . So he had aspiration pneumonia and had feeding tube and dementia and heart problems .
     I talked to his wife who was the medical power of the attorney and tried to have her agree for DNR- not to put on machines. He was seen by cardiologist and they stated that nothing could be done about his valve or the atrial fibrillation other than trying to control the heart rate. He did better with the antibiotics and then was discharged . He came back in  1month with episode of fall and low blood pressure and an abscess on the scalp. He had low blood counts again and needed to be transfused  and he was on antibiotics and he also had to have the surgery to drain the abscess. He was not only demented but was very uncooperative and would swing and try to hit doctors and nurses and would constantly curse. It is not his fault as he did not know much as he had dementia. I talked to the wife  and told her the limitation . We certainly can give antibiotics, which we did . We can transfuse him which we did . But the dementia and the aspiration and the leaky valve and the pressure built up in lung was not going to get any better . But she would not agree for DNR. The treatment is bandage approach as we are not treating the main problem dementia and stroke and the heart problem and so we treat the symptoms . But we are not 'helping' him or her . I am sure it is painful to watch our own relative 'suffer'  and be in hospital , but I do not know the reason for the not doing him DNR. She has  no liability for the bill  and may be the after life belief system  , may be fear of loosing husband - whatever it is , it is not helping her or him or the health care cost .