It happened some time ago. She is a 31 yr old Type 1 Diabetic patient of mine. She called me up one day saying a guy will come to see me asking about her health condition. He is her prospective bride groom. The families contacted through a matrimonial ad. He had met her and her family. Now he wants to know how healthy she is.
In India most of the time it is the family/parents who search and find partners for their sons and daughters.[Things are changing but slowly] The parents of my Type 1 patient were in search of a bridegroom for some years now. She had called me before also, saying a guy or his parents may come and ask about her. But nobody had come to me yet.She had a stable and well paying Govt job and this had attracted many suitors.Still her T1 status might have dissuaded her prospective grooms. As far as I know she had said no to one or two suitors too.
He called me 2 or 3 times on phone before fixing a suitable time to see me. He was a serious looking guy, little bald may be around 35 years. He introduced himself and mentioned the name of my patient[his proposed bride].
We were silent for sometime.Then I started interviewing him.He is only having a temporary job in a Company,but his family had some agricultural land and according to him are financially stable.
He did not knew how to start his questions.I helped him by asking what he want to know.
How serious is her Diabetes?
Will she need Insulin through out her life?
Can she become pregnant and deliver children?
Will the children inherit her Diabetes?
Some how I thought this Guy is nice and dependable. I wanted my patient to get a good partner.So the picture of her health status that I presented to him was very positive.
Yes, she needs Insulin through out her life.Her body is not producing Insulin,a hormone essential for Sugar metabolism. We are injecting it so that she can live normally.
She have no other defect.
She can become and pregnant deliver normal children.
Finally I also added that she is having the best blood sugar control among my Type 1 patients.
I had a feeling that he was satisfied and happy. She came the next day and wanted to know everything.I told her in detail.Then she asked me 'How you feel about him?' I said I felt he is nice and dependable. She looked at my face intently and I gave her a reassuring smile.
Sunday, August 31, 2008
Saturday, August 30, 2008
Who profits from illness?
The other day I was travelling with an Indian guy settled in US.He is a retired person aged about 60 years.He has been in US for last 35 years. He had come to India for attending a marriage of one his nephews.After the customary lamentations about the 'dismal' situation in India our chat turned to the subject of health care in USA.
He said recently he had to do an emergency surgery for Piles in USA and it cost him about 20000 US dollars. I first thought I heard him wrongly.In India for 20000$ a person can replace both his knees and do a coronary bypass surgery.I asked him again and he said Yes the bill was for twenty thousand dollars.He also added that his Insurance Company payed only 6000$.He is paying the rest from his pocket in instalments.
Then I said the doctors in US must be having handsome earnings as the patients have to pay so much. He said only a few docs have good savings. He revealed that his son is a Doctor and is still paying off his debts incurred while studying even though he passed out 5 years ago.
So who profits from the illness among common people? May be Insurance companies,Drug Companies,Corporate Hospitals etc. Is there any way out so that quality health care is easily affordable to all?
He said recently he had to do an emergency surgery for Piles in USA and it cost him about 20000 US dollars. I first thought I heard him wrongly.In India for 20000$ a person can replace both his knees and do a coronary bypass surgery.I asked him again and he said Yes the bill was for twenty thousand dollars.He also added that his Insurance Company payed only 6000$.He is paying the rest from his pocket in instalments.
Then I said the doctors in US must be having handsome earnings as the patients have to pay so much. He said only a few docs have good savings. He revealed that his son is a Doctor and is still paying off his debts incurred while studying even though he passed out 5 years ago.
So who profits from the illness among common people? May be Insurance companies,Drug Companies,Corporate Hospitals etc. Is there any way out so that quality health care is easily affordable to all?
Friday, August 22, 2008
Type 2 or Type 1 Diabetes? Not sure yet
The 12 yr old girl with Diabetes about whom I posted few days ago came with her lab reports. The C peptide level was in the upper range of normal.It means considerable amount of Insulin is being secreted from her Pancreas.
Does it mean she is having Type 2 Diabetes? We cannot be sure yet. There is something called 'honey moon' period in Type 1 Diabetes where the patient's requirement of Insulin injections will be less or even nil. That does not mean the patient is not suffering Type 1 Diabetes. After such honey moon period which lasts for few months the Insulin requirement will increase and the patient will show all features of Type 1 Diabetes.
