TOO LATE TOO LITTLE

   We often see patients that do not change in spite of  overwhelming proof about good life style and good , healthy habits . But as a physician we continue to tell patients about these things . I often wonder when insurance companies talk about 'prevention ' . This is because most of the things that are recommended are 'early doagnosis' rather than 'prevention ' . The only thing that is true  prevention is healthy eating , exercise, ,do not smoke or drink too much alcohol or do drugs .So this story is of one my patients , that occurred sometimes ago.
   I saw Eddie in the office for the complaint of shortness of the breath.He was 58 years old and was smoker . He smoked 2 packs per a day . He was also obese with weight of 280lbs .He had high blood pressure and diabetes . He also drank 3 to 4 drinks a day. I had my work cut out . I did breathing test and that did confirmed the diagnosis of COPD , the lung disease due to smoking . Due to obesity it had gone down further. I told him to quit smoking and do daily walk and some exercise. I also told him to cut down on his alcohol intake , this would reduce his calorie intake . We put him on some medicines for the COPD , and ordered sleep study . With weight and history of snoring I was sure that he would have sleep apnea. He also had some swelling of the feet , which could be due to his obesity , . However I wanted to make sure that there was no problem with his heart . He had seen cardiologist in the past and the work up was OK.
     He came for the follow up and had not stopped smoking or drinking . Had lost no weight . But he was taking medicines and was feeling little better . The sleep study did confirm the sleep apnea . He was prescribed the CPAP mask to treat it . He did not like it and so was not using it . I educated him on the need for the treatment of sleep apnea and the issues that would get worse if he did not use it . On the next follow up there was no change in his behavior . He was still smoking and drinking and had not lost any weight . He had started using CPAP at least for part of the night . I did not have much to add . His heart test was OK and he was happy about that .
    This continued for next 6 or 8 months . He continued to come with same complaints with no change in his habits . I tried to adjust medicines and educate him .
    He did not come for next 6 months . He had missed his 2 visits and so when he came for the follow up I was surprised . I hardly could recognise him . He was well groomed and had lost 60 lbs of weight . He had stopped smoking and given up drinking . He was going for the daily walks and was using CPAP . He was accompanied by a lady . He told me that he had applied for the disability and if not approved , he was going to quit the job and get married to the lady , who was accompanying him .. I was pleasantly surprised . I asked him as to how did it happen . His answer was , he was  'reborn '.christen . I did see him once again in next 2 months . His disability was approved and he was moving out of town to a small town near  coast and had bought a small boat .
     So I thought this was the happy ending of a good story, till I got a call . I had a call from a hospital near by . He had moved to a place about 60 miles from my office and had a new doctor . He was admitted to  the hospital after a fall .The story was that he was doing fine and had gone for fishing with his wife . He had a boating accident and fell down and had an injury to cervical spinal cord and was paralysed bellow neck. He was on respirator and was not going to get off. I spoke to the doctor in that hospital about his medical problems and tests etc. They were not going to be of much value in the treatment or prognosis.

HEALTH CARE AND YOU AND ME AND OTHERS

. I am a practicing MD for last 30 years and seen lot of changes. I feel that there are ‘problems with the current health care system and we can do a lot to fix it provided concerned parties are willing to do it. I do not believe that the change in the law that just was approved by the high court will do anything to cut cost as it is more based on ‘belief’ than reality or the understanding of the system .I hope that republicans can come out with a plan and not just oppose present one . Please read the outline of some thoughts.

-The presumption that ‘insurance companies have failed’ is to put blame at wrong place.  The insurance company collects the premium, spends it on expenses for running the  business (advertising ,agents, commission, salaries etc) and medical expenses. If the expenses are more, premium goes up.   To state they have failed is naive. This can be compared to going to buy a shirt. The final cost of the shirt that the retail store will charge is based on acquisition cost plus overhead plus profit if any of these things go up, and then cost of the shirt will go up.

In our office my young secretary , under 30 years of age cannot get insurance for 8% of her salary.(as required by new law ).Health Insurance costs $3600 for a young patient like under 30 years of age with no major medical (preexisting ) problems.. This is higher than 8% of average salary. If healthy person is ‘subsidized’, who pays the difference? The cost will not come down even if everyone buys or is forced to buy.  

