Saturday, March 30, 2013

A Near Miss

No one came to the door after several knocks. I confirmed the room number on my invoice.

I had spoken to the guest an hour before and announced my arrival time. Taking for granted that doctors are never early, some guests wander off, but I wasn’t early. This was serious. Unlike the case when a travel insurer sends me, when guests call and then vanish, I don’t get paid.

Some guest sleep soundly. I phoned the room; no one answered. I called the concierge to ask her help; before I finished, she offered to phone the room, put me on hold, and came back a minute later to announce that, sadly, the guest hadn’t answered, but she would be happy to take a message.

Sticking my business card in the door frame, I returned to the lobby and wandered about. Occasionally, for mysterious reasons, guests decide they must meet me downstairs. I look like a doctor in an old movie with a white beard, suit, and doctor’s bag, but no one took the bait.

I struck gold in the hotel restaurant where a man leaped up from a crowded table and hurried over. He began reciting his symptoms until I suggested we wait for some privacy.

When asked why he wasn’t in his room, he answered that he was hungry but that he had told “the hotel” where I could find him. He pointed to a desk clerk who was busy checking in a family.

Wednesday, March 27, 2013

The Opposite of the Last Post: Things I Don't Say

1. Get plenty of rest. 

Rest treats fatigue, but that’s all. I tell patients with minor illnesses to stay in bed only if that’s where they want to be.

2. Watch your diet. 

For minor illnesses, proper nutrition isn’t very helpful. If you have no appetite, forcing food down makes you feel worse without accomplishing anything useful.

3. Drink plenty of liquids. 

There are two problems here.

A.  More water evaporates during a fever, so replacing it is a good idea, but a healthy adult can safely ignore this for a day or two. If the fever lasts longer, a doctor’s first step is not to replace liquids but to find out what’s happening.

B.  Since the dawn of history, people have believed that a sick body is full of toxins. This is common sense (almost always wrong when applied to your health). Nineteenth century doctors prescribed drugs to produce vomiting or diarrhea, and patients knew this worked because they could see the smelly toxins pouring out. We no longer believe in “purges”, but enthusiasts (doctors among them) still believe that urinating expels toxins, so they advise you to drink 6 or 8 or 10 glasses of waters a day.

4. Take aspirin or Tylenol. 

“But then the fever came back,” patients tell me as if this were bad. In fact, these drugs wear off after a few hours. The fever of common infections won’t harm a healthy person, and aspirin or Tylenol won’t shorten the course of any ailment.  It’s all right to take them to feel better but not essential.

5. Keep warm.  Keep cool. 

We shiver when our tem­perature rises and sweat when it falls. That’s how the body warms up and cools down. Shivering or sweating are not necessarily ominous signs; nor is it good “when the fever breaks.”

Saturday, March 23, 2013

Things I Say All the Time

Long experience has taught me that patients love to hear the following.

1.  “This isn’t a serious problem, and it never turns into a serious problem.”

Doctors know that many tiresome ailments such as hemorrhoids, bladder infections, migraine, or herpes never turn into something worse, but patients don’t know this. A doctor must tell them. 

2.  “I want you to call me any time.”

Doctors say this all the time, but you know what happens when you try. I show guests my cell phone and promise to answer in person if they call. Naturally, I do this because I’m a compassionate physician, but there’s an element of self-interest. If guests aren’t getting better, I want them to tell me – not the hotel.

3.  “Staying in bed won’t make this go away any faster.”

Travelers waste valuable days in a boring hotel room, so I try to take the pressure off. This myth is so universal that when I reassure non-English speaking guests, I ask them what I’ve just said. Almost always, they repeat it back minus the negative.

4.  “You’ll feel under the weather for a few days; then you’ll feel better.”

Guests may suffer for weeks, but once they see a doctor, they want things to move quickly. If I don’t explain that this might not happen, I often hear from them the next day.

5. “It’s not your fault.”

A baleful consequence of the popularity of alternative medical theories is that patients believe they’re responsible for getting suck. Mostly, they’re not.  

Monday, March 18, 2013

Neither Rain Nor Snow

My phone rang as I was driving to the Langham in Pasadena. Coris USA, a travel insurer, had a housecall. Since I was on the freeway, I couldn’t write, so I asked for the address, planning to collect the remaining information from the patient. I hate to be late, so I told the dispatcher I might not arrive for two or three hours. 

The Langham guest had a sore throat, an uncomplicated visit. I reached the Coris destination, a private house in Hollywood, an hour after the call. The gate in the surrounding fence was locked. The buzzer felt loose in its housing, giving the impression that it was broken. This seemed the case because no one appeared.

What to do… Usually I phone the patient, but I didn’t have a number. I considered phoning Coris, but whoever answered would ask for the patient’s name which I also didn’t have. He might or might not succeed in tracking down the original dispatcher, but it was guaranteed I’d spend a long time on hold in a chilly drizzle.

The railing was my height, and there were footholds. I was tempted. The passersby certainly wondered at an elderly man in a suit struggling over a fence, but I succeeded without falling or tearing my clothes.

The young woman who answered the door denied that anyone wanted me. It turned out this was not a private house but a youth hostel. The woman consulted other residents; one remembered someone who had called a doctor, but she had left. 

The resident didn’t have her phone number but offered to leave a message on Facebook. I called Coris to warn them that matters were not looking well.

