Saturday, June 28, 2014

It Never Hurts to Check

Universal Assistance asked me to visit a sick Costa Rican in Downy. The call arrived at 4 p.m. on Tuesday.

“Downy is thirty miles away,” I explained. “The distance is not a problem, but I don’t want to go during the rush hour. Will she wait till nine?”

The dispatcher checked and obtained approval. The next hurdle was confirming the address. It was 9640 Bell Avenue.

“Is that B – e – l – l?” I asked, spelling it out because English is never the native language of travel insurance dispatchers.

“Yes,” he said.

I checked Google maps (“29.4 miles; 39 minutes; 1 hour 17 minutes with traffic”). That address turned up in an adjacent city but not Downy itself. My first instinct was to accept it. As a visitor, the Costa Rican was unfamiliar with local geography, but several unhappy experiences have persuaded me that it never hurts to check. 

“Not ‘Bell,’ said the desk clerk when I phoned. “It’s B – u – e – l – l. Buell.”  Google found it in Downy.

Tuesday, June 24, 2014

"I Can't Afford That!"

I hear this now and then when a guest learns my fee, more often as a hint (“I’ll talk to my husband and call you back…”).

My routine when hotels call is to listen to a patient’s symptoms, deliver an opinion and advice, and discuss options; only half my callers require a housecall. Once a guest agrees to a visit, I reveal the cost.

Hearing a reluctance to pay, I mention local walk-in clinics. Their basic charge is less than mine, although that difference disappears if the doctor orders tests and writes an expensive prescription.

I feel uncomfortable suggesting leaving the room if it’s a struggle – for example if someone is vomiting or dizzy. This guest had been dizzy all day. In these cases, I insist on coming, telling them they can pay whatever they feel is fair.

Guests always object, and she was no exception, but it works out. Some end up paying the usual, but I’ve taken as little as $5.00.

Since she had already protested the fee, my expectations were low. They dropped to zero when I approached the hotel and saw paramedics loading her into an ambulance.

The guest’s symptoms were not life-threatening, but paramedics lean over backwards to take patients to the hospital, having been burned in the past when they didn’t. 

I wondered if she had called them because of worries about my fee. She may not have realized that paramedics will send a bill.

Friday, June 20, 2014

Making Your Doctor Feel Bad

If your physician announced that an evil spirit had taken up residence in your liver, you might object. If he asked you to lie on the floor surrounded by a ring of tongue depressors while he and his office staff demanded that the spirit go away, your confidence in his ability would drop still lower. Yet many cultures consider this the sensible way to treat illness.

If a prescription gave you diarrhea, you would complain. But until well into the twentieth century, people looked on a good “purge” as an excellent way to expel toxins. Physicians took pride in their cathartics, and when patients discussed a doctor’s skill, they gave high marks for the violence of his purges.

People who consult a doctor expect him to behave in certain ways. 21st century Americans frown on exorcism or purges, but this is not a mark of superiority because we seem to expect medicine. It should be one only a doctor can prescribe; over-the-counter drugs don’t count. Pills are good; an injection works better.

Most of you will deny expecting medicine whenever you see a doctor. You want help. If you’ll get well without medicine, you won’t be upset… I often encounter such sensible patients, but the other sort turns up regularly. I’m slower to prescribe than most, so I have many opportunities to see disappointment in patients’ eyes when they realize I don’t plan to “give them something.” This makes me feel bad.

Doctors genuinely want to help you, and it depresses us when we can’t. We also feel bad when we’ve done our best, and you don’t feel “helped.” So we often add a prescription to convince you we’re doing what a proper doctor should do.

Monday, June 16, 2014

Following Instructions

I drove into the hills late at night and parked on a narrow street. Following instructions from the caller, I walked up a driveway. It rose steeply and seemed to go on and on. There were no lights, but luckily I carry a flashlight for examining throats. After a hundred yards, I came to a small house with no lighted windows. No one answered my knock. There were two cars in the garage, so I assumed someone was at home. I pounded on the door inside the garage. The lights came on, and a nervous woman’s face appeared at a window.

“I’m the doctor,” I said. “Is this 2322 North Beverly Glen?”

It wasn’t. That was the house on the street. My instructions to “park on the street and walk up the driveway” weren’t wrong, but the caller failed to add that his front door was only a few yards up. 

Thursday, June 12, 2014

Do You Want Me to be Your Doctor?

This blog gives the impression that I’m a skilled, caring physician.

Am I really that good?... Asked to make a case, I might mention several diagnostic coups, but anecdotes are the lowest form of evidence. Don’t believe any statement backed by an anecdote. Still, I’m confident that I’m at least better than average.

I mention this because readers often ask me to be their doctor. Since I’m long past retirement age and make housecalls exclusively, I can’t be anyone’s family doctor. That’s obvious from my posts, but it doesn’t discourage them.

