Cookbook Medicine

Last month, I discussed an educational campaign to persuade doctors to stop doing things that don’t work. Readers wondered at the fuss. I mean, if something doesn’t work, why not forbid it? If penicillin won’t cure your toe fungus, the pharmacist couldn’t fill your prescription. If you arrived at the radiology suite for a CAT scan of your brain, the technician would inform you that CAT scans for migraine are rarely helpful, so he couldn’t do one.

This will never happen. It’s “cookbook medicine” which everyone agrees is bad. Medicine is a science, doctors emphasize – except when someone tells them to do something they don’t want to do. Then medicine is an art, and everyone knows there are no rules in art.

We know from the movies that the hero never follows the book. That’s for fuddy-duddies.  

Here’s an example. Preparing a patient for surgery is a complicated process. It requires dozens of tests, procedures, and reminders. But no one is perfect; nurses and doctors often forget a few. It turns out that the consequences are disastrous. In one study where some surgeons followed a checklist and others didn’t, the death rate dropped by almost half -- from 1.5% to 0.8% with the checklist. Complications dropped from 11% to 7%. Other studies agree.

As a result some nations and many states passed laws requiring checklists for operations.. Hospitals hand them out. Some surgeons take them seriously. Some ignore them. Some consider them more bureaucratic paperwork; they check the boxes whether or not they’ve obeyed. It turns out that commercial airlines also require an elaborate checklist before taking off. Pilots probably obey more often than surgeons, but, for your peace of mind, don’t Google either topic.  

Low Back Pain

Finishing at a hairdresser, a guest at a West Hollywood hotel had bent over and thrown out her back. Now she wanted “a shot” so she could stand and get back to the hotel.

I’ve cared for several hundred guests with back pain. These are fairly satisfying visits. I deliver an injection which makes the patient giddy, so time passes more quickly. By the following day, the pain is not so bad. Back pain slowly improves even if not treated.

Hotel guests are already in bed, and that’s where they stay. This lady would have to move, and over the phone I warned that the injection would not make that easier. Powerful narcotics work best against “deep” pain such as a kidney stone or heart attack, not so well when it’s sharp and acute. If I were to give you a huge dose of morphine and then touch a lit match to your fingertip, you’d feel the usual amount of pain. These warnings rarely work, and they didn’t work this time.

Beverly Hills treats residents kindly. For example, parking is much easier than in surrounding Los Angeles. If you’re just passing through, Beverly Hills shows no mercy. Traffic lights along Santa Monica Boulevard change simultaneously, so there’s no hope of getting through even when streets are empty. During the rush hour, traffic proceeds a few streets at a time. I cultivate tranquility, listen to my CD book, focus on the car ahead, and never look at my watch.  

Fortunately, the beauty shop closed at five, so I encountered only the patient, her companions, and a few employees. I examined her and then delivered the shot, gave pain pills for later, and assured her that she’d feel not-so-bad after a night in bed. Groaning and supported by friends, she hobbled off.

Doctors Should Keep Their Mouths Shut

A teenager at a downtown hotel had strep throat. Unlike most other bacteria, strep remains as sensitive to penicillin as it was seventy years ago. This is good news because penicillin is a terrific drug. It doesn’t upset your stomach, it has few side effects, it’s cheap….

“He’s allergic to penicillin,” said the mother.

“How do you know?” I asked.

She thought for a while. “The doctor told us. I think he had a rash…”

Once you’re branded as allergic to penicillin, no doctor in his right mind will prescribe it. This was bad news because I carry amoxicillin, a form of penicillin, and hand it out gratis. I don’t carry a substitute, so the mother had to find an open pharmacy and pay about twenty times amoxicillin’s price.

Ten percent of the population believes they’re allergic to penicillin and almost all are wrong. Ninety percent wrong is the usual figure, but some studies find almost zero genuine penicillin allergies.

What happened in this case? Chances are, years earlier the doctor prescribed a penicillin either to treat an infection or as a placebo, and the patient’s mother noticed a rash a few days later. Everyone knows that chicken pox and measles and rubella produce a rash, but any viral infection, including the common cold, can produce a pink, spotty eruption. To make matters worse, five or ten percent of everyone who takes amoxicillin or Augmentin (which contains amoxicillin) develops a similar rash. It’s harmless and disappears in a few days. Stopping the antibiotic doesn’t speed this up.

Experts agree that none of these are allergies.  

But why take a chance? Laymen worry. It’s 100 percent safe (and much quicker) to diagnose an allergy.

If a doctor had told you to flush $1000 down the toilet, you’d object, but that’s the equivalent if you go through life with a nonexistent penicillin allergy. If you’re lucky!... Rarely, you could be in serious trouble.

Skin tests are accurate, so you might want to see an allergist. It costs a few hundred dollars which insurance might not cover. 

Drugs that Cost a Lot

New drugs for Hepatitis C, leukemia, and several rare diseases can cost $50,000 per month. Companies that sell them stress that developing a new drug is expensive and that these are superior to previous drugs. This is true although it’s hard to judge if their profits are excessive. They might be.