Let us hope it is not Type 1 Diabetes but only time will tell.Meanwhile I have started her on Oral tablets in addition to Insulin.Let us see the response.
Does it mean she is having Type 2 Diabetes? We cannot be sure yet. There is something called 'honey moon' period in Type 1 Diabetes where the patient's requirement of Insulin injections will be less or even nil. That does not mean the patient is not suffering Type 1 Diabetes. After such honey moon period which lasts for few months the Insulin requirement will increase and the patient will show all features of Type 1 Diabetes.
Let us hope it is not Type 1 Diabetes but only time will tell.Meanwhile I have started her on Oral tablets in addition to Insulin.Let us see the response.
Saturday, August 16, 2008
Patient loyalty
Some patients are very loyal to their doctor. They hate seeing another doctor. They will believe only if their favourite doctor tells them, but their loyalty land them into trouble sometimes.
A patient of mine, a 50-year-old diabetic, developed sweating and mild chest pain. As I was away for a day, he consulted another doctor. An Electrocardiogram (ECG/EKG) was done and the doctor found some changes suggestive of early heart attack. The patient was asked to get admitted in an Intensive care Unit. Not believing the doctor, the patient waited for a day to see me. That night the patient became worse and he died on way to Hospital.
Being a one man practise, many a time it is difficult for me to arrange substitute medical care when I am out of station. Though I tell them to see the nearest available doctor in case of emergency, many are reluctant. When I come back from a break of few days many of these loyal patients accuse me of orphaning them. Their affection make me feel good ,but at the same time the accusation make me feel guilty.
A patient of mine, a 50-year-old diabetic, developed sweating and mild chest pain. As I was away for a day, he consulted another doctor. An Electrocardiogram (ECG/EKG) was done and the doctor found some changes suggestive of early heart attack. The patient was asked to get admitted in an Intensive care Unit. Not believing the doctor, the patient waited for a day to see me. That night the patient became worse and he died on way to Hospital.
Being a one man practise, many a time it is difficult for me to arrange substitute medical care when I am out of station. Though I tell them to see the nearest available doctor in case of emergency, many are reluctant. When I come back from a break of few days many of these loyal patients accuse me of orphaning them. Their affection make me feel good ,but at the same time the accusation make me feel guilty.
Thursday, August 14, 2008
Diabetes Type 1 or Type 2?
She was 12 years old, studying in 7th standard. She was admitted in a nearby hospital with fever, vomiting, and recent lose of weight of 10 kgs. Her urine sugar test showed brick red color (meaning more than 2 percent glucose). Her blood sugar was then checked. It was 468mg percent. She was diagnosed as type 1 diabetes with Diabetic ketoacidosis[DKA]. She was managed with Insulin and intravenous fluids. She recovered well. She was then referred to me to confirm the diagnosis of type 1 Diabetes.
As they walked in, the child looked relaxed. The parents were tensed and stressed. What they were hoping was, I will tell them that this is not real diabetes. They repeatedly told me that no one in their family were diabetic.They did not had any clue why their daughter had so high blood sugar. Neither had I.
She was an obese child. According to parents, she had lost about 15 kilograms in 4 months. All started after she was ill with chicken pox.
Is she having an Insulin dependent type 1 Diabetes seen commonly in children or is she having a type 2 diabetes commonly seen in adults, but now also seen in obese teenagers?
If it is type 1 diabetes, she will need Insulin life long. If it is type 2 diabetes, she may be able to manage with diet, exercise, and tablets for a long time.
Diagnosis is little tricky in her case. History of obesity is in favour of type 2 diabetes, but sudden weight loss, DKA, and history of chicken pox suggests type 1 diabetes (type 1 often follows a viral infection).
Two tests may help me. One is a test for antibodies against pancreatic cells. Such antibodies are seen in most type 1 patients. Other is estimation of C peptide, which is an indirect measurement of body's insulin production. C peptide will be low in type 1 diabetes.
Antibody tests are costly. C peptide estimation is less costly.The family is poor with both parents not having any regular employment. So, I opted for C peptide estimation.
