Monday, July 28, 2014

The No-Housecall Mode

Half a dozen times per year, a hotel guest suffers a bloody nose. I don’t make housecalls for nosebleeds because there’s nothing I can do. Treatment is to pinch the nose, releasing pressure every five minutes to check if bleeding has stopped. I tell guests to repeat until they get bored. If bleeding persists, the next step is cautery or nasal packing, both of which require expertise.

I regularly hear “I can move it, so I know it’s not broken…” but this is as true as most popular medical theories.  Examining a wrist, finger, ankle, foot, or ribs I can suspect a fracture, but I’m never certain. Most common fractures aren’t urgent, so I often tell guests it’s OK to wait to see if there’s quick improvement. If not, they need an X-ray.

All insect bites look the same, bee stings included. Redness and itching spread, peaking at two days before slowly fading. I explain this over the phone, but guests often want me to take a look.

When a guest suggests he has bronchitis, I immediately go into no-housecall mode because this is a fake diagnosis doctors use when they prescribe an antibiotic as a placebo (other fake diagnoses are “sinus infection” and “strep”). You may be surprised to read that bronchitis is not a disease but a fancy medical term for coughing. 

Not every guest who mentions bronchitis is demanding an antibiotic, but all are seeing me for the first time. They’ve seen their family doctor many times, and if he or she routinely prescribes antibiotics (so common even good doctors do it), my failure to do so requires an explanation. Most guests accept it, but a minority do not conceal their disappointment, and a tiny minority are upset.

I hate it when I do the right thing and patients are unhappy, so I refer these guests to a walk-in clinic where the doctor will probably prescribe an antibiotic for their bronchitis. 

Thursday, July 24, 2014

Lost On Campus

It was after nine when I left for Long Beach, thirty miles away. Freeway traffic moved swiftly; the patient was a sixteen year-old with a sore throat, usually an easy visit.

Google maps guided me to 1250 Bellflower Boulevard which turned out to be the student union of California State University in Long Beach. 1250 Bellflower Boulevard is the address of the university, not any particular building. The student union was deserted. It was the summer break. I left messages on a cell phone that may or may have been the patient’s.

A couple walking nearby pointed me in the direction of distant residence halls which, when I arrived, did not look like residence halls. I phoned the travel insurer who had sent me. The dispatcher managed to contact the patient and then passed on her directions. She was not familiar with the campus, so I couldn't find her. I told the dispatcher that, since the patient was an adolescent, she was undoubtedly part of a group with a group leader.

The patient agreed that such a person existed and went off to find him. After a considerable delay he came on the line, determined my location, and talked me through a complex warren of street to the proper building. As usual, caring for the patient was the easiest part.

Sunday, July 20, 2014

Don't Get on the Plane!

“My flight leaves tonight” is a phrase I like to hear because it means the guest will return to the care of the family doctor. Until then he or she is my responsibility. Now and then, I don’t like to hear it. 

A guest awoke feeling well but after a few hours noticed some abdominal pain.

When I hear “abdominal pain” I ask about vomiting and/or diarrhea and hope it’s present. That points to a stomach virus, usually a short-lived and not very serious problem.

Abdominal pain alone can mean a stomach virus, but I also consider serious conditions (gallstones, diverticulitis) and potentially fatal ones (ectopic pregnancy, blood clots). I prefer to send these guests directly to an emergency room, but sometimes I end up at the hotel.

This guest thought over my question before deciding that he had diarrhea. Maybe… My abdominal examination turned up nothing requiring urgent attention. He was not elderly, so several life-threatening problems were unlikely. The pain itself was unpleasant but not excruciating.

It was a difficult decision, but doctors are paid generously to make difficult decisions.

I told him that he probably had a stomach virus, but I couldn’t rule out something serious. I would give him something for the diarrhea and check back in a few hours. I added that he might need some tests and that he must not get on the plane if the pain persisted.

When I phoned after three hours, he had checked out.

Wednesday, July 16, 2014

I'm Not In It For the Money!

The phone rang at 3:30 a.m. An airline pilot at the Costa Mesa Hilton needed a doctor, explained the caller. Could I go?

That Hilton is 46 miles away, but I go regularly for an agency that provides medical care to foreign airline crew (American crew are on their own). It’s an easy drive at this hour. I accepted for several seconds until I woke up and remembered that the 405 freeway closes at the Orange County border during the wee hours for major construction. Despite the hour, closing the freeway produces an immense backup, and the detour through city streets is slow and tedious. Forced to go, I take a different freeway which is ten miles longer and only slightly less tedious.

I was in luck. Wee-hour patients usually suffer intense symptoms such a vomiting; they don’t like to wait. This guest had a cold and didn’t object to a visit later that morning.

I breathed a sigh of relief and went back to sleep. The delay would cost me $150 because the agency pays less for daytime housecalls, but it was worth it.


Saturday, July 12, 2014

When Murder is Cost Effective

At a recent medical conference, a speaker came up with a radical proposal.

People regularly come to an emergency room complaining of chest pain, he said. Most are not having a heart attack, but doctors do a careful exam and many tests and often observe them for hours. Even if little turns up, doctors lean over backwards to admit someone with a possible heart attack. In the end, some are so obviously not having a heart attack that the doctor sends them home.