-Fairness. If I exercise, eat properly, stay healthy, why should I be ‘penalized’?  Having a medical disease is not always one’s fault. But to have same premium for everyone irrespective of medical history, is unfair to those who work hard to stay healthy. In the existing system, we do subsidize. The ‘family coverage’, in which 2 adults and children are covered, does not cost 3 or 4 times that of individual coverage. But there is going to be a limit as to how much a healthy person should contribute to the coverage for people with serious health issues.

-Health care cost is a square. To reduce cost all sides must be reduced. These sides are providers, recipients, drug companies and lawyers. The cost goes up due to lack of controls and fear of malpractice. The waste of resources is seen daily. I have seen 12 -14 CT scans brain being done on one patient in a span of 8 -10 months. This may be because of lack of understanding on part of MD and ‘demands’ on part of the family.

     The cost of health care has increased due to greed, ignorance, malpractice, new technologies and treatments.

     Greed is on the part of the physicians, patients and the hospitals. There are family physicians who are doing cardiac stress tests, sleep studies, echo cardiograms, which they are not well trained to interpret. Since the reimbursement for the nuclear stress test has gone down, more cardiac PET scans are done. Now a days hospitals ‘own’ doctors’ practices. These hospital owned physicians get more money from insurance companies and Medicare, than independent physicians. The hospitals get more money for the same tests done in an office by a physician. Hospital-employed physicians get higher compensation as office is considered an extension of hospital. Why is there a difference for the same tests?

New drugs and new technologies. In 1980, we did not have MRI, PET scans, Stents and many other drugs , including drugs for HIV. Today, the  ICD  ( implantable defibrillators )costs $29000 plus hospital cost(probably another $20000) , PAH (pulmonary hypertension) treatment with drugs costs $50,000 a year. One tablet of a drug called Tolvaptan costs $300. This is used for low salt in blood.

      DME (Durable Medical Equipment) is adding to expense. These is use of oxygen , mobility  scooter ,home health monitors, treatment of sleep apnea with CPAP etc are all expensive and there use is on rise .Unless we decide to change the ‘rules’ as to who is covered and how much, cost will continue to rise. There is no way to reduce premiums, no matter how many more healthy people buy insurance  

 My suggestion is to divide the population into several groups.

Group one- Individuals in the lowest socioeconomic group who cannot afford any premiums and have no resources – will receive Medicaid.

Group two –Individuals in this group will be those who do not qualify for Medicaid and cannot afford any premium either because their income is slightly higher than allowed by Medicaid or have assets that are higher than allowed by Medicaid will be in this group. These are ‘True indigent patients. The society takes care of them, provided

 1) One and All medical providers i.e. all physicians, all the hospitals, all the radiology clinics, all labs, and all other health care provider, will participate.

 2) Patients cannot sue.

3) Providers will get ‘tax credit’ for the services .This could be as little as 10% of Medicare allowable charges.

Group three -People who can’t afford regular insurance but do have some money to spend on their own health care. These patients could  be the young people who do not have major medical problem, but want to have some coverage to cover for major health care related expense They should buy ‘high’ deductible policy and get tax credit if they have to spend more than certain amount. e.g. If they have $5000 deductible policy and have to spend $10000, then will get some tax credit for the amount that they spent .

Group four -The people who can afford regular insurance policy will be in this group.

Group five -The Medicare population will be in this group.

Group six -There should be higher deductible for expensive procedures-ICD, bariatric surgery for older patients .The cost for certain procedures is so high that we cannot cover it fully. We as society have to decide if these high ticket items should be covered at what cost . One suggestion could be ‘higher’ deductible for them. It could be age related or health care related.

  Lastly the ‘Cookbook’ medicine in certain situations will reduce cost; this has been tried in certain situations. What tests get ordered and get covered will be based on age of the patient, his medical history and his physical examination. If this approach is followed then the MD cannot be sued.e.g size of nodule in lungs seen on the CT scan and frequency with which the CT scan needs to be repeated.