Type 1 or type 2? The answer may become clear next week when the lab results come.
As they walked in, the child looked relaxed. The parents were tensed and stressed. What they were hoping was, I will tell them that this is not real diabetes. They repeatedly told me that no one in their family were diabetic.They did not had any clue why their daughter had so high blood sugar. Neither had I.
She was an obese child. According to parents, she had lost about 15 kilograms in 4 months. All started after she was ill with chicken pox.
Is she having an Insulin dependent type 1 Diabetes seen commonly in children or is she having a type 2 diabetes commonly seen in adults, but now also seen in obese teenagers?
If it is type 1 diabetes, she will need Insulin life long. If it is type 2 diabetes, she may be able to manage with diet, exercise, and tablets for a long time.
Diagnosis is little tricky in her case. History of obesity is in favour of type 2 diabetes, but sudden weight loss, DKA, and history of chicken pox suggests type 1 diabetes (type 1 often follows a viral infection).
Two tests may help me. One is a test for antibodies against pancreatic cells. Such antibodies are seen in most type 1 patients. Other is estimation of C peptide, which is an indirect measurement of body's insulin production. C peptide will be low in type 1 diabetes.
Antibody tests are costly. C peptide estimation is less costly.The family is poor with both parents not having any regular employment. So, I opted for C peptide estimation.
Type 1 or type 2? The answer may become clear next week when the lab results come.
Wednesday, August 13, 2008
'Positive' Grand mother
When we think of HIV positive people, we imagine some one in their 20s or 30s, but there are a few 'positive' women (and men) who are in their 50s and having grand children. HIV testing may be delayed because of the age as the treating doctor may not consider this possibility.
She came with her husband 7 years ago. He was very sick having all the features of defective immunity. His test proved he is 'positive'. She was also found to be positive but with a near normal immunity. She had 3 children all in their 20s. They were all tested and found negative.
At that time, there was no free Government supply of medicines [ART] for HIV/AIDS. I prescribed medicines to prevent opportunistic infections. ART was too costly and he could not afford to take it continuously. He died within 2 years.
Last month she came to me again. She is 52 now and is living with her son. She is the proud grandmother of 3 kids. She came with recurrent fever and weight loss. She had fungal infection in her mouth, and I could make out that her immunity is low. Lab tests confirmed it, and I referred her to Govt ART Centre where she will get free anti HIV medicines. If everything goes well, she will be able to live a near normal life for a long time.
She is grateful for this opportunity to live well because of free ART, but laments the fact that her husband did not get such a chance.
When I started practising Medicine, I had helplessly seen scores of patients with advanced HIV/AIDS dying in my hospital. ART was unavailable or unaffordable. Now the availability of free ART has dramatically changed the situation.
A scientific discovery in health, whether it is a new technology or a drug , should be made available to whole mankind as soon as possible, otherwise such discovery only adds to the pain of the poor.
She came with her husband 7 years ago. He was very sick having all the features of defective immunity. His test proved he is 'positive'. She was also found to be positive but with a near normal immunity. She had 3 children all in their 20s. They were all tested and found negative.
At that time, there was no free Government supply of medicines [ART] for HIV/AIDS. I prescribed medicines to prevent opportunistic infections. ART was too costly and he could not afford to take it continuously. He died within 2 years.
Last month she came to me again. She is 52 now and is living with her son. She is the proud grandmother of 3 kids. She came with recurrent fever and weight loss. She had fungal infection in her mouth, and I could make out that her immunity is low. Lab tests confirmed it, and I referred her to Govt ART Centre where she will get free anti HIV medicines. If everything goes well, she will be able to live a near normal life for a long time.
She is grateful for this opportunity to live well because of free ART, but laments the fact that her husband did not get such a chance.
When I started practising Medicine, I had helplessly seen scores of patients with advanced HIV/AIDS dying in my hospital. ART was unavailable or unaffordable. Now the availability of free ART has dramatically changed the situation.
A scientific discovery in health, whether it is a new technology or a drug , should be made available to whole mankind as soon as possible, otherwise such discovery only adds to the pain of the poor.
Monday, August 11, 2008
A happy death?
