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Thursday, June 27, 2013

Concierge Doctors

I belong to the American Academy of Family Physicians (AAFP), the leading organization for family doctors with about 100,000 members. My physician brother, more activist than I, belongs to more  liberal physician organizations which are much smaller.

I bought a lifetime membership years ago, so I’m stuck with it, but its heart is in the right place. The AAFP wants members to practice high quality, compassionate medicine and requires that they stay educated and pass a test every seven years. It expresses deep concern with Americans who can’t afford medical care but refrains from urging doctors to greatly inconvenience themselves to remedy this. Most doctors are conservative; the AAFP’s leadership is more politically sophisticated than its members, but, in the end, it reflects their interests.

That brings me to today’s subject. I was perusing the AAFP’s weekly news bulletin. One article cheerfully announced that direct primary care was piquing everyone’s curiosity and that two physician-entrepreneurs would provide the “inside scoop” in a web workshop free to AAFP members.

I was preparing to move on when, with a shock, I realized that direct primary care is a euphemism for concierge medicine. The AAFP was plugging concierge medicine!!! That’s like promoting Mexican cancer clinics!

If you’ve followed this blog you know my low opinion of concierge doctors. They don’t accept insurance. Patients usually pay a monthly or yearly retainer in addition to the usual fees; in exchange, they receive quick access, longer appointments, and, if necessary, housecalls. This money pays for the doctor but nothing else. Tests, X-says, therapy, specialists, and hospitalization cost extra. It’s a luxury service.

When concierge doctors address the public they extol the superior care they deliver to a grateful clientele. Around the lunch table with only doctors present, they extol the pleasures of a cash-only practice. I've never met a concierge doctor I could respect. 

Finishing the article, I hit the “comment” button and forgot my rule about not responding in the heat of emotion. The satisfaction of delivering my opinion which included the adjective “sleazy” evaporated when I read the avalanche of abuse that followed.

Later that day an E-mail from an AAFP official explained that readers were complaining at the lack of respect shown in my response, so it was being deleted. It vanished, but the angry responses remained. You can read them at http://www.aafp.org/news-now/practice-professional-issues/20130508directwebinar.html. If that’s too much of a mouthful, google “inside scoop on running a direct primary care practice” and it will turn up.    

Tuesday, June 25, 2013

More Easy Visits

"A bee stung my wife. That was two days ago, but today it’s more swollen."

I explained that bee stings usually get worse for 48 hours before they improve.

“We catch a plane tomorrow, so we’d like to see a doctor.”

Before I left, the phone rang again. A man’s ears had become plugged when his plane descended, and they remained plugged. He worried about an infection. I explained that pressure changes while flying don’t cause infections, and the discomfort often persists for a day or two. I suggested a decongestant, but he wanted someone to look in his ears.

A visit from the hotel doctor is not cheap, but I’m liberal with phone advice. Only about half my calls turn into a visit. Now and then I have the delightful experience of making a housecall because the guest wants one despite my assurance that it’s not necessary. In this blog, I’ve recounted occasions where what seemed like a no-brainer turned out to be no such thing once I arrived. That rarely happens, and it didn’t happen this time.

The bee sting turned out to be a bee sting, and the guest’s ears looked normal. Who says medicine is stressful?

Wednesday, June 19, 2013

An Easy Visit

A Biltmore guest with a sore foot had a meeting after breakfast. Could I come now?

I’m an early riser. so the 5:50 a.m. call found me writing this blog. Reaching the Biltmore, ten miles distant downtown, is no problem if traffic is moving, but it wouldn’t be moving soon, and I hate driving during the rush hour.

I considered sending him to a nearby 24-hour clinic. But a sore foot was an easy visit (i.e. not serious and not a respiratory infection). If I hurried, I might escape gridlock, so I told him to expect me around 6:30.  

I left my car at the entrance and hurried to the room. As expected, it was an easy visit. Leaving the hotel, I saw that my car had vanished.

Most Biltmore parking valets recognize me; this one hadn’t, so I had delivered my keys and my mantra (“I’m the hotel doctor. I’ll be here twenty minutes. They hold my car”). He had nodded and smiled and then proceeded to follow orders and drive my car deep into the building. Then he dropped my keys off at the parking kiosk whose attendant demanded the usual parking fee when I appeared.

I returned to the lobby to track down a manager willing to overrule the attendant. Following this, I waited my turn for the valet to retrieve my car. That fifteen minute delay pushed me past a critical point, morphing the half hour drive downtown into more than an hour to return.

Saturday, June 15, 2013

A Good Call


A singer felt a sore throat coming on, his manager explained. He might need a shot of cortisone the day of his show. I’ve given several; singers seem to think they work, and they’re harmless.

These are good calls. I drive to a hotel, give an injection, collect money, and return home. What’s not to like?