Old drugs once cost slightly more than nothing. A single Lomotil, the leading diarrhea remedy once cost a few cents. It’s now thirty cents for the generic (that’s wholesale; you’d pay more). Colchicine, an excellent gout remedy that doctors have used for several thousand years, cost a nickel a pill. A few years ago it jumped to $5.00. Everyone expressed outrage, including our elected representatives. But it’s still $5.00

How do you explain that?

You may be surprised to learn that Medicare Part D, launched in 2006, which pays for prescription drugs, was a Republican program. Anxious to protect the free market, Republicans included language forbidding Medicare from negotiating drug costs. Doctors and hospitals must accept what Medicare pays but drug companies set their own prices. The Veteran’s Administration (which has the power to negotiate) pays much less. Drug companies are not required to sell to the V.A., but they do, so they’re not losing money. They’re not required to sell in foreign countries where the government regulates drug prices. But they do.   

Unquestionably, hanky-panky is going on. I would not be surprised if a bottle of aspirin jumps to fifty dollars in the near future. You can expect our elected representatives to express outrage.

Being Sick, and French

If you are French, in Los Angeles, and want a housecall, you call a French lady, Veronique Mastey. How she acquired this business is a mystery, but it is not trivial because I’ve made dozens of visits for her.

This year I returned to a mansion in Pacific Palisades to care for a member of Johnny Hallyday’s entourage. I doubt if the name rings a bell, so I must add that Johnny Hallyday is the greatest rock star you have never heard of. He’s been an idol in France since the 1960s, selling over 100 million records, 18 platinum.

We Work Miracles But Not All the Time

Practitioners of complementary medicine (alternative medicine, herbal medicine, homeopathy, naturopathy, acupuncture, etc.) always know what to do. That’s because all follow a theory that explains (1) what causes illness and (2) the proper treatment. This is very satisfying.

Doctors like me don’t have a theory of disease. I hate to say we use science because many people – some with college degrees – believe “scientists” are like “Episcopalians” or “Republicans.” They hold certain opinions, but it’s OK to have other opinions. It’s a free country.

Rather than say doctors are scientific I like to say we search for the truth. We try to find out what makes people sick and then what works to help. This is hard. Throughout history everyone assumed that the best doctors were wise, but this isn’t so. Wise doctors throughout history answered big questions, but they were usually wrong. Hippocrates came up with a few gems that everyone quotes, but most of his advice is garbage or the usual platitudes doctors deliver when they don’t understand what’s going on (avoid stress, eat nutritious food,…).

By searching for the truth (remember that’s another word for science) doctors have turned up miracles. An appendectomy or a kidney transplant is a miracle. The same is true for antibiotics, vitamin B12, immunization, anesthesia, even the discovery of germs (no wise man in any other culture came up with the idea that tiny bugs cause disease).

Doctors work miracles but not all the time; surgeons do better than medical doctors. I help most patients, but I don’t save lives often. When I do, I write about it here.

A Useful Technique

“It sounds like a stomach virus. These usually don’t last long. You’re healthy, so vomiting for a while isn’t life-threatening, but it’s definitely miserable. I make housecalls, so if you’d like me to come….”

“It sounds like a stomach virus. These usually don’t last long. Here’s what I want you to do. Don’t eat anything. Don’t drink anything. Get some ice from the ice machine. Lay quietly with a piece of ice in your mouth. Don’t chew. Keep sucking on the ice. I promise to call back in two hours. If you want a housecall, I can come.”

I’ve given these two pieces of advice thousands of times. If, after hearing the first piece, a stoic vomiter decides to wait, I deliver the second, but sometimes I go straight to number two.

“The fish tasted funny, and I’ve been throwing up since two. Can you give me something?”  The caller was at the Beverly Garland in Universal City. It’s an easy fifteen mile trip but not at 6 p.m. on a weekday. I try not to drive long distances when the freeways are jammed. To avoid this, I use a technique we in the medical profession call “stalling.”

At least half have improved when I call back, so I lose a good deal of money, but I wouldn’t have it any other way.

Medicine and Pornography

Twenty years ago my back began hurting. After a week of hobbling, I went to a doctor who ordered an X-ray that showed “arthritis.” He injected something into the area. I didn’t notice an improvement, but after a few weeks the pain disappeared. Almost all low back pain goes away.

I had received what medical experts calls a “low value service.” You would call it a “useless test.” Good studies show that if you have acute back pain alone (without another symptom such as fever or a neurological defect) X-rays rarely help, and that includes super-X-rays such as CT scans or MRIs.

For years the medical establishment has been waging a campaign called “Choosing Wisely.”  It’s an admirable effort to persuade doctors (tactfully, no pressure…..) to stop ordering worthless tests, performing procedures that don’t help, or prescribing useless antibiotics. You can Google it.

Is it working?... Maybe a little. For decades journals have published studies in which a medical group tries to encourage its doctors to practice better medicine. Sometimes these programs flop. Sometimes they succeed but never dramatically. Unless it’s unpleasant (like a colonoscopy) patients like doctors to do stuff. Doctors themselves like to take action even if they know (they usually know) that it probably won’t work.

It’s like watching pornography. Most doctors feel a twinge of shame after they do something that’s not likely to help. They don’t disagree with experts who disapprove. But when a patient walks in, and they feel the itch…..