He was 74. He had diabetes and high blood pressure. He had also suffered from a Minor Stroke. He was a regular in my clinic for last 7 years. He takes his medicines regularly, tests his blood sugar frequently, and follows all my advise religiously. He came for his regular followup 2 weeks ago.
Today morning he is no more. His son called me and told me that he died in his sleep. He was apparently normal when he went to sleep. Today morning he did not wake up. Probably he had a peaceful death.
He wished for such a death. He never wanted to trouble his children and relatives. He never wanted his children to spend their hard-earned money to make him survive for a few more months or an year. He asked me never to admit him in ICU if he fell ill. He was a pensioner and could easily afford the medicines I prescribed, but nothing more than that.
Was he conscious when he died? What was his thoughts then? Did he yearn for a few more days of life? Or was he happy in death? One never knows.
Today morning he is no more. His son called me and told me that he died in his sleep. He was apparently normal when he went to sleep. Today morning he did not wake up. Probably he had a peaceful death.
He wished for such a death. He never wanted to trouble his children and relatives. He never wanted his children to spend their hard-earned money to make him survive for a few more months or an year. He asked me never to admit him in ICU if he fell ill. He was a pensioner and could easily afford the medicines I prescribed, but nothing more than that.
Was he conscious when he died? What was his thoughts then? Did he yearn for a few more days of life? Or was he happy in death? One never knows.
Friday, August 8, 2008
Stress and Blood Sugar
She is 71 years old, a diabetic patient of mine for last 3 years. She is on 3 types of tablets to control her blood sugar. She checks her blood sugar regularly and keeps all her appointments with me, but her blood sugar fluctuates wildly. One month it will be 185mg post meal and the next month it will be 360.
She always look depressed. She never smiles at me. All my efforts to bring a smile on her gloomy face are always wasted.
She always come with her son, but she is not living with him. She lives alone in a big house with a house maid. Her son lives in the same town a few kms away.
I was curious about her fluctuating sugars. Her diet seems to be same. Her sleep is always good as she is taking a sedative. Level of activity is also the same. Then why the fluctuation?
Slowly, I realised there is a pattern to the fluctuation. She has 2 daughters. They stay some distance away in a different town. Once every 2 months she go to one of her daughter's place and stay there for 2 weeks. If she was tested immediately after her return from such a trip the blood sugars were near normal. When she stays alone, her blood sugar rises up.
Actually, she had realised it before me. She never wanted me to advise her to stay with her children.
When I asked her, 'why don't you stay with your children' her reply was immediate. 'Why can't they stay with me? At least my son should stay with me.I was brought up in an aristocratic family. I believe in staying in my own house built by my late husband. I cant go and live in my son's house'.
The son sheepishly smile all the time [I thought he must be thinking the same thing.Why should I live in a house built by my Dad?].
What can I say to this adamant lady? After a few minutes, I told her 'your children may also be like you,fiercely independent. So, better not to complain'. I suggested a longer stay at her daughter's place and then bid her goodbye.
Independence at old age if not stressful to your mind is good, but if it affects your health adversely then you should rethink.
She always look depressed. She never smiles at me. All my efforts to bring a smile on her gloomy face are always wasted.
She always come with her son, but she is not living with him. She lives alone in a big house with a house maid. Her son lives in the same town a few kms away.
I was curious about her fluctuating sugars. Her diet seems to be same. Her sleep is always good as she is taking a sedative. Level of activity is also the same. Then why the fluctuation?
Slowly, I realised there is a pattern to the fluctuation. She has 2 daughters. They stay some distance away in a different town. Once every 2 months she go to one of her daughter's place and stay there for 2 weeks. If she was tested immediately after her return from such a trip the blood sugars were near normal. When she stays alone, her blood sugar rises up.
Actually, she had realised it before me. She never wanted me to advise her to stay with her children.
When I asked her, 'why don't you stay with your children' her reply was immediate. 'Why can't they stay with me? At least my son should stay with me.I was brought up in an aristocratic family. I believe in staying in my own house built by my late husband. I cant go and live in my son's house'.
The son sheepishly smile all the time [I thought he must be thinking the same thing.Why should I live in a house built by my Dad?].
What can I say to this adamant lady? After a few minutes, I told her 'your children may also be like you,fiercely independent. So, better not to complain'. I suggested a longer stay at her daughter's place and then bid her goodbye.