The manager added that the show would take place the following Saturday, and he’d phone if the singer wanted me. 

On Saturday the manager informed me that the singer was free around midday. He would call to give an hour’s notice. Midday passed without a call.

That often happens. While I was preparing dinner at 6 p.m. the manager phoned to ask my services. But there was a hitch. The singer was no longer in Los Angeles but at a resort hotel in La Puente thirty-five miles away. Although weekend freeways are usually fast, this trip took an hour. The resort was hosting an event called The Urban Music Festival; it was packed with black people, the women in dazzling gowns, the men dressed as gangsters.

No one answered when I knocked on the singer’s door. I phoned the manager and heard voicemail. I paced the hall for half an hour, knocking and phoning now and then. I checked with the concierge who obligingly offered to call the room.

My phone rang as I was driving off. I retraced my steps to the room, now packed with the singer’s colorful entourage. I gave the shot, collected my money, and returned home to supper.

Tuesday, June 11, 2013

Catching the Flight Home

A Belgian tour leader informed me that a 70 year-old in his group had severe abdominal pain and wanted a visit.

I explained that this would require more evaluation than I could perform. The guest should go to an emergency room.

“Absolutely,” said the tour leader. “But they want a doctor to come. If you decide he must go, you will explain it so they understand.”

He was not being honest, as I later discovered. Anxious to avoid the hassle of accompanying the couple to the hospital, he had insisted on a housecall hoping I would make the problem go away.

He had not passed on my advice, so they were shocked when, after an examination, I repeated it. The husband refused to go, pointing out that their return flight left the following day. He added that he was merely constipated. His doctor in Belgium had agreed and recommended an enema.

I responded that being on the spot gave me priority. The guest picked up the phone and managed to reach his doctor who agreed that a CT scan was a good idea. The guest assured me he would think it over and go to an ER if the pain persisted.

I passed a worried night. In the morning, the wife declared that her husband felt a littler better. Feeling “a little better” in response to a doctor’s query means “no better.” I warned them not to board the plane if the husband had any abdominal pain. Two hours later the wife phoned to announce that he was entirely better, and they were leaving for the airport.

Thursday, June 6, 2013

The Miracle Game

A guest’s ankle injury didn’t seem serious, so I told her we’d wait a day before deciding on an x-ray. At her request, I wrapped the ankle in an elastic bandage while explaining that orthopedists believe that elastic bandages accomplish little.

As I wrapped, I mused on the superiority of western medicine. Unlike popular (and wealthier) media physicians, I have little respect for alternative, complementary, holistic, herbal, or natural healing systems that receive far more attention than this obscure blog.

My reasons have something to do with the fact that we genuinely help patients, but I prefer to stress how often we don’t. Alternative healers never say: “This treatment could be better…” or “We thought we understood this disease, but we were wrong…” or “We screwed up…” I and my scientifically trained colleagues do this all the time. But we learn from our mistakes.

When I’m feeling particularly hostile, I challenge alternative medicine fans to play the miracle game. I’ll name one of our miracles; then it's your turn. No fair using a secret cure. It has to be something we all agree on.  

My first western medicine miracle: the appendectomy. Appendicitis victims once died after weeks of agony. Then we discovered that snipping off the appendix (something any bright high school student can do) cured it. We take this for granted, but it’s a miracle that's saved millions of lives. Now let’s hear yours….


Saturday, June 1, 2013

Getting Their Money's Worth

Dentists don’t make housecalls, and many disappear after office hours, so I hear about problems for which I am not trained.

Over Memorial Day weekend, a woman explained that her daughter had undergone dental work before they left town and suffered pain since. The jaw appeared swollen, and the mother suggested it was an infection that required antibiotics. In fact, most tooth pain doesn’t require an antibiotic; even a dental abscess must be drained.

So I felt stress driving to the Universal Hilton. I don’t like making a housecall where I don’t solve a problem.

The daughter’s jaw didn’t appear swollen, but any painful part of your body looks abnormal. The tension rose as I took her temperature and washed my hands. What would I say if I didn’t know what was happening?

Those situations have occurred but not this time. When I peered at the affected tooth, it looked normal, but on the nearby gum I saw an angry half-centimeter ulceration. She had a canker sore. They’re excruciating, but they heal in a week. I used to suffer them after accidentally striking my gum while brushing my teeth, so the dental work might have provoked it.

I reassured the parents and handed over a bottle of liquid Lidocaine to alleviate the pain. The mother looked relieved.

“I’m sorry I called you out over something so trivial,” said the father as he paid me.

I assured him that almost everyone I see has a minor problem, but he seemed less grateful than his wife. Men often feel they’re not getting their money’s worth if the problem turns out to be less serious than they expected. But that’s another post.