After ten minutes the door burst open, revealing the patient, gasping for breath after running several blocks. The visit itself was uncomplicated. 


Monday, March 11, 2013

Three Great Sins of the Medical Profession

We’re guilty of them all, but there are extenuating circumstances.

1.  Doctors give treatments that relieve symptoms but don’t cure the underlying problem.
     Sometimes this is the best we can do.  The cure for severe menstrual cramps is menopause, hysterectomy, or pregnancy.  Drugs only relieve the pain, but patients appreciate it.  No doctor cures migraine, asthma, emphysema, osteoporosis, or the flu, but we relieve a great deal of misery.

2.  Doctors order too many tests and prescribe too many drugs.
     Correct, but partly we’re responding to great pressure. Most patients with a painful injury assume they need an X-ray, but they don’t.  Those with a high fever, sore throat, swollen glands, cough, or clogged sinuses assume they need an antibiotic, but they usually don’t.  Doctors hate to disappoint patients, so they lean over backwards to “do” something like order a test or prescribe.

3.  Doctors order too few tests and prescribe too few drugs.
     We can’t win.  Some HMOs and insurance plans restrict tests and drugs doctors can order.  This infuriates doctors as well as patients, but the sad fact is that experts set up these guidelines to discourage needless tests and wrong or unnecessarily expensive drugs. Mostly, guidelines fail. Even the guilty doctors agree that we vastly overtest and overprescribe.

I can think of three more sins. Next time.

Friday, March 8, 2013

D as in "Dog"

A travel insurer sent me to Koreatown, an older area of Los Angeles, home to a mixture of Koreans and Hispanics. It’s a colorful neighborhood, and like all colorful neighborhoods, parking is a chore. I found a spot several blocks away from the apartment.

Travel insurance patients are subletting or visiting friends, so searching the directory near the locked entrance never reveals their name. Phoning her number, I heard a voicemail message. That was not bad news because insurance services pay for no-shows, but I had to make an effort. I phoned the agency to explain. The dispatcher urged me to wait while she tried to contact the client. I waited. After five minutes, a resident entered the building; I followed and knocked on apartment 1D. The lady who answered denied that anyone needed a doctor.

After another ten minutes, I decided I’d done my duty and returned to my car. My phone rang as I arrived.

The client was taking a shower, said the dispatcher. She was now ready to receive me. I recounted my experience at apartment 1D, but 1B turned out to be the correct number. In my defense, during the original call I confirmed that the patient was in 1D as in “dog.” But English was not the first language for both guest and dispatcher.

Monday, March 4, 2013

Taking Things Out of the Ear

Cleaning his ear, a guest removed the Q-tip and saw that the cotton at the tip had disappeared.

Extracting objects from an ear is a satisfying experience for everyone involved. Over thirty years, I’ve removed ten cotton balls and one bug.

Mostly I remove wax. I’ve done this 110 times. Using a curette, one can scoop it out in seconds. Ear-nose-threat specialists use a curette, but I don’t have the nerve, having seen bloody results from attempts by other GPs. I use a large syringe.

All hotel rooms have an ice bucket. I fill it with warm water and set it on the bathroom sink. Warned they are about to get wet, guests remove expensive clothing, drape a towel over their shoulders, and lean over. After filling the syringe, I pull the ear back, rest the tip just inside the opening, and squirt. Most impactions require a dozen attempts or less. A few specks flowing out herald the great moment, and the plug itself may pause coyly at the opening.

“Get ready for the big show!” I announce before delivering the final spray. Guest invariably recoil with horror as a soggy brown lump, often the size of a kidney bean, flies into the sink.

Sometimes I pay a heavy price. Guests who work hard with a Q-tip (a device perfectly designed for pushing wax) confront me with a solid wall of material resting deep inside. Time passes as I refill the bucket and work the syringe. Water drips from the guest. My thumb aches from pushing the plunger. At intervals I stop, either because the guest begs for a rest or to peer inside with my otoscope to check the waxy wall, now glistening but stubbornly immobile. I often joke that when doctors die and go to Hell, they receive a syringe and a patient with an ear sealed with concrete.

During training, doctors learn a rule for procedures that aren’t working (difficult spinal taps, searches for slivers): keep trying. So I persevere, ignoring my throbbing thumb. On two visits, I stopped at the guest’s request. All other ear washes succeeded although a few exceeded fifteen minutes.

Friday, March 1, 2013

Taking Things Out of the Eye

Few actions bring more pleasure than removing something from a guest’s eye. Patients have kissed my feet in gratitude.

It’s easy. With one hand, I lay a Q-tip horizontally across the upper lid. With two fingers of the other hand, I grasp the eyelashes and fold the lid back over the Q-tip, exposing its underside. That’s usually where a speck lies. Experts warn never to try to remove something on the eyeball itself, but I’ve never encountered this. 

This agreeable experience doesn’t happen often: thirteen times according to my records. Mostly, guests who think they have something in their eye are suffering a corneal abrasion. This was the case fifty-four times.

The cornea is extremely sensitive; injuries produce intense discomfort, but minor ones heal in a day or two. I prescribed antibiotic drops and an oral pain remedy. Patients yearn for the anesthetic drops I use during the examination, but they damage the eye when used regularly. No doctor should prescribe them.