Independence at old age if not stressful to your mind is good, but if it affects your health adversely then you should rethink.
Sunday, August 3, 2008
Unaffordable Health Care
Rapid advances in Medical Science is now giving more and more treatment options to the patient. Whether it is Leukemia, Cancers, Parkinsonism, Rheumatoid Arthritis, Diabetes or many of the other chronic diseases, newer and newer drugs brings hope to the suffering millions, but will their hope of a better life be fulfilled?
The astronomically high costs of newer drugs make sure that only the fortunate few will be able to get the benefit. For the rest it will be pure agony of suffering with the knowledge that treatment is available but is unaffordable. Maybe, they would have been better off if there was no treatment. Then they could have suffered and died peacefully.
Why newer drugs are so costly? Why we cannot share the fruits of scientific research evenly among all human beings of the World? Why a handful of pharmaceutical Giants reap the profit of our scientific advances?
The astronomically high costs of newer drugs make sure that only the fortunate few will be able to get the benefit. For the rest it will be pure agony of suffering with the knowledge that treatment is available but is unaffordable. Maybe, they would have been better off if there was no treatment. Then they could have suffered and died peacefully.
Why newer drugs are so costly? Why we cannot share the fruits of scientific research evenly among all human beings of the World? Why a handful of pharmaceutical Giants reap the profit of our scientific advances?
Friday, August 1, 2008
Doctor,please give me your cellphone number
Doctor, please give me your cellphone number.Then in case of an emergency we can contact you directly.
I receive such request very frequently. How should I respond?
You will think that this is a reasonable request. Each and every patient should be able to contact the treating doctor directly in an emergency. You wont have any second thoughts about how I should respond. But.............
I am sure if each and every patient I treat get my cellphone number, I wont have a single minute of peaceful living. I will be deluged with calls while sleeping, eating, bathing, driving, when seeing patients in my Consultation room, while taking rounds etc etc. Sense of propriety and ethics are forgotten. The facility will be misused [as some already do who have somehow got my cell number.]
I am available in the daytime at my land phone numbers. At night in case of an emergency, the patient have to approach the hospital were I work. The staff at the hospital can contact me 24 hours a day.
For some of my patients, I give my cellphone number without hesitation. They are
1. HIV positive persons
2. Type 1 diabetes patients
I don't hesitate for HIV positive persons, because I feel with all the stigma and discrimination they face, they should at least be positively discriminated by me. They should be able to talk to me anytime they want.
Type 1 diabetes patients need constant communication with the treating doctor as they have to self manage a lot and may need physician guidance in management.
Another reason for lack of hesitation is that 'positive' persons and type 1 diabetics under my care constitute less than 1 percentage of total number of patients. So, I need not loose sleep giving away cellphone numbers to them.
Do you think of me as a selfish and uncaring doc?
I receive such request very frequently. How should I respond?
You will think that this is a reasonable request. Each and every patient should be able to contact the treating doctor directly in an emergency. You wont have any second thoughts about how I should respond. But.............
I am sure if each and every patient I treat get my cellphone number, I wont have a single minute of peaceful living. I will be deluged with calls while sleeping, eating, bathing, driving, when seeing patients in my Consultation room, while taking rounds etc etc. Sense of propriety and ethics are forgotten. The facility will be misused [as some already do who have somehow got my cell number.]
I am available in the daytime at my land phone numbers. At night in case of an emergency, the patient have to approach the hospital were I work. The staff at the hospital can contact me 24 hours a day.
For some of my patients, I give my cellphone number without hesitation. They are
1. HIV positive persons
2. Type 1 diabetes patients
I don't hesitate for HIV positive persons, because I feel with all the stigma and discrimination they face, they should at least be positively discriminated by me. They should be able to talk to me anytime they want.
Type 1 diabetes patients need constant communication with the treating doctor as they have to self manage a lot and may need physician guidance in management.
Another reason for lack of hesitation is that 'positive' persons and type 1 diabetics under my care constitute less than 1 percentage of total number of patients. So, I need not loose sleep giving away cellphone numbers to them.
Do you think of me as a selfish and uncaring doc?
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