  

 

   

 

IT WAS NOT THE TIME

   The God has kept certain things in his ( or her ) hands . We can not decide the of birth ( though with c section to some extent we can ) or death . I often talk about this in various ways . " When spring unwinds completely , then we die ". Or ,"It is related to our previous karma , that are going to come to fruition , once that is done , we die ."and many other.The story that I am going to tell one related to this part .
    James was my patient for many years . His son was a policeman and the daughter in law  was a nurse in our hospital .He had advanced COPD , the emphysema , that was a result of several years of smoking . He was on oxygen , most of the times and was short of breath on walking couple of hundred feet. At times he used wheel chair. He was admitted to hospital several times . I had talked to him and his wife , as well as to the daughter in law about the advanced disease and DNR status , especially the respirator . I knew that if he goes on respirator , he would be very difficult to be weaned off it , and we will be talking about 'trach' and then may be discharging to a nursing home with the respirator.As usual the answer was 'I will think about it '.
     As it happened , he was admitted to the hospital with the shortness of the breath. This time in spite of the treatment , he continued to get worse and I had to move him to ICU. I tried everything , but he continued to get more short of breath . No decision was made on the respirator. So one late evening he was put on the respirator. As the time passed on we could not wean him off the respirator and so now the talk of doing trachostomy were done . The family was not sure , but only other option was to the withdrawal , which meant discontinuing the breathing machine . This would certainly would have caused demise , and the family was not ready . ( This is common problem, as we can decide not to put patient on respirator , which is less painful or traumatic than so called 'pulling the plug ').
     One late night I got a call from the ICU. James had a cardiac arrest . As it happened , there was cardiologist in the ICU and he conducted the code and did every thing to help , but James did not make it . I talked to the nurse and got the telephone no. of the wife and the daughter in law . I decided to call the daughter in law . I thought it would be better to tell her than the wife . I told her what had happened . She had pushed the mother in law in past to make James DNR. But the decision was never made . She told me that she will get her mother in law and come to the hospital,as they lived only couple of miles away. As soon as I hung up the phone , I had call from the ICU. When I called them the nurse came to the phone , and said ,"guess what  . " I was in no mood to do that at 2 am . So she continued , 'James is alive  ' 'WHAT' I asked . Then I came to know that once the cardiologist pronounced him dead , when the nurse went to his room to disconnect the lines and the monitor  she noticed that he had started breathing and heart rate was 45per min . So she decided to put him on the respirator. I told them to call me when the family came in . It was in next 10 mins. that they called me again . I talked to the daughter in law . She had told the mother in law that he had cardiac arrest and not told that he had passed away . So when I told her the whole story , she the daughter in law made the decision on DNR. ,to which his wife had agreed .
       James lived for another 2 and half days . So this why I feel that one can not predict the time of the departure .

YAMA THE DON'T CONTINUED

     As was stated before there 5 'Don'ts ' and 5 'Dos'.  The 5 that were not to be done were , do not kill, do not lie , do not steal, do not have casual sex and lastly do not 'collect ' or do hoarding . We come across different things in our day to day life and some give us good feelings and some bad feelings . The things that give us good feelings we desire and that gives us bad feelings we try to avoid. This leads to our action of trying to have more of what gave us the pleasure . Say we enjoyed a concert of sitar or listened to a composition of particular musician on CD . We enjoyed , so now we want to have same experience , so now we 'buy ' CD with his music . This is in a way hoarding . This is not as bad , but  now we have expensive taste and now we need money to satisfy it . So we have to get money to satisfy.This is very easy to understand if I take an example of drug habits.The 'desire' to do drugs is so intense that people commit crime .We all understand that this is bad , but even at a lesser level this leads to attachment and bad action and sorrow , if do not get what we get attached to . So if we go a party and we like a appetiser, We take 5 or 6 , or even 10. This will leave others with  less or none . We go a garden and see beautiful flowers and pluck one or two , it is OK.But instead we decide to take 100 . This is hoarding. Collecting thing that we do not need for day to day activity or 'need ' is hoarding. This does not mean that one should never 'store' anything . In India families 'store ' grains for the entire season , when the new crop is in the market . This would not be considered hoarding . But if this same thing is done by a so called 'sadhu ' it will be hoarding . So the last of the Yama is do not do hoarding .
  The the difference in these 5 is that 1st 3 are not natural behavior , while last 2 are natural behavior that need to be controlled . We on an average do not kill , or steal or hoard everything. So our natural tendency is not killing or stealing or hoarding. So we have to be careful only in special situation or under special circumstances. The celibacy and all ways telling truth are not natural . Here we have to control our natural tendencies all the time .
   There are 5 Niyamas or 5 'Dos ' These are ,'cleanliness'( shaunch ), 'satisfaction '(santosh ).control on our sense organs (tapa),study of scripture ,(swadhyay ), and offering our all deeds to God (ishwarpranidhan ).

