Monday, April 30, 2012

Satisfying and Unsatisfying Problems

A guest interrupted my questioning to dash into the bathroom, and I heard the sounds of gagging as she vomited.

While waiting, I took a vial of ondansetron from my bag and began filling a syringe. After a few minutes I heard the toilet flush.

“Why don’t I give the vomiting injection now?” I said when she reappeared. “You’ll probably want one.” She agreed with enthusiasm.

I finished my exam, made a diagnosis – the common stomach virus – and delivered advice and a packet of pills. I also went to the ice machine down the corridor and filled her ice bucket, so that she could suck on the chips for the next few hours. She was very grateful and equally grateful the following morning when I phoned to learn she had recovered. Most stomach viruses don’t last long, a day or so.

Vomiting and diarrhea are usually satisfying problems for a doctor. Most skin problems are easy. I rarely have a problem with earaches, backaches, minor injuries, common eye inflammations, even most urinary and gynecological complaints. A hotel doctor’s patients are healthier than average, but serious problems occur. It turns out that these are not necessarily “hard.” When I encounter someone with chest pain, eye pain, sudden weakness, difficulty breathing, or an injury that may be serious I know what to do. At the end patients receive the care they should receive, and we both know it. That’s a satisfying feeling.

What is the most unsatisfying problem a doctor faces? Rare diseases? Puzzling symptoms? Neurotics? Drug addiction? None of these. Most doctors would agree that it’s the common viral upper respiratory infection. About twenty percent of everyone who consults a doctor suffers. Hotel guests are no exception. No one tries to educate me about heart attacks, but everyone is an expert on these. Patients tell me how they acquired theirs (“I got caught in the rain”), or why (“I’m not eating right; my resistance is low”), the proper treatment (“my doctor gives me a Z-pak”), and what will happen if I disagree (“It’ll go to my chest”). These explanations are always wrong.

You catch a virus from another person. The illness lasts from a few days to a few weeks. If you see a doctor, he or she will prescribe an antibiotic at least half the time. The antibiotic is useless. Doctors know this but prescribe them anyway.

No patient agrees. “I have a good doctor,” they reply. “He would never do that.”

My response is that prescribing useless antibiotics is not necessarily a sign of incompetence. It’s so common that good doctors do it. One expert calls this avalanche of unnecessary antibiotics one of our greatest environmental pollutants. It’s producing a growing race of “superbugs:” germs resistant to all antibiotics.

Here’s a professional secret. When doctors chat among themselves, we often bring up the subject. Challenged by colleagues like me, prescribers never claim that antibiotics cure these infections. They know they’re a placebo, but they respond with a powerful argument. “When I’m finished, I want patients to be happy, and they are happy. One hundred percent. What’s your experience?”

It’s not as good. When I deliver sympathy, advice, and perhaps a cough remedy to patients with a respiratory infection, most seem genuinely grateful, but a solid minority drop hints (“Isn’t there something to knock this out….?” “My regular doctor gives me…..” “I have a meeting tomorrow, and I can’t be sick…”).

Doctors love helping patients. That’s why we went into medicine. Equally important, we want you to feel “helped,” and we are super-sensitive to your gratitude. Almost everyone is too polite to argue with a doctor, but we can detect the tiniest trace of disappointment as you leave. It hurts us. Every doctor knows that he can eliminate this pain and produce heartfelt gratitude by prescribing an antibiotic. This is terribly tempting, and after a few dozen or few hundred or few thousand disappointed patients, most doctors give in.

Monday, April 9, 2012

Stuck in Liberalism

Walking along Pico, a busy street, I passed a man lying face down on the sidewalk. His head lay on the curb; one leg remained on a bus bench, so he had clearly toppled off. Even prosperous Los Angeles neighborhoods possess a few resident homeless, and this was probably one. He looked disheveled.

Naturally, I continued past. After a dozen paces I stopped because my conscience was hectoring me. “You have to help this fellow,” it pointed out.

“I’d rather not,” I replied. “Someone else will notice…”

“You’re a doctor. You have to help.”

“I do fine with patients,” I pointed out. “But this is not a professional situation.”

“Not good enough!” said my conscience. “Doctors have a moral obligation to help.”

“That’s flattering, but many doctors disagree. You should read the physician forums on the internet. Most are very conservative.”

“Why are you wasting my time?”

“….They hate Obamacare. They think welfare patients are deadbeats. They don’t even like patients with private insurance. Their idea of heaven is a cash-only practice.”

“Are you finished?...” asked my conscience. “Do you think I’m going to let you walk away?”

While I paced in a circle, debating this irritating voice, a hundred cars and dozens of pedestrians passed by. Finally, I gave up. The 911 dispatcher listened to my report and then transferred me to the fire department. The fire department dispatcher listened and then transferred me to the paramedics.

“How old is he?” asked a paramedic.


“What do you mean ‘middle-aged’?” he snapped. “Forty… Fifty… Sixty?”

“Fifty,” I guessed.

After several more questions designed to show that I was bothering him, he told me to wait until the ambulance arrived. As I waited, the man stirred.

“That’s all I need!” I thought. “For him to get up and walk away.”

But he didn’t. The ambulance arrived within five minutes, and the paramedics went to work. When they ignored me, I walked off.

This story demonstrates that I may not be the humanitarian that comes across in elsewhere in this blog. When I pick up the check at a restaurant or declare all my income to the IRS or stop my car at a stop sign at 3 a.m. on a deserted intersection, or don’t insult a telemarketer, I tell myself that I’ve done the right thing, but it’s surprisingly unsatisfying. I wish someone would express approval.

Of course, my wife praised my compassion when I told her the story, but I knew I had cheated by skipping the dialogue with my conscience.

Being liberal may be contrary to human nature, but I’m stuck with it.

Wednesday, April 4, 2012

No Good Deed Goes Unpunished

An Austrian lady had left home without her medication. Could I come and write a prescription?

These requests arrive perhaps once a week. A surprisingly number of travelers forget to pack their narcotics, Ritalin, or sleeping pills; all are willing to pay for a visit to remedy this oversight. No sensible hotel doctor complies (but that does not include all hotel doctors). For the rest, I have no trouble replacing legitimate, ongoing medication. This lady needed blood pressure pills.

In the past, I offered to phone a pharmacy, but this took a long time as patients scrambled to find the name, dose, and instructions. Nowadays I tell guests to go to a pharmacy, explain exactly what they need, and give my number. I would approve it over the phone.

Guests are pleased that it is so simple and more pleased to learn that I don’t charge for this. I enjoy their gratitude and tell myself that this is good P.R.

Several hours later, a caller explained that he was the tour leader for an Austrian group.

“I was told you gave a prescription for one of our members. Could you tell me where is the pharmacy?”

The lady’s English was not good, so she had misheard me. I repeated my instructions. An hour later, I answered a call from the driver for the tour bus. He had given the name of the lady’s medication to a pharmacist who had refused to accept it. Again, I explained that the lady had to tell the pharmacist precisely what she needed including the dose and instructions.

An hour later, a pharmacist informed me that a customer was requesting a medication that didn’t exist in the US. I pointed out that there was undoubtedly something similar.

He phoned back with a suggestion, and I told him to give the lady as many as she needed. He asked for the dose and instructions. I told him the lady would have to determine that.

Several hours passed before the pharmacy called again because the lady had to phone her doctor in Austria. In the end, she received her medication.

Don’t forget to pack your pills.