Monday, July 29, 2013

More Sins

4. Doctors order too many tests and prescribe too many drugs.

Correct. We love tests, but so you. Most patients with a painful injury assume they need an X-ray, but they don’t.  Those with a high fever (“flu”), sore throat (“tonsillitis”), cough (“bronchitis”), or stuffiness (“sinus infection”) 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.

5. Doctors order too few tests and prescribe too few drugs.

We can’t win.  Some clinic directors and insurance plans restrict the tests and drugs we can order. This infuriates doctors as well as patients, but the sad fact is that experts set up guidelines to discourage useless tests and wrong or unnecessarily expensive drugs. Guidelines sometimes work.

6.  Doctors ignore alternative and folk medical practices.

I notice enthusiasts treat folk medicine with respect, but no one advocates folk dentistry... It turns out that many alternative practices work but less dramatically than advocates claim.  Acupuncture definitely relieves pain. Unfortunately, its action is unpredictable and not always complete. Despite vivid reports, Chinese surgeons rarely use it for anesthesia. Chiropractic manipulation relieves some backaches for a limited time.

Sunday, July 28, 2013

Three Great Sins of the Medical Profession

Critics regularly denounce us for certain practices. These denunciations are more or less correct, but they miss the point.  Examples -

1. Doctors give treatments that relieve symptoms but don’t cure the underlying problem.

Right, but 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 don’t pay much attention to diet, liquid intake, rest, and other natural treatments.

Definitely, and it’s the right thing to do.  Diet, rest, etc. help prevent disease but don’t do much once you get sick... A perfect example were tuberculosis sanitariums, the oldest government supported medical program. They began appearing in the nineteenth century. Patients received nutritious food and plenty of rest in a healthy, rural environment. They were discharged (sometime after years) when their TB became inactive. No one was cured, and many relapsed. When drugs appeared after 1945 sanitariums closed. Nowadays doctors encourage TB patients to eat a nutritious diet, but they’ll get better even if they don’t – provided they take their drugs.

3. Doctors spend too little time explaining how to relieve stress.

Perhaps....  Stress makes everything worse but doesn’t cause anything. Seeing a doctor for stress results from what I call the “medicalization of society” - the notion that life’s difficulties (a hateful job, unsatisfying sex life, shyness) represent a medical problem. There’s no harm in this; a good doctor can listen sympathetically and make sensible suggestions which require no medical training.

Thursday, July 25, 2013

More Guests I Didn't Help

Last week a travel insurer asked me to see nine sick hotel guests. My first thought was food poisoning, but their symptoms turned out to be coughing and sore throat.

I love multiple visits at the same hotel, but I wouldn’t love these. I visualized the scenario: a large group arrives for an expensive vacation when they fall ill, and in America you need a prescription for an antibiotic. Luckily, they tell themselves, we have travel insurance. The doctor will come and give us our Amoxicillin, and we’ll be fine.

As I repeat relentlessly, my philosophy on antibiotics is that I prescribe them if they’ll help, and I don’t prescribe them if they won’t. This puts me at odds with doctors around the world not excluding the US. If you always receive antibiotics, it’s reasonable to assume that’s what you need.

When I see victims of a respiratory infections (twenty percent of a family doctor’s business) I do my best. Most seem satisfied, but some are clearly disappointed, and a few make it clear that I have failed them.

I did not want to see nine consecutive patients with a respiratory infection. Luckily, there was a walk-in clinic nearby.

Tuesday, July 23, 2013

A Guest I Didn't Help

A flight attendant at the Airport Holiday Inn was suffering an allergy attack. She couldn’t fly because of the congestion, and her airline required a doctor’s exam and note. This is a common request which I fulfill regularly, but I couldn’t fulfill hers because she was American.

When a British Air, Quantas, or Cathay-Pacific crew member falls ill, the local supervisor calls on a national housecall service or individual (in Los Angeles, me), and the airline pays. US airlines don’t do this. Their employees are on their own. I occasionally make a charity visit to an American flight attendant too sick to leave the room but not sick enough for the paramedics. Mostly I refer them to an urgent care clinic.

Sunday, July 21, 2013

Caring for Celebrities

Searching my housecall database (17,174 visits) for “celebrity” turns up 92 hits although that includes their wives and children.

Yesterday you read about my encounter with a famous person. I mentioned him by name because I was never his doctor, but I’m sure you don’t expect stories about celebrities I cared for. Unfortunately, literary agents do expect this. News that it’s forbidden has proven the kiss of death for my memoirs. They are still making the rounds, but I began this blog four years ago in an effort to find an audience.

Most celebrities are nice, but over thirty years I’ve cared plenty of misbehaving luminaries including several who died under dramatic circumstances. Agents have assured me that “you can’t libel the dead.” This turns out to be a legal fact, but the dead’s loved ones have been known to sue after reading unflattering remarks.

Saturday, July 20, 2013

The Time I Didn't Care for Woody Allen

“Woody Allen needs a doctor. How quickly can you get here?” The caller was the concierge from the J.W. Marriott.
“Ten minutes,” I replied. The J.W. Marriott was in Century City, near Beverly Hills, a five minute drive.

