Thursday, November 29, 2012

Addicted to Gratitude

“You saw me at the Marriott yesterday. I still don’t feel good.”

“I’m sorry,” I said. “I did mention that you’d be under the weather a few days.”

“I still have a temperature. The Tylenol only works a few hours. The cough medicine isn’t doing much. I need something stronger.”

“I would love to make you better, but, as I explained, there’s no cure for these respiratory viruses.”

“What if it’s bronchitis? My doctor tells me I have a lot of bronchitis.”

“‘Bronchitis’ is just another word for coughing. It’s a virus that runs its course.”

“I guess I just have to be sick. Thank you, Doctor Oppenheim,” she said before hanging up. She remained polite but did not conceal her disappointment. I felt bad.

I also felt a surge of anger at my fellow doctors, most of whom prescribe antibiotics for viral infections. No doctor believes they work, but prescribing them guarantees a patient’s gratitude; doctors are addicted to your gratitude. 

My practice is to prescribe antibiotics when they’ll help and not to prescribe them when they won’t. After I do this, about three quarters of patients seem genuinely grateful. Most of the remainder are dissatisfied but remember their manners. Perhaps one percent make it vividly clear that I have failed them. I must admit that, if I see an explosion in the works, I whip out my prescription pad, but sometimes I’m too late.

Sunday, November 25, 2012

The Superiority of American Medicine

Patriots boast that American medicine is the best in the world. My view is more nuanced, but let me take their point of view. You’ll be amazed at the dumb things foreign doctors do!

They don’t give antibiotics for ear infections!
If your child suffers a miserable, painful ear infection, your doctor prescribes an antibiotic. In many European countries, doctors give medicines for pain and fever but no antibiotic. If you’re wondering what happens to these poor children with earaches, the answer is: they get better. Even in America, experts are debating whether or not antibiotics work for ear infections. Maybe they don’t. Until experts make up their minds, American doctors will prescribe antibiotics.

They don’t care for hysterectomies!
Many women develop lumpy growths on the uterus called fibroids. Although harmless, fibroids may cause pain and irregular menstrual bleeding. A gynecologist can cure this by removing the uterus. Called a hysterectomy, it’s the second most common operation American women undergo (after caesarians; America leads the world in both). Naturally, a woman without a uterus can’t have children.

The French have the odd idea the world would be a better place if there were more Frenchmen, so French doctors don’t sterilize women if they can avoid it. Mostly, they perform an operation that cuts off the fibroids but leaves the uterus intact. The surgery is more complicated and takes longer than a simple hysterectomy. American gynecologists could do the same, but they don’t, and they rarely discuss it with patients because they know American women aren’t interested.

They don’t try to cure every patient.
American doctors order more tests and prescribe more antibiotics, chemotherapy, and other powerful drugs than foreign doctors. They also perform far more surgery. All these extras don’t necessarily cure. Sometimes they make patients sicker, but the important thing is that we’re doing something. American like aggressive doctors.

Foreign doctors spend a great deal of time making patients feel better – for example by ordering physical therapy (massage, exercise, heat, baths). American doctors prescribe physical therapy to help recovery after surgery or injuries. European doctors prescribe it after childbirth and for migraines, irritable bowels, arthritis, fatigue, depression – dozens of problems. European doctors actually send patients to health spas for baths, massage, etc., and health insurance pays for it! If you believe this is a waste of money, American doctors agree. Patients may feel better after a spa treatment, they explain, but it’s psychosomatic (in other words, if someone feels better -- but it’s only psychosomatic -- that’s bad).

They give free medicine to children!
No discounts, no deductible, no co-pay – just free. In a dozen countries including Canada, the government also pays for hospital care, doctor visits, nursing homes, and it even pays women to take off work to care for newborn babies. These foreign countries claim their citizens live longer, have lower infant and maternal mortality, and enjoy better health. This sounds wonderful, and it’s also true, but American advocates of the free market point out the soul-destroying price those nations pay: higher taxes. Americans must never follow that path, they warn.

We haven’t. President Obama took for granted that the most efficient, lowest cost universal program, the single-payer (i.e. everyone pays a tax; the government pays for health care) would never pass, and he was probably right. The result is Obamacare, a tortuously complex Rube-Goldberg program that avoids direct taxes and relies on individuals and businesses buying insurance.

Liberals point out (with complete lack of success) that single payer systems benefit the free market. Employee insurance premiums have always burdened American business. We’ve all read that $1,500 of the cost of a Chevrolet is what General Motors pays for medical benefits of those who built it. The companies that build Hondas and Volkswagens don’t pay employee health insurance.

Sunday, November 18, 2012

The Evils of Common Sense

“I can walk on it, so I know it’s not broken.”

It turns out that the fibula, one of two bones in the lower leg, doesn’t bear weight. You walk on your tibia.

