The Evils of Common Sense

Everyone yearns to understand their medical problem. In the absence of evidence, they use common sense which turns out to be a terrible way to get at the truth. It’s a good rule that any common sense explanation of a medical problem is wrong. Here are others that I hear all the time.

“I can walk on it, so I know it’s not broken.”

It turns out that the fibula, one of two bones in the lower leg, doesn’t bear weight. You walk on your tibia.

“I can move it, so I know it’s not broken.” You may know, but I’m not so sure.

“I have to let this run its course…”

Seeing smoke pour out of your car’s exhaust, no one explains that the engine is repairing itself by expelling bad things. Yet plenty of patients believe vomiting or diarrhea is the body’s attempt to cleanse itself. In fact, it’s a malfunction. It’s OK to suppress it although exceptions exist for a few serious diseases.

“Fever is your body’s way of fighting an infection.”

Google “does fever treatment help” for an avalanche of praise for fever's healing properties from doctors and medical sites as well as laymen – a good sign that it’s nonsense.

Here are questions that you might ask.

1. In what specific infections is lowering the fever harmful? I can’t think of any.

2. What infections do doctors treat by giving patients a fever?  The answer is none (doctors tried this about a century ago, but it wasn’t helpful).

3. Every day, across the world, a hundred million people take medicine for fever. How many end up at the doctor who explains that they made the problem worse?

I Love Medicare

I have collected Medicare since 2005. There’s a belief that this means I get free medical care, but that’s definitely not true. Both Medicare Part A and B have deductibles, and sensible retirees buy a policy that pays most of what Medicare doesn’t pay (and it doesn’t pay quite a lot). There is also Medicare Part D which requires a premium that pays for drugs. Believe it or not, Part D was passed by Republicans.

Being Republicans they made sure the plan met the approval of pharmaceutical companies, and it does. They love it. Part D specifically forbids Medicare from negotiating for lower prices. Other government departments such as the V.A. can negotiate. Hospitals and private health insurers can negotiate. Medicare can’t. As a result, Part D premiums, no less than drug prices, have been shooting up each year.

The result is that I pay about $550 a month for medical insurance. In exchange, I get almost no medical bills. I love it. Even though Medicare is a government program, I receive less paperwork than when I belonged to Blue Cross (even writing “Blue Cross” produces a surge of anger; I hated it). 

My brother, a physician, detests Obamacare. He is liberal and an activist, and he dislikes Obamacare because it delivers a bonanza to insurance companies with no controls on cost. His criticisms are correct, but I tell him that as premiums skyrocket the outcry will force Washington to take action.

Conservatives tell us that in European national health plans the downtrodden physician takes his orders and pitiful salary from the government. In fact, all these countries have some private insurance. In many, such as Switzerland and the Netherlands, everyone buys medical insurance from private carriers just as they do in the US. The difference is that laws closely regulate them. The carriers aren’t losing money.

Things will work out.

Historical Diseases

Standby MD asked me to see a guest at the Doubletree – in Santa Ana. That’s fifty miles away, but it was Sunday morning; freeway traffic was light, a perfect time to go to Orange County.

The guest was an elderly Canadian man suffering diarrhea and vomiting. He mentioned that half a dozen members of his tour were affected; several had gone to the emergency room.

That brought back memories of a guest in 1991 with the same symptoms. Stomach viruses are the second most common ailments a hotel doctor encounters. They’re miserable but short-lived; I had delivered the usual advice and remedies, but when I called to check the next day, I learned that he was in the hospital with cholera. I remembered that he had flown in from Peru.

Cholera also causes diarrhea and vomiting. It’s extremely rare in the US. In fact, if an American patient turns up with any of the major historical diseases (cholera, malaria, rabies, leprosy, typhoid, typhus, plague, even tuberculosis) it’s almost certain that the American doctor will get it wrong on the first visit.

The Canadian gentleman was already recovering, but my phone rang before I left with a request to see another tour member. She was sick enough to send to an ER where she stayed until the evening. There is little cholera in Canada, so this was a stomach virus.

Colic

I saw a young Australian couple traveling with an infant. A placid sleeper in Australia, the infant had been screaming off and on since arriving six days earlier, attracting complaints from other guests, driving the poor parents to desperation. They wanted to go home.

It was colic, a surprisingly common affliction of healthy infants. In theory, they are suffering abdominal pain, but all tests are negative, and none of the innumerable treatments work well. It disappears after a few months. I wrote them a note. 

Another Death

When I arrived at the hotel, a father explained that his daughter was under treatment for leukemia. They were visiting relatives when, a few hours before, she had refused to speak.

Except that she was bald from chemotherapy, the daughter looked fine. She was sitting up in bed, arms folded, looking glum. When her parents appealed to her to talk to me, she obviously heard but merely shook her head and remained silent. She did not resist when I examined her, and nothing abnormal turned up. I was faced with a sullen teenager who didn’t appear sick.

This was another occasion when, for no obvious reason, things didn’t seem right. I told the parents she needed to go to an emergency room. They obeyed, and the daughter died soon after being admitted. 

A Death

A guest at the Park Sunset complained of the flu. His temperature was 101; my examination was normal, but patients with influenza have a normal exam.

He looked miserable, but he was forty-one and in good health, and everyone with the flu looks miserable. There was no reason not to give the usual remedies and check back later. This happened long ago, but I still remember the inexplicable feeling that something was not right. I couldn’t bring myself to leave him in the room.

Leaving after extracting a guest’s promise to go to an emergency room is a bad idea. If the guest decides not to go and something dreadful happens, I’m the last doctor he’s seen. Calling paramedics was another option, but they might not share my unease.  

Explaining that he required further attention, I drove him to the nearest hospital. The next day I phoned. He had been admitted and died a few hours later. The doctor who cared for him was as mystified as I. We theorized he was suffering an overwhelming infection from an unknown source. Perhaps he took drugs. This was early in the AIDS epidemic, and victims sometimes died abruptly when their immunity vanished. We never found out.

Not Hitting the Jackpot

“Our client had a heart attack,” explained the dispatcher from Universal Assistance. “He wants to go home, but the specialist says he needs a doctor. We have hired a medical flight, and we want to know if you can go to New York. You come back the same day.”

Experts advise waiting a week or two after a heart attack to fly, but no one knows the risks of flying earlier because no one does. An expert who suggests that a physician go along is covering his ass, not delivering advice based on evidence.

Still, the insurer had agreed, no minor matter when an air ambulance coast to coast costs about $40,000. I had no idea what I would earn; nor did the dispatcher, but it would be breathtaking. Hiring a doctor for a day to testify in a malpractice trial runs to $7000.

I still remember with pleasure the single occasion I flew first class. Flying in a private jet while earning the price of a European vacation might leave an even better memory.

But would the patient require a doctor’s skills? It was unlikely, but I could not dismiss the possibility. Like most doctors, I can perform basic CPR, but I and most doctors have long since forgotten advanced CPR: complex drugs and techniques required for various cardiac malfunctions. Emergency room doctors, paramedics, and ICU nurses deal with these.

Wistfully, I informed the dispatcher that those were the appropriate escorts.