“I don’t know….” She seemed doubtful. “I guess you should come.”

That sounded strange. How many doctors appear at your door ten minutes after you call…? I threw on my suit and raced to my car. Turning into the hotel entrance drive, I encountered a sight that made my heart sink: a paramedic ambulance.
“We couldn’t wait,” the concierge called out as I hurried past. There was still a chance. Most 911 calls are not emergencies. Long ago, paramedics declined to transport anyone who didn’t seem seriously ill. Sadly, they were burned in several well-publicized cases when someone died after they left. Thereafter, their refusal rate plummeted, but I never lost hope.

Leaving the elevator, I headed straight for the inevitable crowd. As I approached it parted, providing a fleeting glimpse of Woody Allen rolling past on a gurney. I returned home, disappointed and unpaid.
My experience with movie stars is that their screen personality owes much to reality, so I theorized that he had suffered an anxiety attack. Agitated guests make hotel employees nervous, so they’re quick to call paramedics, but this is overkill. I have a soothing manner, white hair, and a white beard (less white when I saw Woody Allen in 1993). Once I arrive and settle into a chair, I rarely fail to calm a panicky guest. Phoned in the middle of the night, I do the same without getting out of bed. Woody Allen should have waited for me.

Tuesday, July 16, 2013

Why You Get Sick

You  get sick because:

1.  No one is perfect.  Humans are full of clumsy design defects.  Our back muscles are too weak, so even normal activity can injure them.  Human veins are too flabby to resist a normal blood pressure; that’s why we get hemorrhoids and varicose veins.  Roughage may be good for you, but humans can’t digest some of its carbohydrates.  That’s why a high fiber diet causes gas.

2.  Your “resistance” is too strong.  Don’t blame a fever on that infection you caught.  Your body itself generates extra heat whenever an invader is present.  Some experts claim fever is good for you, but the evidence is thin.

The human immune system is too strong for its own good - and trigger happy!  Allergies occur when it tries to defend you against an innocent pollen, drug, or food.  Even worse, it may decide one of your own organs is the enemy and mount a vicious attack.  Thyroiditis, the most common cause of thyroid deficiency, is an “autoimmune” disease.  An overactive immune system may also assault the heart (rheumatic fever), liver (chronic hepatitis), kidney (nephritis), joints (rheumatoid arthritis), or skin (eczema, hives).

3.  Nature plays no favorites.  It assumes germs and viruses have as much right to exist as you.  Catching the flu, for example, is not a sign of weakness.  Most healthy people exposed to a new flu virus get sick.  They recover, but this is not a defeat for the virus.  Multiplying during the illness, many escape into the air to infect others.  The flu virus normally infects a victim for a week or so, then moves on.  That’s the role it plays in nature.  Your role is to get the flu now and then.

Medical science works to give humans an advantage in this competition, and we’ve done pretty well.  But nature is impartial.

Sunday, July 14, 2013

Wrong Reasons for Getting Sick

When I walk into a hotel room, guests often tell me why they fell ill. They also blame themselves. In both cases they’re usually wrong.

You don’t get sick because:

1.  Your “resistance” is low.  You got that cold because another person gave it to you.  If it’s your fifth cold of the year, this is a sign of what we in the medical profession call – here comes a fancy scientific word -- bad luck.  It’s not a defect in your immune system.  People with poor resistance suffer terrible diseases.  There is no immune defect that gives victims too many minor infections.

2.  Your diet is missing something.  Americans suffer plenty of nutrition-related ailments, but most result from too much rather than too little of some element.  Examples are obesity, high blood pressure, coronary artery disease, and tooth decay.  Deficiencies are less common with calcium leading the list.  The average American women consumes too little.  Lack of calcium increases the risk of osteoporosis (fragile bones), but this takes decades to develop.

3.  You don’t get enough (sleep, exercise, water, leisure).  Researchers have proved beyond a doubt that lack of sleep makes you sleepy.  Subjects kept awake for days become very drowsy.  They don’t go crazy or get sick.  Exercise improves your sense of well-being and strengthens heart, muscle and bone, and it probably slows osteoporosis.  Among younger people, sloth is not responsible for any disease.  Drinking x glasses of water a day is a harmless folk remedy.  It doesn’t flush toxins from the body.  Doctors often suggest it to prevent bladder infections, but there’s no evidence that it works.   

4. You're under stress.  Stress makes everything worse, but it doesn't cause anything. 

In a few days I'll reveal the real reasons why you get sick.                                                

Tuesday, July 9, 2013

Having the Proper Credentials

A Brazilian woman had suffered abdominal pain off and on for weeks. Her doctor had found nothing abnormal. It resolved, so she flew to the US, but the pain had come back, explained the travel insurer who phoned to request a housecall.

Her host lived in the Hollywood Hills and spoke excellent English. She may have been a show business personality because the walls were covered with celebrity photographs and posters. After examining the guest, I explained that she needed further evaluation and tests, perhaps an ultrasound because one possible diagnosis was gallstones.

Her host spoke up. “You are ordering an ultrasound? Where must we go?”