But medicine is not perfect, he added. Three percent of those sent home are having a heart attack. They sue the hospital and win.

These suits are old news. Over the years, hospitals have become more and more liberal about admitting patients with chest pain. But, in the end, some are sent home.

No matter. Three percent are having a heart attack, and they sue. The average payout is over $400,000.

“It’s an impossible situation. What can a hospital do?” asked the speaker. He went on to inform the audience that hiring a hit man to kill someone costs $10,000.

“Do the math,” he said.    

Thursday, July 10, 2014

Going Back to College

Every summer, a hundred Brazilian adolescents descend on UCLA’s dormitories to study English. When one gets sick, a counselor phones April Travel Insurance which phones me.

Middle-class teenagers suffer respiratory infections, upset stomachs, and minor injuries, so, once I learned to deal with UCLA’s draconian parking policy, I found these easy visits.

I graduated UCLA fifty years ago, and returning is a strange experience. Crowds outside the dormitories shriek, laugh, and chatter. It sounds like a kindergarten. Were we that noisy? There's nothing strange about the women's fashions, but the men look like dorks. My generation had long hair and tight clothes. Nowadays it’s short hair and baggy clothes. They wear shorts. Don’t they realize how silly they look? We kept books in lockers. Now everyone has a backpack. Especially odd is the number of Asians who make up over a third of the enrollment. They speak perfect English, so they’re clearly American. Where were they when I attended?

In my day, when you entered a university building, you found a door and entered. Today all doors except the main entrance are locked. Students manning the front desk consider names and room numbers privileged information. Using the elevator requires a key which all students carry. This is identical to hotel security and probably no more effective.

On arriving, I phone a counselor who comes down to escort me. The dorm rooms are tinier than I remember, and little studying occurs because the desks are piled with personal items. Delivering medical care is easy, but it’s summer, and foreigners believe that air conditioning is unhealthy, so the rooms are hot.      

Sunday, July 6, 2014

Turning Bad News Into Good

A glum eleven year-old sat on the bed. His glum parents and two glum adolescents sat nearby. The eleven year-old had developed a sore throat on the family’s departure. It had worsened, casting a pall over their vacation. They hoped I would make it go away.

Doctors love making things go away, and this would happen if the child had strep, the only throat infection (diphtheria aside) that medical science can cure.

Parents assume that a child with pus-covered tonsils has strep, but many viruses do this. Researchers have determined that a doctor can diagnose strep by observing four signs.  (1) pus-covered tonsils, (2) swollen neck glands, (3) fever, and (4) absence of cough. Since it’s strictly a throat infection, other respiratory symptoms such as cough or congestion make strep unlikely.

This patient had zero out of four. His throat and neck glands were normal; he had no fever; he was coughing.

Working hard to turn this into good news, I explained that the child had an ordinary virus. He would feel under the weather for a few days before getting better. I handed over several over-the-counter remedies, assuring them that these would help. Staying in bed wasn’t necessary. They should try to enjoy themselves.

When the father politely asked if, perhaps, an antibiotic might speed things along, I explained why it wouldn’t. Never forgetting their manners, the parents expressed gratitude. I urged them to phone if any problem developed, adding that I would answer in person.

We parted on good terms, but I could sense their disappointment.  

Wednesday, July 2, 2014

Bringing the Housecall into the 21st Century

Housecall agencies spring up regularly. I keep track of them so I saw Medicast’s web site when it came to life a few months ago.

During an interview with two energetic founders, I learned that they plan to bring the housecall into the 21st century, slashing the cost with volume, marketing, and digital technology. They would launch in June 2014 after a massive marketing campaign. Doctors were rushing to sign up, they added.

I agreed to join them but declined the canvas carry-all they were offering, preferring to keep my traditional doctor’s bag. A handout listed required drugs and supplies which Medicast would sell to its physicians, but they agreed that I could handle my own selection.

They gave me an Ipad Mini. All their doctors receive one. Potential customers download the Medicast app which gives them the choice of signing up for a paying program that provides free housecalls or paying nothing and summoning a doctor when they need one. Clicking the app connects them to a dispatcher who records their credit card information and sends a text message to a doctor on-call. The program then automatically dials the client.

“Hotel guests phone my cell directly, or I phone them,” I said. “Wouldn’t that be quicker?”

“Doctors hate giving out their private numbers,” they explained. “This way you don’t appear on caller-ID, so patients can never bother you.”

A Los Angeles housecall costs $249 during business hours, $349 during nights and weekends. While this is in the ballpark of my fee, Medicast keeps about one third. Medicines and injections cost extra, so a Medicast doctor has the opportunity to earn more – a lot more if he’s creative, and some doctors show a positive genius in this area.

The app includes a tempting feature: a button a doctor can swipe to go “off call.” I don’t mind that hotels and insurance services phone 24 hours a day, but I sometimes can’t resist flipping the button when I go to bed.

Carrying the Ipad everywhere is a minor annoyance, and software bugs still make an appearance. If another doctor answers, the app doesn’t notice, so I’ve phoned patients who’ve already set up a housecall.

Business is brisk. My Ipad chirped nine times in June to announce a call although some may have been software glitches. All were from local residents, so they don’t overlap with my clients, but employees at two hotels have reported visits from a Medicast representative.