“I can move it, so I know it’s not broken.” You may know, but I’m not so sure.

Patients yearn to understand their problem. In the absence of evidence, they use common sense which turns out to be a terrible way to get at the truth. In fact, it’s a good rule that any common sense explanation of a medical problem is wrong. Here are others that I hear all the time.

“I have to let this run its course…”

Seeing smoke pour out of your car’s exhaust, no one explains that the engine is repairing itself by expelling bad things. Yet plenty of patients believe their vomiting or diarrhea is the body’s attempt to cleanse itself. In fact, it’s a simple malfunction. It’s OK to treat it although exceptions exist for a few serious diseases.

“Fever is your body’s way of fighting an infection.”

This may not be wrong (scientists still debate this), but it leads to many sensible beliefs that, being sensible, are wrong.

Google “does fever treatment help” for an avalanche of praise for fever's healing properties from doctors and medical sites as well as laymen. Don’t believe it.

Here’s the truth. Your body generates fever in response to viral and bacterial infections. It’s an immune response. Enthusiasts regularly quote studies showing certain germs that grow at 98.6 don’t grow as rapidly at 102. Common sense teaches that you shouldn’t interfere. But you already know my opinion of common sense.

Here are questions that you might ask.

1. In what specific infections is lowering the fever harmful? I can’t think of any.

2. What infections do doctors treat by giving patients a fever?  The answer is none (a note to nitpickers: I know medical history – I’m talking about doctors today).

3. Every day, across the world, a hundred million people take medicine for fever. How many end up at the doctor who explains that this made the problem worse?

Wednesday, November 14, 2012

Warning: This Blog May Vanish

I suspect this blog will disappear on January 15, 2013. That’s when Medscape shuts down its E-mail which I’ve been using since the 1990s. At first, I assumed this would be no problem. I would log on using my other E-mail addresses, but they don’t work.

Innocently, I went to a Google forum to ask how to transfer the blog to another E-mail. Almost immediately a responder explained that I must use the permissions wizard – “carefully.” My heart sank as I read an entire page of instructions, links, and warnings plus the suggestion that it works best using two computers and two browsers. I didn’t understand.

My current plan is to recreate the blog which will probably require a different name, so keep your eyes peeled.

Saturday, November 10, 2012

Election Results

Now that the election is over, Obamacare will go forward.

As a member of the entitled class, I have collected Medicare since 2005. Being on Medicare doesn’t mean everything is free; that requires signing up for Medicare Part B and D and for supplementary insurance. I pay about $350 a month. In exchange, I get almost no medical bills. I love it. Even though Medicare is a government program, I receive less paperwork than when I belonged to Blue Cross (even writing “Blue Cross” produces a surge of anger; I hated it). 

My brother, a physician, detests Obamacare. He is liberal, and he dislikes Obamacare because it will deliver a bonanza for the insurance companies with no controls on cost. His criticisms are correct, but I tell him that when premiums skyrocket – as they will, especially if younger people are allowed to opt out of buying insurance – the outcry will force Washington to take action.

Conservatives tell us that in Europe's national health plans the downtrodden physician takes his orders and pitiful salary from the government. In fact, all these countries have some private insurance. In many, such as Switzerland and the Netherlands, everyone buys medical insurance from private carriers just as they will do in the US. The difference is that laws closely regulate them. The carriers aren’t losing money.

Things will work out.

Wednesday, November 7, 2012

Historical Diseases

Standby MD asked me to see a guest at the Doubletree – in Santa Ana. That’s fifty miles away, but it was Sunday morning; freeway traffic was light, a perfect time to go to Orange County. I quoted the fee which was larger because of the distance. The dispatcher promised to call back after consulting his supervisor.

Some travel insurers won’t pay extra. When the phone remained silent throughout breakfast, I suspected that was the case, but approval finally came through.

The guest was an elderly Canadian man suffering diarrhea and vomiting. He mentioned that a dozen members of his tour were affected; several had gone to the emergency room.

That brought back memories of a guest in 1991 with the same symptoms. Stomach viruses are among the most common ailments a hotel doctor encounters. They’re miserable but short-lived; I had delivered the usual advice and remedies, but when I called to check the next day, he was in the hospital with cholera. That’s when I remembered he had flown in from Peru.

Cholera also causes diarrhea and vomiting. It’s extremely rare in the US. In fact, if an American patient turns up with any of the major historical diseases (cholera, malaria, rabies, leprosy, typhoid, typhus, plague, even tuberculosis) there’s a good chance the American doctor will get it wrong on the first visit.

The Canadian gentleman was already recovering, but my phone rang before I left with a request to see another tour member. She was sick enough to send to an ER where she stayed until the evening. There is little cholera in Canada, so this was a stomach virus or run-of-the-mill food poisoning.