I explained that I wasn’t ordering an ultrasound but referring her to a doctor who could do whatever tests would provide more information. My next step would be to go home, fax my report to the insurer’s American office in Miami, and follow it up with a call to alert the dispatcher. He would phone facilities until he found one willing to accept the Brazilian insurance and then call the client. It might take a few hours.

“I have a fax machine. Why not call now?”

I didn’t know the fax number. It was at home.

“Then I will call.” Examining her guest’s insurance papers, she found a fax and phone number, but they looked foreign. As she dialed, I warned that the Brazilian office probably didn’t handle policyholder medical problems, but she waved me off. 

The followed a long conversation in Portuguese. Afterward, she explained that she had laid out the problem. They promised to get back to her.

I returned home, faxed my report, and called the Miami office. Before I could report back to the Brazilian lady, she called me.

“What is your license number?” she asked.

“Why do you want that?”

“Brazil never called, so we went to Cedars-Sinai. The ultrasound department needs your license for the test.”

“Don’t do that!” I said. “The ultrasound will not solve her problem. Even if it’s normal, she has to see a doctor. And it’ll be very expensive unless the insurance approves.”

I phoned the Miami office to urge them to deal with Cedars-Sinai. Within minutes my phone rang. It was the Brazilian lady again.

“There is something serious…. Cedars-Sinai has no record of you.”

“Probably because I’m not on their staff.”

“They check everywhere. They cannot find your name. I am very disturbed.”

I assured her I was a real doctor.

“How do I know that? When I called for a doctor, you came to the house in an hour. That is suspicious.”

She could Google me, I suggested.

The dispatcher called with equally unsettling news. He had phoned Brazil to obtain approval for the extra expense. This is never a problem because I phrase my medical reports so they are undeniable. Unfortunately, the Brazilian office had an earful from the Brazilian host who had emphasized her friend’s past suffering. This provided an irresistible excuse to claim a pre-existing condition and deny approval.  

After waiting for several hours, the patient felt better, so everyone went home. I warned that she still needed an evaluation and offered to refer her to a colleague’s office. Her host remained polite but informed me that the next doctor she consulted would have to have better credentials.   

Friday, July 5, 2013

Long Time No See

"Hey, Doctor! It’s been a while.”

I love it when parking valets recognize me. That was the good news. The ‘it’s been a while’ was not so good. This was my first visit of 2013 to Le Parc, an upscale West Hollywood hotel. It was once a regular, delivering 20 to 40 calls per year since its first in 1993.

Hotel doctoring is viciously competitive, and another doctor had worked his magic a few years ago, reducing calls to nearly zero. Hope springs eternal; hotels occasionally realize their mistake and return to the fold. Maybe this was a sign.

The guest had injured her thigh five days earlier. X-rays in an emergency room were negative, but since yesterday her pain had worsened. I didn’t find anything abnormal except for a huge black-and-blue mark. This may have been normal healing, but she needed another X-ray.

“Doctor O! How’s business!” The desk clerk also recognized me. When I ask why a hotel has stopped calling, employees always respond that no one has been sick, so I’ve stopped asking. But I couldn’t resist. The desk clerk assured me that no one had been sick.

“Long time, no see,” said a parking valet, not the same one who greeted my arrival. When I responded that hotel doctoring is a dog-eat-dog business, he laughed.

Tuesday, July 2, 2013

Not Being an Asshole

Last week on a plane returning to Los Angeles, a flight attendant asked if a doctor were on board. A passenger was ill. Reluctantly, I raised my hand.

Walking up the aisle, I relieved my fears by recalling that hotel employees who tell me a guest is seriously ill are usually wrong. I learn this by talking to the patient. That’s how a doctor gets most of his information.

In answer to my questions, the passenger revealed that he was forty with no medical problems. His only medication was a tranquilizer which he didn’t have. His complaint was a tight chest and difficulty breathing, but he appeared to be breathing normally. He didn’t object to my diagnosis of anxiety attack; he’d had them before. I reassured him and reassured the flight attendant that he’d be OK until the plane arrived. This turned out to be true.

After hearing the story, my wife said that she expected no less of me because I’m a caring, compassionate doctor. She often says things like that which is one reason I love her.

In fact, I raised my hand because I believe that a physician asked for help has a moral obligation to respond. If he doesn’t, he’s an asshole. Responding did not make me feel good, but not responding would feel worse.

Plenty of doctors keep quiet under those circumstances and comfort themselves with excellent reasons. It was unlikely that I could handle a genuine emergency. I haven’t performed CPR in decades; in any case doing so in that packed cabin was impossible. The plane was an hour from landing, so diverting it would not have helped. Standing by helplessly would make me look foolish. Doctors hate that. The passenger might sue. This has happened. You’ve probably heard of “good Samaritan” laws, but they are not absolute, and any good lawyer can find a reason they don’t apply.

The problem is: if you behave like an asshole for excellent reasons, you’re still an asshole.

The moral obligation to respond is not universal, although physicians don’t disagree unless they’re sure you’re not overhearing (for example on physician internet forums where they express other opinions you don’t want to hear – see my blog post for February 12, 2010).