WHEN IT RAINS IT POURS

   We were taught in medical school that  usually there is only one diagnosis that can explain the patient's symptoms. There are always exception to the rule and this is not a rule anyway.But we sometimes come across situations where there are more than 1 diagnosis and sometimes we have 2 major diagnosis , both of which are serious or bad.The patient that I am going to describe is one such case.
    I saw this 68 years old patient , who was referred to me for the evaluation of lung mass . Patient was ex-smoker and had persistent cough and so the primary care physician ordered a x-ray . The x-ray showed a spot and he was referred to me . The primary care physician had ordered CT scan too . I saw him and looked the CT scan and then discussed withe patient . I usually tell patient that we need to answer 3 questions , i.e. Is it cancer , Has it spread and lastly what can we do . Then I tell patient how to do the  workup to get to the answers. We do  a PET scan , a bronchoscopy and biopsy and breathing tests .If needed we do additional scans based on these tests . When I looked at the CT scan of the chest I thought that he may lymph nodes involved in the Cancer process and we may not be able to do the surgery, which is the best treatment even today. But what bothered me more was mention by the radiologist of some other abnormality in the belly. When we do CT scan of the chest , to include the lower part of the lungs they end up including the upper part of the belly.So we sometimes see part of liver or upper part of kidney etc . Since these are not done to check on belly parts, they are not always conclusive . This was what I thought. But in case of these situations I end up ordering CT scan of the belly .
      It was 4-50 pm on the day after the CT scan was done , when I got preliminary report faxed to me . It showed an aortic aneurysm . THE SIZE WAS MORE THAN 15 CMS BY 8 CMS . This is huge . I was stunned . He had lung cancer that may be inoperable, and now has huge aneurysm that had potential for rupture due to shear size being huge .The time was so close to closing time of all the physician's office , that I would be lucky to get them on phone . I put a call to the vascular surgeon and at the same time a call to the primary care physician . When I talked to the vascular surgeon , he was not excited , definitely not as much as myself . He told me to fax him the report and told me that he will see him as planed . I had talked to the patient and told him about the aneurysm . He had no symptoms of pain or any other that would suggest impending rupture , so the surgeon was OK with seeing him in next day or two.I was concerned.Primary care was referring him to a different surgeon , who was not a chest surgeon .
     The surgeon saw him in the office and called me . He wanted to do the aneurysm repair first and then do the lung resection . As it turned out , the aneurysm repair was done . It was a long surgery, but the patient did well. He was discharged and the in next 6-7 weeks he had lung resection . The lymph nodes were positive for the cancer spread , but it was only one , and he was started on chemotherapy. . As of today he is off the chemotherapy , had new CT scan and new PET scan  and there is no evidence of cancer .
    The major problems and he did well. But I would still say , when it rains , it pours.  

