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Saturday, August 13, 2011

Years ago, I noticed that International Travel Assist was taking six months to pay and then only after repeated phone calls. When it refused to give me a credit card number, I began declining its visits. With the stock market diving along with my retirement nest egg, I’m less inclined to turn away business. So I accepted an ITA visit to a middle-aged man with a bellyache.

“He has terrible pain,” his wife announced as she ushered me into his room. I dismiss many worried complaints (“His fever isn’t going away….” “His mucus is green…”), but this one often means bad news.

Sure enough, the man looked sick. He was feverish. His abdomen felt exquisitely tender and rigid, a sign of peritonitis. He needed to go to an emergency room, I informed them. I dialed ITA’s number to let them know.

Uneasily, I recalled that International Travel Assist had other ways to economize besides stiffing doctors. Sure enough, after hearing the news the dispatcher informed me that the patient must first go to the Airport Medical Center, an urgent care clinic. I often do the same when guests from nearby hotels need something I can’t provide such as an x-ray. It’s not part of a hospital, and the doctor on duty has the same training as I.

I gave the patient and his wife directions to the clinic. Since many doctors lean over backward to send patients to emergency rooms, a second opinion probably saves ITA money, but it wouldn’t in this case because my patient needed an ER. There was always a chance the doctor on duty would decide to send him home, so I phoned the clinic to make sure he thought twice.

Telling a doctor what to do is counter-productive, so I chose my words carefully. I was sending a man with bad abdominal pain and peritoneal signs, I explained. If it were an office patient, I would have sent him to the hospital for scans and a surgical consult, but his insurance insisted he go to an urgent care clinic.

He thanked me for the information. “We don’t have too many facilities here,” he added. “But we’ll do what we can.”

“Don’t do anything. Send him to the hospital,” would have been tactless, so I didn’t say it. Once a doctor decides a patient needs emergency care, allowing a test to change his mind is a bad idea. Thus, I thought the man had an abdominal infection. Had I ordered a blood count, an elevated white cell count would point to an infection. Good... But sometimes the test comes back normal. What then? The answer: send him to the ER anyway. It’s another rule of medicine that a doctor shouldn’t order a test that doesn’t change the treatment, but we disobey that all the time.

So the man passed a few miserable hours while the doctor ordered tests that doctors order when a patient has a fever and bellyache: a blood count and an abdominal x-ray. I have no idea of the results, but I checked to make sure he’d gone to the hospital, and he had.

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