These requests bring up a serious problem:  how do you find a good doctor? Searching the internet – something all these callers have done – turns up an avalanche of physicians yearning to care for you.
All seem humane, state of the art, eager to serve. Why isn’t the choice easy? The answer, of course, is that these are advertisements: fawning and phony.

It’s almost impossible for doctors to advertise without appearing shifty. They invariably point out their expertise, but you take that for granted. They extol their warmth, dedication, compassion. That sounds creepy, but they can’t resist.  

I’m not after your business. Unlike other doctor blogs, I don’t promote my political views or try to make you healthier. I give medical advice but only if it contradicts what you hear elsewhere or seems amusing.

I enjoy describing life as a hotel doctor and delivering opinions on the world, mostly as it relates to medicine. I write what I want although my wife exerts a modest influence (almost always by saying “you can’t post that...”).

I’m often the hero of my stories, but they’re mostly day-to-day events, some of which I wish hadn’t happened. The result is that I come across as a real human being. Why shouldn’t I? I’m a good writer, and that’s the impression I want to give. Most doctors can’t write; neither can their advertising agencies.

Terrific doctors aren’t rare. Their patients know who they are, so the best way to find one is to poll people you know. Asking doctors is OK, because they’re unlikely to name anyone bad, but they tend to prefer their friends. The only terrific doctors I know are those I’ve seen in action – most often caring for me. Ask around.

Sunday, June 8, 2014

Amazing Facts On Nutrition

Although a third of the world would be better off on the typical American diet, it’s not ideal, but the defects are not what you believe.What should you worry about?

Protein?  Not a problem.  Most adults consume more than they need. There’s no advantage to a high protein diet but not much harm either. Your body will use as much as it needs and turn the rest into fat.

Carbohydrates?  Americans should eat more. With obesity so common this sounds peculiar, but grains, vegetables, and fruits tend to have fewer calories. They’re also high in roughage.  Americans need more roughage.

Fats?  Fat is OK. Eat less animal fat but more chicken, fish, or vegetable fat. This lowers your cholesterol, but a low cholesterol diet is not particularly low in calories. Fat is fat.

Sugar?  Americans consider sugar positively sinful. Like sin, it’s probably not good for you. Sugar certainly contributes to obesity and tooth decay but doesn’t cause serious diseases such as diabetes or heart attacks.

Preservatives?  They may do more good than harm. In poor countries a leading killer of children is diarrhea, often from spoiled food. This was also true in the U.S. during the nineteenth century. Refrigeration and canning makes this less of a problem today, but considering how careless we are storing and preparing food, preservatives still prevent disease. 

Here are questions I hear most often.

“How can I make sure my diet is nourishing?”

Answer:  “Eat a variety of food. By consuming a good mixture of vegetables, fruits, grains, proteins, and dairy products, you’ll get everything you need.”

“How will I know if I’m missing something?  For example, how can I get enough riboflavin?  What foods have riboflavin?”

Answer:  “I don’t know.”

“You’re a doctor, and you don’t know the foods with riboflavin?”

Answer:  “I could look it up. It’s not important. Eating a variety is important.”

“I haven’t had much energy lately. Is it because I’m not eating right?”

Answer:  “Probably not.”

Wednesday, June 4, 2014

Should I Make a Housecall?

Only half my callers require one.

As I often mention, I’m happy to phone a pharmacy when guests forget legitimate medication: blood pressure pills, heart pills, contraceptives, etc. I don’t do this for guests who tell me “I had the same thing last year, and my doctor prescribed……” 

Exceptions exist. If a caller has had gout I believe him. It’s acceptable to treat a young woman with a typical bladder infection over the phone. If you’re wondering about symptoms of a “typical” bladder infection, I’m not telling. You have to tell me. Most “my doctor prescribes...” calls concern upper respiratory infections where the guest has received the traditional useless antibiotic and believes he needs another.

Guests with stuffy ears don’t object to a housecall, but ordinary congestion causes bilateral ear discomfort without pain. Over the phone, I explain the aggressive use of nasal spray before takeoff and before the plane descends.

Injuries can be tricky. A doctor’s exam rarely diagnoses a fracture, but most common injuries are not urgent, even when a fracture is present. If guests are willing to wait until business hours, I can send them to an orthopedist’s office, more civilized than an emergency room. For back pain, a housecall is better. If you go where there’s an x-ray, you’ll get one, and experts agree that back x-rays are almost never helpful.

Much of my decision on making a housecall depends on the law of averages. Chest pain in a fifty year-old is usually not serious, but it’s unwise to assume this. It’s less unwise in a twenty year-old. A sore throat in a ten year-old might be strep which medical science can cure, but strep is mostly a disease of children and adolescents. After fifty it’s almost unheard of. The law of averages is a big help in bronchitis for which doctors often prescribe antibiotics. You’ll want to know what percent of bronchitis requires an antibiotic. It’s zero.