LOYALTY

     Is there a loyalty amongst patients ? This is a question that is often asked today. Now a days patients decide about which doctor to go to, by looking at the list of doctors on the insurance plans and not by talking to other patients /friends etc . But I still do see patients that love me and would not change for anything. They would rather change the insurance plans or even the primary care physician before they wold go to some other physician. Again this does not happen with every patient that I see, but ,it does on many occasion s. This one is a story of one such patient.
     I had seen Dorothy for the 1st time , when she came to me for  shortness of the breath. She was smoker , and had advanced emphysema.I had to admit her to the hospital . It took almost a week to get her better and let her go home . She had to be put on oxygen . We did pulmonary function test and her lung capacity was 30 %. I  continued to see her for next few months and year went by . In next 2 years I admitted her several times and in one of them she had to be put on respirator . I had difficult time to wean her down /off the respirator and we needed to do the tracheostomy . I was however successful in getting her off the vent . then and in next couple of months her trach was removed . This did however  made her think and after great discussion she decided to be DNR--Do Not Resuscitate . Her husband was general contractor and was having hard time . So he had to move about 100 miles from my office .He and Dorothy continued to come to my office and I did admit her couple of times . The routine was he would call me and bring her to my office, and I would assess her and either would adjust medicines or admit her to the hospital. At times it was so late that I would see them in the emergency room or even just do direct admit her without seeing her and see her only when she was in the hospital .
    We had several discussions about her deteriorating health and the risk of not making it . Both of them were very clear , in that she did not want to be put on breathing machine. She was very clear in her mind and thought precess and he was clear about it and was supportive of it.
   On one Sunday, I was making my rounds in the hospital when he called me . It was about 8am and Dorothy was short of breath. She did not have a good night and tried to hold off on calling me , she did not want to be in the hospital again. She was too tired to get in and' fight it '. I told him to bring her to the hospital . He was already in the car and told me that it would make him about 2 hours to get to the hospital .I told him it was fine and called the admitting office and told them to get a bed . They had her information as she was in the hospital several times.
    I continued to see patients. It was 11 am and I had not gotten a call from him . And I got a call . My answering service called me to inform me that a 'state trooper ' wanted to talk to me . I was not too sure as to what was going on . I called him , he asked me if I knew One Mrs. Dorothy . I told him 'yes'. He informed me that she died in the car. He wanted to know if I would sign a death certificate.I told if I would sign it . I talked to the husband . He was driving to our hospital and she continued to feel badly . And then she went to sleep . He thought that she had not slept well during last night, so she was sleeping . In fact she must have gone in co2 narcosis or coma . ( when the blood carbon dioxide goes up , it causes sleepiness and the person goes in to coma). In next 10 or 15 minutes he realised that she was not breathing . He stopped the car and called 911 . That is when the state trooper showed up  , along with paramedics. She was gone and so he called me .
     I told him that this was for the good that she died before getting in the hospital,where she would be struggling for breath and then  after few more hours would have died anyway.

AND NOW SOME COMMENTS

     I wrote about bad things that happened to patients.But if I would write about patient getting in the hospital for pneumonia and gets treatment and gets better and goes home , no one would read it . So what sticks in my mind is the worst cases or unusual outcome , either good or bad . But on a lighter note , we do see patients that tell jokes and sometimes say things that turn out to be funny .
     I happen to be a lung specialist , and so listen to the lungs of every patient. Most of the patients do acceptable breathin' style ' But some make it funny . Some take deep breath and exhale for long time .It almost feels like they are preparing for diving deep under water. Some do short and rapid breathing , while some continue to breath normally . So I have developed a habit of telling patients to ,'breath in and out ', when I am ready for listening to the lungs.No one usually asks me any thing, when I say this line . But one time when I said this to one patient, he said,"is there any other way ?(than breathing in and out ).I had no answer.
     When I see new patient I usually ask for  routine questions first,like high blood pressure, diabetes, TB, heart attack or stroke etc . When I am done with this I ask , 'so tell me why are you here?' Some say,'my doctor send me , I don't know,'or the symptom,like cough or shortness of breath etc. But one time when I asked , so why are you here, the patient asked me if I had electric outlet . When I showed him one in our exam room , he took a tape recorder and plugged it in . IT was recorded by his wife while he was asleep and it was recording of his snoring..He was in my office as the snoring was so loud that the wife could not take it and as he had refused to accept it she recorded it . Needless to say that he had sleep apnea.
      One of the common reason why patients come to me is chronic cough. (I often say in joking way that your cough and cold id my bread and butter.)So when I asked this new patient about the complain, she told me about the chronic cough. Interestingly enough , she did not cough at all in my office . So I was not too sure as to how bad was the problem . Then the daughter who was with her made  a statement, "she is coughing for so long and so much that our parrot has started making coughing sound . (thinking that she was trying to teach parrot the sound of coughing .)I had to believe it .